Jan L' Bernheim1,2,3, Peter Theuns4, Piet Calcoen3,

1
BRIDGING CULTURAL RELATIVITY IN QOL ASSESSMENT BY
ANAMNESTIC COMPARATIVE SELF ASSESSMENT (ACSA)

• Jan L. Bernheim1,2,3, Peter Theuns4, Piet
  Calcoen3,
• Mehrdad Mazaheri4, Francis Heylighen2, Matthias
  Rose5
• Depts of 1Human Ecology and End-of-Life Care
  Research Group,
• 2 Leo Apostel Centre for Interdisciplinary
  Studies,
• 3 Centre for Bioethics,
• 4 Psychology, Vrije Universiteit Brussel,
  Belgium,
• 5 Dept. of Psychosomatics, Charité-Humboldt
  University, Berlin, Germany
• jan.bernheim_at_vub.ac.be

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2
Much of the material of this presentation is in
press as

• J. L. Bernheim, P. Theuns, J. Hofmans, M.
  Mazaheri, F. Heylighen, M. Rose.
• The potential of Anamnestic Comparative Self
  Assessment (ACSA) to reduce bias in the
  measurement of Subjective Well-Being.
• J. of Happiness Studies, 2005

3
A tall orderMeasuring subjective wellbeing
(SWB), the perception of Quality of Life (QOL)is

• Quantifying what is qualitativeMaking objective
  what is subjective

4
WHAT FOR ?

• To calculate
• Quality Adjusted Life Years (QALYs)
• Happiness Adjusted Life Years (HALYs)
• As input and outcome measures for
• Policies health, social, economic, ...
• Research

5
PURPOSES OF THIS PRESENTATION

• I. Discussion of some problems biases in the
  measurement of SWB
• II. Presentation of ACSA, a personalised
  alternative instrument to the conventional global
  question (CQ) on SWB
• III. Results of large-scale empirical comparison
  of ACSA and CQ

6
Taxonomy of Quality-of-Life measures
7
Why are multiple item instruments more
descriptive than evaluative, and are single-item
(global) ratings necessary?

• Multidimensional questionnaires always incomplete
• Individual people have different preferences,
  which moreover change over time (Response Shifts,
  see Schwartz, C.E. and Sprangers, M.A.G. 2000,
  Adaptation to changing health Response shift in
  quality-of-life research, (Washington, DC
  American Psychological Association).)
• Dimensions of QoL not independent, but
  interacting (life complex, therefore SWB at
  emergent level)
• Bernheim, J.L. 1999, How to get serious answers
  to the serious question How have you been?
  subjective quality of life (QOL) as an individual
  experiential emergent construct, Bioethics 13,
  pp. 272-287.

8
Which global question is better suited for what?
OR
9
Examples of sequential ACSA ratings during
illness (from Bernheim, J.L., and M. Buyse
1984, The Anamnestic Comparative Self Assessment
for measuring the subjective quality of life of
cancer patients, J. Psychosoc. Oncol. 1, pp.
25-38.)

• All scale-points used
• Some scores beyond scale
• (Retrospective) Baseline rating usually within
  (high) mode of CQ ratings in healthy subjects in
  affluent countries

10
Reminder of Terminology and Definitions

• LABEL
• CQ Conventional Question
• Anamnestic (based on memory)
• Comparative
• Self
• Assessment

• CONTENT
• How have you been?
• How have you been, relative to your best and
  your worst times?

11
Problems with the conventional global question
(CQ) on QOL

• Trivialisation of response (How are you
  today?) ? random or socially desirable responses
  
• Proximate / peer relativity (the neighbours)
  ?tendency to normal distribution
• Cultural bias (Veenhoven, Lau Cummins, Diener,
  e.g. Diener, E., Diener, M. 1995,
  Cross-cultural correlates of life satisfaction
  and self-esteem, Journal of Personality and
  Social Psychology, 68, 653-663.), possibly
  related to
• Personality traits (Steel, P. and Ones, D.S.
  2002, Personality and happiness a
  national-level analysis., Journal of Personality
  and Social Psychology 83, pp 767-781)

12
Frequency Distribution for Subjective Wellbeing
(Western vs Asian) A. Lau R. Cummins 2004 QOL
Research 13 1496, 2004
0 10 20
30 40 50
60 70 80
90 100 Percentage of Scale
Maximum (SM)
Population Mean (Western)
Population Mean (Asian)
13
SATISFACTION WITH LIFE AS A WHOLE A. Lau R.
Cummins, QOL Research 13 1496, 2004

14
QUESTION HK-AUS difference real, or cultural,
different peoples using other scales?

• A. Lau R. Cummins, QOL Research 13 1496 , 2004

15
Identifying a cultural response bias A. Lau R.
Cummins QOL Research 13 1496, 2004
Can you recall feeling really bad / really good
sometime in your life ? On the scale from 0
to 10, how would you have rated yourself at these
times ?
16
RESULT A. Lau R. Cummins, QOL Research 13
1496, 2004
How satisfied when ..?
17
CONCLUSIONS of A. Lau R. Cummins, QOL Research
13 1496, 2004

• Chinese use a narrower range of the scale than
  Australians they admit to less happiness or
  misery.
• Part of the apparent deficit in life satisfaction
  among Chinese is an artifact by cultural bias in
  the utilisation of scale of SWB.

18
Aims of our own Study

• Compare ACSA and CQ for
• Sensitivity to socio-demographic variables
• Discriminating power
• Responsiveness sensitivity to objective
  evolution
• (J. L. Bernheim, P. Theuns, J. Hofmans, M.
  Mazaheri, F. Heylighen, M. Rose. The potential of
  Anamnestic Comparative Self Assessment (ACSA) to
  reduce bias in the measurement of Subjective
  Well-Being. J. of Happiness Studies, in press,
  2005)

19
Methods
20
METHODS
n2545 general hospital patients replied to both
CQ and ACSA, administered as written
questionnaires
21
ResultsI. Discrimination II. Sensitivity to
objective change
22
Discrimination (inter-group comparisons)
Sensitivity to objective change (after life- and
QOL-saving transplantation in End-Stage-Liver
Disease ) (CQ and ACSA ratings /- SD normalised
to 0-10 scale)
23
Results III. Sensitivity to socio-demographic
variables
24
Structural Equation Model for surveyed
socio-demographical variables to predict Qol
25
Sensitivity to socio-demographic variables
26
Conclusions and discussion on ACSA vs CQ
comparison

• OBSERVATIONS
• ACSA more discriminating
• ACSA more sensitive to objective changes
• ACSA minimally sensitive to fixed
  socio-demographic variables such as gender age
• and possibly less to personality traits

• POSSIBLE EXPLANATIONS
• Less randomness by serious or even solemn
  question, concrete and individually pertinent
  scale anchors,
• Respondent his own control
• ACSA self-anchored internal standard with
  personal biographical references
• Respondent his own control

27
Cultural gaps bridged by ACSA?

• Hypothesis If Asians and Europeans are asked to
  use ACSAs biographical scale anchors, this may
  normalise their QOL scales. Thus, we could
  dispense with the need for cultural correction
  factors when comparing QOL in different
  cultures.
• Future research more intercultural comparisons,
  further study of scale properties.

28
Does taking a face-to-face ACSA interview qualify
as Deep Listening?

• In clinical practice, ACSA opened a broad area of
  communication between patient and caregiver
• Respondentss appreciation (control study by
  clinical psychologists)
• high 60
• moderate 22
• low 18
• (Souris, M., Ledure, G. and Bernheim, J.L .
  1983, L'auto-évaluation anamnestique comparative
  (ACSA). III. Fiabilité de la méthode et tolérance
  des malades cancéreux, Psychologie médicale 15,
  pp. 1625-1626.)

29
Future Research on putative universal
applicabiliity of ACSA

• Problem people have objectively different life
  circumstances characterising their ACSA scale
  anchors (e.g. Switzerland vs Rwanda or Cambodja)
  ?ACSA would be universal only on condition that
• self-defined biographical extreme scale anchors
  would represent the (individually specific)
  saturation levels of happiness and misery, and
• every adult would (if only for short times) have
  lived through (an) extreme(s) saturating their
  capacity for perception of happiness and misery
• ?Research question Are happiness/unhappiness,
  like all receptor-mediated perceptions,
  saturable?

30
Some References

• Bernheim, J.L. 1983, L'auto-évaluation
  anamnestique comparative (ACSA).I. Description
  d'une méthode de mesure de la qualité subjective
  de la vie des malades cancéreux, Psychologie
  médicale 15, pp. 1625-1626.
• Bernheim, J.L. 1999, How to get serious answers
  to the serious question How have you been?
  subjective quality of life (QOL) as an individual
  experiential emergent construct, Bioethics 13,
  pp. 272-287.
• Bernheim, J.L., and M. Buyse 1984, The
  Anamnestic Comparative Self Assessment for
  measuring the subjective quality of life of
  cancer patients, J. Psychosoc. Oncol. 1, pp.
  25-38.
• Buyse, M., J.L. Bernheim and N. Rotmensz 1983,
  L'autoévaluation anamnestique comparative
  (ACSA). II. Résultats d'une étude pilote portant
  sur 65 patients cancéreux, Psychologie médicale
  15, pp. 1623-1624.
• Cummins, R.A. 1996, The Domains of Life
  Satisfaction An Attempt to order Chaos, Social
  Indicators Research 38, pp. 303-328.
• Diener, E., Diener, M. 1995, Cross-cultural
  correlates of life satisfaction and self-esteem,
  Journal of Personality and Social Psychology, 68,
  653-663.
• Inglehart, R. 2004, World Values Survey.
  http//www.worldvaluessurvey.org/news/index.html
• Ouweneel P. and R. Veenhoven 1991,
  Cross-National Differences in Happiness
  Cultural Bias or Societal Quality? in
  BleichrodtN Drenth, P.J. (eds), Contemporary
  issues in cross-cultural psychology (Swets
  Zeitlinger, Amsterdam), pp.JH1.
• Schwartz, C.E. and Sprangers, M.A.G. 2000,
  Adaptation to changing health Response shift in
  quality-of-life research, (Washington, DC
  American Psychological Association
• Souris, M., Ledure, G. and Bernheim, J.L . 1983,
  L'auto-évaluation anamnestique comparative
  (ACSA). III. Fiabilité de la méthode et tolérance
  des malades cancéreux, Psychologie médicale 15,
  pp. 1625-1626
• Steel, P. and Ones, D.S. 2002, Personality and
  happiness a national-level analysis., Journal
  of Personality and Social Psychology 83, pp
  767-781
• Veenhoven, R. 2005, World Database of Happiness.
  http//www.eur.nl/fsw/research/happiness
• ).
• .