A process-based approach to health-related quality of life as a “way of living”

Introduction
There is an historical initiative to establish common theoretical ground to support a framework for assessing health-related quality of life (HRQL). Our aim was to add to this effort with an analysis of theoretical/philosophical themes embedded in HRQL questionnaires and patient reports.

Methods and Results
We reviewed recent developments in HRQL assessment. This included analyzing a representative sample of psychometric measures of HRQL to schematically summarize core theoretical/philosophical themes that are embedded in questionnaire items. This analysis indicated a state-based framework for HRQL that was characterized by themes of hedonic and eudaimonic well-being, and desire-satisfaction. In contrast, a review of patient reports of HRQL indicated a process-based framework where goal-directed activities aimed to secure aspirational life goals while striving to accept the reality of declining health. Given this difference in HRQL themes we used a meta-philosophical approach, based on Hadot’s idea of philosophy as a way of living, to identify a process-based theoretical framework for HRQL assessment that addressed patient-reported themes. The Stoic modification of eudaimonic well-being was examined where HRQL and well-being are viewed as a process (vs. state) aimed at transforming the experience of loss or grief in response to adversity through goal-directed activities/exercises (euroia biou, good flow in life). We then introduced a complementary research agenda for HRQL assessment that incorporates self-reported, goal-directed activities that are initiated or maintained to promote HRQL.

Conclusion
A process-based approach to HRQL assessment may increase the spectrum of clinically relevant features that currently comprise operational measures of this patient-reported appraisal.