Assessing the level of quality of life as a determinant of mental health in South Africa.

We all use the term "quality of life" often. One needs to ask what the term actually mean. In answering this question one also has to look at how the term ties in with constructivism, and distinguish between individual and societal quality of life. Different contexts of existence should be taken into account in the assessment of the quality of life. The nature of a definite and close relationship between quality of life and mental health will be determined as well as the importance of a holistic perspective in assessing quality of life. This will be done by using the Meta-approach of Jordaan and Jordaan adapted by Kirsten (1994:18-116). The results of this assessment could provide a point of departure for the promotion of quality of life.

2.1 What is meant by quality of life?

The term "quality of life" is frequently used in everyday life, without a clear definition of its meaning as is suggested also by what Aristotle had to say; although he was referring to happiness. Quality of life and happiness as will be pointed out later are not concepts removed from one another. Smedly (1979:5) remarked almost two decades ago that:

"Quality of life is a concept which is intuitively easy to grasp but theoretically almost impossible to define".

Möller, Schlemmer and Du Toit (1987:13) refer to quality of life as a situation where the needs of the individuals get satisfied and where they experience a general feeling of contentment. Initially, Van Wyk (1993:33) points out, a man’s competency to maintain himself economically was used as an objective yardstick to determine quality of life. Such a materialistic yardstick however, provides a false image of a person's well-being, because it only gives an indication of a persons quantity of life. As a consequence a general change of focus took place in as much as a subjective experience of the way of living, especially with regard to selfactualization, became more eminent. McDowell and Newell (Thomas in Watkins, Hervey, Carson & Ritter, 1996:315) reflects similar sentiments:

"… there has been a clear evolution in definitions of quality of life, from viewing it in material terms of income, career success and possessions, toward emphasising spiritual rewards such as satisfaction, personal development and subjective well-being".

Traynor (1992:37) continues in the same vain in grappling with the definition of quality of life, and is of the opinion that intrinsically most people will have an intuitive understanding of what quality of life means to them personally at any given moment in time. It is a fairly nebulous, abstract, subjective and multi-faceted concept which is difficult (if not impossible) to describe in the definitive and the parameters which apply to one person are not absolutely transferable from one individual to the next. These parameters may not even be transferable from one day to the next in the same individual. These ideas serve as a reflective synopsis of the mainstream thoughts on quality of life.

Traynor (1993:37)comes to the rightful conclusion in so far as :

"What is clear from reading the literature is that definitions are as subjective as the feeling which constitute quality of life but most authors relate it as somewhat synonymous with a general concept of happiness and fulfilment" (see Aristotle’s remark).

2.2 Quality of life and constructivism

In determining the essence of quality of life it seems as if one needs to move away from the traditional positivistic scientific method to try and establish the "truth" about what quality of life is. Because the underlying assumption of this method is that knowledge or the "truth" is out there somewhere. All that needs to be done is to discover it to prove it (Donald, Lazarus & Lolwana, 1997:40). A constructivist view on the other hand, is based on the fundamental assumption that people create knowledge (or meanings) from the interaction between their existing knowledge or beliefs and the new ideas or situations they encounter. Knowledge or meanings which are constructed by individuals and whole societies are closely tied to social, historical and cultural contexts. Therefor taking a social constructivist perspective concerning quality of life, one can say that because individual social and cultural contexts differ, the meanings (in this instance of quality of life) people make may be unique to themselves or their cultures, potentially resulting in as many meanings as there are meaning makers (Airasian & Walsh, 1997:445) of what constitutes quality of life. Two different people or two different families having basically the same "objectve" means to live by will in all possibility judge their quality of life differently

This leave us with two important conclusions, namely that different contexts as well as the interaction between them are important in the creation of meaning (of what constitutes quality of life); and that this meaning is not only created by individuals, but also by societies. In other words quality of life could be referring to an individual as well as a collective state. These two conclusions will be dealt with next.

2.3 Individual and societal quality of life

Lauer (1989:6) makes a distinction between personal and social problems. He defines a personal problem as one whose causes and solutions lie within the individual and in the individual’s immediate environment. A social problem on the other hand, is one whose causes and solutions lie outside the individual and the immediate environment. The distinction is not based on the individual’s suffering, because a certain amount of suffering may occur in either case.

It could be illustrated as follows: If one individual in a city is unemployed, that individual has personal trouble. This person may be lazy, have personality problems, lack skills, have family difficulties that consume all of his or her energy. If however, there are 100 million jobs in a society and a 150 million people are looking for work, we confront a social issue. Even if there are no personal problems, a third of the people will be unemployed. Such a problem cannot be resolved by dealing with individual personalities or motivations. In reality more often than not the situation is not as simple, it is far more complicated and could be a mixture of personal and social problems.

Much in the same way one would also be able to distinguish between individual quality of life (instead of personal problems) and societal quality of life (instead of social problems). This will mean that the level of quality of life enjoyed could be determined and experienced by the individual on the one hand or determined and experienced by the society at large. In reality there could also be more often than not a mixture of the two.

2.4 Different contexts for the creation of meaning as determinants of the experience of quality of life.

Different writers often use different terms for reference to the contexts of life as determinants of the experience of quality of life, for example domains of quality of life, things that influence quality of life and aspects of life

Möler et al (1987:56-57) distinguishes two domains of quality of life found in a study in South Africa:

A general domain - reflecting mans spiritual wellness

A specific domain - including mans experience of his career, material aids, social integration in the group, relationship with people in the community, intimate relationships, nutrition taken in and so fourth.

According to Lauer (1989:30) there are considerable agreement about things that influence the quality of life and the kinds of things that Americans define as important to the quality of their lives. They desire the following:

When a contradiction is incompatible with such conditions, in other words when people are exploited or unjustly restricted in opportunities, subjected to unnecessary stress, or treated with ridicule, the quality of their lives will be diminished.

Traynor (1993:37-38) is of the opinion that:

"It is evident then that the definitions of what constitute quality of live focus on a myriad of aspects of live - social, economic, health, religious, physical, emotional and interpersonal. What is equally clear is that individuals will attribute subjective weighting to each of these aspects depending on personal circumstances at any particular point in time".

Form these ideas it is possible to conclude that there are a number of contexts that have been identified that would have an important bearing as far as the influence on quality of live is concerned. The question can however be rightfully asked if one doesn’t need a holistic perspective on contexts that might influence quality of life, in order to take full stock of influences that might impinge or enhance experienced personal or societal quality of live. This might be done by using Jordaan & Jordaan’s (1990:35-62) Meta-approach. This approach will be explained later.

2.5 Assessment of quality of life.

Due to the fact that it is virtually impossible to give an authoritative definition of quality of life, as well as the multi-faceted nature of the concept of quality of life, as was described earlier, assessment of quality of life in the singular sense borders onto the impossible. If one however look at all the different contexts of human existence in a holistic sense, one will be able to use different tools such as questionnaires, scales, profiles and psychometric tests to measure certain specific factors that influence quality of life, for instance anxiety, depression, family relationships, health status, socio-economic status, personal history, income, literacy, etc. Caution should however be taken when using standardised psychometric tests, because not all of these tests can be used due to the fact that they have not been standardised on all of the different cultural groups in South Africa.

It is of fundamental importance to note that "measurement" referred to in the previous paragraph is more of a calibrated effort to obtain objective information on the level of quality of life. In this sense Thomas (in Watkins et al, 1996:315) refers to two main categories for the measuring of quality of life. The first is an indirect category which focuses in whole or in part on activities of daily living, or indicators of quality of life (like the examples given in the previous paragraph). The second approach to the measure of quality of life uses instruments specifically developed for this purpose. Examples given is a "quality of life index for patients with cancer", the "satisfaction with life index scale" and a "quality of life interview"

A different method is that of assessment which does not necessarily exclude the tools for measurement already referred to. Assessment is far broader in focus and include also an interpretation of all the relevant facts. To illustrate this one could think of the case of cancer patients who are not only evaluated by medical professionals on so-called "objective" criteria concerning their condition, and thereby experiencing an imposed external value system, but their values and preferences as patients should also be taken into account. Assessment should preferably be used, instead of only measurement.

Due to the relative culture-friendliness of assessment the said Meta-approach of Jordaan and Jordaan (1990:35-62) could serve as a workable model for assessing the level of quality of health. By using this approach one could look holistically at all the contexts - or indeed the relevant ones - of human existence, and in using the techniques of analysis and synthesis come to an understanding of the dynamics which determines personal or societal quality of life (Kirsten 1994:18-116). In doing so one can try to evade trying to explain quality of life in a positivistic sense. The important distinction made here is understanding in the hermeneutical sense versus explaining. The hermeneutical method of Dilthey (Jordaan & Jordaan, 1990:Preface; 48) holds that understanding embrace an element of communication; of identification and sympathy with the object of study (for instance another human being). In other words we are talking about a dialogue between the person doing the assessment of quality of life and the person or society being assessed - as reflected in Dilthey’s well-known dictum: "Understanding is the finding back of you in me". One could describe this approach as an "empathic approach."

Palmer (1982:105) gave the following interpretation:

"The key word for human studies, Dilthey believed, was understanding. Explaining is for the sciences, but the approach to phenomena which unites the inner and outer is understanding. The sciences explain nature, the human studies understand the expressions of life… and must attempt to formulate a methodology of understanding that will return to the fullness of life, of human experience".

Before describing the meta-approach, it would be nessassary to clarifiy the concept of mental health and where it ties in with quality of life.

What is meant by mental health?

Although mental health could be viewed as follows: "In common usage the term mental health often mean psychological well-being and mental illness"(Schwartz & Schwartz, quoted by Callicutt & Lecca, 1983:5), the focus in this paper is a positive one. Mental health viewed on a continuum is not equal to zero, but on average more than zero over time (Kirsten, 1994:131). Any thing less will mean a stale no-growth situation, or mental illness. Mental health as a positive term needs to echo the same sentiments as Schlebush (1987:111) in the context of health psychology:

"If health is defined in negative terms i.e. simply as the absence of disease, treatment of the diseased patient becomes the primary objective. Should it, however, be defined in positive terms, i.e., as an individual’s biopsychosocial functioning, a more comprehensive programme of healthcare delivery with emphasis on promotion and maintenance of health becomes obvious. The health professional’s approach, therefore can be one of sick care or one of health care". This positive stance is also a meaningful in terms of quality of life. Referring to quality of life in other than positive terms, would in essence not be quality of life any more, but the lack of it. The following views also express the positive meaning given to the concept of mental health.

Van der Westhuizen (Translated, 1989:159) designate mental health as the full and harmonious functioning of the total personality. It also refers to an active daily life of quality, being even tempered, alert, considerate and with a happy mood. He is also of the opinion that mental health indicates good adaptation and integration into the environment and goes along with a feeling of contentment, happiness and a zest for life. It also indicates the absence of psychopathology.

The erstwhile Psychological Society of South Africa (Phasa, 1989:5) gave the following definition of mental health:

"Mental health refers to those conditions in a society leading to a situation where people in their individual capacities (irrespective of age gender or colour), and in interaction with one another as members of groups and communities are able to live lives of quality in all contexts of their existence, and where the options for actualising their potential are present".

It is evident from these descriptions of mental health that the concept of "a life of quality" features in both, and that the concepts of mental health and quality of life are inextricably linked if the views on both are compared. It seems as if neither of the two can exist without the other, because we find significant commonalties between them, for instance: contentment and happiness, the importance of the environment and needs being met.

The relatedness of mental health and quality of life will therefor mean that the assessment of the level of one will give a fair indication of the other. A lower or higher level of quality of life will similarly impact on mental health.

A holistic perspective in assessing the level of quality of life.

It was pointed out earlier that different authors indicated various contexts of existence for the creation of meaning as determinants of the experience of quality of life. Some of the contexts they cited were the same, some were different. In order to form a comprehensive idea of all the contexts that could possibly influence the level of quality of life, one needs to use a holistic view, a model that includes all contexts of human existence. Jordaan and Jordaan (1990:35-62) provides such a holistic model in the form of what they call a Meta-approach.

4.1 Using the Meta-approach for assessing the level of quality of life.

The point of departure used in this approach is that all human experience, behaviour, problems and phenomena can be studied and understood by the analysis and synthesis of all contexts and subcontexts of human existence. These contexts form together a system of totality, where the concept of a system are being understood as an open hierarchical organisation which functions in an interdependent way. The four contexts of human existence are:

The biological context

The intra-psychic context

The ecological context

The meta-physical context.

Due to the hierarchical organisation of these contexts they could be divided into numerous subcontexts (see figure 1).

"Those who know how close the connection is between the state of min of man - his courage and hope, or lack of them - and the state of immunity of his body will understand that sudden loss of hope and courage can have a deadly effect" (Frankl, 1988:75).

This insight of Victor Frankl who survived Nazi concentration camps reflect upon the inseparable relationship between mind and body. Although one might distinguish a biological as well as a intra-psyhic context, they are never separable. These two contexts form a unit the basic "building blocks" of a human being, because man is a psycho-biological unit. Bootzin and Acocella (1984:187) describes this unity very eloquently in the following way:

Logically it would seem that mind and body are essentially the same thing or, at most, two aspects of the same thing. "Mind", after all, is simply an abstract term for the workings of the brain. And the brain is not only part of the body but is directly connected by nerves to all other parts of the body. Therefore whatever is going on "mentally" inside a person is also going on physically, and vice versa. Yet the fact remains that most of the time we are completely unaware of the activity going on in our brains. All we are conscious of are the effects of that activity - effects that we think of as "mental" not physical. This is undoubtedly one reason why we tend to regard the mind as something apart from the body".

The ecological and meta-physical contexts can be grouped together as the world-out-there. These two contexts include literally everything that is not part of man’s psyhcobiological unit. The list provided in figure 1 is by no means a reflection of all the content of the world-out-there.

Kirsten (1994:18-116) provides an explanation of the four contexts of human existence in the following sections.

4.2.1 The biological context.

The importance of the biological context starts at conception and ends with death. It is therefor important to keep all of the determinants in mind throughout life. Physical development, consisting firstly out of physiological development (which has to do with the changes in the internal structure and functioning of organs) and secondly, physical outward development is standing in the centre of the biological context. Damage and dysfunction cause by illness, trauma or default as well. All these factors are direct determinants of quality of life.

4.2.2 The intra-psychic context.

All of the different but integrated aspects of the intra-psychic contexts constitute the inner world of a person, his/her intimate world of experience. This context provides the necessary structure for the differentiation and integration of a persons experiences, behaviour, problems and phenomena. The intra-psychic context embrace a persons ability: of consciousness of him/herself as a person; to perceive, think, learn, remember, to have feelings, needs and desires and plans to fulfil them and to form a self-image related to specific behaviours and patterns of behaviour.

4.2.3 The ecological context.

This context consists of the interdependent relationship between a person and the living environment (people, animals, plants), and lifeless environment (natural, geographic, climatetological, and man-made). The ecological context includes in other words everything in the physical environment.

4.2.4 The meta-physical context.

Contents out of this context refer to everything that lays outside that, that could be perceived by the senses. These are things that cannot be proven, yet cannot be disproven. It has got to do with answering great questions like: What is the origins of all things? This question and its variants has got to do with the answering of a universal meta-physical hankering by way of giving answers through: philosophical, religious, cultural, aesthetical and unformalised manifestations.

One’s own scientific perspective, whether you are an educationist, psychologist, biologist, neurologist, architect, town planner, philosopher, artist, religious leader - or whatever can contribute to the understanding of personal or societal experience of quality of life. The reason for this is that all sciences form border sciences which could partake in inter- and intra-disciplinary co-operation to form a multidisciplinary body of knowledge. This knowledge could be used for the understanding of the influence of different contexts, in the creation of meaning, and therefor as determinants of the experience of quality of life.

The hierarchical composition of contexts provides a perspective on the developing persons (his/her/their biological and intra-psychic contexts) and his/her/their relationship with the world-out-there (ecological and meta-physical contexts). Due to this inter- and intra-action between different contexts and their subcontexts personal or societal experiences are formed concerning the experienced level of quality of life. This could result in overt or covert forms of behaviour, problems or phenomena indicative of the experience.

This will mean that in order for us to understand human experience, behaviour, problems and phenomena, in this instance about quality of life, and more specifically the assessment of the level of quality of life and ultimately also mental health, one has to start with the process of analysis of all the contexts of human existence, That could be an analysis in a personal or a societal sense. One should make use of interdisciplinary insights as far as possible.

After a proper analysis has been done, one needs to proceed with the process of synthesis. In carrying out this process one needs to put the contexts "back together again" but in a logical and understandable way so that the inter- and intra-activeness of all the contexts and subcontexts are reflected in the answer.

5. The assessment of the quality of life as a point of departure for the promotion of quality of life and mental health.

Lombaard (1992:206)is of the opinion that the quality of life of a community cannot be improved for its people (the same could be said for individuals). In this sense Smedely (in Lategan, 1982:14) comes to a significant conclusion about the meaning of quality of life: "The message is, therefore, clear: let us stop trying to improve the quality of life of others and start to facilitate the attempts of others to help themselves".

By using the Meta-approach with the said methods of assessment one could be in a better position to facilitate and empower people to enhance personal or societal quality of life in their own desired way, because one understands their position, and not out of a paternalistic orientation. Aid in the promotion of quality of life and mental health should be a function of a top-down as well as a bottom-up effort directed at any one or more of the contexts of existence. Specific ways and strategies in going about in dealing with the promotion of quality of life and mental health however, forms the scope of another paper.

6. Conclusion.

Quality of life and mental health are indeed closely tied together. Although quality of life is an illusive term, each and every person or society would be able to say what they see as important to them - different persons and societies are unique. Therefor one has to accommodate different persons and society’s subjective perceptions and circumstances in determining and understanding what quality of life mean. Measurement alone cannot be used to determine the level of quality of life, assessment is of paramount importance to determine that. In order to truly do an understanding assessment of the level of quality of life, one has to make use of the processes of analysis and synthesis of all the contexts of human existence. Proper and thourough assessment would ultimately provide the groundwork needed for the promotion of the level of quality of life as well as mental health.

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