**3. Specific questionnaires: focusing on the difference between the quality of life concept and the health concept**

Often, as before said, the concept of quality of life is confused with the concept of health, but this is wrong because the term health is not enough to explain the quality of life. For example, some individuals can live with a poor functional status or a poor health status but they express a high quality of life, or vice versa; moreover, quality of life cannot also be equated simply with the terms "lifestyle," "life satisfaction," "mental state," or "well-being." As anticipated in the last decades, several scientific studies have tried to define this construct better, outlining the most appropriate areas and tools for the investigations and the observation of this concept; in fact during the past years two classes of complementary health status measures have emerged: objective measures of functional health status and subjective measures of health and well-being. These measures are multilevel and multidimensional, and there are many published quality of life measures. A really important measurement scale is the World Health Organization's Quality of Life scale; this questionnaire measures this specific area by examining the answers that the subject can provide on a Likert scale (from 1 to 5). This questionnaire exists in two versions:


These scales can also be used to assess variation in quality of life across different cultures or to compare different subgroups. The WHOQOL-Brief is a 26-item version, which summarizes the WHOQOL-100 (i.e, the 100-item version, which is longer); both these questionnaires are useful in clinical settings, medical practices, audits, policy-making, and in the assessment of the effectiveness of different treatments. The brief version of WHOQOL can also be used in a variety of different cultural settings, it is easily administered and does not impose a huge burden on the respondent. The answers are always given on a Likert scale (from 1 to 5); the questions that are addressed in the short version of the test are presented in **Box 1**.

The creation of this questionnaire involved a collaborative approach to international instrument development [16], the aim being to develop a questionnaire that could be individually filled in a collaborative way and in several settings. In order to achieve these results, several culturally different centers were involved in operationalizing the scale's questions about the quality of life, and also in question writing, question selection, and pilot testing. Thanks to this approach, standardization and equivalence between different settings were guaranteed. Many centers in different geographic areas were selected in order to include differences in the levels of industrialization, types of health services, and other elements that were relevant

**7**

**Box 1.**

*WHOQOL-26 items.*

*Quality of Life and Biopsychosocial Paradigm: A Narrative Review of the Concept and Specific…*

to the measurement of quality of life (e.g., the perception of self, the perception of the dominant religion, and the specific role assigned to the family in a cultural context). This method ensured a real internationality of the collaboration.

3. To what extent do you feel that physical pain prevents you from doing what you need to do?

4. How much do you need any medical treatment to function in your daily life?

13. How available to you is the information that you need in your day-to-day life?

17. How satisfied are you with your ability to perform your daily living activities?

14. To what extent do you have the opportunity for leisure activities?

*DOI: http://dx.doi.org/10.5772/intechopen.91877*

1. How would you rate your quality of life?

2. How satisfied are you with your health?

6. To what extent do you feel your life to be meaningful?

5. How much do you enjoy life?

7. How well are you able to concentrate?

8. How safe do you feel in your daily life?

9. How healthy is your physical environment?

10. Do you have enough energy for everyday life?

11. Are you able to accept your bodily appearance?

12. Have you enough money to meet your needs?

15. How well are you able to get around?

16. How satisfied are you with your sleep?

19. How satisfied are you with yourself?

21. How satisfied are you with your sex life?

25. How satisfied are you with your transport?

18. How satisfied are you with your capacity for work?

20. How satisfied are you with your personal relationships?

22. How satisfied are you with the support you get from your friends?

26. How often do you have negative feelings such as blue mood, despair, anxiety, depression?

23. How satisfied are you with the conditions of your living place?

24. How satisfied are you with your access to health services?

## *Quality of Life and Biopsychosocial Paradigm: A Narrative Review of the Concept and Specific… DOI: http://dx.doi.org/10.5772/intechopen.91877*

to the measurement of quality of life (e.g., the perception of self, the perception of the dominant religion, and the specific role assigned to the family in a cultural context). This method ensured a real internationality of the collaboration.


*Quality of Life - Biopsychosocial Perspectives*

the common language.

aspects regarding the lines of intervention consistent with their own expectations. Therefore, not only quantitative methods like indicators and surveys, but also qualitative surveys and dynamic surveys, such as participatory research-process methods, are useful for the purposes of these surveys. These methodologies are often indicated as the first fundamental step when carrying out interventions in a city or territory [15]. Today the social aspect of quality of life is increasingly present, so the concept of quality of life now is often strictly related to the terms "livable" and "livability," referring to the more or less desirable economic and social environment of a town, a metropolis, or a country: nowadays, these terms have become part of

**3. Specific questionnaires: focusing on the difference between the** 

a Likert scale (from 1 to 5). This questionnaire exists in two versions:

• the World Health Organization's Quality of Life scale-100 (WHOQOL-100);

• the World Health Organization's Quality of Life scale Brief (WHOQOL-Brief).

These scales can also be used to assess variation in quality of life across different cultures or to compare different subgroups. The WHOQOL-Brief is a 26-item version, which summarizes the WHOQOL-100 (i.e, the 100-item version, which is longer); both these questionnaires are useful in clinical settings, medical practices, audits, policy-making, and in the assessment of the effectiveness of different treatments. The brief version of WHOQOL can also be used in a variety of different cultural settings, it is easily administered and does not impose a huge burden on the respondent. The answers are always given on a Likert scale (from 1 to 5); the questions that are addressed in the short version of the test are presented in **Box 1**. The creation of this questionnaire involved a collaborative approach to international instrument development [16], the aim being to develop a questionnaire that could be individually filled in a collaborative way and in several settings. In order to achieve these results, several culturally different centers were involved in operationalizing the scale's questions about the quality of life, and also in question writing, question selection, and pilot testing. Thanks to this approach, standardization and equivalence between different settings were guaranteed. Many centers in different geographic areas were selected in order to include differences in the levels of industrialization, types of health services, and other elements that were relevant

Often, as before said, the concept of quality of life is confused with the concept of health, but this is wrong because the term health is not enough to explain the quality of life. For example, some individuals can live with a poor functional status or a poor health status but they express a high quality of life, or vice versa; moreover, quality of life cannot also be equated simply with the terms "lifestyle," "life satisfaction," "mental state," or "well-being." As anticipated in the last decades, several scientific studies have tried to define this construct better, outlining the most appropriate areas and tools for the investigations and the observation of this concept; in fact during the past years two classes of complementary health status measures have emerged: objective measures of functional health status and subjective measures of health and well-being. These measures are multilevel and multidimensional, and there are many published quality of life measures. A really important measurement scale is the World Health Organization's Quality of Life scale; this questionnaire measures this specific area by examining the answers that the subject can provide on

**quality of life concept and the health concept**

**6**


To summarize, quality of life questionnaires should include different domains:


It is also important to mention that with regard to the measurement of quality of life in illness situations, there are specific questionnaires [17] such as the WHOQOL for people with HIV or diabetes.

In summary, we can state that it is important to note that the definition of quality of life always includes a reference to the physical state of the subject, but is no longer considered only on the basis of the quality of the functionality of a person, detectable with standardized parameters, since they are described in relation to the degree of satisfaction perceived with respect to this level of functionality: this definition shifts the emphasis from the scope of objectively definable functionality to that of subjectivity; the detection of both these two aspects can probably constitute a reliable measure of the quality of life [1]. Finally, we can affirm that within the sphere of objectivity, disease is understood as a defined clinical framework and the different areas of functionality: physical, psychological, social, and work. In the context of subjectivity, the perception of disease and patient satisfaction are placed in the various areas of life, in which it is conceivable that the state of health may influence. Concluding, we can detect that the most common method of measuring quality of life is the administration of questionnaires, and that there are two families of questionnaires: generic and specific for pathology [1].

### **4. A new perspective: well-being as a promotion of quality of life**

Health care professionals are increasingly recognizing that measurements only focused on disease outcomes are an insufficient determinant of health status. Accordingly, nowadays the focus has shifted from the idea of physical/psychological well-being as the elimination of a problem or a disease to a conceptualization of well-being as a promotion of quality of life. This shift of perspective has radically changed not only our concept of health and disease, but also that of the human being, of his/her life process and crises [18]. For a long time, the conditions of well-being have been defined on the basis of normative models that have produced health models consistent with the biomedical model, which was very reductive. Only in relatively recent times, and certainly thanks to the contribution of health psychology, we have begun to implement a new approach that claims the specificity of a discipline connected to the singularity and uniqueness of the subject. This uniqueness, to be grasped, also requires openness to a complex thought, capable of overcoming the reductionist perspective and the dichotomies [18]. Today we accept that to understand a phenomenon we have to take into account the context, the

**9**

*Quality of Life and Biopsychosocial Paradigm: A Narrative Review of the Concept and Specific…*

individual perspective and perception of the person that is involved in this context, and the multiple dimensions that contribute to the generation and understanding of the reality that we are studying. All these cognitive shifts have a particularly important impact on care systems and on devices that are designed to intervene in critical situations, which are also the result of the culture and context that can produce them, and consistent with the social representations of illness, health, quality of life, and with the scientific theories that are built on those representations. Today we agree on the need to abandon the medicalist logic of "restitutio ad integrum" adopting a new mentality that redirects our approach to reality [18]: also the concept of quality of life is therefore now detached from the biomedical model, which has been surpassed also thanks to the biopsychosocial model that we will analyze in

The biopsychosocial paradigm characterizes health psychology [19] and the specific areas regarding quality of life that are analyzed in depth by this discipline. The perspective of the biopsychosocial paradigm was introduced by George Engel who coined the term "Biopsychosocial Approach" as a privileged modality both to decode and understand the processes of health and disease throughout the existential path, and to articulate forms of care [20, 21]. The biopsychosocial model is inspired by the paradigm of complexity, in sharp contrast to biomedical reductionism, as well as to the hierarchization of sciences. It adopts the perspective of the general theory of systems developed by Von Bertalanffy [22], which considers a set of interrelated events as a system that manifests specific functions and properties according to the level to which it is placed compared to a wider system. In fact, this systems theory states that all levels of the organization are connected to each other, so that the change of one affects the change of the other; for example, a biological change affects the psychological level and social level and vice versa [20, 21]. The biopsychosocial model refers to three basic principles: dialogue-connection, relationship, and humility. This paradigm considers the person as a "whole": as a genetic heir, a subject of reflection and decision, as well as a historical-cultural and family subject. The axioms of this model are inclusive (focused on the understanding of diversity) and not exclusive, the perspectives of this approach are conceived as global, always considering biological, psychological, and social facets together [19]. Today we therefore refer to the biopsychosocial model whose fundamental assumption is that every condition of health or disease is a consequence of the interaction between biological, psychological, and social factors and we therefore move beyond the old dualism that separated the body from the mind; it is therefore an attempt to see people in their entirety. It is based on the key concept that the person represents a biological unit made of both body and mind, that is, not only of a biological body but also of psychic and emotional factors, which play a decisive role not only in balancing the life of the individual but also in the genesis and development of organic diseases. Health can therefore be understood as the product of the interaction between a physical-mental-social unit. As a matter of fact anyone who wants to sufficiently understand another person cannot simply observe the individual aspects, which, although important, do not allow to understand his/her overall situation, but must approach him/her on the contrary by seizing his/her entirety and his/ her complexity. The centrality of this model has been confirmed and validated by scientific literature. This model marked the shift from a traditional medical model centered only on the body (and on illness as a purely biological event) to a medicine centered on the person [20, 21]. Today there is the awareness that a biopsychosocial

*DOI: http://dx.doi.org/10.5772/intechopen.91877*

**5. The biopsychosocial paradigm**

the next paragraph.

*Quality of Life and Biopsychosocial Paradigm: A Narrative Review of the Concept and Specific… DOI: http://dx.doi.org/10.5772/intechopen.91877*

individual perspective and perception of the person that is involved in this context, and the multiple dimensions that contribute to the generation and understanding of the reality that we are studying. All these cognitive shifts have a particularly important impact on care systems and on devices that are designed to intervene in critical situations, which are also the result of the culture and context that can produce them, and consistent with the social representations of illness, health, quality of life, and with the scientific theories that are built on those representations. Today we agree on the need to abandon the medicalist logic of "restitutio ad integrum" adopting a new mentality that redirects our approach to reality [18]: also the concept of quality of life is therefore now detached from the biomedical model, which has been surpassed also thanks to the biopsychosocial model that we will analyze in the next paragraph.
