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Table 1 Critique of three most commonly used HRQOL models

From: Systematic review of health-related quality of life models

Criteria and Description (Bredow,[10]) Wilson &; Cleary Model of HRQOL[12] Ferrans et al. Revised Wilson and Cleary Model of HRQOL[13] World Health Organization International Classification of Functioning Disability and Health (WHO ICF)[3]
Internal criticism    
Adequacy    
Addresses a defined area    
· Completeness · Complete overall conceptualization of HRQOL from biomedical and social science perspectives · Expanded Wilson &; Cleary’s model to better explicate individual and environmental factors · Complete overall conceptualization of health from biomedical and social science perspectives
· Gaps · Gaps include management of therapeutic regimens and self-management · Gaps still include management of therapeutic regimens and self-management · Gaps include determinants of health, management of risk factors, and self-management
· Need for refinement · Refinement for specific practice situations needed. · Refinement for specific practice situations needed. · Refinement for specific practice situations needed.
Clarity · Main concepts well-defined, although individual and environmental characteristics not explained. · Main concepts well-defined, including individual and environmental characteristics. · Main concepts well-defined, with the exception of overlap between activities and participation.
Explicit components · Explicit proposition that dominant relationships exist with the potential for reciprocal relationships. · Explicit proposition that dominant relationships exist with the potential for reciprocal relationships. · Explicit propositions exist with reciprocal relationships that can be used to map the constructs and domains.
· Concepts (components) defined · Strength of the relationships of each component is unclear and with each additional relationship the complexity increases. · Propositions were added with individual and environmental characteristics. · Explicit assumption that model provides a multipurpose classification and can serve as a unified and standard language for health care workers, researchers, policy-makers, and the public.
· Explicit propositions (Relationships) · Other relationships were implied. · Nonmedical factors removed; described as part of individual and environmental characteristics.  
· Explicit assumptions (Beliefs) · Explicit assumption that understanding relationships among these domains will lead to the design of optimally effective clinical interventions. · Explicit assumption that understanding relationships among these domains will lead to the design of optimally effective clinical interventions. · Another explicit assumption is that model can be used to help plan interventions for functional goals and health, worldwide.
Consistency    
Consistency    
· Concepts Congruency · Concepts consistently defined. · Concepts consistently defined. · Concepts consistently defined.
· Assumptions (beliefs) · Assumptions were congruent · Assumptions were congruent · Assumptions were congruent
· Propositions (relationships) · The figure depicts dominant directional relationships whereas the text mentions reciprocal and other non-depicted relationships. · Propositions were congruent. · Propositions were congruent.
Logical development · Emerged based on research from biomedical and social sciences. · Revision of Wilson &; Cleary · Integration of medical and social models for a biopsychosocial approach.
Based on previous work Evidence supports · Relationships depicted don’t always hold true, research evidence supports lack of relationships in some instances (e.g., biological vs. symptoms) · Emerged based on empirical evidence and the need for further clarity. · Evolved over time from the WHO ICIDH model in 1980 to the WHO ICF in 2001, with the WHO ICF-CY for children and adolescents added in 2007.
    · Based on systematic field trials and international consultation.
Level of development    
Level of abstraction (grand, middle range, or practice) · Middle range but global Middle range but global Middle range but global
External criticism    
Complexity    
· Number of concepts · 5 main abstract concepts (biological/physiological, symptom status, functional status, general health, quality of life) · 5 main abstract concepts with further development of the individual and environmental factors. · 6 main abstract concepts (body functions, body structures, activity, participation, environmental factors, and personal factors).
· Parsimony · Parsimonious because used only 5 main concepts to explain abstract HRQOL. · Parsimonious because used only 7 main concepts to explain abstract HRQOL. · Parsimonious because used only 6 main concepts to explain abstract health and health-related states.
· Complexity · Overall model is complex with multiple relationships · Overall model is complex with multiple relationships · Overall model is complex with multiple relationships
Discrimination · First HRQOL model to combine biomedical with social science · Revised Wilson and Cleary’s HRQOL model · Belongs to a family of WHO Classifications, with the WHO ICF being specific to functioning and disability.
Unique theory of HRQOL with clear boundaries · Unique to HRQOL · Unique to HRQOL · Not unique to HRQOL.
  · Boundaries are purposefully not clear as two theories are combined and the relationships between concepts are additive. · Clear boundaries and limited to HRQOL of individuals. · Clear boundaries addressing health and health-related domains.
  · Hypotheses generation may help to clarify boundaries.   · Does not cover non-health related circumstances.
Reality convergence · Moving from cellular level to quality of life in model seems more realistic than traditional biomedical model by itself. · Realism added with the incorporation of nonmedical factors into individual and environmental factors. · Assumptions seem true, realistic, and consistent.
· Assumptions “real world” · “Makes sense” for real world application. · “Makes sense” for real world application. · “Makes sense” for real world application.
· Theory/model “makes sense” · Assumptions are difficult to actualize · Assumptions more realistic  
Pragmatic Guided literature applied to real world settings: Guided literature applied to real world settings: Guided literature applied to real world settings:
Operationalized in real-life settings · 3 literature reviews, · 2 literature reviews · 3 literature reviews
  · 4 descriptive, · 1 instrument development · 2 instrument development
Model testing in entirety not done Model testing in entirety not done
  · 6 correlational, · Overall, generic and situation-specific measures exist · Overall, generic and situation-specific measures exist
  · 1 randomized trial, · Response shift is a concern for general health and quality of life components · Response shift may also be a concern.
  · 1 qualitative,   
  · 1 mixed methods   
  · 1 model revision (Ferrans) Model testing in entirety rarely done   
  · Overall, generic and situation-specific measures exist   
  · Response shift is a concern for general health and quality of life components   
Scope    
· breadth of theory/model · Broad model to explain complex nature of HRQOL · Further broadens Wilson and Cleary’s scope by expanding on individual and environmental factors · Broad model to explain health and health-related domains for all people.
· applies across ages (lifespan), health and disease conditions, cultures, socioeconomics, and individuals/families/ communities · Could apply to individuals of all ages, life spans, health and disease conditions, and perhaps cultures depending on their orientation to the meaning of quality of life and general health.   · Could apply to individuals of all ages, life spans, health and disease conditions, and cultures across the world.
· WHO ICF-CY specifically covers infants, children, and adolescentzs.
  · May not apply to those who are unable to define their own general health or quality of life (e.g., infants, comatose), or those who have very limited functioning.   · Focus is on individuals (with or without disabilities), families, communities, and populations.
  · Primarily applies to individuals, less to families and communities.   
Significance · Most widely cited HRQOL model · Emerging citations for Revised HRQOL model · Emerging citations for the use of the WHO ICF for hypothesis testing (mainly instrument development).
· Potential impact on practice · Guides HRQOL assessment toward a more comprehensive approach to improving HRQOL
Potential for intervention research but limited evidence exists to date.
· Guides HRQOL assessment toward a more comprehensive approach to improving HRQOL · As a clinical tool, can be used for needs assessments, matching treatments with conditions, and evaluating outcomes.
· Hypotheses lead to assessment or interventions · Because of the complexity of the model and lack of testing of the full model, supporting interventions would be difficult. · Potential for intervention research but limited evidence exists to date. · As a research tool, can be used for measuring quality of life, outcomes, environmental factors, or other constructs.
· Potential for intervention research but limited evidence exists to date. More of a mapping and classification framework, rather than hypothesis generating.
Utility Hypothesis generating for: Hypothesis generating for: Hypothesis generating for:
Hypothesis generating for clinicians, researchers, epidemiologists, policymakers · Clinicians for a broader view of HRQOL than just biological factors and symptoms. · Clinicians for a broader view of HRQOL than just biological factors and symptoms. · Clinicians for needs assessments, matching treatments with conditions, vocational assessment, and rehabilitation and outcome evaluation
  · Researchers to guide measurement and intervention studies: · Expands focus of article (audience) from physicians (Wilson &; Cleary) to nurses and other health professionals (Ferrans). Model could be applied to any health care discipline. · Researchers to guide development of measures for outcomes, quality of life, or environmental factors
  · Potentially relevant to epidemiologists if using global measures across populations (e.g., SF-36). · Researchers to guide measurement and intervention studies. · Epidemiologists to collect and record data for populations and management information systems
  · More research evidence and emphasis on environmental factors needed to convince policymakers. · Potentially relevant to epidemiologists if using global measures across populations (e.g., SF-36). · Policymakers to plan social security, compensation systems, and policies.
   · More research evidence and emphasis on environmental factors needed to convince policymakers. · Educators to design curriculums that emphasize awareness and social action.
    · Although potential for hypothesis generation in these areas, there is currently limited evidence found in the HRQOL literature documenting these applications.