European perspectives on quality of life in old age

Introduction

The main purpose of this special section of the European Journal of Ageing is to provide a sample of research that is at the forefront of European work on the quality of life (QoL) of older people. The five articles, from their different perspectives, provide overviews of recent developments in this field from several European countries, addressing and examining the topic at various levels: the micro level of the individual, the meso level of the family and community and the macro level of the society. These issues are of interest not only to European researchers and practitioners, but also to a global audience.

The key to these developments on the European scene is the striving of the scientific community for enhanced European collaboration, culminating in the creation of the European Research Area in Ageing (ERA-AGE) and the launch of the European Journal of Ageing in 2004. The special section includes five articles that deal with various aspects of QoL starting with an account of QoL at the macro-level on “Welfare states and quality of later life: distributions and predictions in a comparative perspective” by Andreas Motel-Klingebiel, Laura Romeu Gordo and Jörg Betzin. This is followed by the micro–meso-level with the article by Ruth Katz, which looks at “Intergenerational family relations and subjective well-being in old age: a cross-national study”, and the article on “Older adults loneliness: myths and realities” by Pearl Dykstra. The special section is followed by the article on “Care-related quality of life in old age” by Marja Vaarama and concluding this special section with the micro/meso level and the article on: “The home environment and quality of life-related outcomes in advanced old age: findings of the ENABLE-AGE project” by Hans-Werner Wahl, Oliver Schilling, Frank Oswald and Susanne Iwarsson.

In this opening article, we will try to outline briefly various approaches to, or models of, QoL, relate to the current state of knowledge of QoL in old age and finally outline priorities for European future research in this field.

Quality of life: dimensions and scope

As we witness the phenomenon of global ageing, concern about the QoL of older people has heightened. QoL is a rather amorphous, multilayered and multifaceted complex construct encompassing a variety of components: objective, subjective, macro-societal, micro-individual, positive and negative, which are interactive (Lawton 1991; Tesch-Römer et al. 2001). Research on this topic started with an emphasis on objective factors such as the level of income, education or housing. However, one of the main issues relating to objective factors is that these measures do not take into account the impact of culture, values and ideological attitudes of the individual (Evans, 1994; O’Boyle 1997). Pinquart and Sorenson (2000) in their meta-analysis on findings from 286 empirical studies concluded that in order to interpret the findings “research is needed that investigates the association between subjective well-being and those aspects of life that show increased risk of loss and decline in old age” (p. 187). Three central limitations of the QoL concept are its apparent open-ended nature, its individualistic orientation and its lack of theoretical foundations (Walker and van der Maesen 2004). The widely acknowledged complexity of the concept, however, has not inhibited scientific inquiry. As Fernández-Ballesteros (1998) has shown, there was a substantial increase in citations of QoL across five different disciplinary databases.

QoL is an important ingredient for the study of the balance between family relations and welfare policies. A large part of the existing research on QoL has focused on health-related QoL (De Vries 1999). Liu (1976) argued that quality of life has as many definitions as the people asked to define it. A review of 80 articles on the topic revealed little agreement between the authors. Despite this difficulty, there is a general agreement regarding five domains that contribute to personal quality of life: physical, social, emotional and material well-being, personal growth and activity (Felce and Perry 1995).

Another key factor behind this growth in scientific inquiry is the concern amongst policy makers about the consequences of population ageing, particularly for spending on health and social care services, which has prompted a search for ways to enable older people to maintain their mobility and independence, and so avoid costly and dependency-enhancing institutional care. These policy concerns are not peculiar to Europe, but are global (World Bank 1994), nor are they necessarily negative, because the new policy paradigms such as “a society for all ages” and “active ageing”, both of which are prominent in the 2002 Madrid International Plan of Action on Ageing, offer the potential to create a new positive perspective on ageing and a major role for older people as active agents in their own QoL. A significant part of the impetus for this positive approach comes from within Europe (Walker 2009).

Models of quality of life

Given the complexity of the concept and the existence of different disciplinary perspectives, it is not surprising that there is no agreement on how to define and measure QoL and no theory of QoL in old age. Indeed, it is arguable whether a theory of QoL is possible because, in practice, it operates as a meta-level construct, which encompasses different dimensions of a person’s life. Nonetheless, a theory would not only lend coherence and consistency, but would also strengthen the potential of QoL measures in the policy arena (Noll 2002). As part of the European FORUM project, Brown et al. (2004) prepared a taxonomy and systematic review of the English literature on the topic of QoL. In this, Bowling (2004) distinguishes between macro- (societal, objective) and micro- (individual, subjective) definitions of QoL. Among the former, she includes the roles of income, employment, housing, education and other living and environmental circumstances; amongst the latter, she includes perceptions of overall QoL, individuals’ experiences and values, and related proxy indicators such as well-being, happiness and life satisfaction. Bowling also notes that models of QoL are wide ranging, including potentially everything from Maslow’s (1954) hierarchy of human needs to classic models based solely on psychological well-being, happiness, morale, life satisfaction (Andrews 1986, Larson 1978), social expectations (Calman 1984) or the individual’s unique perceptions (O’Boyle 1997, Brown et al. 2004, p. 4).

Bowling distinguishes eight different models of QoL, which may be applied, in slightly adapted form, to the gerontological literature and these include: (1) Objective social indicators of the standard of living, health and longevity, typically with reference to data on income, wealth, morbidity and mortality (Scandinavian countries have a long tradition of collecting such national data) (Hornquist 1982; Andersson 2005). (2) Satisfaction of human needs (Maslow 1954), usually measured by reference to the individual’s subjective satisfaction with the extent to which these have been met (Bigelow et al. 1991). (3) Subjective social indicators of life satisfaction and psychological well-being, morale, esteem, individual fulfilment and happiness, usually measured by the use of standardised, psychometric scales and tests (e.g. Bradburn 1969; Lawton 1983; Veenhoven 1999; Veenhoven 2000; Clarke et al. 2000). (4) Social capital in the form of personal resources, measured by indicators of social networks, support, participation in activities and community integration (Wenger 1996; Bowling 1994; Knipscheer et al. 1995). (5) Ecological and neighbourhood resources covering objective indicators such as levels of crime, quality of housing and services and access to transport, and subjective indicators such as satisfaction with residence, local amenities and transport, technological competence and perceptions of neighbourliness and personal safety (Cooper et al. 1999; Kellaher et al. 2004; Mollenkopf and Fozard 2004; Scharf et al. 2004; Wahl et al. 2007). (6) Health and functioning, focussing on physical and mental capacity and incapacity (for example, ADL and depression) and broader health status (Verbrugge 1995, Deeg et al. 2000, Beaumont and Kenealy 2004). (7) Psychological models of factors such as cognitive competence, autonomy, self-efficacy, control, adaptation and coping (Brandtstädter and Renner 1990; Filipp and Ferring 1998; Grundy and Bowling 1999). (8) Hermeneutic approaches emphasising the individual’s values, interpretations and perceptions, usually explored via qualitative or semi-structured quantitative techniques (WHO QoL Group 1993; O’Boyle 1997; Bowling and Windsor 2001; Gabriel and Bowling 2004a).

A common feature of all of these models identified by Brown et al. (2004) is that concepts of QoL have invariably been based on expert opinions rather than those of older people themselves (or, more generally, those of any age group). This limitation has been recognised only recently in social gerontology, but has already led to a rich vein of research (Farquhar 1995; Grundy and Bowling 1999; Gabriel and Bowling 2004a, b). This does not mean, however, that QoL can be regarded as a purely subjective matter, especially when it is being used in a policy context. The apparent paradox revealed by the positive subjective evaluations expressed by many older people living in objectively adverse conditions, such as poverty and poor housing conditions, is a longstanding observation in gerontology (Walker 1980, 1993).

Understanding quality of life in old age

Developmental changes in old age affect QoL. These changes can have negative effects on objective QoL. But simultaneously, there are inner changes that can improve subjective QoL. In comparison with younger people, elders achieve more balance in self-perception, which strengthens a realistic evaluation of self-capacity and helps maintain QoL (Atchley 1991). The approaches that are based on the notion that the individual’s personal point of view, or the living experience, is central to QoL perception do not usually consider the societal perspective. Tesch-Römer et al. (2001) note “it is important to know which opportunities societies create for their members” (p. 71). The OASIS (Autonomy in Old Age: The Role of Service Systems and Intergenerational Family Solidarity”) study, in which respondents from four European countries (Norway, UK, Germany and Spain) and from Israel participated, looked at variables that impact on the quality of later life, examining the links between family relations to QoL. The data show that the most salient variables related to subjective QoL of those aged 75 and above were perceptions of the level of living and health situation, pointing to the importance of provision for basic needs to achieve QoL, whereas only the emotional component of solidarity in family relations had an impact on QoL (Katz and Lowenstein 2003; Lowenstein 2007).

In the light of the wide spectrum of disciplines involved in research on QoL in old age and their competing models, is it possible to draw any conclusions about how it is constituted? The answer is yes, but because of the lack of either a generally agreed definition or a way to measure it, such conclusions must be tentative. First of all, although there is no agreement on these two vital issues, few would dissent from the idea that QoL should be regarded as a dynamic, multifaceted and complex concept, which must reflect the interaction of objective, subjective, macro-, micro-, positive and negative influences. Not surprisingly, therefore, when attempts have been made to measure it, QoL is usually operationalised pragmatically as a series of domains (Hughes 1990, Grundy and Bowling 1999).

Secondly, QoL in old age is the outcome of the interactive combination of life course factors and immediate situational ones. For example, prior employment status and mid-life caring roles affect access to resources and health in later life (Evandrou and Glaser 2004). Research suggests that the influence of current factors such as network relationships may be greater than the life course ones, although, of course, the two are interrelated (Wiggins et al. 2004). What is missing, even from the interactive approaches, is a political economy dimension. Quality of life in old age is not only a matter of individual life courses and psychological resources, but must include some reference to the individual’s scope for action: the various constraints and opportunities that are available in different societies and to different groups, for example, with reference to factors such as socio-economic security, social cohesion, social inclusion and social empowerment (Walker and van der Maesen 2004). Hence, a consideration of the over-arching and framing macro-conditions, should also become an accepted practice in research on QoL in old age (Heyl et al. 2005).

Thirdly, predictors of QoL in old age often differ amongst groups of older people. The most common empirical associations with QoL and well-being in old age are 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 socio-economic status (Bengtson et al. 1996; Tesch-Römer et al. 2001, Gabriel and Bowling 2004a,b). Comparative European research also points to different priority orders amongst older people in different countries, for example, a greater emphasis on the family in the south compared to the north (Walker 1993; Polverini and Lamura 2005). Another example of variations within Europe is the greater impact of objective living conditions on subjective QoL in former socialist countries, like East Germany and Hungary, compared to the more developed and affluent countries of Europe (Mollenkopf et al. 2004).

Fourthly, while there are common associations with QoL and well-being, it is clear that subjective self-assessments of psychological well-being and health are more powerful than objective economic or socio-demographic factors in explaining variations in QoL ratings (Bowling and Windsor 2001; Brown et al. 2004).

Prioritising future research on quality of life old age

Based on the above review and the data presented in the articles in this special issue, we should consider what more we need to know and do with regard to QoL in old age. There are many open research questions. For example, why are levels of satisfaction and well-being in general high amongst older people? Which role does age and ageing play for different sub-groups of older people (young–old versus old–old to their subjective QoL? What really matters in very old age or in the case of chronic illness and the need for care? What exactly is the role of social and familial network resources in relation to QoL in late life? What is the significance of the residential context amongst both older people who live on their own and those who live dependently in a residential institution? Which physical and social conditions are suited to support the person’s QoL? What is the interrelationship between the two? Whilst empirical research indicates that care has a role in the production of QoL for frail older people, the issues are when, how and under what conditions? And, on a more general level: which personal resources and which environmental and social conditions are contextually most or least important for QoL? More research is needed to determine the strength and contextual salience of each of the variables using a clearly defined QoL model.

Further knowledge gaps concern cohort-related aspects, for instance: what is the frame of reference of today’s older people’s evaluations of their lives, and with whom and at what times will future generations compare their situation in the family, in work and in the larger social milieu? What will QoL be for future cohorts of older people in the light of demographic change and structural uncertainty, precarious jobs, long-term unemployment, cuts in pension levels and reduced welfare provision? Will they be able to cope or compensate for changing environments and resources?

We have also to consider both theoretical and methodological shortcomings. On the theoretical level, it is striking how little research and conceptual thinking is shared amongst European gerontologists studying QoL. There is a general agreement that a basic definition and comprehensive model of QoL are urgently needed. Such a model should incorporate different perspectives (individual, societal, social policy) and conceptualisations and enable research on the societal level as well as on the individual level. For that very reason, the basic dimensions included in a model of QoL should reflect science, social policy and the views of older people. Furthermore, theoretical work is needed to clarify and give reasons for methodological key concepts and operationalisations, indicators and scales. In particular, the implicit theories held by older people concerning the quality of their lives must be incorporated into a basic definition of QoL. Such theory development needs to be undertaken by disciplines working in collaboration. Also, there is an urgent need for comparable approaches and measures to be adopted if the full potential of past, ongoing and future research is to be realised. Such a harmonisation may consist of both the post-harmonisation of existing data and pre-harmonisation aimed at developing comparable instruments. Further, there is a need for coordinated, longitudinal and repeated cross-sectional studies on the dynamics of QoL. Such research is required urgently to assess and distinguish cohort effects, effects of ageing and the impact of changing values and expectations in QoL. Most existing national longitudinal studies concern one historic cohort in which ageing-related changes in QoL are studied (an exception is LASA in The Netherlands (Hoogendijk et al. 2008), which adds new cohorts at specific time intervals). But, given generational and social changes, a cohort-sequential design is necessary to distinguish these from those changes associated with ageing. In view of the unique spread of nations and cultures in Europe as well as around the globe, it is vital that definitions and methods are cross-cultural and dynamic. Finally, more attention should be given to the heterogeneity of ageing and the aged.

The questions raised here correspond with the research gaps and priorities, which emerged in two European Framework Programme projects that focus specifically on QoL in old age: the FORUM on Population Ageing Research and the European Research Area in Ageing, ERA-AGE. The FORUM project (2002–2004) conducted a series of scientific workshops on three topics, one of which was QoL, aimed at identifying knowledge gaps and prioritising research from a European-wide perspective. The outcomes of the FORUM process command a high level of consensus amongst both scientists and key research end-user groups. The ERA-AGE project (2004–2009) was designed to promote long-term coordination of national research programmes and to promote interdisciplinary research and international collaboration in the field of ageing across Europe. A wide range of recommendations were made by the FORUM project and ERA-AGE spanning bio-medicine, health and social care as well as QoL. In the latter field, the key research priorities covered: environmental resources, socio-demographic and economic resources, health resources, personal resources, social participation and support networks (the full set of recommendations intended for national and European research funders and policy makers can be viewed on the FORUM and ERA-AGE websites (http://www.shef.ac.uk/ageingresearch and http://era-age.group.shef.ac.uk/). In ERA-AGE 2 (2009–2012), a major research programme on QoL in old age is hoped to be mounted.