THERESA M. BECKIE1 and LESLIE A.

HAYDUK2

MEASURING QUALITY OF LIFE

ABSTRACT. This paper considers quality of life (QOL) to be a global, yet

unidimensional, subjective assessment of one’s satisfaction with life. This concep-
tualization is consistent with viewing QOL assessments as resulting from the
interaction of multiple causal dimensions, but it is inconsistent with proposals to
limit QOL to health-related quality of life (HRQOL). We test the unidimensional
yet global conceptualization of QOL using data from coronary artery bypass graft
(CABG) patients. The Self-Anchoring Striving Scale (SASS) and four other indi-
cators derived from the literature, all seemed to function as indicators of a single
concept (QOL) that was repeatedly drawn upon as the patients determined their
responses to these indicators. However, only about half the variance in each indi-
cator was attributable to that common QOL source. Several structural equation
models are used to assess whether the superior performance of the Life 3 indi-
cator is an artifact of the repetition of an item within this indicator. The data
convincingly indicate that the superior performance is not a memory artifact,
and that even the repetition of an identically worded item prodded the patients
into drawing yet again upon the same QOL factor that grounded all the other
measures.

INTRODUCTION

Over the last decade, quality of life (QOL) has emerged as a focal
concern in the treatment of patients with chronic health conditions.
An improved QOL is often cited as an outcome goal of medical inter-
ventions (Schipper, 1992), but confusion remains over the definition
and measurement of this elusive concept (Campbell, Converse, and
Rodgers, 1976; Coyle, 1992; Carter, 1989; Young and Longman,
1983; Bowling, 1991; Ebersole, 1995; Kinney, 1995; Phillips, 1995).
Many researchers assert that QOL is a multidimensional construct
(Shye, 1989; Palys and Little, 1980; Gillingham, 1982; Cella and
Tulsky, 1990; Roy, 1992; Lim et al., 1993; Fletcher, 1995; Grady et
al., 1995) but the arguments supporting this view usually confound
the dimensionality of a concept with the multiplicity of the causal
sources of that concept, as we explain below.
There is no gold standard for measuring QOL, and there is little
evidence for the construct-related validity of the various measures

Social Indicators Research 42: 21–39, 1997.

c 1997 Kluwer Academic Publishers. Printed in the Netherlands.
22 THERESA M. BECKIE AND LESLIE A. HAYDUK

that have been proposed. Consequently, the current health care litera-
ture is composed of studies using measures that are inconsistent, and
often of questionable relevance to the QOL construct. This makes
the caliber of the research related to QOL uneven, and it becomes
nearly impossible to consolidate the accumulating studies through
meta-analyses.
This paper attempts to improve our understanding of QOL in two
ways. The early portions of this paper resolve several confusions
in current conceptualizations of QOL. These discussions lead us to
consider QOL as a global personal assessment of a single dimension
which may be causally responsive to a variety of other distinct dimen-
sions. The later segments of this paper attempt to determine whether
the currently available global measures do indeed tap into a common
global dimension. Evidence from structural equation models based
on data from coronary artery bypass graft (CABG) patients provide
some support for this contention, but some cautions are in order.

ANNULLING SOME CONCEPTUAL ENTANGLEMENTS

The health care literature displays considerable confusion, diver-

gence, and even contradiction, in the meanings assigned to QOL
(Fletcher, 1995; Clark, 1995). Quality of life, health-related quality
of life (HRQOL), health status, functional assessment, and even
needs assessment, have been used indiscriminately to describe the
same dimensions and sometimes even the same instruments (Gill
and Feinstein, 1994; Fletcher, 1995). Health care researchers tend to
view social science conceptualizations of QOL as being too broad
because they embrace a multitude of factors such as happiness,
life satisfaction, or subjective well-being. Modification of these
factors are not directly intended outcomes of health care interven-
tions, so their inclusion seems orthogonal to the evaluation of med-
ical therapies (Kaplan and Anderson, 1990; Patrick and Erickson,
1993).
Guyatt (1993, 1995) and McCarthy (1995) recommend focus-
ing on HRQOL precisely because characteristics such as income,
freedom, and quality of the local environment, are outside the realm
of intended medical outcomes. In contrast, Tennant (1995) sees the
switch from QOL to HRQOL as an attempt to perform “a feat
 MEASURING QUALITY OF LIFE 23

of methodological alchemy. It transmutes existing impairment and

disability measures, validated for quite a different purpose, into so-
called QOL” (p. 440). We, like Tennant, view the narrowing of QOL
to HRQOL as an impediment, but our dissatisfaction is as much
conceptual as it is methodological.
We view many of the disagreements over the definition of QOL,
and the discussions of its dimensionality, as being artifacts of impre-
cise thinking about variables in causal networks. Think for the
moment, of QOL as being the dependent variable in a regression
equation where the predictor variables include several health causes
and several social/psychological causes. In this context it is imme-
diately clear that QOL can remain a single variable, the dependent
variable, no matter how many causes we put on the list of predictors.
Hence the number of causes of QOL does not determine the dimen-
sionality of the concept QOL. It is entirely consistent to claim that
QOL is both unidimensional and multiply caused.
Does the presence of several health causes (predictors) and several
non-health causes suggest that we make two new dependent vari-
ables, one by combining the health causes into an index, and the
other by combining the social/psychological causes into a second
index? The answer is clearly no; this is not recommended. Construc-
tion of these types of indices would magically switch what were
originally a set of causal predictor variables into new dependent
variables, merely on the basis of our (well intentioned) disciplinary
bias to clump these variables together as “our health variables” and
“their other variables.” Pointing to the disciplinary slant of the causal
variables does not constitute evidence of any kind about the causal
adequacy or inadequacy of the original QOL dependent variable.
Hence the disappearance or abandonment of QOL would be driven
by something other than a failing in the QOL variable itself. This may
be intentional disciplinary boundary maintenance, or a fear that the
other variables are stronger causes than our own, but either way, the
identities or characteristics of the causal variables does not provide
any evidence for or against the QOL variable itself.
More devastatingly, the model with QOL as a dependent variable
and several medical and social causes, permits all the causal vari-
ables, and specifically the health variables, to be entirely uncorrelated
with one another. The original model we postulated makes no claims
24 THERESA M. BECKIE AND LESLIE A. HAYDUK

about the relationships or lack of relationships between the causal

predictor variables, other than that these are not redundant or colinear
with one another. Combining the previously medical variables into
a soon-to-be dependent variable with the “proper” disciplinary slant
(HRQOL) would be entirely indefensible if this resulted in combin-
ing several independent (uncorrelated) health factors into a single
index. The independence of these factors would guarantee that they
are enmeshed in different causal networks. The independence and
separate causal positionings of these variables is permitted, and is
unproblematic, as long as these remain causal variables. But the
independence, or even a low degree of relatedness between these
variables, would render useless any index created by combining
these variables. The diverse causal composition of the items com-
prising the index would guarantee that there would be no single
causal network in which the index could function. Some parts of the
index would prefer to be in one causal network, while other parts
would prefer to function in other causal ways. Here we see shades
of the methodological alchemy Tennant was referring to.
Ultimately, it is not our disciplinary, or political, or ideological,
preferences that should divvy up the QOL causal world, but evidence
from that causal world itself. There is no long-term gain from bicker-
ing about measurement in a way which merely supplants QOL as
a dependent variable with another favored dependent variable. A
more useful tack would be to find a way to potentially reject the
basic model proposing that QOL is a unidimensional entity which
is causally dependent upon several other things. We should begin
by tentatively accepting the unidimensionality of QOL (which is
entirely compatible with it having many causal sources) and then
turn immediately to seeking information that might potentially reject
its unidimensionality. That is, we should seek information from real
patients in real circumstances, that could potentially shock us by
questioning the existence of QOL as a unidimensional entity, no
matter how many causes it has.
There are two basic styles of information capable of providing
such a rejection, and hence which are also capable of standing as
independent supporting evidence. One style is factor analytic in its
conception, though confirmatory factor analytic in intent. A model
postulating that a single underlying dimension (QOL) accounts for
 MEASURING QUALITY OF LIFE 25

several indicators purporting to measure that dimension can be

potentially rejected if the variances and covariances of the indi-
cators do not behave as if they were created through dependence on
a single common causal source, namely QOL. This is the basic tack
taken in this paper.
A second approach is to place multiple indicators of the puta-
tive unidimensional entity (QOL) in a causal model containing
likely causes and/or effects of QOL. Hayduk (1987: 215, 1996: 7)
discusses how proportionality constraints render such models poten-
tially rejectable. We plan to estimate such models for the patients
in the current study, using the multiple discrepancies theoretical
approach developed by Michalos (1980, 1982, 1983, 1985, 1986,
1991a, 1991b) but for the moment we will not delve into the differ-
ences between Michalos’ system and any of the other proposed
causal systems (Stewart, 1992; Wilson and Cleary, 1995).
Before turning to the data, we must make one further substan-
tive point. A unidimensional QOL indicator can also be a global
QOL measure. Think again of the regression model with QOL as the
dependent variable. Imagine that QOL is a metric assertion of a life
that is or is not pleasant to live, which results from an assessment,
judgment, or comprehensive personal evaluation incorporating a
variety of health, social, and psychological dimensions, where these
dimensions may interact and combine in complex patterns (Andrews,
1991; Andrews and Withey, 1976; McKennell and Andrews, 1980,
1983). The wide ranging and global nature of the considered vari-
ables, and the complexities of how they are combined in arriving
at a judgment or assessment of QOL, merely asserts that a regres-
sion model having QOL on the left side of the equation would have
to include a wide diversity of variables and complex interconnec-
tions among the variables on the right side of the equation, if it is
to successfully mirror how the QOL assessments arose. The diver-
sity and complexity of the combining entities does not speak to
the dimensionality of the entity that emerges through the judgment,
assessment or evaluation. Hence it is entirely reasonable to postu-
late that a unidimensional QOL variable can result from a global
assessment spanning diverse and complex domains.
If the complex and interactive global assessment results in QOL
being more than the sum of its parts (Moller and Schlemmer, 1989),
26 THERESA M. BECKIE AND LESLIE A. HAYDUK

this is a major concern for the second strategy suggested above,

where the causal sources of QOL are at issue. For the first strategy and
the strategy adopted in this paper, however, it is of no concern. The
confirmatory factor analytic approach avoids this challenge because
it makes no claims, assertions, or assumptions about the complexity
or simplicity of the process producing the anticipated underlying
factor (QOL). The factor analytic approach is agnostic as to whether
the QOL scores arise in sum-surpassing and interactive ways, or not.
The factor analytic approach merely examines whether the resultant
judgments or assessments, however they are arrived at, are stable
enough for patients to consistently recognize and respond to across a
variety of measurement tasks. In factor analysis, the issue is the stable
recognizability of QOL, not the summative or non-summative nature
of the sources of the consistently recognized QOL. The sources of a
factor in factor analysis are entirely unspecified.
With this said, we can turn to an examination of several global
measures of QOL as reported by CABG patients.

THE PARTICIPANTS AND THE INDICATORS

A convenience sample of 306 patients was drawn from patients

undergoing CABG surgery at the University of Alberta Hospitals in
Edmonton between July 1992 and May 1993. Of the 495 patients
surviving first-time CABG surgery, 189 were dropped from the study
either because they: had additional cardiac surgical procedures, were
not functional in english, were not competent enough to complete
the required tasks, or had a history of psychiatric illness. All of the
306 eligible subjects agreed to participate.
The patients participated in a face-to-face interview just prior to
their first follow-up visit with their cardiothoracic surgeon, which
occurred anywhere from three to six months after their CABG
surgery. The various scales and questionnaire items completed dur-
ing the interview, included the five measures of perceived global
QOL that are the focus of this paper. The five measures of QOL
include the Life Satisfaction item from the Index of Well-Being
(IWB) (Campbell et al., 1976), the Life 3 Scale (Andrews and
Withey, 1976), the Faces Scale (Andrews and Withey, 1976),
the Life-as-a-whole item from the Multiple Discrepancies Theory
 MEASURING QUALITY OF LIFE 27

(MDT) (Michalos, 1991a), and the Self-Anchoring Striving Scale

(SASS) (Cantril, 1965).
The Life Satisfaction item from the IWB (hereafter referred to
as Life Satisfaction) reads, “How satisfied are you with your life as
a whole?” and is scored Not at All Satisfied (1) to Very Satisfied
(7) with unlabeled intervening categories. The Life 3 Scale, is a
derived measure, which is the average of two identical questions
(Life 1 and Life 2) asking the respondent at the beginning and end
of the interview to evaluate their life-as-a-whole on a labeled scale
from Terrible (1) to Delighted (7). None of the participants reported
noticing the repetition of this item. The Faces Scale is a means of
eliciting QOL assessments without using verbal labels for the scale
categories. The Faces scale asks the respondent to express “how
you feel about your life as a whole” by selecting one of seven faces
ranging from a very happy-face (mouth corners up, scored 7) to a very
sad-face (mouth corners down, scored 1). The Life-as-a-Whole item
(hereafter called MDT1) from the MDT questionnaire (Michalos,
1991a) reads, “How do you feel about your life as a whole right
now?” The response categories are: Terrible (1), very dissatisfying
(2), dissatisfying (3), mixed (4), satisfying (5), very satisfying (6),
and delightful (7). The Self-Anchoring Striving Scale (SASS) is
depicted as a 10-step ladder, using only numbers as descriptors of
the rungs of the ladder. The respondent is shown the ladder and asked
“Where on the ladder would you place your present life?” The base
of the ladder is illustrated with a zero and labeled “the worst you can
imagine.” The successive rungs are sequentially numbered, and the
top rung is labeled “10 the best you can imagine.”
These measures were selected because they are being used in both
health related research and social/psychological research, because
the measurement properties of either the specific item, or the index
containing the item, has received considerable attention, and because
each measure provides a global evaluative assessment of one’s life.

RESULTS

Most of the study participants were caucasian (95.4%), married

(79.4%), males (85%), between the ages of 40 and 75 (81.4%),
living within the city of Edmonton (53.9%). The mean age of the
28 THERESA M. BECKIE AND LESLIE A. HAYDUK

participants was 61.8 years (sd = 9.7). The majority of the partici-
pants had attained a formal education of at least high school (70.1%)
and 49 patients had received a university degree. Most of the patients
were either employed full-time (35%) or retired (47.1%) at the time
of surgery.
Most participants waited less than a month for CABG surgery with
a modal wait of 7 days and a median wait of 22 days. Eight percent
had required immediate surgery and 21% were elective cases. Most
patients (70.3%) underwent revascularization of 3 or 4 coronary
arteries.
The means (and standard deviations) of the indicators for the
CABG patients are: Life Satisfaction 5.55(1.00), Life 1 5.46(0.91),
Life 2 5.36(0.83), Life 3 5.41(0.76), Faces 5.43(0.98), MDT1
5.10(0.83), SASS 6.80(1.67). Thus the distributions for all the QOL
indicators display a clustering of cases slightly nearer the very satis-
fied/delighted end of the QOL scales, with a thinner tail extending
off toward the dissatisfied/terrible values.

FIVE MODELS OF QOL

The five models estimate are depicted in Figures 1 through 5, and

LISREL’s maximum likelihood estimates (Joreskog and Sorbom,
1988) for these models appear in Table I. We begin with a confir-
matory factor model (Figure 1), and follow this with three models
progressively exploring the implications of the fact that the Life 3
indicator was an average of two identical questions. Model 2 (Figure
2) incorporates the repeated items as separate indicators. Model 3
(Figure 3) demonstrates how both the repeated indicators and their
average can be incorporated into a single model. This sets the stage
for Model 4 (Figure 4) which provides a direct test of whether
the repeat measure contained a memory artifact or whether it was
produced through a repeated appeal to the same causal source under-
lying all the other measures. The final model (Figure 5) reports on a
data prompted modification.
Let us now consider each of these models more thoroughly. Model
1 postulates that there is a single concept (variable), namely the
patients’ true QOL, that grounds their responses to all the indicators.
A fixed 1.0 loading has been used to scale the QOL concept to the
 MEASURING QUALITY OF LIFE 29

TABLE I
Maximum likelihood estimates for the models of quality of life (n = 306)

Models
One Two Three Four Five
Df 6 10 17 16 15
 2
9.35 13.29 13.50 13.04 6.66
p 0.155 0.208 0.702 0.670 0.966

Squared multiple correlations

MDT1 0.505 0.495 0.495 0.497 0.497
FACES 0.434 0.422 0.422 0.426 0.395
SASS y0.500 y0.500 y0.500 y0.500 y0.500
SWB11 0.485 0.500 0.500 0.502 0.505
LIFE 1 na 0.402 0.402 0.389 0.400
LIFE 2 na 0.698 0.698 0.689 0.709
LIFE 3 0.676 na y1.00 y1.00 y1.00

Lambda coefficients
MDT1 0.492 0.490 0.490 0.489 0.500
FACES 0.540 0.536 0.536 0.537 0.528
SASS y1.00 y1.00 y1.00 y1.00 y1.00
SWB11 0.583 0.595 0.595 0.595 0.610
LIFE 1 na 0.483 y1.00 y1.00 y1.00
LIFE 2 na 0.582 y1.00 y1.00 y1.00
LIFE 3 0.523 na y0.50 y0.50 y0.50
+y0.50 +y0.50 +y0.50

Error variance
MDT1 0.341 0.348 0.348 0.346 0.346
FACES 0.547 0.559 0.559 0.555 0.586
SASS y1.421 y1.421 y1.421 y1.421 y1.421
SWB11 0.519 0.504 0.504 0.502 0.499
LIFE 1 na 0.494 0.494 0.504 0.496
LIFE 2 na 0.208 0.208 0.214 0.201
LIFE 3 0.189 na y0.00 y0.00 y0.00
y = fixed coefficient
na = not applicable
 = p < 0.05.
30 THERESA M. BECKIE AND LESLIE A. HAYDUK

Figure 1. Model 1: A confirmatory factor model of QOL with five indicators.

Figure 2. Model 2: Separating the duplicated indicators.

SASS indicator, and a fixed error variance for this indicator has been
specified as suggested by Hayduk (1987, 1996). Our specification
of the error variances as accounting for half the variance in SASS
 MEASURING QUALITY OF LIFE 31

Figure 3. Model 3: Incorporating the duplicate indicators and their average.

Figure 4. Model 4: Testing whether life 2 is a methodological artifact or a retapping

of QOL.
32 THERESA M. BECKIE AND LESLIE A. HAYDUK

Figure 5. Model 5: A data prompted model revision.

indicates our suspicion that SASS reports are influenced by many

factors unique to the SASS scale, in addition to SASS being respon-
sive to true QOL. Thus the 1.0 loading guarantees that each unit of
change in QOL results in (corresponds to) a unit of change in SASS,
but SASS remains different from QOL because there are substantial
other sources of variation unique to SASS. The loadings and error
variances for all the other indicators were estimated.
When estimated with the data from the CABG patients this
model fits with the covariances of the indicators tolerably well. The
probability for the model 2 is 0.155, while it would have taken a
probability of 0.05 or less to demonstrate that the data was inconsis-
tent with the common-source conceptualization of QOL. The esti-
mated loadings and error variances (Table I) indicate that roughly
half the variance in each of the indicators can be attributed to the
action of a common cause (QOL), though Life 3 seems to have a bit
of an edge because about 68% of its variance can be attributed to the
common cause.
The second model deletes Life 3 and replaces it with the two
indicators from which it was created, namely Life 1 and Life 2.
This model fits the data about as well (2 = 13.29, p = 0.208) and
 MEASURING QUALITY OF LIFE 33

provides the interesting observation that the second of the repeated

measures (Life 2) seems to be better than the first measure (Life 1). It
has higher explained variance despite the identical wording of these
two indicators. This could be because the first measurement (Life
1) was taken earlier on in the interview, before the CABG patients
had repeatedly pondered their QOL, while the second measure was
taken later. Alternatively, this might be a memory artifact that could
substantially challenge the conceptualization of QOL as a common
source for these indicators. If the CABG patients had remembered
their earlier Life 1 rating and merely re-reported this when it was
time to make their Life 2 rating, the higher explained variance might
merely constitute evidence that this is an artifact of a misspecified
model (a model not permitting any memory effect) as opposed to a
stronger measure.
This is a serious challenge, whose implications are worth perus-
ing. If we could demonstrate that the Life 2 indicator was mostly, or
substantially, a memory effect we would have a substantial challenge
against what, so far, seems to be the strongest single indicator.
To directly test the possibility of a memory effect, we must
redesign the model in a way which permits Life 1 to potentially
influence Life 2. Model 3 boosts the Life 1 and 2 variables up to the
conceptual level by making them LISREL concepts that are identical
to the corresponding Life 1 and 2 indicators. That is, the Life 1 con-
cept is made the complete and entire source of the Life 1 indicator
by fixing the corresponding loading at 1.0 and the error variance on
the Life 1 indicator at zero. Similarly, a new Life 2 concept is created
by using a fixed 1.0 loading to the Life 2 indicator and a zero error
variance on the Life 2 indicator.
Model 3 also reintroduces the Life 3 indicator as the average of
Life 1 and Life 2 concepts. From Figure 3, you should be able to
determine that the equation for Life 3 is

Life 3 = 0.5(Life 1) + 0.5(Life 2) + zero error

so
Life 3 = (Life 1 + Life 2)/2

or the average of the two indicators. This segment of the model is

“guaranteed to work” in that we know Life 1, Life 2 and Life 3 are
34 THERESA M. BECKIE AND LESLIE A. HAYDUK

connected in this way, though the overall model might not work as
well when the model segment for Life 3 is included. If the Life 1 and
2 indicators were at odds with the other indicators, any such conflict
would be enhanced by adding in Life 3, and hence the overall model
fit could potentially decline with inclusion of the model segment
containing Life 1, 2, and 3.
In fact, the model 2 (13.50) stays about the same, indicating no
such conflict, and the 2 probability (0.702) actually increases due
to the additional degrees of freedom created by inclusion of the Life
3 indicator. With this model as a baseline, we can now proceed with
the test for the potential memory effect from Life 1 to Life 2, as
indicated in Figure 4.
When an effect from Life 1 to Life 2 is introduced into this
model, the estimated effect is small (0.036, 0.039 standardized) and
insignificant. While a significant effect here would have substantially
challenged the QOL model by challenging one of the strongest indi-
cators, the insignificance of this effect stands as an equally substantial
confirmation of the basic model. That is, we now have some direct
evidence that even repeating a globally worded question about one’s
QOL does not lead the respondents to merely repeat a previous
response. The respondents developed their response for even an
identically worded question by drawing upon the same common
source that underlies all of the QOL indicators. That is, it appears
the CABG patients actually performed a reassessment of their
QOL. Furthermore, this reassessment appears to provide a slightly
better measure of QOL because there is a slightly stronger loading
on QOL and because there is slightly less error in the repeat measure.
That is, fewer or weaker extraneous sources contribute to the repeat
measure.
The final model (Figure 5) introduces one additional coefficient
into the previous model. The modification indices for the previous
models had suggested that there might be some covariance between
the errors on the Faces and SASS indicators. When a covariance
between these errors was permitted, this did indeed result in a signifi-
cant improvement in the model (a difference 2 of 6.38 with 1 df, p
< 0.05) and a correspondingly significant error covariance. The esti-
mated covariance (0.149) corresponds to a rather weak correlation of
0.16. This correlation asserts that there is some source of consistency
 MEASURING QUALITY OF LIFE 35

between the Faces and SASS indicators over and above the consis-
tency provided by QOL. This observation must be treated with some
caution, however, because by freeing the coefficient with the largest
modification index we are implicitly selecting the most significant of
the possible error covariances. Hence, this estimate has an unusually
high likelihood of capitalizing on chance. Consequently, though we
report this correlation, we treat this as a suspicion, but not as strong
evidence, that some common source other than QOL is required to
connect the Faces and SASS indicators.

SUMMARY AND DISCUSSION

This paper began by considering the dimensionality, globality, and

domain specificity of QOL. Considerable clarification was provided
by the pedagogic ploy of imagining QOL as a dependent variable in
a regression equation including both health and non-health variables
among the list of complex and interacting causes. From this per-
spective it seems entirely reasonable to claim that QOL remains
a unidimensional concept despite the multiplicity, diversity, and
complexity of its causes. The diversity of the sources of QOL war-
rant describing QOL as a global assessment, despite its unidimen-
sionality, and despite our current inability to specify its potentially
interactive (non-summative) sources. From this perspective, restrict-
ing QOL to HRQOL is an ill conceived attempt to transform a set of
potentially independent causal sources into a single new dependent
variable.
Granting the reasonableness of conceptualizing QOL as a globally
derived unidimensional assessment, however does not guarantee that
the forces controlling QOL in the real world function in this way.
Consequently we sought ways to test this conceptualization using
data from CABG patients.
A confirmatory factor model postulating QOL as a common
source for five QOL indicators was tested and found to be con-
sistent with (not significantly different from) the covariances of the
indicators. Conceptually this model is similar to what is done in
ordinary factor analysis, though some details of the model specifica-
tions, and the presence of a specific model test, provide a more rigid
assessment than usual.
36 THERESA M. BECKIE AND LESLIE A. HAYDUK

The most problematic aspect of the estimates from this model was
the relatively large proportion of error variance in all the indicators.
About half the variance in the available indictors arose from sources
unique to each indicator, and not from QOL.
The indicator with the smallest proportion of error variance, Life
3, was the average of two identical questions. We developed a series
of models to investigate these items, and we found that the superior
performance of the repeated measure definitely could not be attri-
buted to a memory effect, or a direct carryover from the identical
prior question. The good fit of this model, combined with a small
and insignificant memory effect, provides strong and independent
support for the contention that the patients were drawing upon the
same source that led to all their global QOL assessments when they
responded to the replicate measure.
At the moment we can not make a recommendation as to which
global measure is best. The repeated Life 2 indicator was clearly
the best in terms of explained variance, even though the identically
worded Life 1 indicator was the worst in terms of explained variance.
The repeated assessments of QOL during the interview may have
sharpened the patient’s focus, but lacking specific evidence for this,
inclines us to reserve judgment until we have pursued the second way
of evaluating these measures, namely through structural equation
modeling of the sources of QOL assessments.

ACKNOWLEDGEMENTS

This research is based in part on a Doctoral Dissertation completed

by the first author under the direction of Dr. Steve Hunka at the
Centre for Research in Applied Measurement and Evaluation in
the Department of Educational Psychology at The University of
Alberta. The University of Alberta human research ethics policy and
the Medical Research Council of Canada (1987) ethical guidelines
were followed during this study. Ethical clearance was granted by
the University of Alberta Hospitals, the Medical Ethics Committee
of the University of Alberta Faculty of Medicine, and the Division
of Cardiothoracic Surgery.
 MEASURING QUALITY OF LIFE 37

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 MEASURING QUALITY OF LIFE 39

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THERESA M. BECKIE LESLIE A. HAYDUK

University of South Florida University of Alberta
Tampa, Florida Edmonton, Alberta
e-mail: tbeckie@nurse.hsc.usf.edu