The concepts of quality of life, health and well-being analyzed from the perspective of the International Classification of Functioning (ICF)
Quality of life, health and well-being conceptualizations from the perspective of the International Classification of Functioning, disability and health (ICF)
The International Classification of Functioning, Disability, and Health (ICF) constitutes the conceptual framework of the WHO for a new understanding of functioning, disability, and health. Its essential components are integrated into the dynamic functioning/disability equation. Due to its content validity, the ICF is the basis for the clarification of concepts of wide health use such as well-being, health status, quality of life, or health-related quality of life.
Hence, the analysis of the domains of health, those related to it, and functioning are the starting point of this work. Health domains are intrinsic to the person as a physio-psychological entity. Health-related domains are those extrinsic to the individual but cannot be separated from their health. Operation refers to the set of aspects of both domains.
Well-being is a global concept that encompasses those related to health and those not related to it, such as autonomy and integrity. The concept of Well-being is interchangeable with that of Quality of Life (QoL) by simply reversing the point of view: objective vs subjective. The same is true for Health-Related Quality of Life and Functioning (HRQL). HRQL is to CV as Functioning is to Wellbeing. For this reason, the ICF represents a standardized and international basis for a health operation and functioning based on the domains of health and those related to it.
The World Health Organization’s International Classification of Functioning, Disability, and Health (ICF) has provided a new foundation for our understanding of health, functioning, and disability. As a content-valid, comprehensive, and universally applicable health classification, it serves as a platform to clarify and specify health-related concepts that are frequently used in the medical literature as well-being, health state, health status, quality of life (QoL ), and health-related quality of life (HRQoL).
The ICF entity’s health and health-related domains and functioning will be used as starting points to reach the objective of the paper.
Health domains refer to domains intrinsic to the person as a physiological and psychological entity. Health-related domains are not part of a person’s health but are so closely related that a description of a person’s lived experience of health would be incomplete without them. Functioning refers to all health and health-related domains within the ICF. Well-being is made up of health, health-related, and non-health-related domains, such as autonomy and integrity. QoL is the individual’s perceptions of how life is going in health, health-related, and non-health domains. HRQoL is the individual’s perceptions of how life is going in health and health-related domains. “
Quality of life
It seems founded to maintain a certain skepticism when handling the concept “quality of life” as a scientific term due to its indiscriminate use in various fields.
The first use of the concept took place at the end of the 1960s, in the so-called scientific investigation of charitable social assistance with the work of the group of Wolganf Zapf. Then the concept was defined as the correlation between a certain objective standard of living, of a certain population group, and its corresponding subjective assessment (satisfaction, well-being).
In the following decades, the term “quality of life” was used interchangeably to name a number of different aspects of life such as health status, physical function, physical well-being (symptoms), psychosocial adjustment, general well-being, life satisfaction, and happiness. The meaning of the term “quality of life” is indeterminate, and although it may have an adequate adjustment in certain circumstances, it is not without an ideological risk. In its essence, it seems a linguistic, cultural, and phenomenological matter, perhaps belonging to the world of philosophy and that, as a hypothetical construct, challenges its scientific handling.
For medicine, in the philosophical background of the idea of the quality of life, there are at least two fundamental contradictions: one, the slide of medicine towards biology and the dialectical contradiction of current biological medicine with its theory of the individualistic person of the market, the consumer (foreign to medicine) and, another, the opposition between quantity and quality, the fact that qualities are opposed to each other, have different referential and degrees of difficult ordering and that some qualities are not allowed to be added.
In general, quality of life refers to the set of conditions that contribute to making life pleasant and valuable or to the degree of happiness or satisfaction enjoyed by an individual, especially in relation to health and its domains.
More recently, the construct “quality of life” has been assimilated to that of subjective well-being, encompassing cognitive judgment and positive and negative mood.
Conceptual vagueness and its subjective component hampered the progress of the quality of life research within medicine. The first attempt at sophistication consisted of narrowing the object of his study from the total reality and coining the term “health-related quality of life” to name only the aspects of life-related to health, disease, and treatments. Other aspects not so closely related to health such as cultural, political, or social were left out and excluded, calling them “quality of life not related to health”.
Health-Related Quality of Life is, therefore, the aspect of quality of life that specifically refers to the health of the person and is used to designate the concrete results of clinical evaluation and therapeutic decision-making. This basic use of the concept began in the USA some 30 years ago, with the confluence of two lines of research: one that of clinical research on the measurement of “functional status” and the other that of psychological research on well-being. and mental health.
Thanks to the active attitude of the patients (fueled by the increase in “consumerism” in health services and the vindication of patients’ rights), thanks to the methodological advances of psychometry and the combination of measures of physical function and from psychic well-being, modern clinical research on health-related quality of life was born.
The literature supports the idea of HRQL as a multidimensional construct although there has been some attempt to demonstrate its conceptual unity, based on the notions of well-being and functioning extended equally to the three physicals, emotional and social dimensions of human life. The social dimension of the quality of personal life, despite its relevant role, has been the last to be considered.
As social beings, our health depends substantially on a favorable interpersonal exchange in terms of material or emotional rewards and cognitive approval. Therefore, the sociological perspective of quality of life reminds us that the individual person is not the exclusive objective of medicine. The health of the population is also an objective. We know from systems theory that certain characteristics become visible only when we look at the whole system rather than at its elements in isolation. This is also true for the study of health. We cannot fully understand the determinants of population health by simple inference from information obtained from individuals, and this challenges the limited individual perspective that seems to dominate the current quality of life research. The ultimate question is whether we should treat the individual, the organism as if it were a whole, a unit when perhaps the unit of human life is the group and not the individual.
HRQL research and its practice – considered as a particular type of medical innovation – constitute the most successful social movement within medicine. Now, if the good part of the quality of life research is its growing recognition, its availability of funds, and its impressive achievements in terms of optimizing patient care, its bad part is the lack of creativity and its low levels of theoretical reasoning and methodological innovation.
There are different disconnections between the philosophical discourse of HRQOL, the sociological studies of the lives of patients, and the technical psychometric aspects of the measurement. The clinical approach to HRQL measurement has obscured the true meaning of the subject for the philosophy of science.
Initially, this measurement was aimed at knowing the quality of life of the patient as opposed to that of health professionals; that is, to know to what extent both perceptions coincide or are opposed. From this perspective, the HRQL concept is subjective and is difficult to express as a quantity. But as for clinicians, changes in HRQoL are decisive in the demand for care, adherence to treatment, or satisfaction with services, a multitude of standardized tools were developed in an attempt to obtain reliable, valid, and sensitive scores to changes throughout the weather. Now this means, technically for research.
Thus, innumerable research groups developed new conceptual models that later failed in their empirical verification but, nevertheless, they continued to develop HRQL measurement tools that today are gathered in hundreds of instrument banks.
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