care-quality-commission-report-recognising-excellence-in-healthsocial-care-8th-july-2011

RESEARCH THESIS IN SUBMISSION FOR THE AWARD OF
DOCTOR OF PHILOSOPHY

TITLE:
WELL-BEING AND OLDER PEOPLE:
A QUALITATIVE INVESTIGATION INTO THE CONCEPT OF WELL-BEING
AS INFORMED BY THE PERSONAL PERSPECTIVES OF OLDER PEOPLE
DRAWN FROM CLINICAL AND NON-CLINICAL POPULATIONS.

AUTHOR:
ANDREW PAPADOPOULOS. BSc (HONS), MSc, C.Psychol.
INSTITUTE OF GERONTOLOGY
KING’S COLLEGE LONDON
UNIVERSITY OF LONDON.
SEPTEMBER 2008

1


TO: JENNY.
MY APPRECIATION FOR A SHARED JOURNEY
AND FOR YOUR SUPPORT, ENCOURAGEMENT AND GUIDANCE
THROUGHOUT,
WITH LOVE

2


ABSTRACT
The term Well-Being is widely used in health and social care. Yet there is todate, no consensual definition of well-being apparent in the literature.
Theoretical formulations of well-being have been grounded within a wide

variety of frameworks, models and perspectives of human existence with
insufficient attention having been given towards the development of a model
or theory of well-being informed by the perspectives and opinions of older
people themselves.
In addition, research clearly shows that ethnicity and mental health have
important contributions to our understanding of well-being, but have rarely
been considered together in well-being research.
Accordingly, the following research sought to investigate whether a concept of
well-being is evident from the personal perspectives of older people drawn
from clinical, non-clinical and ethnic minority populations.
Grounded Theory was identified as the principal method for this investigation
and for reasons of Triangulation, three sources of data were chosen:
i)

An analysis of ten clinical case files involving former patients who had
received psychological treatment for a range of psychological
difficulties.

ii)

A non-clinical population of older people drawn from the Thousand
Elders Project – University of Birmingham.

iii)

A smaller non-clinical population of older people drawn from an
African-Caribbean Community Centre in Birmingham.

Data was analysed using a Grounded Theory approach with respect to the
interview samples with a purely thematic analysis to analyse the data from the

clinical cases.
Results:
Six overarching themes emerged namely: Integrity of Self, Integrity of
Other, Belonging, Agency, Enrichment and Security. Each theme was
considered as reflecting a distinctive property of well-being and each having
three psychological dimensions: Subjective; Behavioural and Contextual.
Each dimension was further divided in terms of reflecting either positive or

3


negative connotation (cc Table 26 p188 “A Proposed Structural Model of
Well-Being”).
A second level of analysis of all codes was undertaken in order to explore
whether operational relationships or meanings existed between codes. This
level of analysis intended to reflect how the structural properties and
dimensions identified might work together in the day-to-day lives of
individuals. Eight Themes or psychological Styles were identified which were
then aligned into four Typological dimensions namely: Self-assured vs.
Insecure, Something vs. Nothing, Giver vs. Martyr, Receiver vs.
Dependant (cc Figure 4 p213 “A proposed operational model of wellbeing”).
It is proposed that the psychological styles Self-assured vs. Insecure and
Something vs. Nothing reflect a single axis of psychological Self (one which
is congruous with several existing psychological models of the self) whilst
Giver vs. Martyr and Receiver vs. Dependant reflect a single axis of
Management of Self (that is, the way in which individuals manage challenges
and threats to one’s core Self in terms of the nature of relationships people
form with each other).
It was concluded that firstly; the models taken together appear to offer a
unique construct and understanding of well-being in terms of the current

literature, but one which aligns itself more with Eco-systemic rather than Biomedical, Eudemonic or Existential perspectives. Secondly; that together, the
models offer a framework for understanding both the structure and
operalisation of well-being in the context of older people. Thirdly that the
models offer a basis for integrating research on Psychological Well-Being and
Quality of Life research in Older People.

4


ACKNOWLEDGEMENTS
I would like to give my sincerest thanks to the following, without whom this
research doctorate could not have been undertaken:
A) Professors Simon Biggs and Anthea Tinker, Institute of Gerontology, King’s
College London; and Dr Jan Oyebode, School of Psychology, University of
Birmingham, for their academic supervision, guidance and support
throughout.
B) Jenny LaFontaine, Consultant Nurse; Dr Sarah Willott, Clinical
Psychologist; Dr Rachel Spector, Clinical Psychologist, Vercella Phillips and
my other colleagues at Birmingham and Solihull Mental Health NHS Trust for
additional academic advice and support with independent script analysis.
C) Teresa Morton, Birmingham and Solihull Mental Health NHS Trust; Valerie
Madill, Age Concern, Kingstanding, Birmingham; Dr Laxman Nayak, Centre
for Applied Gerontology, University of Birmingham; Deska Howe, AfricanCaribbean Resource Centre, West Bromwich, Birmingham, for their help,
support and facilitation in enabling me to contact those older people who
agreed to participate in the research.
D) Professor David De La Horne and Martin Preston, Directors of Psychology,
Birmingham and Solihull Mental Health NHS Trust, for their agreement for me
to have time and support towards the completion of the PhD.
E) To all those older people with whom I have had the privilege and pleasure
to have known and worked with throughout my professional career and to

whom I owe much by way of my knowledge and understanding of late- life
psychology.
F) To my family and friends for their encouragement and support. In particular,
to my Wife Jenny, for her help and tolerance during some very difficult times.
G) Finally, I owe particular gratitude to all those people who gave their
consent and time to participate in the research.

5


SUMMARY
The term Well-Being has been widely used to both inform and determine
health and social policy, care and treatment and the evaluation of intervention
systems as applied to older people. Yet there is to-date, no consensual
definition of well-being apparent in the literature.
It is concluded, from the literature review, that theoretical formulations of wellbeing, have been grounded within a wide variety of theoretical models and
perspectives of human existence with insufficient attention having been given
towards the development of a model or theory of well-being informed by the
perspectives and opinions of older people themselves.
Where well-being indices have been used within the context of outcomeoriented research, such indices have varied widely (e.g. across health,
psychological and existential dimensions) and have often been used
interchangeably with similar indices denoting Quality of Life and Life
Satisfaction.
In addition, research clearly shows that ethnicity and mental health have
important contributions to our understanding of well-being, but have rarely
been considered together in well-being research.
If the term is used both as a basis for informing policy and provision to older
people and as a criteria for evaluating intervention outcomes, there is an
ethical obligation to ensure that the term reflects a valid (evidence-base)
foundation for defining and describing parameters of human existence.

In addition, both the term itself and the way it has been used, has been largely
constructed and informed from the perspectives of professionals and
academics.
There is a methodological imperative, therefore, to investigate whether a
concept of well-being can be identified from the perspectives of older people
themselves. In the absence of any evidence for such a construct then,
arguably, the term remains assumptive.
Accordingly, the following research has sought to investigate whether a
concept of well-being is evident from the personal perspectives of older
people.
Specifically, the research asks:

6


“Do the personal narratives of older people, as reflected in clinical, nonclinical and ethnic minority populations, provide a meaningful
framework for a construct of well-being specific to late life?
Principal Aims of the Research:
•

To critically evaluate the available literature on well-being in relation to
its use, definition and research methodology and to develop a
reasoned methodology for the current research.

•

To explore how older people, drawn from clinical, non-clinical and
ethnic minority populations, construct well-being as derived from an
analysis of the results.

•

To consider how this construction of well-being compares and contrasts
with those in the literature and to develop a theoretical model of wellbeing based upon it.

•

To critically evaluate the methodology, results and theoretical
constructions developed within the current research with a view to
providing reasoned directions for future research and to discuss the
implications for policy and provision in the care of older people.

Methodology:
Given the aims of the research and that it focuses upon the lived experiences
of participants, Grounded Theory was identified as the principal and most
appropriate method for this investigation.
Procedure:
For the purposes of Triangulation, three sources of data were chosen.
The first, involved an analysis of the case notes of ten clinical cases involving
patients with a range of psychological difficulties who had undergone a course
of psychological treatment but who had been discharged prior to the research
(Clinical Sample).

7


The second source of data involved interviewing a non-clinical population of
older people drawn from the Thousand Elders Project – University of
Birmingham (Non-Clinical Sample).
The third source of data, involved interviewing a smaller non-clinical

population of older people drawn from an African-Caribbean Community
Centre in Birmingham (Ethnic Minority Sample).
A series of open questions were developed and formulated as a semistructured interview procedure and piloted with a small sample of older
people.
The data from these pilot interviews were analysed for content and richness of
information. The interview procedure, together with the original questions, was
revised accordingly.
The revised protocol was then used to interview the Non-Clinical and Ethnic
Minority Samples sample. In addition, it was used to inform the analysis of the
Clinical Sample.
Analysis:
Data drawn from the case files (Clinical Sample) was analysed using
Thematic Analysis. This data was secondary and incorporated clinical terms
and procedures within its content. The analysis of each case was used to
inform the analysis of each subsequent case.
Data drawn directly from the interviews (Non-Clinical and Ethnic Minority
Samples) was analysed using a Grounded Theory approach.
Results:
Firstly:
Six overarching themes emerged and were defined in terms of their
relationship with the data, namely: Integrity of Self, Integrity of Other,
Belonging, Agency, Enrichment and Security. (cc Table 26 p188 “A
Proposed Structural Model of Well-Being”)
Each theme was conceptualised as reflecting a distinctive property of WellBeing and as consisting of three psychological dimensions: Subjective;
Behavioural and Contextual. Each dimension was further conceptualised as

8


having either positive or negative connotations according to the way in which

respective codes were aligned.
No specific themes differentiated the three data sources suggesting that the
model is representative of the views of all older people in the sample.
Discriminative characteristics were identified between the clinical and nonclinical samples only at a dimensional level.
Secondly:
A second level of analysis of all codes was undertaken in order to explore
whether additional relationships or meanings existed between codes; i.e.
those reflecting the way in which Well-Being is operationalised or applied in
the day-to-day lives of the research participants.
Eight Themes or Psychological Styles were identified which were then aligned
into four Typological dimensions namely: Self-assured vs. Insecure,
Something vs. Nothing, Giver vs. Martyr, and Receiver vs. Dependant.
Identifying the structural source of codes for each dimension (from Table 26
p188) revealed that Self-assured vs. Insecure and Something vs. Nothing
reflected codes drawn primarily from the property Integrity of Self, whilst Giver
vs. Martyr and Receiver vs. Dependant, were drawn mainly from properties
Integrity of other and Belonging respectively. It is proposed that the
psychological styles Self-assured vs. Insecure and Something vs. Nothing
reflect a single axis of psychological Self (one which is congruous with
several existing psychological models of the self) whilst Giver vs. Martyr and
Receiver vs. Dependant reflect a single axis of Management of Self (that is,
the way in which individuals manage challenges and threats to one’s core
Self in terms of the nature of relationships people form with each other. cc
Figure 4 p213).
Identifying the percentage of codes denoted for each psychological style by
each data set, it can be shown that for the Clinical Sample, the greatest
proportion of codes prioritise Insecure, Nothing, Martyr and Dependant, whilst
for the Ethnic Minority Sample, the greatest proportion of codes prioritise Selfassured, Something, Giver and Receiver. The Non-Clinical Sample codes
prioritised Giver with the others falling between the Clinical and Ethnic
Minority, codes (cc Figure 4a p214). It is proposed that the Ethnic Minority

Sample experience the greatest level of well-being with the Clinical Sample
9


experiencing the least and that well-being within the Ethnic Minority Sample is
mainly drawn from their supportive and affirming relationships with family,
friends and their faith, and the interests they pursue both individually and
within their close community.
Poor well-being as reflected within the Clinical Sample appears related to a
history of difficult relationships and poor self-concept where managing threats
to one’s core self is mediated via relationships that involve either dependency
or martyrdom or a dynamic interplay between the two.
The Non-Clinical Sample appear to comprise individuals who whilst neither
having a strong sense of self nor being ontologically insecure manage their
self by primarily giving to others.
In terms of the principal aims of the study, it was concluded firstly; that the
models taken together appear to offer a unique construct and understanding
of Well-Being in terms of the current literature, but one that aligns itself more
with an Eco-systemic perspective rather than Bio-medical, Eudemonic or
Existential perspectives as described in the literature review. Secondly, that
together, the models offer a framework for understanding both the structure
and operalisation of well-being in the context of older people. Thirdly; that the
models offer a basis for integrating research on Psychological Well-Being and
Quality of Life research in Older People.
The results are discussed in the light of the literature review and regarding
directions for further research.

10

CONTENTS

ABSTRACT

3

ACKNOWLEDGEMENTS

5

SUMMARY

6

LIST of TABLES

13

INTRODUCTION

15

LITERATURE REVIEW

20

SECTION 1) THEORETICAL PERSPECTIVES ON WELL-BEING

23

i) BIO-MEDICAL PERSPECTIVES ON WELL-BEING

23

ii) PSYCHOLOGICAL PERSPECTIVES ON WELL-BEING

26

iii) EUDEMONIC PERSPECTIVES ON WELL-BEING

35

iv) EXISTENTIAL PERSPECTIVES ON WELL-BEING

39

SUMMARY AND REFLECTIONS

45

SECTION 2) FACTORS INFLUENCING THEORETICAL PERSPECTIVES ON WELL-BEING

48

i) WELL-BEING AND QUALITY OF LIFE

48

ii) WELL-BEING AND MENTAL HEALTH

53

iii) WELL-BEING AND ETHNICITY

56

SUMMARY AND REFLECTIONS

62

CONCLUSIONS

64

RATIONALE AND AIMS OF PRESENT STUDY

67

METHODOLOGY

69

•

METHODOLOGICAL APPROACH

69

•

DESIGN

72

•

SOURCES OF DATA

76

•

PROCEDURE:

81

1.

ETHICAL CONSIDERATIONS

2.

PILOT PHASE

81

3.

MAIN STUDY

84

A) Clinical Case Studies

84

B) Non-Clinical Sample

85

81

C) Ethnic Minority Sample

86

4.

PROCEDURE FOR THE ANALYSIS OF DATA SETS

87

5.

SOFTWARE

96

6.

SELF IN ROLE

97

RESULTS AND ANALYSIS

102

•

SUMMARY

103

•

THE CLINICAL SAMPLE

113

•

THE NON-CLINICAL SAMPLE

130

•

THE ETHNIC MINORITY SAMPLE

152

11


•

INTEGRATING THEMES: A STRUCTURAL AND OPERATIONAL MODEL OF WELL-BEING

DISCUSSION

176

216

•

THEORETICAL CONSIDERATIONS

220

•

METHODOLOGICAL CONSIDERATIONS

230

•

THE RESEARCH QUESTION: TOWARDS A THEORY OF WELL-BEING

234

•

FUTURE DIRECTIONS

238

CONCLUSIONS

242

REFERENCES

246

APPENDICES

280

1.

Tables denoting narrative examples

280

2.

Prospective participant information sheet

284

3.

Participant consent forms (I, ii, iii)

389

4.

Clinical Case Description sample

393

5.

Letter of approval: King’s College Research Ethics Committee

398

6.

A personal perspective on the research

399

7.

Kings College Schedule for the assessment of Well-Being (first draft)

405

8.

Well-Being intervention programme (first draft)

411

9.

Data Tables

414

12


LIST of TABLES
TABLE No
1

SAMPLE
CLINICAL SAMPLE

TITLE
Derived Codes vs. Frequency of Occurrence in
Sample

PAGE No

Appendix
414

2

CLINICAL SAMPLE

Convergent codes identified by independent
assessor (A01 to A03) denoted as “Y”

Appendix
416

3

CLINICAL SAMPLE

Description of Codes as Derived from the Case
Summaries

119

4

CLINICAL SAMPLE

Allocation of Meanings against Codes

121

5

CLINICAL SAMPLE

Constructed Themes with Associated Codes

123

6

CLINICAL SAMPLE

Description of Identified Themes with example
narrative segments drawn from associated
Codes for each Theme

Appendix
280

7

CLINICAL SAMPLE

Organisation of Identified Codes with
Associated Narratives Grouped within
Subjective, Behavioural and Contextual
Meanings for Respective Properties:

124

8

NON-CLINICAL SAMPLE

Derived Codes vs. Frequency of Occurrence in
Sample

Appendix
417

8a

NON-CLINICAL SAMPLE

Identified sub-codes for “Contented life”

9

NON-CLINICAL SAMPLE

Convergent codes identified by independent
assessor

Appendix
421
Appendix
422

10

NON-CLINICAL SAMPLE

Number of Scripts(Documents) Containing
Individual Codes

Appendix
424

11

NON-CLINICAL SAMPLE

Appendix
426

12

NON-CLINICAL SAMPLE

Identified Codes from Clinical (Case Study)
Sample Post-Treatment Compared with Codes
from Non-Clinical Sample and Pre-Treatment
Description of Codes as Derived from the
Scripts (documents) quotations

13

NON-CLINICAL SAMPLE

Allocation of Meanings against Code

139

14

NON-CLINICAL SAMPLE

Identified Themes with Associated Codes

143

15

NON-CLINICAL SAMPLE

Description of Identified Themes with example
narrative segments drawn from associated
Codes for each Theme

Appendix
286

16

NON-CLINICAL SAMPLE

Organisation of Identified Codes with
Associated Narratives Grouped within
Subjective, Behavioural and Contextual
Meanings for Respective Properties:

146

17

ETHNIC MINORITY SAMPLE

Derived Codes vs. Frequency in Sample

17a

ETHNIC MINORITY SAMPLE

Identified sub-codes for “Contented life”

18

ETHNIC MINORITY SAMPLE

Convergent codes identified
by independent assessor

Appendix
428
Appendix
431
Appendix
433

19

ETHNIC MINORITY SAMPLE

Number of scripts containing
Individual codes

Appendix
436

20

ETHNIC MINORITY SAMPLE

Description of codes as derived from
associated quotations across all scripts

158

21

ETHNIC MINORITY SAMPLE

Allocation of Meanings against Codes

162

22

ETHNIC MINORITY SAMPLE

Identified Themes with Associated Codes and
Frequency of Occurrence across all Scripts

166

136

13


23

ETHNIC MINORITY SAMPLE

Description of identified Themes with example
narrative segments drawn from associated
codes for each Theme

Appendix
339

24

ETHNIC MINORITY SAMPLE

Organisation of Identified Codes with
Associated Narratives Grouped within
Subjective, Behavioural and Contextual
Meanings for Respective Properties:

170

25

INTEGRATING PERSPECTIVES

Relationship between codes from Clinical
Sample with those from Non-Clinical and
Ethnic-Minority Samples

182

26

INTEGRATING PERSPECTIVES

Organisation of Identified Themes with
Associated Narratives and codes across
Dimensions for Respective Properties:
PROPOSED STRUCTURAL MODEL of WELLBEING

188

27

INTEGRATING PERSPECTIVES

Organisation of Identified Themes with
Associated Narratives across Dimensions for
Respective Properties: PROPOSED

STRUCTURAL MODEL of WELL-BEING

194

28

INTEGRATING PERSPECTIVES

Categorisation of all codes according to
Psychological Type

200

29

INTEGRATING PERSPECTIVES

Psychological Types: Definitions constructed
from supporting codes

206

30

INTEGRATING PERSPECTIVES

Frequency of Occurrence of Codes Located
Within Respective Well-Being Properties

208

31

INTEGRATING PERSPECTIVES

Frequency of codes falling within each
Psychological Type for all data samples

210

32

INTEGRATING PERSPECTIVES

Percentage of Codes Derived from Associated
Data Sets for Psychological Type

212

FIGURES
FIGURE
1
2
3
3a
3b
4
4a

TITLE

DESIGN
TYPOLOGY OF THEMATIC ANALYSIS
PHASES OF THEMATIC ANALYSIS
FLOW CHART OF ANALYSIS
MODEL BUILDING PROCESS
OPERATIONAL MODEL OF WELL-BEING
OPERATIONAL MODEL OF WELL-BEING

PAGE No
75
89
93
110
111
213
214

EXAMPLES DRAWN FROM DATA SAMPLES

14


INTRODUCTION
In the series of Reith Lectures entitled “The end of Age” (BBC Radio 4, May
2001), Professor Thomas Kirkwood highlights a change in thinking amongst
academics surrounding biological ageing. The traditional construction that
biological ageing was a programmed process facilitating eventual death has
been abandoned for the contemporary notion that humans are biologically
programmed for indefinite survival.
He goes on to argue, that this contemporary view of ageing creates new

challenges for both individuals and societies. Firstly, the most notable
challenge concerns both the freedom to make choices and the nature of
choices available in determining our futures. Secondly, the need to draw upon
and integrate wider disciplines in the field of gerontology. Thirdly, to explicitly
re-think our existing conceptions of healthy ageing from the traditional focus
on illness and functional ability alone, to include the broader perspective of
Well-Being where quality of life, life satisfaction and meaningful existence are
essential components.
However, whilst the concept of well-being has attracted a wide range of
disciplines from philosophy (dating back to the early Greeks) to economics, it
nevertheless remains an amorphous concept that lacks any agreed theoretical
framework (Bowling, 2001).
According to Honderich (1995), well-being embodies our ideas about what
constitutes human happiness and the sort of life that it is good to live.
Accordingly, well-being is considered to be both a condition of the good life
and what the good life achieves. However, the notion of a good life can be
further delineated between that which relates to leading a moral life (reflecting
Aristotle’s notion of Eudemonia) and a life in which comfort and enjoyment
reflect a large part (Hedonism).
In the context of psychological research on well-being, Ryan and Deci (2001)
suggest that both Eudemonic and Hedonic approaches account for the
majority of research in this field:

15


A) Hedonic:
Within a Hedonic perspective, well-being consists of subjective happiness,
pleasure and avoidance of pain as experienced within various life domains.
Broadly constructed, a Hedonic approach is concerned with life satisfaction as

measured or considered in emotional terms (Diener and Suh, 2005)
B) Eudemonic:
A Eudemonic perspective considers well-being as a set of potentialities or
ideals that constitute what it means to live a good life from an individual
perspective. These may be identified as hierarchical needs e.g. as denoted in
Maslow’s Theory of Motivation (1970) or as dimensions reflecting:
relatedness, self-perception, engagement, independent action and purpose
e.g. as denoted in Ryff’s multidimensional model of Well-Being (Ryff and
Keyes, 1995) or that of Bright on Wholeness in later life (1997).
In a similar manner to the Hedonic approach, well-being from a Eudemonic
perspective appears to have dimensional qualities but where such dimensions
reflect the extent to which one may have achieved a potential rather than the
degree of emotional valence that is held surrounding a particular life domain.
These perspectives, which may reflect several disciplines, tend primarily to be
characterized by attempts to unify both subjective (experiential) and objective
(behavioural/observed) correlates of people’s lives under one or more
descriptive meta-construct.
However, some authors have argued against the distinction between what is
essentially good and what is enjoyable suggesting that both are necessary
pre-requisites of well-being (Honderich, 1995). According to this view, wellbeing is a concept that spans both the moral and non-moral aspects of life;
reflecting a complex interplay of both. In addition, this view suggests that
given well-being cannot be enjoyed by individuals living in conditions of
poverty and oppression, it follows therefore that well-being has a political
dimension.
Accordingly, the challenge facing health and social policy in the context of
older people is identifying both the conditions of well-being that are
meaningful to older people themselves and the political arrangements and
mechanisms which will facilitate it. The question of the distribution of wellbeing is, according to Honderich (1995), essentially a matter of social justice.
16

In 2004, the Government of the United Kingdom produced a well-being
manifesto (Jackson, 2004). The manifesto itself is grounded within a model of
well-being that consists of two psychological dimensions of well-being and a
contextual dimension of well-being:
1) Life Satisfaction:
Diener et al. (2005) suggests that life satisfaction encompasses a broad
category of phenomena including emotional responses, domain–specific
satisfaction and more global judgments of life satisfaction. The concept of life
satisfaction has been widely used within the literature on well-being both as a
basis for defining well-being (Diener et al. 1999) and as an index of
psychological well-being in itself (e.g. Goff 1993; Chow & Chi 1999; McColl et
al. 1999; Hillerås et al. 2000; Lundgren et al. 2000).
2) Personal development:
The concept of personal development encompasses the components of those
multidimensional models of well-being that are arguably grounded within a
Eudemonic perspective, which considers well-being as a set or
conglomeration of potentialities. As denoted above, these may be identified as
hierarchical needs e.g. as denoted in Maslow’s Theory of Motivation (1970) or
as dimensions reflecting: autonomy, purpose in life, self-esteem and the
notion that life has meaning e.g. as denoted in Ryff’s multidimensional model
of well-being (1989) or that of Bright (1997).
3) Social well-being:
This contextual component is based on Keyes’s classification of social wellbeing that identifies a sense of belonging to community, social contribution,
engagement in pro-social behaviour and a positive view of society (Keyes,
1998)
Reviewing the research in this area, Marks and Shah (2005) denote that
whilst life satisfaction is inversely related to mental health difficulties including
depression, personal development appears to be strongly linked to overall
health, longevity, resilience and the ability to cope with adverse

circumstances.
Many of the components of well-being encompassed by life satisfaction and
Eudemonic perspectives parallel those identified as quality of life indicators
within quality of life research. For example, Gabriel and Bowling (2004)
17


explored quality of life indicators in older people as part of the Economic and
Social Research Council (ESRC) Growing Older Programme. The authors
suggest that from the perspectives of older people themselves, quality of life is
about:
•

Having good social relationships;

•

Help and support when needed;

•

Living in a home and neighbourhood which is perceived to give
pleasure, security and access to local facilities and services;

•

Engaging in hobbies/interests and leisure activities;

•

Having a social role and maintaining social activities;

•

Having a positive psychological outlook and being able to accept
circumstances which cannot be changed;

•

Having good health and mobility;

•

Financial security and sufficiency to meet basic needs and enjoy
life

•

Retaining one’s independence and control over one’s life.

Not surprisingly some would suggest that quality of life and well-being appear
to be synonymous constructs relating to the physical, the material, the social,
the emotional and the developmental (Felce and Perry 1995). Others would
argue that well-being reflects the subjective experience and evaluation of
one’s life, whilst quality of life reflects the objective context or domain (and
way of living or relating within that context) from which well-being is derived
(Peace et al. 2004).
Following an extensive review and synthesis of the research on well-being
and well-being measures up to 2003, Hird (2003) concludes the following:
1. There is no agreement regarding the concept or definition of wellbeing.

2. There is no agreement as to how well-being should be measured.
3. Objective indicators of well-being used in the research only allow
for group and individual comparisons to be made. Idiosyncratic
variation and understanding of well-being cannot be made using
objective indicators alone.

18


4. Similarly, subjective indicators of well-being will provide
measures of the level of well-being experienced by an individual
but may not indicate why this level may be high or low.
5. Psychological well-being uses concepts and indicators in relation
to self-esteem, resilience, coping etc. Such indicators also relate
to mental health and therefore could provide a strategic direction
regarding what is needed and how, in order to facilitate positive
mental health.
6. In the context of research, simply asking a single question about
well-being is open to bias and prejudicial assumptions.
Given the issues raised by Hird, one might conclude that policies and services
to older people that are based upon an assumptive construct, is unethical.
If a construct of well-being is to be used as a basis for informing policy and
provision, then such a construct needs to be evidenced from the perspective
of older people themselves.
Accordingly, the principal question that the current research will seek to
address is:
Do the personal narratives of older people, as reflected in clinical and
non-clinical populations, provide a meaningful framework for a
construct of well-being specific to late life?
Sources of Literature

The following search engines were primarily used in this research:
Medline, ProQuest, PsyClic
Other sources of literature reviews included:
Centre for Policy on Ageing-New literature on old age
Ageing and Society
Ageing and Mental Health
The Gerontologist
British Journal of Clinical Psychology

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LITERATURE REVIEW
Contemporary literature on well-being, in the context of older people, reflects
a broad spectrum of perspectives principally drawn from Philosophy,
Psychology, Medicine, Theology and Social Gerontology.
The scope of the following literature review is to identify, consolidate and
critique the ways in which well-being has been described and studied and to
thereby provide a rationale for the current research.
Critique of denoted perspectives is undertaken based on:
A) Their relevance in reflecting the experiences, views and circumstances of
older people.
B) The adequacy of identified indices of well-being, drawn from these
perspectives, as predictors of the impact and adjustment of older people to
the challenges they face.
Section 1) explores the theoretical frameworks that have underpinned
research on well-being and older people.
The first framework explores well-being from a bio-medical perspective and
evaluates its relevancy and ethical implications as applied to the
circumstances and experiences of older people.

The second framework draws upon studies, informed from Psychological
perspectives, which investigate how the properties and dimensions (as
denoted indices) of well-being influence the challenges and adjustment to
these challenges, faced by older people. This section is further divided into
two sub-sections. The former, focuses upon studies deploying objective
correlates of psychological functioning; informed from a predominantly
Positivist (physical science) perspective. The latter, focuses upon studies
deploying subjective correlates; informed from a predominantly Humanistic
perspective.
The third framework considers well-being from a Eudemonic perspective.
Having its origins in Aristotle’s Nicomachean Ethics (Honderich 1995), this
approach considers well-being as grounded in happiness and what it means
to live a good life. Accordingly, descriptions and models of well-being
reflecting this perspective tend to identify and integrate subjective, behavioural
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and/or contextual domains of human existence under one or more metaconstructs.
The fourth framework investigates well-being from an Existential perspective.
This approach, grounded in Existential Philosophy (Reker and Chamberlain
2000), also concerns itself with the wider perspective of human existence.
However, here well-being is considered under the central tenant of a
meaningful life, rather than as reflecting a happy life or a good life. As a
theoretical framework, it defines both the dimensions and properties of
meaning and denotes the life domains from which individuals derive meaning.
Accordingly, this perspective is considered to be one which seeks to integrate
and arguably unify perspectives two and three above. It will also be discussed
as a basis for comparison in the light of the results from the current research.
Section 2) explores well-being research and older people in the contexts of
quality of life, mental health and ethnicity, where these factors have been

shown to both influence theoretical perspectives on well-being and inform
policy and service provision to older people.
The first part explores the use of well-being in the context of Quality of Life
research and considers whether well-being and quality of life are
synonymous.
The second part explores the research on ethnicity and well-being. It suggests
that whilst racial identity per-se is not a factor in predicting subjective wellbeing, ethnicity informs the meanings individuals may hold or construct
surrounding indices of subjective well-being. No such relationship appears to
be particularly evident within the literature on gender and well-being in older
people.
The third part explores the research on mental health and well-being and
considers the importance of drawing upon the perspectives of older people
who experience mental health problems.
Accordingly, it is argued that both ethnicity and mental health requires
representation within well-being research.
The concluding section provides an overview regarding the way in which wellbeing has been described and studied in the literature and seeks to

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consolidate critical appraisals of the research as a basis for providing a
rationale to the present study.

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SECTION 1) THEORETICAL PERSPECTIVES ON WELL-BEING
i) Bio-Medical Perspectives on Well-Being
Well-being in the context of biomedicine is traditionally considered to reflect
the presence or absence of illness symptoms or functional disability (Sidell

1995) in medical, psychiatric and neurological modalities. Indeed, within this
framework, the construction of successful ageing has been used as a basis
for defining in part, well-being (Rowe & Kahn 1987, 1997).
One of several models of successful ageing, Rowe and Kahn define
successful ageing in the context of their model as the ability to maintain:
i)

Low risk of disease and disease-related disability through
adopting a healthier lifestyle.

ii)

High mental and physical functioning.

iii)

Active engagement in life.

Whilst having received much criticism in terms of not considering the many
possible patterns of ageing that older people experience and that the model
can be seen as having a Eurocentric value base (Ouwenhand et al. 2007), it
has been extensively used as an evaluation tool for exploring the effects of
intervention systems and health promotion programmes on older people.
What can be described as the health-related paradigm of well-being (Sidell
1995), has dominated and arguably continues to dominate Health Policy,
practice and research in Western culture since post industrialization.
Historically, this perspective developed prominence in the Western culture
during the Enlightenment at the end of the 18th century. Often termed as
Modernism, this period was characterised by value and power given to three
major features:

•

Reason over ignorance

•

Order over disorder

•

Science over superstition

Informed largely by positivist thinking and research, modernism arguably gave
birth to the pathologising of illness and disability (Tarnas 1996).
However, contemporary “Post-Modernist” conceptions of the bio-medical
perspective seek to broaden the scope of its definition and meaning from

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simply one pertaining to illness and functional disability, to the inclusion of
social adjustment, competency and quality of life (Katz and Peberdy 1997).
Bury (1982) argues that a principal advantage of a health-centred formulation
of well-being is that it objectifies illness and disability and thus separates it
from the self. Bury goes on to suggest that this division has a social function.
It enables the social legitimization of illness behaviour and abdicates
responsibility for the condition and often its remediation, from the individual.
Yet this model has received much criticism during the past 20 years
particularly with respect to its legitimacy for informing the provision of health
care to older people and those with chronic illnesses.

As a facet of the care delivered to those with chronic illnesses, Bury (1982)
asserts that by definition, since medicine cannot cure chronic illness, the
ultimate responsibility for managing the condition is often placed upon the
individual sufferer.
In relation to older people specifically, a model of well-being that is solely
grounded within the dimensions of illness, disability and competence, is
incongruous with the perspectives of older people themselves and arguably
may serve as a basis for reinforcing ageist stereotypes, identities and care
practices in some contexts (Bytheway, 2005; Biggs, 2004; Sidell, 1995).
Informed from a social constructionist perspective, Harding and Palfrey (1997)
argue that many chronic illnesses, such as the Dementias, are predominantly
socially constructed in such a way as to provide society with a legitimate basis
for disempowering and controlling such individuals. Care practices informed
from social constructions are thus considered as performative acts or simply
socially sanctioned modes of behaviour intended to establish conformity.
In addition, a bio-medical perspective on well-being has a different
connotation for older people that younger people. Several studies have shown
that older people per se, consider such health related indices of well-being as
a means to an end, in terms of accessibility to quality of life activities, rather
than an end in them selves (Nesbitt & Heidrich, 2000). As Asberg et al. (1990)
point out, health can never be the ‘goal’ of life but it is an important means for
achieving what one wants in life. Similarly, Lawton (1991), and Sarvimáki and
Steinbock-Hult (2000), argue within the context of older people, that the goal
of healthcare cannot simply be freedom from disease or disability but to
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enable people to live as good as a life as possible despite illness and
decreasing capacity.
Freund (1982, 1988, 1990) identifies two key components of health related

well-being: Firstly, that which pertains to physical processes and the mind
and secondly, the relationships between body and mind and our social
existence. He suggests that well-being is a product of the body’s capacity to
regulate its biophysical processes with a more global ability for individuals to
exert control over these processes in relation to one’s social existence and
emotional functioning.
In an attempt to link psychological correlates with health. Antonovsky (1984)
postulates the concept of Sense of Coherence.
Firstly, Antonovsky suggests that we need to think salutogenically about
health. He argues that the traditional way of conceptualising health is to
consider people as being either healthy or diseased where being healthy
reflects a state of homeostasis and being ill or diseased reflects a disruption to
homeostasis (“pathogenic paradigm”).
He claims that this form of dichotomous thinking not only supports ageist
stereotypes of illness identity, but fails to account for those people who may
have a chronic illness yet remain functionally active. In addition, addressing ill
health from this viewpoint is commonly about identifying and ameliorating
pathogenic causes rather than recognising that
•

Pathogens are endemic in people’s lives and eradicating them will not
lead to health.

•

Psychological factors are intrinsic in predicting peoples response to ill
health

•

We invest in studying high-risk groups rather than understanding the
“symptoms” of wellness.

Thinking salutogenically therefore is seeing the normal state of individuals as
one of entropy, disorder and of disruption of homeostasis rather than of
balance and equilibrium. Accordingly, he considers individuals to move back
and forth along a continuum of health-ease and dis-ease. Where one is
located on this continuum, in terms of one’s ability to cope with adverse health

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