02.wellbeing qolife 2008 jhp curs2

http://hpq.sagepub.comJournal of Health Psychology

DOI: 10.1177/1359105308093860 2008; 13; 764 J Health Psychol

Laura Camfield and Suzanne M. Skevington On Subjective Well-being and Quality of Life

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764

On SubjectiveWell-being andQuality of Life

LAURA CAMFIELD & SUZANNE M.SKEVINGTONUniversity of Bath, UK Abstract

We integrate the multi-disciplinaryfields of quality of life (QoL) andwell-being (WB) and appraise theimpacts of health factors. Theoreticaland methodological limitations arediscussed and new conceptual andtechnical advances identified, Theseare informed by cross-cultural andcommunity perspectives. Following adefinitional review, social inequalities,and links with happiness areexamined. Demographic, experientialand personal factors are outlined.Implications for poverty research areaddressed. As the concept of SWBrecently converged with thelongstanding international QoLdefinition (WHOQOL Group, 1995),we discuss the separate need forSWB. Future collaborative conceptualand pragmatic research isrecommended.

Journal of Health PsychologyCopyright 2008 SAGE PublicationsLos Angeles, London, New Delhiand Singaporewww.sagepublications.comVol 13(6) 764775DOI: 10.1177/1359105308093860

AC K N OW L EDGEMENTS. This research was conducted within the ESRCprogramme on Wellbeing in Developing Countries (WeD), University of Bath.Support from the UK Economic and Social Research Council (ESRC) isgratefully acknowledged. The work was part of a programme of the ESRCResearch group on Well-being in Developing Countries (WeD) although theviews remain those of the authors. Thanks to Professor Norman Sartorius andProfessor Julia Fox-Rushby for discussion of an early draft of the manuscript.

C O M P E T I N G I N T E R E S T S : None declared.

A D D R E S S . Correspondence should be directed to:SUZANNE M. SKEVINGTON, WHO Centre for the Study of Quality of Life,University of Bath, Bath, BA2 7AY, UK. [Tel. +44 (0)1225 386830;Fax +44 (0)1225 386752; email: [email protected]]

Keywords

culture definitions health poverty quality of life subjective well-being


CAMFIELD & SKEVINGTON: QUALITY OF LIFE AND SUBJECTIVE WELL-BEING

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HERE WE review literatures that could improveunderstandings about the relationship between con-ceptualizations of quality of life (QoL) and well-being (WB). Although health psychology is adeparture point, a multi-disciplinary appraisal isessential. Unusually, cross-cultural research informsour analysis. Acknowledging that both QoL and WBare conceptualized as objective and subjective, thisdistinction is considered with reference to socialinequalities and related economic factors. At thissubjective level, dimensions of happiness and lifesatisfaction (LS) are also important. This analysis isjuxtaposed by two established frameworks: one onself-determination, and another on human needs. Inbetter understanding the relationship between WBand QoL in health, an aim is to draw out broaderimplications (e.g. for studying poverty).

Without definitional and conceptual agreementand in the absence of careful operationalization andstatistical modelling, it is not yet possible to con-clude with any certainty what the universal relation-ship between QoL and SWB might be. Severalpossibilities exist. Is QoL synonymous with SWBor with WB in general? Is the QoL concept subor-dinate to SWB or could SWB be nested withinQoL? If QoL is not the same as SWB how much dothese concepts differ semantically and conceptu-ally? If they overlap conceptually, then in whatways and to what extent does this occur? Is it appro-priate to use them synonymously as so often hap-pens in the literature and in practice? This debatebecomes richer when QoL is viewed as a multi-dimensional rather than unidimensional concept, asmany contemporary instruments indicate, because itis then necessary to inquire which dimensions arequintessential to each concept and therefore at anoperational level, which should be included in theirrespective measures. The synthesis becomes morechallenging when cross-cultural contrasts need tobe taken into consideration.

Pioneering work by Diener (1984) located SWBas central to a persons experience containing mea-surable positive aspects and involving a global oroverall assessment of that persons life. Cognitiveevaluations or appraisals of LS as a whole, andemotional reactions to life events were later inte-grated into this definition (Diener & Diener, 1995).Others also focused on the affective dimensions butsome see SWB as more than the absence of nega-tive affect or cognition (Ratzlaff, Matsumoto,Kouznetsova, Raroque, & Ray, 2000: 37). Howeverinternational experts recently redefined SWB as:

An umbrella term for different valuations thatpeople make regarding their lives, the events hap-pening to them, their bodies and minds, and the cir-cumstances in which they live (Diener, 2006: 400).

Life satisfaction is also a salient concept. AlthoughDiener sees LS as a component of SWB and there-fore subordinate to it, the relationship of LS to QoLis less clear. Sirgy (1998) claims LS is an acceptedsocial indicator of QoL and operationalizes itthrough specific component domains in a structuresimilar to those proposed for QoL and SWB.However, LS also appears to be subordinate to QoL.Where bottom-up or grass roots approaches areused to derive appropriate, meaningful items for QoLmeasures, questions about satisfaction are fre-quently proposed by users (e.g. WHOQOL).However focus groups from different cultures do notframe all evaluations about QoL solely in terms ofsatisfaction, as the item stems of the WHOQOL-100show. They also generate questions about capacity,intensity, frequency and importance (Szabo & theWHOQOL Group, 1996). Questions other than aboutsatisfaction are therefore necessary in creating acomprehensive QoL assessment. From the WHO-QOL work we deduce that LS is nestedwithin over-all QoL, and subordinate to the overall concept.

Quality of life has many definitions but in recentyears subjective perspectives have largely replacedobjective ones like functional status. In a WorldHealth Organization (WHO) project that conceptu-alized QoL in cross-cultural terms, QoL wasdefined as:An individuals perception of their position in life,in the context of the culture and value systems inwhich they live, and in relation to their goals,expectations, standards, and concerns. It is a broadranging concept, affected in a complex way by thepersons physical health, psychological state, levelof independence, social relationships, and their rela-tionship to salient features of their environment.(WHOQOL Group, 1995: 1404)Recommended by users world-wide, a sixth domainon spirituality, religiousness and personal beliefswas later added to these five domains by the WHO-QOL Group (1995). Due to its breadth, this defini-tion has received increasing attention outside healthcare, for example in international development(Skevington and the WeD group, 2008).

A comparison of SWB and QoL definitions gener-ates new observations. The recent redefinition ofSWB by Diener (2006) shows considerable similarityto QoL. In acknowledging the centrality of value


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judgements, by including the circumstances in whichthey live, and through specifying bodies and minds,this draws the new definition of SWB closer than everto the QoL definition published more than 10 yearsago by the WHOQOL Group. As with earlier defini-tions of SWB, positive and negative feelings are typi-cally included in QoL as a psychological domain. It istherefore important to inquire whether this redefini-tion has effectively made the concept of SWB redun-dant as the state of subjectivity it describes appears tobe addressed by an existing, accepted internationaldefinition of subjective QoL. However, we are notcurrently able to answer this question fully until newempirical information is gathered. These data wouldbe important in resolving the debate about whether asimple, clear but restricted definition of LS is moresatisfactory in operationalization terms than an over-arching concept of QoL and SWB.

We go on to consider important factors relevant tothis debate. Rich theoretical work on general QoL sum-marized by Cummins (2000, 2006) and Veenhoven(2000), and considerable international work on SWB(Diener & Suh, 2000) are only partially integrated intoresearch on health-related quality of life, (HRQOL),namely the functional effects of an illness and its con-sequent therapy upon a patient, as perceived by thepatient. These research communities appear largelyunaware of each others thinking so it is difficult tounravel semantic misunderstandings. In QoL, method-ology and instrument design seem to be well ahead ofthe theoretical work. In contrast, SWB researchers havefocused on theory but have been slower to developgood methodologies including reliable and valid self-report measures similar to those available in the QoLfield, although there are notable exceptions such as theSatisfaction with Life Scale (Diener, Emmons, Larsen,& Grifin, 1985; Pavot & Diener, 1993).

Another conundrum concerns the consistentlypoor relationship observed between subjective andobjective dimensions across all these concepts.Although SWB and QoL studies established thatpeople give fairly accurate reports of their WB(Diener & Lucas, 2000; Sandvik, Diener, &Seidlitz, 1993), the question remains as to whyobjective proxies for SWB or utility like income,correlate so poorly with subjective self-reports.This loose relationship between objective lifecircumstances and perceived QoL is partiallyexplained by several mediating processes of adapta-tion or response shift (Schwartz & Sprangers,2000), positive cognitive bias, homeostasis, unreal-istic optimism, positive illusions and illusion of

control. These foundation stones of positivepsychology (Snyder & Lopez, 2002) show promisefor detailed understandings of good QoL.

One impediment has been the use of self-reportmeasures per se, because shared methodological prob-lems compromise their use. Self-report is influencedby mood (Diener, Suh, Lucas, & Smith, 1999;Schwartz & Strack, 1999), orientation (Schkade &Kahneman, 1998) and timing (Redelmeier &Kahneman, 1996). Social desirability bias arises fromcultural norms, for example humility in East Asia(Diener et al., 1995a), self-aggrandisement in the USA(Diener, Suh, Smith, & Shao, 1995b; Diener et al.,1999; Oishi et al., 1999a). However, these influencesseem to affect overall SWB measurement more thantheir component domain scores, which build a moredetailed picture of satisfaction with key life areas(Schwartz & Strack, 1999). Furthermore, cognitivepsychologists are still uncertain about exactly how thebrain integrates SWB components into overall judge-ments of WB (Kahneman, 2005). We know even lessabout this process in relation to QoL domains.

A greater challenge to SWB research is cross-cultural applicability. Christopher (1999) andKitayama and Marcus (2000) argue that SWB can-not be studied cross-culturally as its definitions areculturally rooted in moral visions. They say thatSWB is less relevant to collectivist societies (e.g.Japan) who use group or social judgements, thanindividualistic societies (e.g. the USA). Features dis-tinguishing these cultural extremes are self-defini-tion, goal structure, greater emphasis on norms thanattitudes and on relatedness as opposed to rationality(Triandis, 1996). However this argument is not gen-erally accepted. International investigations continueto show more complex differences in the way SWBjudgements are constructed. For example, self-esteem and self-consistency correlate more stronglywith LS in individualist than collectivist societies(Diener & Diener, 1995; Suh, 2000). Satisfactionwith freedom is less predictive of SWB in collec-tivist societies, and individualists are more likely touse emotions than norms to judge LS (Suh, Diener,Oishi, & Triandis, 1998). These national differencesare paralleled among ethnic groups in the USA(Diener & Suh, 1999), and are not attributed toshortcomings in equivalence between languagetranslations (Ouweneel & Veenhoven, 1991).

Some problems in studying SWB can be attenu-ated by supplementing self-report with ostensiblyless subjective methods like experience sampling(Kahneman, 1999, 2000), memories of positive or



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negative events (Sandvik et al., 1993), objectivepeer reports or diary records. SWB researchers mightdraw on mixed-methods techniques like cognitivedebriefing, which are useful in QoL research tounderstand meanings better, and could be helpful inimplementing studies in rapidly changing societies,or where ongoing interventions destabilize reporting.

However this lack of correlation between subjec-tive and objective well-being (OWB) does not meanthat subjective measures are less reliable, as is con-ventionally assumed. The two are better conceptual-ized as separate thermometers measuring differentprocesses in the same body, but in related ways. Evenif SWB was a distorted perception of reality (asimplied in describing discrepancies between SWBand OWB as false consciousness) it is still an inher-ently valuable perspective as it improves understand-ing of how informants perceive and report theirworld, irrespective of their reasoning (Clark, 2000,pp. 4548). The realityillusory dichotomy which isa tenet of Marxist theory has damaged progressbecause it constrains creative thought (Weatherell,1999) and impedes the development of new prag-matic solutions through inhibiting direct explorationof the subjective. However, this distrust of the sub-jective is by no means limited to Marxism.

Social inequalities in health,economics and well-being

Health and income are key to understanding therelationship between OWB and SWB and relevantto poverty. Social, psychological and material defi-ciencies experienced by the poor contribute toexplanations of diversity in health status nationallyand globally (Marmot & Wilkinson, 1999). A cor-pus of epidemiological research testifies to a directrelationship between morbidity and mortality withincome, and shows how the inequitable availabilityof material resources within and between societiesaffects and is affected by health status (Davey-Smith, Gunnell, & Ben Schlomo, 2001; Gwatkin,2001; Wilkinson, 1996). Poorer groups experiencemore disability, infectious diseases, chronic ill-nesses and a shorter life directly resulting frominadequate housing and nutrition, hazardous workenvironments and problematic lifestyle habits suchas smoking (Leon & Walt, 2001; Marmot &Wilkinson, 1999). Furthermore chronic illness anddisability related to the major global diseases of heartdisease (30% global mortality), diarrhoea, malaria,TB, HIV (WHO, 2001), can seriously damage QoL.

Ageing studies indicate this may be cumulativeacross the lifespan, particularly where illness per-sists, progresses or is terminal. However the bur-den of disease approach where indicators ofmorbidity, mortality, income and life-expectancydrive health policy decisions (Murray, Frenk, &Gakidou, 2001), has yet to incorporate a culture-sensitive measure of subjective QoL, and this isoverdue (Fox-Rushby, 2002).

Not only do poorer sectors of society have poorerhealth, they also have less access to the range ofquality resources that generate and sustain goodhealth. Where health care is freely available, poorerpeople who need it most should be its heaviest users.Sen (1990) compared SWB in countries with a sim-ilar Gross National Product and showed how incomeper capita and human capabilities assessed by objec-tive social indicators sometimes diverge. He attrib-utes this to the relative standards of different welfaresystems (Sen, 2001). However annual evidence fromUN-affiliated organizations shows that even wherecare is free at the point of use, it is still not deliveredto the sectors with the greatest need. Where userspay as they use health services (e.g. India, the USA),the inequalities gradient is steeper, and the poorbecome further disadvantaged by the system.Furthermore while some economies with high eco-nomic growth (e.g. South Korean, Taiwan), havesuccessfully increased both life years and quality,others with similar growth rates such as Brazil, haveneither lengthened life, nor improved QoL.Paradoxically Sri Lanka has improved mortalityrates and QoL, but has little economic growth (Sen,2001). These relationships persist even when dura-tion of growth, baseline mortality and inequality areaccounted for. Consequently including psychologi-cal factors of WB within a behavioural health eco-nomics framework (Kahneman, 1999) could providegreater explanatory power by adding variables notformerly of interest to economists, for example com-petence (Easaw & Ghoshray, 2004).

Happiness, QOL and SWB

While there is considerable research on generalQoL and health-related QoL, the relationship ofthese to happiness remains opaque. Happiness isseen as synonymous with SWB (Ratzlaff et al.,2000), and is used interchangeably with QoL in theUK (Skevington, MacArthur, & Somerset, 1997)and Australia (Herrman, personal communication)but establishing the universality of these findings is



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more problematic. Happiness has been definedmany times, usually as positive affect (e.g. Layard,2005), but it can also mean general positive mood,a global evaluation of LS, living a good life or thecauses of happiness (Diener, 2006). Dieners defin-ition subsumes LS within happiness, as a subordi-nate component, implying that happiness is akinto well-being.

These issues are particularly evident in poverty.Considering the material obstacles that may preventpoor people from sustaining what is perceived to bea good QoL, it seems almost frivolous to mentionhappiness. However independent bodies of work byDiener, and Veenhoven lead to the conclusion thathappiness is equally important in all societies, irre-spective of differences in wealth or culture. AlsoSuh et al. (1998) found that happiness was of uni-versal importance, and that only 1 per cent hadnever considered it. Cross-cultural investigations ofsubjective QoL in 15 countries world-wide confirmthat although happiness is universally important, itonly constitutes one important dimension out of 24that make up the global concept of QoL (WHOQOLGroup, 1995). So while happiness undoubtedly hasuniversal currency, the paramount position accordedto it may have been overstated.

Since Aristotle, happiness has been seen as a uni-versal goal that is appropriate and attainable. Yet inUSAarguably the most privileged society in theworldgreater material prosperity has not matchedrising levels of happiness over the same period, sothe number of people describing themselves ashappy remained relatively constant. Paradoxically,increasing US divorce and suicide rates provide rec-ognized indices of societal unhappiness. Diener andDiener (1996) noted that individualist nationsreported higher LS alongside higher suicide rates,possibly due to greater personal helplessness.Schwartz (2000) connects disparities between over-whelming levels of choice and unrealistic percep-tions of environmental control to recent explosivegrowth in the US incidence of depression.

Perhaps this disjunction arises from defining hap-piness in purely hedonic and idiosyncratic terms,which may be a mistranslation of Aristotles origi-nal eudaimonia. In its fullest sense, eudaimonismintegrates actualized potential, or recognizing andrealizing ones true nature or self, into WB. Itembodies a life worth having/desiring with intensequalities of harmony, fulfilment and engagement(Waterman, 1993). At this point it shares common-alities with QoL. However SWB includes not just

affect but also LS with meaning. This brings itcloser both to the concept of QoL, and the eudai-monic definitions of happiness proposed by andRyan and Deci (2001) and Ryff and Singer (1998).They point out that psychological WBa norma-tive measurement comprising positive mental healthand absence of distressis as important as SWB,and that the two correlate only moderately(Compton, Smith, Cornish, & Qualls, 1996;McGregor & Little, 1998). It is unclear how dis-tinctive these two concepts are and whether they aretautological. Ryan and Deci (2000) use this defini-tion as the basis of their self-determination theory(SDT) of psychological need, seeing autonomy,competence and relatedness as essential to needsfulfilment and psychological growth. Here WB ismore closely associated with pursuing intrinsicgoals, like close relationships, personal growth andbettering the community, than extrinsic goals, likewealth and materialism. Attributing positive eventsto internal or personal factors also enhances WB.

This eudaimonic orientation and autonomydrawn from SDT provide a conceptual bridge toDoyal and Goughs (1991) Theory of Human Need(THN). Here autonomy is one of two basic univer-sal needs, co-equal with health. Both theories sharea deductive, universalist approach. Drawn fromsocial policy and Maslows theory of need satisfac-tion, the THN has received less attention and field-testing in psychological research compared to SDT;both are central to this debate about QoL. Whilethe universality of QoL is supported globally(Skevington, Sartorius, Amir, & the WHOQOLGroup, 2004), there is limited support for universal-ity in the other two theories. Unpublished reportsfrom Venezuela and Hong Kong support the THN,and national data from Bulgaria (Deci et al., 2001),Japan (Hayamizu, 1997) and Russia (Chirkov &Ryan, 2001) support SDT. Although not included inthe original WHOQOL, autonomy was confirmedas important to QoL in older adults (23 countries)(WHOQOL-Old Group, 2005).

Of additional theoretical interest are changesrelating to goals that affect SWB. Goals are centralto the way people conceptualize their QoL (seeWHO definition on first page). They are embeddedin the THN where need satisfaction can be equatedto goal achievement (Doyal & Gough, 1991). InSDT, SWB is explained by the progress madetowards salient life goals (Cantor & Sanderson,1999; Carver & Scheier, 1999; Diener, Sapyta, &Suh, 1998; McGregor & Little, 1998; Oishi et al.,



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1999b) and is important cross-culturally (Ryan et al.,1999). However, these goals need to be intrinsic,attractive and approachable, not extrinsic, unattractiveand avoidant (Elliot & Sheldon, 1997). They shouldbe optimally challenging (Csikszentmihalyi &Csikszentmihalyi, 1988), pursued autonomously(Ryan & Deci, 2000) and with reasonable expectationof success (Emmons, 1996). However while need sat-isfaction for autonomy, competence and relatedness(Reis, Sheldon, Gable, Roscoe, & Ryan, 2000; Ryan& Deci, 2000) are important globally, the weightgiven to them may differ culturally. In some collec-tivist societies, autonomy correlates poorly with SWBbut relatedness is important to collectivists and indi-vidualists (Oishi, 2000; Oishi & Diener, 2001; Oishi,Schimmack, Diener, & Suh, 1998).

Demographic, experiential andpersonal factors

Here we review demographic, experiential and per-sonal factors relating to SWB and QoL. Mostresearch was completed in Europe and NorthAmerica but stars (*) indicate where developingcountries are included. Personal income is impor-tant to SWB but shows a curvilinear relationship.Diener, Sandvik, Seidlitz and Diener (1993*)observed a steep reduction in SWB when annualhousehold income fell below US$10,000. This maybe due to incomes positive relationship with otherexternal resources, and internal resources like per-sonal control (Lussier et al., 1997), self-esteem(Carpenter, 1997; Tran, Wright, & Chatters, 1991)and optimism (Eckelersley, 1997). Furthermore,income can protect people from situations thatmight compromise their homeostasis (Ahuvia &Friedman, 1998), so that a buffering mechanismmaintains SWB at a level of 75 per cent or higher(Cummins & Nistico, 2002). This psychologicalhomeostasis is akin to the human bodys tempera-ture regulation mechanism. However, once subsis-tence level was exceeded, increases in income didnot coincide with improved SWB (Biswas-Diener& Diener, 2001*; Cummins, 2000; Diener et al.,1993*), possibly due to adaptation. On the contrary,SWB can be reduced, as higher income is associ-ated with more divorce (Clydesdale, 1997), andreduced pleasure in small activities (Kahneman,1999; Parducci, 1995).

Furthermore income is not the only factor, asfinancial needs are important. People who stronglydesire wealth are more unhappy than others (Kasser,

2002*). In SDT terms, this is due to an extrinsic, lesshealthy goal. The limited role of personal income isevidenced in a study of Calcutta slum dwellers whodespite their poverty, reported high satisfactionacross all domains:

In the case of Calcutta, much of our attentionremains focused on the image of poverty and itsrelated ills. However, broader examination reveals aricher picture with positive life aspects. The partici-pants in this study do not report the kind of sufferingwe expect. Rather they believe that they are good(moral) people, they often are religious []; theyhave satisfactory social lives and enjoy their food.[]. So the complete picture requires not just afocus on the deficits of poverty and poor health butincludes the positive aspects of the respondentslives. (Biswas-Diener & Diener, 2001, pp. 347348)Biswas-Diener et al. (2001*) attributed this to afocusing illusion whereby people judge the stan-dards of the lives of others based on a few focalattributes, such as a personal deficit or materialwealth (Schkade & Kahneman, 1998).

Studies show that national wealth has greater influ-ence on SWB than personal income (Veenhoven,1991*; Diener & Diener, 1995*; Diener & Suh,1999*), but even here there are diminishing returns.Not all poor countries report low SWB (Diener &Suh, 2000*), suggesting that culture mediates.Using Maslow (1954), Inglehardt & Klingemann(2000*) and Veenhoven (1991*) indicate that oncebasic needs are met, people move to a post-material-ist phase, focusing on self-fulfilment. Studies of lowincome populations (Mercier, Peladeau, & Tempier,1998), and students in 31 countries (Diener &Diener, 1995*) support this view. Political and per-sonal freedoms in poor countries are not related toSWB in the same way as richer nations (Veenhoven,2000*), so any satisfactory solution must accountfor these complexities.

Annual data on international inequalities show thatnot all those living in poor countries are poor (andvice versa) so assumptions that poorer nations focuson basic, physical needs, and richer ones on complex,cerebral ones are over-simplified (Clark, 2002).Where inequality decreases (national income distrib-ution), average SWB tends to increase (Hagerty,2000). Assessing inequalities may be more importantto health psychology than baseline measures likestandard of living, and links back to Runcimanswork on relative deprivation. Furthermore althoughpolitical freedom and participation influence SWB inricher countries (Diener et al., 1995a; Frey & Stutzer



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2002), they affect poorer nations too (Moller, 1995*,1996). At individual levels, civil participation andsocial trust are strongly linked with subjective health(Poortinger, 2006). Political instability dramaticallyreduces SWB (Inglehardt & Klingemann, 2000*).This deserves further investigation.

As a consequence of focusing on individualstressful life events, psychologists have been slowto study the impact of major environmental disasters,such as famine or tsunami, on community SWB. Suchevents can affect the nations development and econ-omy, and exacerbate poverty where few surplusresources exist to buffer deleterious effects.Furthermore while responses to stressful events canhave a major, prolonged impact on SWB, for examplebereavement (Stroebe & Stroebe, 1996), adaptation toother events is swift (Cummins & Nistico, 2002; Suh,Diener, & Fujita, 1996*; Winter, 1999). Adaptation topoor QoL is partly explained by the response shiftmodel (Schwartz & Sprangers, 1999, 2000; Schwartzet al., 2006).

Community studies of SWB provide a broadercontext. Inequality from socio-economic depriva-tion negatively affects peoples environmental QoL(Drukker, Ferou, & van Os, 2004). Related tosocioeconomic status, neighbourhood status has animpact on SWB (Drukker, Gunther, & van Os,2007), being associated with subjective health, evenafter adjustment for age, gender and ethnicity (Wen,Hawkley, & Cacioppo, 2006). As this is only partlyexplained by individual factors like loneliness, hos-tility and stress, we conclude that community fac-tors should also be addressed to understand health,WB and QoL better.

Resources from social capital and social cohesionhave formed a focus of recent investigations(Berger-Schmitt, 2002). Social capital is The set ofcooperative relationships between social actorsthat facilitate collective action (Requena, 2003:331). However it represents more than social rela-tionships alone, so definitions are contentious(Navarro, 2002). In a survey of 173,236 US adults,social capital level made 11 per cent difference tothe odds of self-rated health (Kim & Kawachi,2007). More social capital was associated with fewerproblems (days), physical and mental activities.Age, ethnicity and state income predicted its rela-tionship with QoL. Low social capital has also beenlinked with poor social QoL in older adults living inrural Bangladesh (Nilsson, Rana, & Kabir, 2005);higher age and poor household economic statuswere factors. Therefore it is possible that income

inequalities and health-related QoL are mediated bysocial capital. This implies that where social capitalcould be promoted in communities, health and QoLmay improve.

Socio-demographic studies show that gender(Cummins, 1995) and age (Carstensen, 1998;Diener & Lucas, 2000; Mroczek & Kolarz, 1998)are indirectly related to SWB. However the patternis more complex in Europe and North Americawhere age correlates positively with LS, despitedeclines in physical health (Okun & Stock, 1984).This disjunction demonstrates the importance ofobtaining information about subjective meanings ofphysical change, instead of assuming their relation-ship with WB. Education has limited effect, and itslink with income could be confounding (Judge &Locke, 1993; Tran et al., 1991).

Heredity accounts for half the variance in SWBexpression (DeNeve, 1999; Newman et al., 1998).Extraversion correlates positively with SWB(DeNeve & Cooper, 1998*) cross-culturally (Lucas,Diener, Grob, Suh, & Shao, 2000*). Personalityexplains SWB stability (Magnus, Diener, Fujita, &Payot, 1993), and because LS is stable (Schimmack,Diener, & Oishi, 2002), could account for thestability of QoL.

Conclusion

We considered the relationship between SWB andQoL through definitions of concepts. Initially weobserved that the SWB field showed more theoreti-cal progress than methodological developmentwhen compared with QoL, where the reverseseemed true. However, closer scrutiny showed thatthe new definition of SWB derived by an expertpanel now displays high convergence with an inter-national definition of QoL (WHOQOL Group,1995). The revised definition of SWB embraces val-ues and life circumstances that are also embeddedwithin the WHOQOL definition which was agreeda decade ahead of the SWB guidelines (Diener,2006). Earlier assumptions about the paucity ofconceptual work in QoL research are therefore mis-taken. On the basis of available evidence drawnfrom cross-cultural research, we suggest that SWBand subjective QoL are virtually synonymous witheach other, and question whether SWB may now besuperfluous to definitional requirements.1 In addi-tion, cross-cultural evidence showed that SWB andQoL contained a substantial component of LS butthis was insufficient to explain either. This research



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implies that LS is a subordinate component in SWBand QoL. While patient satisfaction is a useful out-come indicator in certain situations (e.g. treatmentresponse), this limited concept might be betterreplaced by a comprehensive QoL assessment (USFood & Drugs Administration, NICE). In resolvingsome conceptual opaqueness, this could ease prac-tice for health professionals, as high performanceQoL measures are readily available for use in manysettings and populations. However we recognizethat future research may show that all these con-cepts (and their associated measures) may still havepragmatic value in specified contexts within andbeyond health care. Consequently continuedresearch collaboration between these fields isdesirable.

In distinguishing between objective and subjec-tive factors in WB and QoL we conclude thatincreased material resources do not directly lead toimprovements in SWB, despite continued interestby policy-makers (Layard, 2005). Furthermore,where inequalities exist, this damages QoL asexpected, and furthermore, inequality provides amore useful explanatory variable for health and WBthan standard baseline indices (e.g. wealth).Consequently, researchers may seek to revisit rela-tive deprivation within this context. Furthermore wesaw how social capital acts as a buffer to poor QoLand SWB in poorer communities, although socialrelationships in QoL have only been partlyassessed. Despite the individual focus we also notethat QoL assessment might add a new dimension tounderstanding social cohesion, for example throughinterventions to improve social capital in deprivedcircumstances. This growing area demonstrates theimportance of obtaining community, as well as indi-vidual assessments, because they tap into differentbut complementary levels of experience to providea comprehensive perspective. While demographic,experiential and personality factors will still need tobe accounted for, given their demonstrable value tocross-cultural research, a multilevel approach in thispost-disciplinary area seems likely to be the mostproductive way forward.

Note

1. The authors differ on this point.

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Author biographies

LAURA CAMFIELD trained as an anthropologist, and herresearch focuses on experiences of poverty, resilience,and methodologies for exploring and measuringsubjective wellbeing in developing countries. She is aresearch fellow in the Wellbeing in DevelopingCountries and Young Lives research groups.

SUZANNE SKEVINGTONs research is in global publichealth. She is dedicated to the cross-cultural under-standing and assessment of quality of life and sub-jective well-being in health. She holds a Chair inHealth Psychology at Bath where she directs theW.HO Centre.


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