Quality of Life and the Millennium Challenge: Advances in Quality-of-Life Studies, Theory and Research (Social Indicators Research Series)

Quality of Life and the Millennium Challenge Social Indicators Research Series Volume 35 General Editor: ALEX C. MICH...

Author: Valerie Moller | Denis Huschka

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Quality of Life and the Millennium Challenge

Social Indicators Research Series Volume 35 General Editor: ALEX C. MICHALOS University of Northern British Columbia, Prince George, Canada

Editors: ED DIENER University of Illinois, Champaign, U.S.A. WOLFGANG GLATZER J.W. Goethe University, Frankfurt am Main, Germany TORBJORN MOUM University of Oslo, Norway MIRJAM A.G. SPRANGERS University of Amsterdam, The Netherlands JOACHIM VOGEL Central Bureau of Statistics, Stockholm, Sweden RUUT VEENHOVEN Erasmus University, Rotterdam, The Netherlands This new series aims to provide a public forum for single treatises and collections of papers on social indicators research that are too long to be published in our journal Social Indicators Research. Like the journal, the book series deals with statistical assessments of the quality of life from a broad perspective. It welcomes the research on a wide variety of substantive areas, including health, crime, housing, education, family life, leisure activities, transportation, mobility, economics, work, religion and environmental issues. These areas of research will focus on the impact of key issues such as health on the overall quality of life and vice versa. An international review board, consisting of Ruut Veenhoven, Joachim Vogel, Ed Diener, Torbjorn Moum, Mirjam A.G. Sprangers and Wolfgang Glatzer, will ensure the high quality of the series as a whole.

For other titles published in this series, go to www.springer.com/series/6548

Valerie Møller • Denis Huschka Editors

Quality of Life and the Millennium Challenge Advances in Quality-of-Life Studies, Theory and Research

Editors Valerie Møller Rhodes University Grahamstown South Africa

ISBN 978-1-4020-8568-0

Denis Huschka German Council for Social and Economic Data Berlin Germany

e-ISBN 978-1-4020-8569-7

Library of Congress Control Number: 2008931345 © 2009 Springer Science + Business Media B.V. No part of this work may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording or otherwise, without written permission from the Publisher, with the exception of any material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Printed on acid-free paper 9 8 7 6 5 4 3 2 1 springer.com

Acknowledgments

The seventh annual conference of the International Society for Quality-of-Life Studies (ISQOLS) was held for the first time in a developing country and in Africa, at Rhodes University, Grahamstown, South Africa, 17–20 July 2006. This volume presents a selection of papers from the meeting that broadly address the conference theme ‘Prospects for Quality of Life in the New Millennium’. Many people contributed to the success of the conference. We wish to thank Rhodes University colleagues for their hospitality and assistance: in particular conference manager Carolyn Stevenson-Milln and her staff and volunteers; manager of graphic services Susan Abraham; colleagues in the finance division and the web unit; the housekeeping staff in Oriel Hall where conference participants were accommodated, and our colleagues in the Institute of Social and Economic Research. We are grateful for the financial contributions by Springer, Rhodes University, and the South African-Swedish Partnership Programme (SIDA) towards special functions at the conference. The German Socio-Economic Panel Study (SOEP) at the German Institute for Economic Research (DIW) Berlin made it possible for Denis Huschka to spend several months in South Africa to assist with preparations for the conference.We wish to acknowledge the assistance of the members of the Scientific Committee that screened the papers accepted for presentation at the conference. Post-conference we relied on the knowledge and expertise of many of our colleagues in ISQOLS who volunteered to peer-review the papers in this volume. In alphabetical order, the peer reviewers who willingly provided constructive feedback to authors included Susanne von Below, Jan Bernheim, Jeroen Boelhouwer, Laura Camfield, Andrew Clark, Jan Delhey, Wolfgang Glatzer, Mary Joyce, Ralph Kober, Filomena Maggino, Torbjørn Moum, Heinz-Herbert Noll, Giampaolo Nuvolati, Robin Richards, Lia Rodriguez de la Vega, Stephen Rule, Joseph Sirgy, Peter Theuns, Margaret Westaway, and Michael Whisson. A Rhodes University Council research grant contributed towards the costs of preparing the conference volumes. We are grateful to our colleague Nova de Villiers for sharing her language-editing skills and to Esther Otten at Springer for seeing the project through.

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Acknowledgments

Our sincere thanks go to Joachim Vogel who has inspired several generations of social indicators researchers with his vision of best practice in social reporting. “In a statistician’s paradise, there is readily available statistical information on all aspects of human life. …the secrets of society pour out to the wonder and admiration of the mass media, policymakers and other grateful consumers. And, of course, there are no financial constraints” (1994, p.250).

Without Joachim’s initiative we should not have embarked on the joint SIDAsupported Euromodule project for South Africa. SIDA later provided the additional financial support for our ISQOLS conference that brought us a bit closer to Joachim’s statistical heaven by sparing us many a sleepless night. Most of all, we are grateful to Joachim for his collegial support and guidance before and after the meeting although unfortunately he could not come to Africa in 2006 to share the actual conference experience. Finally, we wish to thank our authors for providing fresh insights into the challenges facing social scientists and policymakers in their efforts to advance quality of life on our planet in the new millennium.

January 2008 Grahamstown, South Africa Conference co-chairs: Valerie Møller Institute of Social and Economic Research; Rhodes University [email protected]

Denis Huschka German Council for Social and Economic Data Permanent Visiting Fellow, SOEP (DIW Berlin) Research Associate, Institute of Social and Economic Research; Rhodes University [email protected]

Reference Vogel, J. 1994. Social indicators and social reporting: traditions and current options for the development of comparative social indicators for the European Union. Statistical Journal of the United Nations ECE 11, 241–260.

Contents

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Challenges for Quality-of-Life Studies in the New Millennium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Valerie Møller and Denis Huschka

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Part I

Learning from the Past to Inform the Future

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South Africa: Yesterday, Today, and Tomorrow . . . . . . . . . . . . . . . . . . John Kane-Berman

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Poverty and the Quality of Life: Lessons from South African Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Francis Wilson

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The Importance of a Mixed Cash- and Harvest Herding Based Economy to Living in the Arctic – An Analysis on the Survey of Living Conditions in the Arctic (SLiCA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Birger Poppel and Jack Kruse

Part II

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Refining Concepts and Measurement to Assess Cross-Cultural Quality of Life

The International Scale Interval Study: Improving the Comparability of Responses to Survey Questions About Happiness . . . . . . . . . . . . . . . . . . . . . . . . . Ruut Veenhoven More Than SF-36? Using Narratives to Elaborate Health and Well-Being Data in Recent Lower-Limb Amputees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Narelle Warren, Lenore Manderson and RoseAnne Misajon

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Contents

6. The Spiritual Dimension of Quality of Life, with Special Reference to Education and Spirituality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Martin Valenkamp and Johannes L. van der Walt Part III

Addressing the Role of Stability and Change in the New Millennium

7. The Impact of Instability on Subjective Well-Being: A Cross-National Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ming-Chang Tsai 8. Stability and Change in National and Personal Wellbeing in Algeria: A Case Study of a Developing Country in Transition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Habib Tiliouine 9. ‘All That Glitters Is not Gold’: Johannesburg and Migrant Access to Social Services . . . . . . . . . . . . . . . . . . . . . . . . . Rodreck Mupedziswa Part IV

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Exploring the Role of Good Governance for a Better Quality of Life

10. Trust and Life Satisfaction in Eastern and Western Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Georg P. Mueller

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11. Quality of Life in Cities: A Question of Mobility and Accessibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Giampaolo Nuvolati

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12. The Main Determinants for Subjective Well-Being: A Quest for the Holy Grail? Can Governments Enhance the Perceived Quality of Life? . . . . . . . . . . . . . . . . . . . . . . . . Dries Verlet and Carl Devos Part V

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Health Care – A Major Challenge in the New Millennium

13. The Vicious Circularity of Mental Health Effects of HIV/AIDS: Symptom and Cause of Poor Responses to the Epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . Kevin Kelly, Melvyn Freeman, Nkululeko Nkomo and Pumla Ntlabati

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14. Universal Coverage but Unequal Access? Experiences of Health Care in Northeast and South Thailand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Laura Camfield

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15. Prospects for Community-Based Rehabilitation in the New Millennium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Harry Finkenflügel

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Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Challenges for Quality-of-Life Studies in the New Millennium Valerie Møller and Denis Huschka

Abstract The International Society for Quality-of-Life Studies held its 7th annual conference for the first time in Africa and a developing country in July 2006. How best to evaluate quality of life in an age of globalisation, democratisation, and human rights, in a time when humankind faces escalating risks and uncertainties – some of its own making – was discussed at the conference. Fifteen papers that respond to different facets of the millennium challenge are brought together in the conference proceedings. The introductory article gives an overview of the so-called millennium challenge and introduces research that responds to the challenge under the headings: Learning from the past to inform the future; refining concepts and measurement to assess cross-cultural quality of life; the role of trust and stability in society; accessibility and good governance in cities; and the challenge of rehabilitation and health care for all in a time of HIV/AIDS. Keywords Millennium, quality of life, poverty, inequality, uncertainty, (in)stability, refugees, amputees, trust, accessibility, good governance, HIV/AIDS, universal health care, community-based rehabilitation The theme of the 7th conference of the International Society for Quality-of-Life Studies (ISQOLS) is multi-faceted. ‘Quality of Life in the New Millennium’ alludes to a turning point, to a completely new era. It signifies an entirely new concept of quality of life that is subject to very different conditions and premises than in the last century.

V. Møller Institute of Social and Economic Research, Rhodes University, Grahamstown, South Africa E-mail: [email protected] D. Huschka German Council for Social and Economic Data, Berlin, Germany, German Institute for Economic Research, Berlin, Germany, and Institute of Social and Economic Research, Rhodes University, South Africa E-mail: [email protected] V. Møller and D. Huschka (eds.) Quality of Life and the Millennium Challenge, © Springer Science + Business Media B.V. 2009

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V. Møller, D. Huschka

The new millennium is widely considered to be the age of globalisation, democratisation, and human rights. We live in a knowledge society and in a time of risk and uncertainty. It is the interplay of these key trends of the era that call for a fresh approach to quality-of-life studies. In this introduction we first attempt an overview of the challenges for quality-of-life research that relate to the characteristics of the new millennium. A brief outline follows of the conference papers we have selected to represent responses to the new challenges.

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The New Vision of the Good Life in a Time of Rapid Change

Quality-of-life research has made great strides since the social indicator movement started as a scientific enterprise in the 1960s (Land, 1996; Vogel, 1994). Researchers from a wide range of scientific disciplines are now engaged in describing and evaluating the human condition in many different parts of the world. Although quality-of-life researchers are better equipped both theoretically and practically than in the past, the new era has introduced new challenges. One such challenge relates to the very definition of the subject under study. The notion of the good life that has intrigued classical Greek scholars is fluid, and popular conceptions of the good life have shifted over time. The speed with which societies worldwide are changing in the new millennium is breathtaking. It is therefore possible that the vision of the good life has shifted dramatically over the past 40 years since the social indicator movement began. Quality of life denotes both description and evaluation (Michalos, 2006). Qualityof-life scholars develop indicators that measure what is commonly considered to make up an acceptable life of quality and then evaluate whether social reality matches this reference standard. The growing complexity of lifestyles in the new millennium makes it increasingly difficult to compile comprehensive social reports that span the full range of life domains. The same applies for the evaluative dimension of life quality. Most contemporary quality-of-life researchers generally assume that citizens rather than experts should be consulted on their conceptions of the good life, that is, on what are their needs and wants. In an age of specialisation and fragmentation the number of groups to be consulted and the range of viewpoints to be canvassed and adequately interpreted in quality-of-life studies represents a technical challenge for researchers.

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Making Democracy Work

Democracy is currently the political system of choice in the new millennium or is at least considered the best possible system of governance invented to date. The emergent democracies of the Second and Third World have now joined the ranks of the older democracies of the First World. By latest count there were 123 democracies

Challenges for Quality-of-Life Studies in the New Millennium

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among the 193 independent nation states of the world (Freedom House, 2007). It is generally accepted that educated citizens who are well informed are essential to make democracy work. Universal education is one of the Millennium Development Goals. As Alex Michalos notes, democracy, liberal education, autonomy and the good life are inextricably connected (2006: 362). One of the important roles of quality-of-life researchers is to engage citizens in assessing their life circumstances relative to their own conception of the good life. In democracies citizens are able to hold their governments accountable for pursuing the policies and making the interventions that will make the greatest improvements for the greatest number. There are moral and political issues related to the proper role of governments in providing the good life and public goods. Some contributors to this volume (see Verlet and Davos) question the degree to which government can intervene to create the good life for their citizens. This is a pertinent question for community quality-of-life scholars in the new millennium.

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Scarce Resources and Global Inequality

Many of the dominant concerns of the new millennium are results of human progress. Our success as a human race is most evident in our longevity. We have also made enormous technological advances. Population growth, longevity, and technological innovations are telling indicators of the achievements of the human race. However, in some quarters the successful domination of the planet by our own species is regarded as the looming threat of our downfall. There is increasing concern about loss of biodiversity and cultural diversity that is now known to be linked (Maffi, 2001). Ethnic groups and languages are disappearing before we have fully documented their characteristics. Fauna and flora are disappearing before we have discovered their significance for the planet’s and human wellbeing. Sustainable development is a keyword in the new millennium that aptly captures this concern. One definition of sustainable development is that resources should be used prudently in a manner that will ensure that there is sufficient left for future generations. In the millennium, there is a sharp focus on public goods that are not renewable. The debates on the impact of global warming, climate change, and the search for renewable sources of energy as alternatives to fossil fuel, which is currently the world’s major source of energy, impact on views of public goods in the new millennium. Public goods may be distinguished from private goods on the basis of jointness and nonexclusiveness (Olson, 1965). Using a public good does not imply using it up; public goods are to be used but not to be used up. Regarding non-exclusiveness: if everyone is entitled to access and no one can be excluded from enjoying public goods, how do we deal with free riders who overuse or abuse resources thus ruining the life chances of the morally upright? The contemporary debates on carbon-trading and who should foot the bill for assisting the countries most disadvantaged by climate changes not of their own making are prominent quality-of-life concerns in the new millennium.

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Winners and Losers in the Global Era

The dominant model for ensuring that citizens of the world enjoy a standard of living commensurate with the good life is economic growth. The need to constantly grow economies has placed strain on global raw materials and energy resources on an unprecedented scale in the millennium. It is generally accepted that economic growth creates hope and makes large income differentials tolerable. However, a dissenter retorts that “growth is a political sedative, snuffing out protest, permitting governments to avoid confrontation with the rich, preventing the construction of a just and sustainable economy” (Monbiot, 2007). Thanks to the economic growth of the past decades material living standards have risen enormously in many regions. Globalisation has brought good fortune to the few who have found their niche in the new economic order, but it has also increased the gap between rich and poor. The affluence and overuse of resources in richer nations is in stark contrast to the remaining pockets of poverty that still persist in spite of – some would say due to – structural adjustment programmes and campaigns to make poverty history. It is now generally accepted that there are winners and losers in a globalised market; and the inequalities between the rich and poor have increased in the millennium. Inequalities at all levels of society have created political tensions that threaten to destabilise peace and harmony. How to reconcile economic growth with equality is a conundrum for the new millennium that quality-of-life researchers need to consider carefully. Even economists, whose main enterprise is to monitor and better understand how growth benefits society, have sounded warnings that affluence has its downside (among others see Easterlin, 2002; Layard, 2005). Prominent economists of the millennium refer to the hedonic treadmill – the situation where the wants of yesterday no longer satisfy today – that may outstrip the resources required to satisfy the ever rising expectations of a growing world population. As Wolfgang Glatzer presciently observed at an earlier ISQOLS conference (Glatzer et al., 2004), it may not be possible for citizens of the Third World to ever enjoy the standards of living taken for granted by their counterparts in the First World. Understandably, this scenario gives rise to resentment and feelings of deprivation among people living in the poorer countries of the South.

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Mass Communication in the Global Era

In the age of globalisation, mass communication has ensured that citizens of democracies, and even people living in autocracies and closed societies, know how the better half – the rich and famous live. Soap operas project their lifestyles to the farest flung corners of the globe. Thanks to mass communication, material expectations of the good life may never have been as widespread as presently. At the same time the dominant human rights culture of the new millennium has instilled a sense of entitlement among all citizens of the globe. The losers of the global era feel short-changed and can be expected to voice their dissatisfaction and feelings of relative deprivation in quality-of-life studies.


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Mass communication has also brought instant information on developments in all parts of the world. In the new millennium people expect to watch news in the making. Real-time news may have both negative and positive impacts on life quality. It calls on people’s sense of justice and fairness in the case of oppression and exploitation and on people’s sense of solidarity to assist in the case of natural disasters. On the other hand, world travel has also served to expose us to a greater number of epidemics that rapidly move across borders.

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Risk and Uncertainty

We live in a high risk society in the new millennium. Rapid social change accelerates risk and the uncertainties associated with risks. As the sociologist Anthony Giddens (1999) reminds us, earlier times faced risks but never in the same proportions that we are experiencing in this age. Moreover, the risks associated with the rapid social and ecological changes we are witnessing today will be impossible to assess until their impact has been felt. That is, when it is too late. Only then will we be able to know if the doomsayers were mistaken or exaggerated the risks. And depending on the type of risk, we may not be around to do that! There has been a rapid succession of anticipated risks facing society in the new millennium. The ‘millennium bug’, the Y2K that was to have created havoc on the first day of the new millennium, turned out to be benign. With the wisdom of hindsight, the state of alertness was regarded as somewhat overdone. Many other threats have followed in the wake of Y2K. Most countries have adopted a cautious stance in relation to severe acute respiratory syndrome (SARS) and have developed contingency programmes. Not since the report from the Club of Rome in the 1960s on population growth outstripping the planet’s resources (Meadows et al., 1972) have we heard scientists sounding such a sobering wake-up call in the face of climate change. It is now accepted in many circles that members of the human race are perfectly capable of overusing their planet before its sun is extinguished.

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Human Rights and the Millennium Development Goals

Human rights, a dominant leitmotiv of the new millennium, encompasses the notion that all individuals should be given the opportunity to realise their full potential. The importance of human flourishing is a viewpoint held by proponents of the eudaimonic theory of quality of life (Deci, 2008). In contrast to earlier development goals, the Millennium Goals declare human well-being rather than national economic growth as the key objective. The aim is to achieve minimum standards of decent living for all rather than for poor countries to catch up with richer countries in terms of economic indicators.

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The first decade in the new millennium is a cynical one. As cynics, we know by now that the Millennium Development Goals (MDG) of halving poverty by 2015 and raising life expectancy in poor countries will most likely not be achieved. However, what may be more important is that the Millennium Development Goals have resulted in an international moral consensus on what the good life might mean for all the people of the world. The MDG is an inclusive concept. Governments have followed the lead of global institutions such as the United Nations and the World Bank and have tuned into the MDG and adopted them as reference targets for their own development strategies. Consider that in an earlier era the Human Development Index (HDI) (UNHDP, 1990) – also arguably an imperfect measure (see Hagerty et al., 2001) – has served a similar role as moral standard and as reminder of might constitute the good life. Few countries achieve top scores on the HDI. But the HDI has served as guiding principle and yardstick by which ordinary citizens can hold their governments responsible for meeting their basic needs. Similarly, the Millennium Goals – even if not achievable in the short term – can still usefully serve as universal reference target for the good life, an ideal worth working towards. Many of the millennium challenges are in terms of scale. Worldwide cities are growing by 185,000 per day. By 2050 two-thirds of the world’s population will be living in cities and in spite of rising sea levels, the dominant settlement pattern seems to be coastal. Pressure is mounting to provide the housing, facilities, and security that make for a life of quality for new city dwellers. Rapid urbanisation means that the city is fast becoming the dominant arena for quality-of-life studies. The Cold War and Pax Americana created a balance of power that has kept the threat of another world war at bay. However, it is uncertain that the peace may last in the new millennium. With the Cold War behind us, nuclear war is again on the world agenda. Unlike earlier wars, those of the twentieth century and of the new millennium affect civilians as much as soldiers. Technological advancement has created more lethal weaponry that does more harm to humans, infrastructure, and cultural monuments than hitherto. The regional conflicts of the new millennium have sacrificed the lives of millions. Others have been displaced, dispossessed and traumatised by war and conflict. Conflicts also take a heavy toll on global resources; they reverse development gains. These are some of the concerns that form the backdrop to the deliberations of the 7th conference of the International Society for Quality-of-life Studies (ISQOLS) with the theme ‘Challenges for Quality of Life in the New Millennium’ held in South Africa in July 2006.

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The Papers in this Volume

The selection of conference papers included in this volume present advances in the field of quality-of-life studies that address many of the concerns of the new millennium outlined above. Papers are grouped under five broad headings:


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Part I is titled ‘Learning from the Past to Inform the Future ’. Quality-of-life research does not take place in a vacuum. It is important for scholars and their audience to understand the social and historical context of the society under study in order to interpret social indicators and quality-of-life assessments. The first two papers presented by invited speakers aimed to give our international visitors an introduction to South Africa with lessons for quality-of-life studies. John Kane-Berman gives an overview of the challenges that face South Africa in the new millennium. His invited conference paper, presented in the first plenary session to brief international visitors, is based on the social indicators collected and communicated through the annual South African Survey and the newsletter Fast Facts. Francis Wilson, also an invited speaker at the ISQOLS conference, welcomed his audience to the Eastern Cape of South Africa where the isiXhosa pronunciation of ISQOLS with a distinctive click in the ‘q’ is the legacy of the San who lived there thousands of years ago before the Nguni immigrants arrived. In his address, Wilson outlines the milestones and the motivations that shaped South African poverty research before and after the coming of democracy in 1994. The humble lessons learnt by South African researchers are salient for contemporary quality-of-life scholars grappling with issues of sustainable development and social justice in the new millennium. Birger Poppel and Jack Kruse, based in the Arctic, report on the cultural and economic significance of hunting in one of the regions of the world most affected by global warming and climate change. These challenges of the new millennium will have a major impact on how people in the far north evaluate their quality of life in future. Part II is titled ‘Refining Concepts and Measurement to Assess Cross-Cultural Quality of Life’. Quality-of-life research has shifted its focus from once-off and cross-sectional studies to global assessments of quality of life over time. This requires instruments that are capable of overcoming cultural bias in measurements. Ruut Veenhoven outlines an international study that seeks to overcome the cultural bias in the use of happiness scales. This is an international enterprise that calls for the co-operation of scholars in different parts of the world to advance scientific measurement in quality-of-life studies. Narelle Warren, Lenore Manderson and RoseAnn Misajon debrief lower-limb amputees. In the process they identify some limitations of an instrument know as SF-36, a 36-item scale widely used in health-related quality-of-life studies. Their study sounds a warning that the real life experience of this group of patients is inadequately captured in their SF-36 scores. In line with the new trend in quality-of-life studies to look beyond the material to promote well-being, Martin Valenkamp and Johannes van der Walt locate the conceptual space in which to place the spiritual dimension of well-being. Although their essay is addressed primarily to educationists, it will enlighten students from other disciplines. Part III titled ‘Addressing the Role of Stability and Change in the New Millennium’ deals with the monitoring function of quality-of-life studies. The rationale for quality-of-life studies launched in the 1960s was to monitor the impact of societal change and interventions on citizen welfare.

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In a rapidly changing world, Tsai argues that instability is a factor that should not be overlooked in quality-of-life studies. His cross-national study reviews the impact of five different instabilities on happiness and life satisfaction across some 77 developing and developed countries. Inflation appears to have a greater impact than other instabilities such as unemployment and urbanisation. Political stability is found to be a co-determinant of life satisfaction but not of happiness. Habib Tiliouine’s study monitors well-being over two time periods in Algeria, a country that has experienced turbulent times. His longitudinal study examines the impact of social change on well-being assessed at the personal and national level using an international measure. Tiliouine presents his Algerian research as a case study of a developing country in transition. The increasing number of people displaced by natural disasters, wars, and failed states in the new millennium have resulted in a new class of world citizen: refugees and asylum seekers whose citizenship and status is in dispute. Rodreck Mupedziswa’s paper addresses the plight of asylum seekers and refugees who seek a better life in Johannesburg, South Africa, known as the ‘city of gold’. He argues that forced migrants should be regarded as assets rather than social burdens in a host country that has a shortage of skilled workers and prides itself on its human rights tradition. Part IV explores ‘The Role of Good Governance for a Better Quality of Life’. Seen from another vantage point, this section is preoccupied with the role of citizens in holding their governments accountable – one of the hallmarks of modern democracy. The papers in this section are based on European case studies. The authors are careful to take into account the layers of history in their analysis. Georg Mueller compares trust in institutions of the state in Eastern and Western Europe. His study finds that distrust has a negative impact on life satisfaction. Intriguing is Mueller’s examination of the various roles played by the state. On the one hand, the abuse of state power results in depressed citizen well-being, while on the other, the well-run state that maintains the social order acts as a buffer that insulates people from the misdeeds of fellow citizens. The city is the place where resources and services are concentrated. However, restricted mobility and limited access to these resources and services due to congestion depresses quality of life in cities. Nuvolati argues that accessibility is multifaceted and an all-important aspect of city life. His analysis of mobility and accessibility in Italian cities of different sizes concludes that innovative public policies and modern technologies will play an important role in improving access in the new millennium. Dries Verlet and Carl Devos have conducted a wide-ranging study of material and immaterial factors that impact on the daily quality of life of residents of the largest Flemish cities of Belgium. Their research begs the question whether government intervention will indeed result in more satisfied citizens in the new millennium. Part V addresses ‘Health Care – A Major Challenge in the New Millennium’. Good health and longevity are considered a human right in the new millennium. For international happiness researcher Ruut Veenhoven (1996), quality of life is synonymous with a long and healthy life. While modern medicine and food security has increased our life chances, greater mobility and modern lifestyles have also


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introduced new threats to health. Paradoxically, poverty and obesity are juxtaposing problems in developing countries. Kevin Kelly, an invited speaker at the conference, addresses one of Africa’s major health concerns, the HIV/AIDS epidemic. Kelly and co-authors Melvyn Freeman, Nkululeko Nkomo and Pumla Ntlabati argue that the stress experienced by HIV-positive people is not surprising given the way the epidemic has been managed in South Africa. Society has failed to create a positive environment for treatment. Successful HIV/AIDS intervention programmes need to address the mental health of the infected. Not only will this enhance the well-being of people living with HIV/AIDS, it will also curb epidemiological risks, such as drug resistance. In her article Laura Camfield documents the new experience of health care following on the introduction of a new health care system in Thailand aimed to achieve university coverage. Her study highlights the benefits but also the unintended negative consequences of a policy that has had a major impact on the health-related quality of life of ordinary Thai citizens in the new millennium. In the new millennium the rehabilitation of disabled people in society has undergone a paradigm shift from a medical to a human rights model. In an era of human rights, people living with disabilities expect equal life chances and access to opportunities. Harry Finkenflügel reviews the state of the art of Community-Based Rehabilitation (CBR) which is considered superior to rehabilitation in institutions. Finkenflügel challenges quality-of-life researchers to develop better tools to evaluate the benefits of community-based rehabilitation from a community development and empowerment perspective – approaches that are in tune with the new-age values.

References Deci, E.L. (ed.) 2008. Special issue: Eudaimonia. Journal of Happiness Studies 9 (1). Easterlin, R.A. 2002. The income-happiness relationship. In: Glatzer, W. (ed.). Rich and Poor: Disparities, Perceptions, Concomitants (Kluwer, Dordrecht, The Netherlands), pp. 157–175. Freedom House: ‘Freedom in the World’, 2007 edition http://www.freedomhouse.org/template. cfm? page=25&year=2007(accessed 16 January 2008) Glatzer, W., von Below, S., Stoffregen, M. (eds.). 2004. Challenges for Quality of Life in the Contemporary World (Kluwer, Dordrecht, The Netherlands). Giddens, A. 1999. The Reith Lectures: Risk, BBC New Online; at news.bbc.co.uk.reith_99 Hagerty, M.R., Cummins, R.A., Ferriss, A.L., Land, K., Michalos, A.C., Peterson, M., Sharpe, A., Sirgy, J., Vogel, J. 2001. Quality of life indexes for national policy: review and agenda for research. Social Indicators Research 55: 1–96. Land, K. 1996. Social indicators and the quality-of-life: Where do we stand in the mid-1990s? Social Indicators Network News (Sinet) 45: 5–8. Layard, R. 2005. Happiness: Lessons from a New Science (Penguin Books, London). Maffi, L. 2001. Introduction: On the interdependence of biological and cultural diversity. In: Maffi, L., and McNeely, J.A. (eds.). On Bio-cultural Diversity: Linking Language Knowledge and the Environment (Smithsonian Institution Press, Washington/London). Meadows, D.H., Meadows, D.L., Randers, J., Behrens, W.W. III. 1972. The Limits to Growth; A Report for the Club of Rome’s Project on the Predicament of Mankind (Universe Books, New York).

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Michalos, A.C. 2006. Conceptual and philosophical foundations. In: Sirgy, M.J., Michalos, A.C., Ferriss, A.L., Easterlin, R.A., Patrick, D., and Pavot, W. The quality-of-life (QOL) research movement: Past, present, and future. Social Indicators Research 76: 343–466. Monbiot, G. We should welcome a recession now. The Guardian Weekly, 12 October 2007: 18. Olson, M. 1965. The Logic of Collective Action (Harvard University Press, Cambridge, MA). United Nations Human Development Program (UNHDP). 1990. Human Development Report (Oxford University Press, New York/Oxford). Veenhoven, R. 1996. Happy life expectancy: a comprehensive measure of quality-of-life in nations. Social Indicators Research 39: 1–58. Vogel, J. 1994. Social indicators and social reporting. Statistical Journal of the United Nations ECE 11: 241–260.

Chapter 1

South Africa: Yesterday, Today, and Tomorrow John Kane-Berman1

Abstract The South African economy is now growing faster than at any time since the 1960s. The end of apartheid and international sanctions are to thank for this, as is robust demand for our minerals from China. Average per capita income is rising again after years of decline, and the racial distribution of income is changing. A black middle class is in the making, though its size is disputed. President Thabo Mbeki questions data showing an increase in the incidence of poverty. Some studies show a decrease in poverty, but mainly as a result of the extension of social grants made possible by buoyant tax revenues. Unemployment has doubled over the past decade to reach between 27% and 39%, depending on definition. Some 3.3 million jobless people have given up looking for work, for reasons we do not fully understand. The government plans to halve unemployment by 2014. Inter alia, this necessitates pushing up the rate of investment. Much of this investment will be in the public sector, where there are major shortages of infrastructure. The skills deficit that South Africa faces as a result of its poor education system may retard both investment and growth. Another major problem confronting the country is the ravages of HIV/AIDS, Mr. Mbeki’s indifference to which has earned him a place in history. Many people have experienced improvements in the quality of their lives, though the rapid rate of new housing construction has not been enough to keep up 1

Editors’ note: Mr John Kane-Berman, the South African Institute of Race Relations’ (SAIRR) Chief Executive, was invited to present an introduction to South Africa’s social indicators on the first day of the 7th Conference of the International Society for Quality-of-Life Studies (ISQOLS), held at Rhodes University, Grahamstown, South Africa, 17–20 July 2006. His institute was the recipient of the 2006 ISQOLS award for the Betterment of the Human Condition in recognition of ‘an organisation that has developed and used quality-of-life measures in the service of its constituency’. Mr. Kane-Berman’s presentation delivered on 17 July, 2006, is based on information contained in South African Institute of Race Relations publications: the South African Survey, produced annually, and Fast Facts, a monthly information bulletin, http:// www.sairr.org.za.

J. Kane-Berman Chief Executive South African Institute of Race Relations (SAIRR), P.O. Box 31044, Braamfontein, Johannesburg, South Africa E-mail: [email protected] V. Møller and D. Huschka (eds.) Quality of Life and the Millennium Challenge, © Springer Science + Business Media B.V. 2009

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with demand. If AIDS is one terrifying scourge, crime is another. Race relations are basically sound. But the government is committed to a comprehensive policy of racial engineering. Keywords Economic growth, rising incomes, income distribution, black middle class, poverty, unemployment, social grants, investment, infrastructure, skill shortages, HIV/AIDS, Mbeki and AIDS, housing, quality of life, crime, race relations, racial engineering, racial restructuring, employment equity, black economic empowerment This paper is in two parts. The first is a statistical tour of South Africa. The second is essentially a commentary.

1.1

The Statistical Tour

The South African economy is now growing at a rate of about 4% a year on average. This is our best performance since the 1960s, when gross domestic product (GDP) grew at 6%. That rate halved in the 1970s, halved again in the 1980s, and halved yet again in the 1990s, before starting to climb again. The government wants to see the average annual rate rise to 4.5% between now and 2009, and then to 6% by 2014. Some economists believe we need to be much more ambitious, and aim at 8%, which is the rate at which China is growing. Others take the view that skills shortages would prevent this, and that we would also be vulnerable to both higher inflation and larger deficits on the current account of the balance of payments than we would be able to finance by attracting foreign capital. Faster growth could also be impeded by our backlogs in physical infrastructure, such as roads, railways, and harbours. If we measure average wealth – GDP per capita – we find that our most prosperous year was 1981, when GDP per head was about R24,000 (in constant 2000 prices). Thereafter GDP per head declined to just below R20,000 in 1993, after which it began climbing again. This year it could reach about R24,000 again. This means that we will have taken 25 years to get back to where we were in 1981 – a terrible performance. Factors influencing the rate of growth of an economy are numerous and complex. Very roughly we can say that South Africa’s decline during the last few decades of the 20th century was partly to be blamed on political turbulence, economic mismanagement, international sanctions, and global oil price shocks. The recovery in the 21st century is partly a function of better management and the political stability that has accompanied the advent of democracy. High commodity prices, thanks largely to booming demand from China, have also provided a windfall to the South African economy in the last few years. The period since 1960 has seen a change in the distribution of personal disposable income (income after tax). The African share has risen from about a quarter to almost half (or will have done by 2007). The white share has declined from almost 70% to around 40%. (Africans comprise some 80% of the population, and whites

1 South Africa: Yesterday, Today, and Tomorrow

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9%.) In recent years there has been much excited talk of the growth of the black middle class, though little agreement on how it should be defined. One broad definition, which includes young people and the lower middle class, arrives at a middle class of two million. These are the people whose spending has helped to cause the current boom in the retail sector. A much narrower definition – which counts only the upper middle class – puts the African middle class at only 185,000. These people are less likely to believe in government interventionism than the wider middle class. What has happened to poverty? On a very strict definition, having to make do on less than a dollar a day, the poverty rate in South Africa rose from 4.5% (1.90 million people) in 1996 to 9.7% (4.49 million) in 2002, before dropping to 9.2% (4.31 million) in 2004. President Thabo Mbeki has disputed that poverty has increased. Some studies do show a decrease, but largely as a result of the expansion of social grants in recent years. Some of Mbeki’s colleagues, notably the minister of finance, Trevor Manuel, have said that people should work rather than live on ‘handouts’, as he termed them. Manuel’s success in reducing the budget deficit – and therefore the government’s interest bill on its loans – has helped to provide the wherewithal to finance the large increase in spending on social grants. The government has successfully brought down the budget deficit, thanks less to spending cuts than to buoyant tax revenues. It has also reduced the rate of inflation. Not so the problem of unemployment. New jobs have of course been generated – some 3.01 million of them between 1996 and 2005. But the demand for jobs – the supply of labour – has risen by 5.28 million, so that unemployment has also risen, by 2.26 million. There are two definitions of unemployment. The strict one counts you as unemployed if you are out of work, available for work, and looking for work. The expanded definition drops the last of these three criteria. On the strict definition our unemployment rate is 27%, which translates into 4.5 million jobless people. The expanded rate is 39% and the expanded number 7.8 million. These are very high figures indeed. The difference of 3.3 million comprises people who are out of work and available for work, but not looking for it. The question is why, and we unfortunately don’t really know the answer. These people are referred to as ‘discouraged’ workers. Some of them may indeed have been searching fruitlessly for work for so long that they have now given up in despair. But there could be other reasons why these jobless people do not look for work. Some of them could be living off relations, some could be too sick with AIDS, or too poor to travel for job interviews. Receipt into the household of social grants could act as a disincentive to working, or perhaps some might be earning income from renting out rooms in their backyards. Some of the ‘discouraged’ workers might be unwilling to work in the jobs and at the wages on offer. We need much more research into unemployment in South Africa to be able to understand it better. The government aims to halve unemployment by 2014. This means the economy will have to generate between 350,000 and 725,000 net new jobs a year, depending on how unemployment is defined. The generation of jobs is heavily dependent on investment in new productive capacity. Conventional wisdom has it that we must invest about a quarter of GDP

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to grow fast enough to generate enough jobs. Over the past decade, however, investment as a proportion of GDP has been bumping along at only about 15%. The government wants to push this figure up to 25%, and it has started to climb slowly. Over the past quarter of a century, investment by the private sector has accounted for a steadily increased share of total investment, because investment by the public sector has been more or less stagnant. Now the government is committed to spending about R372 million in public sector investment over the next few years – on roads, railways, harbours, municipal infrastructure, and electricity generating capacity. Some of this spending – which includes that of state-owned enterprises such as Eskom and Transnet – is necessary to get the country in shape for the world soccer cup in 2010. Can we do it? Thanks to buoyant tax revenues, the money is there, but being able to spend it depends quite heavily on overcoming the skills shortages plaguing all levels of government. This brings us to our education system. It is not feeding the universities and technikons with enough matriculants, certainly not in maths and science, to enable them to churn out the skilled professionals we need. A large proportion of 10th graders drop out of school before they write matric (12th grade). And among Africans in particular, only a tiny proportion of those who do write matric obtain top-quality maths passes. So it is no wonder that the deputy president, Phumzile MlamboNgcuka, says the skill shortage is a ‘potentially fatal constraint’ on the country’s ability to reach the higher rates of growth necessary to generate the jobs we need. And of course we lose many skilled (and unskilled) people to AIDS. The HIVinfection rate among pregnant women attending ante-natal clinics has risen over the past 15 years to over 30%. There has been a particularly large increase in recent years in the number of deaths of people between the ages of 25 and 34. The number of babies born who are HIV-positive has started to decline, but this may be because AIDS has already killed enough mothers for the birth-rate to drop as well as because the government has started (at the behest of the Constitutional Court) to provide medicine to prevent the disease from being transmitted from mothers to their babies. AIDS has caused life-expectancy in South Africa to drop. We have slipped steadily down the international human development index, to a ranking of 120 out of 176 countries in 2003. Of this tragic, catastrophic, performance the Mbeki government, with its years of indifference to people afflicted with HIV/ AIDS, should be deeply ashamed. History will remember Mbeki’s indifference to HIV/AIDS before it remembers anything else about him. For many others, there have been improvements in the quality of life. Over the past decade the number of households living in ‘formal’ (brick-and-mortar) structures has risen from 6.42 million to 8.88 million, an increase of 2.46 million, or 38%. That is quite an impressive figure. But the number living in ‘informal’ houses (shacks and shanties) has also risen, from 0.63 million to 2.03 million, an increase of 1.40 million, or 228%. These figures tell us that although the rate of formal housing construction has risen substantially, it has not been fast enough to keep pace with demand, with the result that more and more shacks have been erected. Demand for new housing arises from population growth, population shifts (between provinces and/or from countryside to town), and a decline in average household size,

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itself a function of rising affluence among some sections of the population. The problem with promising ‘a better life for all’ – as the African National Congress did before the 1994 election – is that it involves trying to hit a moving target. The government talks of a society ‘free of shacks’, which is a noble but at this stage an impossible dream. Crime remains an enormous problem. The government has steadily increased spending on the criminal justice system. The budget per head has gone up in real terms by 3% a year in the past ten years. But the crime rate – i.e. crimes per 100,000 of population – has dropped by only 0.2% a year. We achieve this dismal result after spending a lot more on the three components of our criminal justice system – the departments of justice, police, and correctional services – than the international average. The rest of the world spends 1% of GDP, we spend 3%.

1.2

Commentary

Among South Africa’s main successes since 1994 are the transition from minority to majority rule, and our re-integration into the global economy. Another success is the fact that the constitution enjoys wide legitimacy across the political spectrum and among people of all races. A fourth success is that race relations are basically sound. Major problems we face are unemployment, very poor public education, AIDS, and very high levels of crime, especially violent crime. The government has no credible policy to deal with any of these.2 In June 1996 the government adopted an economic policy framework known as the Growth, Employment, and Redistribution (GEAR) programme. Key components thereof were to reduce the budget deficit and keep down inflation. These were seen as essential to creating the climate for higher levels of private investment. As already noted, the deficit is down, along with inflation, but investment levels are disappointing. Another part of GEAR was supposed to be the liberalisation of the labour market, which is widely seen as so restrictive that it inhibits the hiring of workers and so causes unemployment to be higher than it might otherwise be. There has been minimal liberalisation, because the labour minister is personally hostile to it and because the government is frightened of a confrontation with the trade unions. While GEAR saw higher levels of economic growth as the key to

2

At the time this speech was delivered, the government was still allowing its health minister to undermine its own (belated and slow) provision of antiretroviral medicines to AIDS patients in the public health sector. She repeatedly sought to discredit them while promoting supposed alternatives such as garlic, beetroot, olives, and lemons. In November 2006, after her supposed remedies had brought ridicule upon the country’s head at an international AIDS conference in Toronto, it appeared that control of the government’s AIDS programme had been given by the Cabinet to the deputy health minister, who promised to stop the campaign to promote vegetables as alternatives to medicine. A proper campaign of public education would be an important part of a credible policy.

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reducing poverty, inequality, and unemployment, the government has since decided that the racial restructuring of the economy is more important than growth. There are two key components to this policy. One is ‘employment equity’, in terms of which all levels of the workforce are supposed to be representative of the racial breakdown of the country. The other is ‘black economic empowerment’, which means that a proportion of the equity (usually 25%) of all companies in the private sector must be owned by blacks by a specified date. There is a wide view that both of these policies are politically necessary, but they come at a price. This includes the loss of (scarce) white skills, as whites are displaced from the public sector in particular (and often then emigrate). Another cost is the generally poor performance of government at national, provincial, and local level as apartheid education policies ensured that there are simply not enough skills within the black population to fill all the vacant posts. (South Africa in fact is short of skills – from engineers to doctors to accountants to nurses to maths teachers to foremen to artisans – whatever their supposed ‘colour’.) One consequence of our skills shortage is that we may not be able to get everything shipshape for the soccer world cup in 2010. The government sets an extremely high priority on the prestige that supposedly comes from hosting this tournament, so there is a chance it may relax some of the racial restrictions in the workplace to enable white skills to be used rather than cast aside. In other words, as was the case under National Party rule, racial restrictions in the workplace may once again prove to be a luxury that the country cannot afford.

Chapter 2

Poverty and the Quality of Life: Lessons from South African Research Francis Wilson1

Abstract After touching briefly on the milestones of poverty research in South Africa during the first three-quarters of the 20th century, the paper focuses on the findings of the Second Carnegie Inquiry into Poverty & Development in Southern Africa (1980–1989) which drew on the work of some 450 researchers primarily from 23 universities around the region. Using some of the most striking findings of the Inquiry (including, particularly, statements by people themselves enduring poverty) the paper analyses the impact of poverty by considering seven lessons that South Africans have learned over the past 20–25 years about the different dimensions of its impact on the quality of life. Keywords South Africa, poverty, quality of life, water, fuel, unemployment, HIV/ AIDS, uncertainty, inequality, governance

1

Editors’ note: We invited Professor Francis Wilson, the then chairperson of the International Social Science Council’s Comparative Research Programme on Poverty (CROP), to address our colleagues in the International Society for Quality-of-Life Studies in a plenary session of the seventh annual conference held at Rhodes University, Grahamstown, South Africa. As founder and head of the University of Cape Town’s Southern Africa Labour and Development Research Unit (Saldru), Wilson led the Second Carnegie Study of Poverty in South Africa (1980–1989). He also coordinated the subsequent Project for Statistics on Living Standards & Development (PSLSD) Study, conducted on the eve of the first democratic elections. The PSLSD brought together academics and policymakers across South Africa’s social divides to back a project that provided the African National Congress-led government with the social indicators it needed to inform its reconstruction and development programme.

F. Wilson School of Economics, University of Cape Town E-mail: [email protected]; [email protected] V. Møller and D. Huschka (eds.) Quality of Life and the Millennium Challenge, © Springer Science + Business Media B.V. 2009

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2.1

F. Wilson

Welcome to the Eastern Cape Province

Welcome to the Eastern Cape which is a very special part of South Africa. It is well known, inter alia, for its rather particular pronunciation. We do not expect our visitors to cope with Eastern Cape English which on one occasion caused a hapless visitor confronted by an E.C. customs official to start taking off his clothes when all the official was doing was to wish him a Nahs trip. isiXhosa, on the other hand, is a different matter. One does need to learn the clicks. Thus whilst you may all have thought that you were coming to an Iskwols conference, you ought by now to realise that if it is being held in the Eastern Cape it is an Isqols event; with the Q as in Qumbu, Iqilika or Miriam Makeba’s Iqira lendlela. Not so difficult if you just practise pulling the tip of your tongue away from the roof of your mouth properly as if you were imitating a horse’s hooves clopping over the cobbles. These clicks, of course, are the legacy of the San who were living in these parts for several thousand years before the Nguni immigrants arrived with their cattle, their maize and their knowledge of how to work with iron. Subsequent interaction – ‘conflict and co-operation’ (together with the mutual cultural exchange) is the South African leitmotif – meant that the southern Nguni acquired three particularly expressive clicks which enhanced the language no end. I am very glad to be here. My research links with Rhodes date back 60 years. Not because I am quite as old as that might imply but because in the bad old days research directors thought nothing of using child labour to make their meagre grants go further. Thus, growing up in the Amathole Mountains, I was inspanned – before I was ten – by Professor Lindsay Robb, Director of the Keiskammahoek Rural Survey, to measure, on a regular basis, the water-table in one of the marshes that fed a tributary of the Tyhume River. As two of the three principal authors of the four-volume survey were relatives, I guess he reckoned that a little unpaid family labour was fine in rural Africa.

2.2

Milestones in Poverty Research

Be that as it may. Poverty research in South Africa has a long history. Among the milestones along the way we note: • • • •

1906–1908. Transvaal Indigency Commission – focused on white poverty 1928–1932. Carnegie Commission into Poor Whites 1930. W.M. MacMillan, Complex South Africa 1942. SA Institute of Race Relations publications by J.D. Rheinalt Jones, A. & W. Hoernle, Ellen Helman & Edward Batson, on poverty, poverty datum lines, etc. • 1943. Jan Burger (Leo Marquard), Black Man’s Burden • 1960s. SA Institute of Race Relations, Facts & Figures compiled by Muriel Horrell and others

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• 1980s. Second Carnegie Inquiry into Poverty & Development in Southern Africa This latter was a major new thrust which drew in some 450 academics and other knowledgeable people from 23 universities and other places around southern Africa. Some 300 papers were prepared for a conference held at the University of Cape Town in April, 1984. Further research was undertaken and the whole was used as a quarry from which to write the report of the inquiry, Uprooting Poverty: The South African Challenge, by Francis Wilson and Mamphela Ramphele (Cape Town, 1989).

2.3

Major Findings

What then were the major findings or lessons of the Second Carnegie Inquiry? • The first point was made forcefully by black South Africans when asked (1980– 1982) whether they supported the idea of a major inquiry into poverty. “There is no need”, they replied, “spending good money discovering that there is poverty. We know that there is. What we want is action.” In digesting this challenge, the researchers had to think very hard about why to collect any information at all. In the process they came to see that ‘mapping the contours of poverty’ was a necessary stage in devising strategies to overcome it. But basic fact-finding alone was not enough. What Jeff Sachs, many years later, was to call ‘clinical economics’ was essential. • Second lesson was the importance of listening. At an early stage of the Inquiry organisers were asked to define poverty so that researchers could know what they were looking for and measure it. On reflection, the organisers said they did not know how to define it. Perhaps researchers might go and talk to those who endured poverty and ask them exactly how they experienced it. The following six insights helped to dispel forever the notion that one could ever measure poverty by means of a single number: 1. Once research workers had got out into the field to ask questions and to observe life as lived by those enduring poverty it was not long before they realised that the most dramatic symbol of poverty in the country was of a woman (always black but very seldom a man) going out for four or five hours two or three times a week to collect firewood; then walking home for several miles with a bundle on her head weighing perhaps 50 kg; and on the way walking underneath an Eskom power line which carried electricity from one city to another. For at the time, South Africa produced 60% of the electricity in Africa; it was wrapping some of its power stations into mothballs because of excess capacity. And yet approximately 80% of all African households did not have access to electricity for their household requirements. (Uprooting Poverty: 44)

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2. One study of three villages in what was then the Transkei found that the average household spent 187 minutes every day collecting water. Whilst another study in 19 villages in the rural Ciskei found that the energy expended by women carrying a container of water, weighing 21 kg, up the steep hill from the contaminated water source was roughly equivalent to the energy expended by miners wielding a pick. At the same time in a rural area of what is now Mpumalanga, there was found to be an average of one water tap for 360 people. Meanwhile white middle-class homes in the metropolitan areas had somewhere between two or three taps per person. (Uprooting Poverty: 48–49) 3. “Poverty,” said Mrs. Witbooi of Philipstown in the Karoo, “Is not knowing where your next meal is going to come from, and always wondering when the council is going to put your furniture out and always praying that your husband must not lose his job. To me that is poverty.” (Uprooting Poverty: 14) 4. On being unemployed in Lesotho: “Now that I am not working it is just like these hands of mine have been cut off and I am useless. Now life for my children will be difficult, they will scarcely eat. Now that I am not working – I do not know what I shall do or what I shall take and put against what.” (Uprooting Poverty: 84) 5. “My husband lost his job [in Cape Town] about five months ago. It was a big shock but we thought we could cope. I was earning a reasonably good wage. We had to cut a few corners though. We had to eat less meat. We had to save on all kinds of things. I had to now catch the train to work, ‘cause it was cheaper than the bus even though it took a lot longer. I also took in other people’s washing. There are a few people here who pay you to wash their clothes. I used to wash clothes every Sunday. Then two months ago I lost my job. We were desperate. There was no money coming in now. We had to spend everything we had in the time my husband was without a job. Now they’ve cut off the electricity and we’re two months in arrears with the rent. They’re going to evict us I’m sure; we just can’t pay though. My husband decided to go to Jo’burg. He went a month ago. He said he would get a job there. He sent some money the first week but I haven’t had any more money since. I don’t know where he is. I haven’t been able to get hold of him. I would like to go to Jo’burg to look for him but what can I do with the children? Before he left we used to take turns to look for work because the children can’t go to crèche because there’s no money. Sometimes they lie awake at night crying. I know they are crying because they are hungry. I feel like feeding them Rattex. When your children cry hunger-crying, your heart wants to break. It will be better if they were dead. When I think things like that, I feel worse. It’s terrible when a mother wants to kill her own children. But what can I do, I’m not a mother worth having.” (Uprooting Poverty: 97) 6. Sis Dinah explains: “You know, people do not understand why we sell liquor. They say that we are corrupting the community. They claim that we are evil because we call to other people’s husbands and sons to come with their sealed wage packets to our shebeens. They say we are breaking family lives. But I want to tell you the honest truth. I started selling liquor in 1965. This is when my husband left to stay with another woman. He left me with five kids. I had to feed,


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clothe and educate them. Mind, these are only the kids. We must still pay rent and do other things. Where are you supposed to get that money, when you know that the money you work for ends up paying the bus fare to Bellville? If you want to survive you must make a plan.” (Uprooting Poverty: 161) The Carnegie Report, when it was published in January 1989, seemed to be whistling in the wind. The apartheid government was firmly in power and looked, to most observers, as if it was still there for a long time to come. And an attack on poverty was certainly not at the top of its agenda. But within a year, on the 2nd of February 1990, the new leader of the National Party and President of the country, F.W. De Klerk made his dramatic speech in Parliament. Political prisoners were all to be released; exiles were permitted to return; and the African National Congress was to be unbanned. Four years later democratic elections were held and the ANC led by Nelson Mandela swept to power, with a mandate that was focused particularly on the eradication of poverty. Two years before this, to prepare themselves for government, Thabo Mbeki with a Cosatu delegation in Washington asked the World Bank in 1992 to help devise strategies against poverty. This request led, amongst other initiatives, to the Project for Statistics on Living Standards and Development (PSLSD) which was co-ordinated by Saldru at the University of Cape Town and which produced the first scientifically sampled national integrated household survey. The main report, South Africans Rich and Poor: Baseline Household Statistics was published in August 1994 just as the new government, which came to power in May, was needing accurate information about the distribution – by race, geography, gender, age – of the various markers of poverty including income; access to clean drinking water; access to energy; health; unemployment; etc. There is no need here to go into all the findings of the PSLSD except to say that they confirmed – but much more precisely and accurately – the results of the Carnegie Inquiry 10 years previously. But the PSLSD, by producing the first (and, it would seem, reasonably accurate) national statistical data set on many dimensions of poverty was part of the wave that ushered in the revolution in the social sciences in South Africa after 1994 – a revolution involving the use of computers, statistical software and global collaboration via the Internet. We shall not enter that rich field here but turn rather to assess what we, in South Africa, have learned over the past 20–25 years about poverty and the quality of life.

2.4

Lessons from Poverty Research

There are essentially seven important lessons: The first is obvious but fundamental and arises from the remarks made by those enduring poverty, a few of which are cited above. The first is that grinding poverty whatever form it takes is detrimental to the quality of life. Thus any strategies to improve that quality must tackle the issue of poverty head on.

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The second lesson flows from this symbiotic link between poverty and the quality of life. If the former has many faces or dimensions, as the Carnegie Inquiry revealed all too clearly, then so too must the quality of life. Rural women walking miles with heavy bundles of firewood on their heads and urban children with nowhere to play except busy streets with careless traffic rushing by all endure a quality of life that leaves much to be desired. At the same time we recognise that poor quality of life may not always be directly related to income as, for example, with the misery of children of a rich but abusive father. Perhaps the third most important insight from poverty studies into the quality of life relates to the experience so concisely articulated by Mrs. Witbooi. Both she and the mother who was praying to God to save her from feeding her children rat poison were trying to cope with the uncertainty of their lives. So too was the man turned away from the mine recruiting office in Lesotho. Not knowing where your next meal is coming from; wondering whether your husband is going to send money from Johannesburg; hoping that the Council is not going to evict you for your inability to pay rent; all these uncertainties are at the heart of the experience of poverty and gnaw at the quality of life. The fourth lesson from the poverty studies relates directly to the experience and consequences of unemployment which mean far more, even, than not being able to feed one’s family. Not being able to get a job also means that one is unable to contribute to society. A person’s sense of self-worth in undermined. “I feel as though these hands of mine have been cut off and I am useless.” The fact that unemployment, by whatever measure one chooses to use, has being growing dramatically over the past decade so that it is now at least as bad, if not worse, than the level of unemployment in the United States at the height of the Great Depression at the beginning of the 1930s is a measure of the challenges still facing this country. More difficult to measure, but real nevertheless, is the impact of the ever deepening chasm of inequality in the society on the quality of life not only of those who are poor but also, paradoxically, on those who are rich. There is a whole field to be explored here by those engaged in QOL studies. Envy (on the side of the poor); guilt (experienced by those who are reasonably well off); and fear (of the burgeoning crime generated by the obscene differentials in this country) all need to be reduced in a society seeking to improve its quality of life. Since the Carnegie Inquiry of the 1980s and the PSLSD integrated household survey of the early 1990s there are two further dimensions of the quality of life which were not adequately foreseen at the time. One relates to the raging forest fire of HIV/ AIDS now burning throughout the society; the other to the unexpected failure of the new democratic government to ensure that all schools and hospitals run properly and improve steadily. One measure of the forest fire, which began smouldering almost invisibly in the 1980s, is that the proportion of pregnant mothers who were found to be HIV+ in 1992 was less than 2%. Eight years later, in 2000, the proportion had risen to 25%. Current demographic projects are that by 2015 no less than nine million South Africans will have died from HIV-related causes. This is eight or nine times as many people as died in the infamous Irish famine in the middle of the 19th century. Evidence is pouring in from around the country – from academic statistical studies;


25

from the considered experience of care-givers in Hospices that have sprung up like mushrooms; from anecdotal material – of the devastating impact of HIV/AIDS (and its lethal symbiotic twinning with Tuberculosis) on the lives of people, particularly those already shackled by poverty. Life expectancy which at the beginning of the 1990s was 65 years is estimated to fall to 41 years by 2010. Problems of governance have not normally been thought of when considering either poverty or the quality of life. But the South African experience of the past decade is such that any focus on the quality of life has to consider governance – the management – at local level of such fundamental institutions in modern society as schools and hospitals. Spending years at school without learning to read, write or do one’s sums properly, or lying sick in hospital without food or clean linen apart from that brought by one’s family are measures of the quality of life that any society would wish to improve.

2.5

To Conclude

South Africa has indeed travelled a long way since the report of the Second Carnegie Inquiry into Poverty and Development was published in 1989. In many important aspects the quality of life – not least in terms of mutual respect – of most people has improved dramatically. But in the long walk to freedom, economic justice and reasonable quality of life for all it is important to recognize that we are still only halfway there.

Reference Wilson, F. & Ramphele, M. 1989. Uprooting Poverty: The South African Challenge (David Philip, Cape Town/Johannesburg).

Chapter 3

The Importance of a Mixed Cash- and Harvest Herding Based Economy to Living in the Arctic – An Analysis on the Survey of Living Conditions in the Arctic (SLiCA) Birger Poppel and Jack Kruse

Abstract “Subsistence” is both a highly disputed theoretical concept within several social sciences’ disciplines, an often used term in international debates and conventions on indigenous peoples’ traditional hunting rights, and an integral part of indigenous peoples’, communities’ and organisations’ campaigns for their rights to maintain traditional lifestyles. The domestic and cash economies of the north are highly interrelated. As Wolfe and Walker (1987) reported, “a family’s subsistence production is augmented and supported by cash employment of family members. The money generated in the commercial-wage sector of the economy enables families to capitalize in the subsistence sector. The combination of subsistence and commercial-wage activities provides the economic basis for the way of life so highly valued in rural communities.” The international core questionnaire applied in the Survey of Living Conditions in the Arctic, SliCA, offers opportunities to examine the importance of a mixed cash- and harvest herding based economy to living in the Arctic, relationships between traditional hunting, fishing and herding activities and activities in the market economy sector, the respondents’ satisfaction with the actual composition of the various activities as well as the preferred composition and the relationship to the overall well-being and the individual. This theme the importance of a mixed cash- and harvest herding based economy to living in the Arctic is one of five international analysis themes suggested by the indigenous peoples’ representatives participating in SLiCA. The analysis is based on more than 7,000 personal interviews with Inuit adults in Greenland, Canada, Chukotka, and Alaska.

B. Poppel Ilisimatusarfik, University of Greenland, P.O. Box 1061, 3905 Nuussuaq, Greenland E-mail: [email protected] J. Kruse Institute of Social & Economic Research, University of Alaska Anchorage, 117 N Leverett Rd, Leverett, MA 01054, USA E-mail: [email protected] V. Møller and D. Huschka (eds.) Quality of Life and the Millennium Challenge, © Springer Science + Business Media B.V. 2009

27 27

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B. Poppel, J. Kruse

Keywords Arctic, indigenous peoples subsistence, mixed economy, informal economy, living conditions in the Arctic, SLiCA, individual well-being, quality of life, life satisfaction Subsistence is a highly complex notion that includes vital economic, social, cultural and spiritual dimensions. The harvesting of renewable resources provides Inuit with food, nutrition, clothing, fuel, harvesting equipment and income. Subsistence means much more than mere survival or minimum living standards. It is a way of life that requires special skills, knowledge and resourcefulness. It enriches and sustains Inuit communities in a manner that promotes cohesiveness, pride and sharing. It also provides an essential link to, and communication with, the natural world of which Inuit are an integral part (Inuit Circumpolar Conference, 1992).

Subsistence is at the heart of many discussions among indigenous peoples and Arctic researchers.1 The discussion has focused on the role of subsistence in modern economies and modern arctic cultures (Kruse et al., 2008). Over the last decades several concepts acknowledging the significance of traditional subsistence activities interwoven with market economic activities have been developed (Poppel, 2006b). Among the concepts developed in response to the new socioeconomic realities to Arctic indigenous peoples Wolfe and Walker evolved the concept the ‘mixed economy’2 to characterise this emerging mode of production based on both cash employment and hunting, fishing and gathering berries etc.: [A] family’s subsistence production is augmented and supported by cash employment of family members… The money generated in the commercial-wage sector of the economy enables families to capitalize in the subsistence sector. The combination of subsistence and commercial-wage activities provides the economic basis for the way of life so highly valued in rural communities (Wolfe & Walker, 1987).

In 1997/98 an international group of researchers3 in a partnership with representatives of the indigenous peoples of the Arctic4 began formulating broad societal goals and living conditions dimensions that would provide the foundation for an international core questionnaire of the Survey of Living Conditions of the Arctic (SLiCA). The team agreed that an important part of this core would be subsistence activities and the related informal and formal relationships.

1 See e.g. Wolfe and Walker (1987), Dahl (1989), Kruse (1991), Huntington (1992), Krupnik (1993), (Nuttall 1992), Hertz (1995), Hovelsrud-Broda (1997), Lynge (1998), Wolfe (1998), Rasmussen (2000), Wenzel et al. (2000), Poppel et al. (2000), Duhaime et al. (2002), Gombay (2003), Usher et al. (2003), Duhaime et al. (2004), Kassam (2004), Rasmussen (2005), Poppel (2006b). 2 The term ‘mixed economy’ had been used earlier (e.g. to characterize economies with elements of market as well as planned economies) but not in analyzing the relations between ‘subsistence’ and ‘market’. 3 The project was initiated by Statistics Greenland in 1997. A further and more thorough presentation of the project can be found in Andersen and Poppel 2002; Andersen et al. 2002; Kruse et al. 2008 and on the project web site: www.arcticlivingconditions.org. 4 From the very beginning, the indigenous peoples, Inuit and Sami have been partners in the steering committee as well as in the projects’ research and focus groups (Poppel 2006a).

3 The Importance of a Mixed Cash- and Harvest Herding

29

Including subsistence in SLiCA required theoretical and methodological deliberations as well as significant pretesting. The international core questionnaire5 applied in the Survey of Living Conditions in the Arctic offers opportunities to examine the importance of a mixed cash- and harvest herding based economy to living in the Arctic, relationships between traditional hunting, fishing and herding activities and activities in the market economy sector, the respondents’ satisfaction with the actual composition of the different activities, the preferred composition of activities, and the relationship of these activities to the overall well-being of the individual. As the SLiCA questionnaire tries to grasp not only the economic, but the social, dietary, and cultural significance of subsistence activities, a broad variety of questions have been asked about individual as well as household activities and behaviour. The importance of a mixed cash- and harvest herding based economy to living in the Arctic is one of five international analysis themes suggested by the indigenous peoples’ representatives participating in SLiCA (Kruse et al., in press). This article presents subsistence-related findings from SLiCA and thus casts some light on subsistence in Inuit settlement regions.6 The findings are based on more than 7,000 personal interviews with indigenous adults (age 15 and above) in Greenland, Canada, Chukotka, and Alaska7. In addition to Inuit, the Native population represented includes Evan, Chuvan, and Yukagir people living in Chukotka. Since 97% of the entire population being represented is Inuit, however, in most instances we take the liberty of simply referring to the population represented by survey results as Inuit adults living in Inuit settlement regions of the Arctic.

3.1

The Economic Aspect – The Importance to the Economy of the Household

To understand the role of subsistence in the household economy it is necessary to investigate different sources of income (e.g. wages, earnings from self employment, social transfers), as well as investments in hunting and fishing equipments. To more fully comprehend the significance of subsistence activities and how the household operates in a mixed economy, the team – led by Peter Usher – developed a household production model (Usher et al., 2003).8

5 6

The questionnaire is accessible on www.arcticlivingconditions.org.

SLiCA includes the Sámi people in Sapmi (the northern part of Fenno-Scandinavia) and the Kola Peninsula. Interviewing among the Sámi is planned to be concluded in 2008. In Greenland the survey also included the immigrant population to Greenland – primarily Danes. As this article only deals with the Inuit of the Arctic, the Danes are not included. 7 Fifteen years and above in Greenland and Chukotka, 16 years and above in Northern Alaska and Arctic Canada. 8 For further discussion of ‘the household production model’ see Usher et al. (2003).

30

B. Poppel, J. Kruse

The model illustrates how the household9 works as a micro enterprise in organising its production activities and allocates its factors of production (land, labour and capital) though the overall goal is not profit maximization and accumulation but rather maximizing the utility (ibid. 180) by minimizing the costs (or maximizing its effectiveness). Moreover the model attempts to grasp the monetary as well as the non-monetary production and the consumption within the household. The team used the household production model to include the following aspects related to subsistence activities in the SLiCA core questionnaire (Poppel, 2006b): • • • • • •

The economic aspect – the importance to the economy of the household The nutritional aspect – part of the diet of the household The social aspect – including intergenerational transfer of knowledge The socio-cultural aspect – principles of sharing and community relations The identity aspect – markers of identity related to subsistence The integration aspect – the mix of subsistence and cash activities

Furthermore the questionnaire contains a number of questions about the activities, attitudes and perceptions of the individual as well as the household.10 In the survey we primarily try to measure the cash-related components of the economy by the labour market activities and by income whereas we measure the subsistence activities primarily by the participation in fishing, hunting, gathering plants and berries, animal husbandry and different kinds of crafts production. The amount of traditional food11 is measured by proportion of total food consumption obtained and consumed. These measures enable us to analyse individual and household participation in the mixed economy. Respondents in Greenland, Chukotka and Northern Alaska were asked about his or her participation in 25 different subsistence activities. The Canadian Inuit were asked about seven activities. The results are compared in Table 3.1. In both comparisons the average number of subsistence activities in Chukotka and Alaska are higher than in Greenland. Participation in subsistence activities appears to be at the same level in Canada as in Greenland.

9

The household defined as a unit of analysis will often include others than the nuclear family (parents and children). It is generally assumed that there among many indigenous peoples is a social and economic co-operation within an ‘extended family’. These relations are highlighted in the questionnaire but not discussed in this article. 10 The questionnaire is accessible at www.arcticlivingconditions.org. 11 ‘Traditional food’ is usually characterised by type of food and preparation and includes in the Arctic primarily meat from marine and land mammals, fish or wild fowl, berries, mushrooms and herbs and ‘traditional food’ typically comes from a variety of activities and sources: the households’ own subsistence activities; gifts from family or other households; sharing due to local traditions and principles; buying food directly from hunters/fishermen, at the local markets, at co-ops or at supermarkets, e.g. Greenland (Poppel, 2006b).


31

Table 3.1 Mean number of subsistence activities that inuit adults participated in during last 12 months by country (Canada, Greenland, Chukotka, Alaska) (http://www.arcticlivingconditions. org/SLiCA Results Report/Tables – Ties to Nature) Count of 25 comparable subsistence activities (GR, CH, AK) Count of 7 comparable subsistence activitiesb (CA, GR, CH, AK)

Canada

Greenland

Chukotka

Alaska

Total

a

5.7

8.0

8.9

6.8

2.7

2.8

3.2

3.5

3.0

a

Data not available Fishing, preparing for a camp, hunting sea fowl, repairing equipment/home, hunting reindeer, elk, sheep, crafts, trapping

b

Whereas roughly 50% of all adult Greenland Inuit participated in between 6 and 16 activities during the last 12 months a little more than 20% of all Greenland Inuit did not participate in subsistence activities at all.12 At the core of the concept of subsistence lifestyle is harvesting (hunting, fishing, herding and. gathering) food. Another approach to measuring subsistence activities is by looking at the results of the activities – the meat and fish consumed in the household. One of the SLiCA questions dealt with the proportion of meat and fish consumed by the household that was harvested by members of the household. The proportion of the household consumption of meat and fish that the household itself harvested reveals the significance of both the amount resulting from the harvest activity, the degree of self-sufficiency of the household – and thereby to some extent the substitution of imported food. In the three countries/regions where the question about self-sufficiency was asked, Greenland is where the lowest proportion (36%) of households perceives they harvested half or more of the total households’ consumption of meat and fish (Table 3.2). Greenland also has the largest proportion of households that did not harvest any meat or fish for the household.13 In contrast to Inuit in Greenland, 61% of Inupiat Inuit in Alaska perceive that they harvest half or more of their meat and fish and less than 10% harvest no meat and fish.14 Table 3.2 supports the hypothesis that subsistence harvesting is still important among the Inuit of the Arctic. Whereas the meat and fish consumed is the result of the harvesting process, hunting and fishing equipment (e.g. boats, dog sleds, skidoos, and rifles) is the necessary

12 For more detailed analyses of the participation in subsistence activities see e.g. Kruse et al. (2008) and Poppel et al. (2007). 13 Percentage results do not always add to 100% as each percentage is rounded to the nearest whole number. 14 The Greenland figures in Table 3.2 (as well as in Table 3.1 and in some of the following tables) seem to indicate that the modernisation process in Greenland that started soon after WWII (and thereby somewhat earlier than in the other regions inhabited by Inuit) has resulted in a closer affiliation to the market economy. A further analysis of this aspect, though, is beyond the scope of this article.

32

B. Poppel, J. Kruse Table 3.2 Proportion of meat and fish harvested by household. Traditional food by country (http://www.arcticlivingconditions.org/SLiCA Results Report/Tables – Ties to Nature)

None Less than half About half More than half

Canada

Greenland

Chukotka

Alaska

Total (%)

a a* a a a

25% 38% 15% 21% 100%

18% 38% 27% 17% 100%

8% 31% 25% 36% 100%

21 37 20 22 100

a

20000 15000 10000 5000 0

l ta To

ka

tk

as Al

ko

ad

hu C

la

an C

en re G

a

a

mean value of subsistence capital owned

nd

US Dollars

Data not available

mean value of subsistence capital purchased in last year

Fig. 3.1 Mean value in US dollars of subsistence capital owned and purchased in last year Source: SLiCA project database and Aboriginal Peoples Survey/Statistics Canada.

means to harvesting and thus are production costs. Figure 3.1 above illustrates that subsistence activities depend on significant capital investments. Alaskan households rank highest when it comes to owning and purchasing subsistence capital (US$18,000 and 5,000 respectively). Chukotkan households represent the lowest amount purchased in the last year (US$2,000). The tables and figures above illustrate that harvesting meat and fish is of importance to the household economies as it substitutes for store-bought food. At the same time harvesting requires investments in hunting and fishing equipment and thus, cash income.

3.2

The Nutritional Aspect – Part of the Diet of the Household

A number of surveys have documented that the traditional food of the Inuit, apart from contributing to the total energy consumption, is a source of important nutrients like protein, vitamin A, vitamin D, iron, zinc, potassium, phosphorus, selenium and Omega-3 fatty acids (AMAP, 2003; Duhaime et al. (in press)). Thus, there are good reasons to focus on the consumption of traditional food and differences across the Arctic. The consumption of traditional food is significant in all regions, but there are important differences (Table 3.3). Overall, two out of every three Inuit households


33

Table 3.3 Proportion of meat and fish consumed by household. Traditional fooda by country (http://www.arcticlivingconditions.org/SLiCA Results Report/Tables – Ties to Nature) None Less than half About half More than half

Canada

Greenland

Chukotka

Alaska

Total (%)

1% 24% 35% 39% 100%

0% 33% 27% 40% 100%

9% 34% 29% 28% 100%

1% 15% 24% 61% 100%

3 29 28 39 100

a

Traditional food includes fish, seal, reindeer, berries, etc.

perceive that half or more of their households’ supply of meat and fish is made up by traditional food. Traditional food seems to account for the largest part of the diet in Alaska (85% at least half), whereas it counts for a somewhat smaller part of the diet among Inuit in Greenland (67%), Canada (75%) and Chukotka (57%).

3.3

The Social Aspect – Including Intergenerational Transfer of Knowledge

Western measures of formal education are not a good indicator of an individual’s subsistence knowledge and skills level. The SLiCA questionnaire contains a number of questions focusing on what is usually characterised as ‘traditional skills’ (e.g. ‘how to butcher a caribou’, ‘navigate at sea’, ‘reading the weather’) Respondents were asked about traditional skills they learned as a child or learned or improved later in their lives as well as the extent to which the traditional skills (20 in all in Greenland and Alaska) are still used today. Among all Inuit (see Table 3.4) more than half perceive that they learned 11 or more skills in their childhood and more than eight out of ten have learned or improved these skills since childhood – most on their own but quite a few with a mentor locally or through a formal class or program. On average, roughly 70% still use the traditional skills today – most in Alaska and fewest in Chukotka. A minority: 6% in Alaska, 12% in Greenland and 23% in Chukotka report they never use traditional skills.

3.4

The Socio-Cultural Aspect – Principles of Sharing and Community Relations

Traditional Inuit culture includes principles for sharing the catch brought home by the hunters to the settlement. These principles influenced the distribution of the catch within the household, the community, and to households in other

34

B. Poppel, J. Kruse

Table 3.4 Traditional skills learned as a child – learned or improved since childhood – still used today (http://www.arcticlivingconditions.org/SLiCA Results Report/Tables – Ties to Nature) Number of traditional education skills learned as a child 0–5 skills 5–10 skills 11–15 skills 16–25 skills

Canada

Greenland

Chukotka

Alaska

Total (%)

a a a a a

20% 39% 36% 6% 100%

12% 23% 26% 39% 100%

7% 29% 41% 23% 100%

16 33 34 17 100

69% 89% 37% 22%

88% 69% 87% 36%

82 86 43 39

53% 24% 23% 100%

86% 9% 6% 100%

69 17 14 100

Learned or improved traditional skills since childhood Since childhood – yes a 86% On own a 89% With mentor a 33% In formal class, program a 48% Still use traditional skills today Yes Some of them No

a a a a

72% 16% 12% 100%

a

Data not available

communities. A series of questions attempt to measure the extent to which these principles for distribution of meat and fish are still in existence among Inuit in the Arctic. Some main results concerning these socio-cultural aspects are condensed in Table 3.5. The mean values for the Arctic regions/countries in some instances disguise substantial interregional differences, whereas the answers to the question about receiving gifts of traditional food reflects homogeneity and a large proportion of respondents confirmed that they did receive gifts of traditional food: roughly 90% in all regions. The category ‘paid for traditional food in last 12 months’ was included to get an estimate of the extent to which ‘traditional food’ is subject to a market exchange, recognizing that there are differences in regulations between regions/countries. Whereas traditional food in Greenland is sold at local open-air markets and in retail shops, commercial purchase of traditional food is not allowed in Alaska and is only permitted in Arctic Canada in the local co-ops. Among Inuit in all the Arctic communities, sharing food (giving and receiving) is an important part of social relations and contributes to cultural continuity. The food sharing can be seen as a form of “social security” providing food for those who lack food while at the same time food sharing strengthens social relations by the demand for “reciprocity” (Poppel, 2006b).


35

Table 3.5 Households received traditional food from others by country (http://www.arcticlivingconditions.org/SLiCA Results Report/Tables – Ties to Nature) Received traditional food from others Received traditional food in exchange for assisting others Received traditional food in exchange for other traditional food Received gift of traditional food Paid for traditional food in last 12 months

Canada

Greenland

Chukotka

Alaska

Total (%)

100%

77%

29%

92%

81

5%

39%

40%

51%

41

a

23%

41%

55%

36

90% 19%

90% 71%

89% 47%

88% 17%

90 53

a

Data not available

3.5

The Identity Aspect – Markers of Identity Related to Subsistence

Closeness to nature and eating traditional food is often emphasized as important identity markers – and not only to indigenous peoples. The SLiCA questionnaire has several questions focusing on identity. One of the questions asked about ‘activities and customs of importance to maintain an Inuit identity’.15,16 The different activities and customs are ranked according to the proportion of all Inuit considering them ‘important’ or ‘very important’ for their indigenous (Inuit) identity. As indicated in Table 3.6 a vast majority (97%) perceives ‘view of nature’ and ‘traditional food’ as important for maintaining their identity. The variations between countries/regions are insignificant. Other subsistence related activities like ‘preservation of traditional food’ and ‘hunting and fishing’ also seem to be important identity markers and seemingly more important to the indigenous identity than ‘occupation or profession’.

15 The question is a multi response question with the possibility to give more than one affirmative answer regarding 15 activities and customs. The four point response scale ranged from “not at all important” to “very important”. 16 In the Greenlandic questionnaire the term ‘Greenlandic identity’ is used, whereas the term ‘Inuit identity’ is used in Alaska and Chukotka.

36

B. Poppel, J. Kruse

Table 3.6 Activities and customs important to maintaining indigenous identity by country (http:// www.arcticlivingconditions.org/SLiCA Results Report/Tables – Cultural Continuity) View of nature Traditional food Childhood upbringing Use of indigenous language Naming kinship relationships Preservation of traditional foods Hunting and fishing Meeting expectations of family and indigenous friends Contacts with other indigenous people Occupation or profession Harvesting of wild berries and plants Religious and spiritual beliefs Participation in traditional cultural events Clothes worn Indigenous poetry and literature

Canada

Grønland

Chukotka

Alaska

Total

a a a a a a a a

97 95 96 97 87 85 79 88

98 98 98 84 100 89 99 81

96 96 94 84 90 96 95 94

97 97 96 92 91 87 87 87

a a a a a

95 86 75 79 71

58 77 98 66 81

93 87 90 81 85

84 84 84 76 76

a a

78 79

71 61

76 73

75 73

a

Data not available

3.6

The Integration Aspect – The Mix of Subsistence and Cash Activities

As referred to in the introduction one of the themes of analysis highlighted by our indigenous partners was ‘The importance of a mixed cash- and harvest herding based economy to living in the Arctic’. An approach to an understanding of the integration aspect is to examine the extent to which households tend to mix cash and subsistence activities Table 3.7 groups households on two dimensions: annual household income and the proportion of meat and fish consumed by the household that was harvested by household members (excluding Canadian Inuit). The bottom income category includes households with poverty level incomes while the top income category reflects households above median total annual household incomes, adjusted for purchasing power. Households with incomes above the median are just as likely to derive more than half of their meat and fish from household harvest activities as households with poverty level incomes. They are less likely to harvest none of their meat and fish than households with poverty level incomes. The most obvious conclusion is that households do not seem to specialise in one kind of activity, it rather seems that there is a tendency to mix activities. That it takes money to participate in subsistence activities might also – at least partly – explain the finding from the SLiCA data that the lower income groups do not seem to compensate their low incomes by hunting and fishing (Kruse et al., 2008).


37

Table 3.7 Percentages of Inuit households by combination of proportion of meat & fish harvested by household and total household income adjusted for purchasing power (http://www.arcticlivingconditions.org/SLiCA Results Report/Tables) None Less than half About half More than half Total

$16,000 or less

$16,001–$50,000

More than $50,000

Total (%)

29% 28% 21% 23% 100%

18% 36% 22% 25% 100%

15% 40% 21% 23% 100%

20 35 21 24 100

The fact that households with higher cash incomes and high level of subsistence activities also invest more in hunting and fishing gear might indicate that low income households are worse off when hunting and fishing and risk harvesting less due to less optimal equipment.

3.7

The Mixed Economy and Subjective Well-Being

To get a better understanding of the role of subsistence activities in the lives of Inuit a number of questions are asked about satisfaction with different aspects of the respondents’ lives, traditional Inuit values and the importance of different activities to maintaining an Inuit identity. The economic development over the last 50 years has meant that most inhabitants of the Arctic, including the Arctic indigenous peoples, take part in market activities as full-time, part-time or wage earners, as self-employed persons and also as consumers. Thus the SLiCA questionnaire includes questions on the respondents’ satisfaction with the combination of productions and which lifestyle she/he would prefer: working on a wage job, or harvesting, herding or processing your food or both?17 (see Table 3.8). The Alaskan and Greenland answers to the question concerning satisfaction with combination of activities in the period prior to the interview are very similar. More than 80% of Inuit adults in Greenland and Northern Alaska are either somewhat or very satisfied with the combination of production activities which they pursue. The corresponding figure in Chukotka is somewhat lower: 55%. Combining the above levels of satisfaction with the individuals’ participation in different productive activities with the knowledge of actual participation in both subsistence and cash activities supports the hypothesis that the mixed economy is not only a matter of necessity but also a matter of choice.

17

Comparable Canadian data are not available.

38

B. Poppel, J. Kruse

Table 3.8 Satisfaction with combination of production activities by country (http://www.arcticlivingconditions.org/SLiCA Results Report/Tables – Material Success) Very satisfied Somewhat satisfied Neither satisfied nor dissatisfied Somewhat dissatisfied Very dissatisfied

Canada

Greenland

Chukotka Alaska

Total (%)

a a a a a a

29% 53% 14% 2% 1% 100%

17% 38% a 33% 12% 100%

30 46 9 11 4 100

52% 35% 8% 3% 2% 100%

a

Data not available

Table 3.9 Preferred ways of making a living by country (http://www.arcticlivingconditions.org/ SLiCA Results Report/Tables – Material Success) Working on a wage job Both wage and harvesting, herding, or processing Harvesting, herding, or processing Self-employment

Canada

Greenland

Chukotka

Alaska

a a

56% –

40% 28%

15% 77%

a

30% 14%

32% –

8% –

a

100%

100%

100%

a

Data not available

Further analysis of the SLiCA data at the individual level states that whether a person is satisfied or not with the combination of production activities he/she pursues matters a lot to the satisfaction with life as a whole: Only one-in-ten of the Greenland and Alaskan Inuit who are very dissatisfied with their own combination of production activities are very satisfied with their life as a whole compared to five-in-ten of those are very satisfied. Table 3.9 illustrates the variety in the answers to the question on preferred lifestyle between respondents in Greenland, Chukotka and Alaska, with the most prominent differences between the respondents from Greenland and Alaska. Roughly 60% of the Greenlanders prefer working on a wage job whereas more than 75% of the Alaska Inupiat prefer a combination of harvesting, herding or processing and a wage job. If the focus is on the proportion of respondents that would prefer a lifestyle including subsistence activities (full-time or part-time), the figures range from 30% in Greenland, 60% in Chukotka and 85% in Alaska. To some extent, the difference between the regions in Table 3.8 reflects the employment opportunities as well as the conditions for subsistence activities in the different regions.


39

Traditional Skills Native Language

Promotion of Values

Strength of Values

Hunting Herding Combination of Activities

Sense of local control Overall Wellbeing

Employment Health

Western Education

Fig. 3.2 One example of a model of hypothesized relationships

3.8

Dimensions of Well-Being Explaining Satisfaction with Life as a Whole

To be able to identify dimensions of well-being and their explanatory power to the individuals’ ‘satisfaction with life as a whole’ different models of hypothesized relationships were established. Through a series of stepwise multiple regressions we then identified the dimensions of well-being that explain the most, second-most and so-on amount of variation in satisfaction with life as a whole. One of the models and results of a related regression analysis are shown in Fig. 3.2. We can conclude that the combination of cash and subsistence activities pursued by Inuit is important to explaining their satisfaction with life as a whole. We have also seen that people appear to differ in their preference of combination of activities, so having a choice seems to be important as well (see Table 3.10).

3.9

Concluding Remarks

Findings from the Survey of Living Conditions in the Arctic document that subsistence activities, defined as harvesting natural, renewable resources to provide food for one’s own household, for gifts for others or to exchange outside the market economy are of significance to a substantial number of Arctic indigenous households. The contribution from subsistence activities to the living of Arctic indigenous households, the individuals’ and households’ combination of hunting and fishing with cash income from paid labour, self-employment (and from transfer incomes) as well as the necessity to be able to fund subsistence activities support a confirmative answer to the question of whether subsistence activities are a significant part of the Arctic economy today. To conclude, the findings reported in this article show that subsistence activities in the Arctic are highly important as a contri-

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Table 3.10 Explanation of variation in satisfaction with life as a whole. Source: SLiCA project database Independent variables Satisfaction with job opportunities Satisfaction with amt fish and game avail locally Satisfaction with combination of production activities Influence over natural resources & environment Satisfaction with job Subsistence level – none low high Respondent employment summary

Standardized coefficient (beta)

t value

significance

0.16 0.14

4.83 4.28

0.00 0.00

0.13

3.44

0.00

0.09

2.65

0.01

0.08 0.02 0.01

2.06 0.62 0.38

0.04 0.54 0.71

R-squared = 0.13, p = 0.00

bution to the consumption possibilities, and highly important for cultural identity. The fact that it is difficult to distinguish between the two aspects of subsistence activities reflects the intertwined nature of culture and economy in the Arctic. A variety of aspects related to subsistence activities – nutritional, social, cultural and identity – go beyond those connected to the economic sphere. Thus participation in subsistence activities (and activities connected to them) seems to influence social relations, cultural continuity and the individuals’ identity. When closeness to nature, participation in hunting and fishing and eating the traditional food frequently are emphasized as important activities to Inuit in the Arctic, it reflects relations and activities important to people’s quality of life and not necessarily romanticist outsiders seeing life in the Arctic through rose-coloured spectacles. In this perspective it might be equally adequate to describe the mixed economy in many Arctic communities from a local point of view as market economic activities as a part of ‘the subsistence way of life’. It is as correct as it is often repeated that the economic, social, cultural and political conditions in the Arctic have changed dramatically since World War II. A swift changing climate has within a limited number of years contributed to the rapid changes of livelihoods and living conditions for Inuit and other indigenous peoples in the Arctic. Changes of the climate caused by humans will, among other things, lead to further melting of the ice cap, more unstable seasons and thawing of the permafrost. The opening of new mining activities, exploration and extraction of oil and gas, and the opening of northern sea routes will increase pressures on the combination of subsistence and market economic activities that form the basis for the prevailing lifestyle and livelihood for many indigenous people in the Arctic. This means that a way of life existing not only out of necessity and tradition but also as the consequence of the choice of individuals could be threatened (Poppel, 2007; Rasmussen, 2007). If the overall objective for political activities is to enhance the quality of life for its citizens, and if the efforts to ensure diversity not only applies to flora and fauna but also to people and societies within the Arctic, the years to come will make demands for clarification of societal goals and the consequences of different economic strategies. Not only a number of jobs but a way of life is at stake.


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References AMAP (2003). AMAP assessment 2003: Human Health in the Arctic. Arctic Monitoring and Assessment Programme, Oslo, Norway. Andersen, T., & Poppel, B. (2002). Living Conditions in the Arctic. Social Indicators Research 58:191–216. Andersen, T., Kruse, J., & Poppel, B. (2002). Survey of Living Conditions in the Arctic: Inuit, Sámi and the Indigenous Peoples of Chukotka (SLiCA). Arctic 55(3) (September 2002):310–317. Dahl, J. (1989). The Integrative and Cultural Role of Hunting and Subsistence in Greenland, Etudes/Inuit/Studies 13(1):23–42. Duhaime, G. et al. (2002). Food Consumption Patterns and Socioeconomic Factors among the Inuit of Nunavik. Ecology of Food and Nutrition, 41: 91–118. Duhaime, G., et al. (2004). Economic Systems. In: Arctic Human Development Report. Under the Auspices of the Icelandic Chairmanship of the Arctic Council 2002–2004. Chapter 4, pp. 69–84, Stefansson Arctic Institute, Akureyri. Duhaime, G., Duwailly, E., Halley, P., Furgal, C., Bernard, N., Godmaire, A., Blanchet, C., Myers, H., Powell, S., Bernier, S., & Grondin, J. (2007). Food Security in the Canadian Arctic. An Integrated Synthesis for an Action Plan. In: Duhaime, G. and Bernard, N. (eds.). Arctic Food Security. Gombay, N. (2003). Making a Living: Place and the Commoditisation of Country Foods in a Nunavik Community. A Thesis Submitted to the Department of Geography, Queen’s University, Kingston, Ontario, Canada. Hertz, O. (1995). Økologi og Levevilkår i Arktis: Uummannarmiut [Ecology and Living Conditions in the Arctic: Uummannarmiut]. Christian Ejlers’ Forlag. Mellemfolkeligt Samvirke. Hovelsrud-Broda, G. (1997). The Seal: Integration of An East Greenlandic Economy. A Dissertation Presented to the Faculty of Graduate School of Arts and Sciences, Department of Anthropology, Brandeis University, Waltham, MA. Huntington, H.P. (1992). Wildlife Management and Subsistence Hunting in Alaska. University of Washington Press, Seattle, WA. Inuit Circumpolar Conference (ICC) (1992). Principles and Elements for a Comprehensive Arctic Policy. Centre for Northern Studies and Research. Montreal, Quebec, Canada. Kassam, K.-A. (2004). Hunting, Subsistence. In: Mark Nuttall (ed.). Encyclopaedia of the Arctic, Routledge, New York. Krupnik, I. (1993). Arctic Adaptations: Native Whalers and Reindeer Herders of Northern Eurasia. Dartmouth College by University Press of New England, Hanover/London. Kruse, J. (1991). Alaska Inupiat Subsistence and Wage Employment Patterns: Understanding Individual Choice. Human Organization 50(4):317–326. Kruse, J., Poppel, B., Abryutina, L., Duhaime, G., Martin, S., Poppel, M., Kruse, M., Ward, E., Cochran, P., & Hanna, V. Survey of Living Conditions in the Arctic, SLiCA. In: Møller, V., Huschka, D, and Michalos, A.C. (eds.) 2008. Barometers of Quality of Life Around the Globe. Springer Social Indicators Research Series. Springer, Dordrecht, The Netherlands. Lynge, F. (1998). Subsistence Value and Ethics. Address to the General Assembly of the Inuit Circumpolar Conference, Nuuk. Nuttall, M. (1992). Arctic Homelands: Kinship Community and Development in Northwest Greenland. University of Toronto Press, Toronto, ON, Canada. Poppel, B. (2006b). Den arktiske Levevilkårsundersøgelse, SLiCA – et komparativt og transnationalt project [Survey of Living Conditions in the Arctic, SLiCA – a comparative and transnational project]. In: Hanne Petersen (ed.). Grønland i verdenssamfundet [Greenland in the International Community]. Forlaget Atuagkat/Ilisimatusarfik, Nuuk. Poppel, B. (2006b). Interdependency of subsistence and market economies in the Arctic. In: Glomsråd, Solveig og Iulie Aslaksen (eds.). The Economy of the North. Statistisk Sentralbyrå/ Statistics Norway, Oslo/Kongsvinger. Poppel, B. (2007). Nogle forskelle mellem levevilkår i byer og bygder – og input til en diskussion om bygdernes fremtid [Some differences between living conditions in Greenlandic towns and

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settlements – as well as input to the discussion about the future of the settlements]. Samfundsøkonomen (April 2007) Nr. 1:19–24. Poppel, B., Andersen, T., & Lyster, P. (2000). Measuring ways of life and living conditions of indigenous peoples of the Arctic – Inuit as an example. Paper (C-Pa 6b) presented at the conference on Statistics, Development and Human Rights. Montreux, 4.-8.9.2000. Poppel, B., Kruse, J., Duhaime, G., & Abryutina, L. (2007). SLiCA Results. Institute of Social and Economic Research, University of Alaska, Anchorage. www.arcticlivingconditions.org. Rasmussen, R.O. (2000). Formal economy, renewable resources and structural change in West Greenland. In: Economie contemporaire. Present-Day Economy. Études/Inuit/Studies 24(1):41–78. Rasmussen, R.O. (2005). Socioøkonomisk analyse af fangererhvervet i Grønland [Socio-economic Analysis of the Greenland Hunters]. Prepared under contract to the Greenland Home Rule Government, Department of Fisheries and Hunting. Rasmussen, R.O. (2007). Fangererhverv, fiskeri og lokaløkonomi. [Hunting, fishing and local economies]. Samfundsøkonomen (April 2007) Nr. 1:25–28. Usher, J.P., Duhaime G., & Searles, E. (2003). The Household as an Economic Unit in Arctic Aboriginal Communities, and Its Measurement by Means of a Comprehensive Survey, Social Indicators Research 61: 175–203. Wenzel, G., Hovelsrud-Broda, G., & Kishigami, N. (eds.) (2000). The Social Economy of Sharing: Resource Allocation and Modern Hunter-Gatherers. Senri Ethnological Studies. National Museum of Ethnology, Osaka. Wolfe, R.J. (1998). Subsistence Economies in Rural Alaska. Cultural Survival Quarterly 22:3. Alaska Department of Fish and Game. Division of Subsistence, Juneau, Alaska. Wolfe, R.J. & Walker R.J. (1987). Subsistence Economies in Alaska: Productivity, geography, and development impacts. Arctic Anthropology 24:56–81. Wolfe, R.J. (1998). Subsistence Economies in Rural Alaska. Cultural Survival Quarterly 22:3. Alaska Department of Fish and Game. Division of Subsistence. Juneau, Alaska. www.arcticliving conditions.org

Chapter 4

The International Scale Interval Study: Improving the Comparability of Responses to Survey Questions About Happiness Ruut Veenhoven

Abstract This study is about survey questions on happiness using verbal response options, such as ‘very happy’ and ‘fairly happy’. The aim is to estimate what degrees of happiness are denoted by such terms in different questions and languages. These degrees are expressed in numerical values on a 0 to 10 scale, which are then used to compute ‘transformed’ means and standard deviations. Native speakers read survey questions on happiness that have been used in their country. For each question separately, they rate the relative value of each of the response options in their language. They do that using an electronic ‘Scale Interval Recorder’. On their computer screen, participants see a vertical bar scale that they can partition into sections by shifting separation lines. The response options are presented next to the scale and move with the bars. Their task is to move the separation lines until they feel that the intervals on the scale correspond with the degree of happiness denoted by each of the verbal response options. The aim is to cover 74 languages. This study will allow a better use of the available survey data on happiness. Keywords Happiness, measurement, cross-national, Thurstone transformation, re-scaling

4.1

Introduction

The subject of happiness has long been a playground for speculative philosophy, but in the last decades it became also a subject of social scientific research. This research focuses on happiness in the sense of overall life satisfaction and assesses that matter in large-scale surveys. This has resulted in a considerable body of empirical findings; much is which is stored in the World Database of Happiness R. Veenhoven Erasmus University Rotterdam The Netherlands, E-mail: [email protected] V. Møller and D. Huschka (eds.) Quality of Life and the Millennium Challenge, © Springer Science + Business Media B.V. 2009

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(Veenhoven, 2006). At this moment (July 2006) that database contains the results of some 2,500 survey studies in 112 nations and this provides a rich source for comparative analysis across time and nations. Happiness is typically measured using single direct questions. Some examples are presented in Scheme 4.1. Though all these questions aim at the same concept, they differ in wording and response options. The ‘Item Bank’ of the above mentioned World Database of Happiness contains no less that 850 variations. This variation in questions used limits the comparability of the available data. As a result, only part is effectively used in comparative analysis and in synthetic

Scheme 4.1 Some survey questions on happiness •

Taken all together, how would you say things are these days? Would you say that you are? -

Very happy

-

Pretty happy

-

Not too happy

• On the whole how satisfied are you with the life you lead?

•

-

Very satisfied

-

Fairly satisfied

-

Not very satisfied

-

Not at all satisfied

In most ways my life is close to ideal -

Strongly agree

-

Agree

-

Slightly agree

-

Neither agree nor disagree

-

Slightly disagree

-

Disagree

-

Strongly disagree

• How satisfied are you with your life as a whole these days? 7

completely satisfied

6 5 4 neutral 3 2 1

completely dissatisfied

4 The International Scale Interval Study

47

studies. For instance, studies on the trend of happiness in the USA typically restrict to answers to one particular question (3-step GSS item) leaving 80% of the available data aside. Likewise, comparison of happiness across nations limits typically to cases for which a particular item on life satisfaction is available (10-step WVS item), leaving out some 30 countries where happiness has not been assessed in that way. There are several ways to cope with this heterogeneity, which I have described elsewhere (Veenhoven, 1993: chapter 7). One of these ways is transforming scores on different questions to a same scale. In the case of numerical scales this can be done using linear transformation, e.g. stretching a score on a 1 to 5 scale to range 0–10. A variant of that approach is Cummins’ (1995) percentage of the scale maximum (%SM). Another method is transforming scores on scales with verbal response options to a common numerical range. This requires that experts rate the numerical equivalents of verbal response options, e.g. a rating of 5 for the verbal response option ‘neither happy nor unhappy’ on a 0 to 10 numerical scale. This method has been proposed by Thurstone as early as in the 1950s (Jones & Thurstone, 1955) and is recently also applied by Smith et al. (2005).1 This paper describes a web-based variation of this rating method and announces a large-scale application that involves all the questions on happiness ever used in general population surveys.

4.2

Approach

This study limits to survey questions on happiness using verbal response options, such as the first three items in Scheme 4.1. Results yielded with such questions can hardly be compared with results yielded by slightly different questions. Below I explain why and then show how comparability can be improved.

Rate Numerical Value of Verbal Response Options As we have seen, happiness is commonly measured using single questions that such as “Taking all together, how happy would you say you are these days?” Such questions are answered by choosing from a list of response options that are ordered from more to less happiness. Often these options are denoted by words such as ‘very happy’, ‘pretty happy’ and ‘not too happy’. Such response scales are of the ordinal level of measurement, which does not allow the computation of means and standard deviation.

1

This study limits as yet to only three languages. Unlike our study, it rates response options irrespective of the lead question.

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R. Veenhoven

Researchers typically avoid that problem assigning numerical values to the verbal response options; in the above case of three response options typically 3 for ‘very happy’, 2 for ‘pretty happy’ and 1 for ‘not too happy’ and they on this basis compute means and standard deviations. Thus they create a (semi) interval scale, which does allow mathematical computation. In doing so, researchers implicitly assume that the distance between ‘very’ and ‘pretty’ happy is the same as between ‘pretty’ and ‘not too’ happy. This may not be the case, possibly respondents see a greater distance between the latter than between the former. If so, unhappiness will be underestimated. Individual scores of 3, 2 and 1 will not fully reflect the real differences in happiness and as a result the variance shared with other variables will not be fully reflected in correlations. Aggregated scores will also be affected, mean scores will be higher and standard deviations lower than factual. In this study we assess what people have in mind when they tick ‘very’ or ‘pretty’ happy and we will use that information to estimate more accurate numerical values for verbal response options to questions about happiness. For example, it might appear that the value of ‘pretty happy’ on scale 1 to 3 is actually 2.5 instead of 2 and ‘not too happy’ 0.8 instead of 1. We then use these estimates to re-analyze available data and check whether this refinement really makes a difference.

Standardize Scales to Range 0–10 In synthetic studies on happiness, researchers often combine findings obtained using slightly different questions. As they try to maximize the number of observations, they accept some diversity in the studies they include. This causes several problems, which can to a large extend be solved by the results of this study. Overcoming Difference in Wording of Response Options Researchers typically assign the same numbers for response options denoted with slightly different words. For instance, if the third response option in the above question is ‘unhappy’ instead of ‘not too happy’, they also code this response as 1. Obviously, this involves a loss of information. This study will help us to do better, because it should generate more accurate estimates of the numerical values to be used for specific response options. For example, it might possibly show that the average respondent would equate ‘not too happy’ with 1.1 point on a 1 to 3 scale and ‘unhappy’ with 0.8 points. These values can then be used to compute weighted scores that more accurately reflect the actual differences in the happiness at stake. Overcoming Differences in Number of Response Options Another problem in research synthesis is that response scales differ in the number of response options. The above example of a survey question on happiness involves


49

three response options, but there are also questions with four responses options and even questions that offer seven. Researchers solve this problem by transforming observed scores to one common scale. One way is to downsize the longer scales, e.g. shortening a 4step scale to range 1–3 by lumping the last two options together. This involves a loss of information and the danger of distortion. Alternatively one can stretch the scales linearly to a common range, e.g. when drawn out to range 0–10, score 2 on range 1–3 becomes 5. This method is discussed in more detail in Veenhoven and Kalmijn (2005: 447–449). In an earlier application on happiness it appeared to produce implausible results, in particular when applied on short scales. In this study we solve the problem in another way. We ask proto-respondents to assign the values of response options on a common numerical scale. We present them with a scale ranging from 0 to 10 and ask them to partition that scale into intervals that correspond to the degrees of happiness denoted by the words used for response options to questions about happiness. The intervals will be greater with shorter response scales, at least on an average, and the meaning of words may vary accordingly. For example, on a 3-step scale the response option ‘very happy’ may be seen to cover the range 10 to 7, with a mean of 8.3, whereas on a 5-step scale the option ‘very happy’ may be seen to denote range 10 to 9 with a midpoint of 9.5. Once obtained, these values will enable us to calculate comparable scores from available frequency distributions of responses to such different questions. Overcoming Language Differences Still another problem is that the same question is often asked in different languages. The meaning of the words used to denote a degree of happiness may rate differently in different tongues. This is a problem in nations were multiple languages are spoken, such as in South Africa, Switzerland and Belgium. It is also a problem for cross-national comparisons of happiness. The most common solution for this difficulty is to reduce translation error, typically by using the technique of forth and back translation. Yet perfect translation is often not possible. A commonly mentioned example is that the English word ‘happy’ can only be translated in French to the word ‘heureux’, which however, may denote a higher degree of satisfaction. With this study we also by-pass this translation problem. We ask native speakers to rate the numerical value of words used for response options in their own language. If it is true that the French are more choosy about how they use the word ‘happy’, they might place the option ‘très heureux’ in the range 10 to 9, whereas the English raters would place ‘very happy’ on range of 10 to 8. This would result in different numerical mid-values, respectively 9.5 and 9.0. These differences are taken into account when we use the values to compute weighted averages from available frequency distributions.

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4.3

R. Veenhoven

Goals

The above described approach serves the following aims: Better Comparability of Happiness over Time The average happiness of citizens was assessed for the first time in the USA in 1945. Since then, more than 200 assessments have followed, but it is still not clear whether Americans have become happier or not. One problem is that increments tend to be small close and to the ceiling, but another problem is that the survey questions have differed slightly over time and that this is likely to obscure the overview of the small trend. That latter problem is typically solved by limitation to identical questions, but this means that about half of the available data must then be left out. Yet we need large amounts of data to discern the trend from random variation. This study alleviates this problem in two ways. Firstly it enhances the comparability of responses to questions that differ only slightly in the wording of responses options; e.g. 3-step items using ‘pretty happy’ for the second option instead of ‘fairly happy’. As argued above, the subtle difference between such words will reflect in the different values assigned by our raters, which are then taken into account in the weighted mean we calculate. Secondly, this study enables the comparison of responses to questions that differ in number of response options. As indicated above, the rating procedure is likely to neutralize the differences in length of response scales. Together this will broaden the database that can be used for analyzing change in happiness in nations. Better Comparability of Happiness Across Nations Currently, the section on ‘Happiness in Nations’ of the World Database of Happiness contains 112 nations where general population surveys had included questions on happiness. Yet again the questions used are not identical. The most commonly used question had only been applied in 78 nations and the translation of this item into the different languages is questionable in some cases. This impedes our ability to make comparative analyses of happiness in nations. This study can lessen the above problem. As in the case of comparison over time it should broaden the database available, as differences in phrasing of response options and the difference in number of response options should cease to be a problem, and finally, translation error should be much reduced by our method. More Opportunity for Meta-analysis of Studies on Happiness In July 2006 the World Database of Happiness included 9,233 correlational findings on happiness yielded by 912 empirical studies. These numbers will double when all the available findings are entered. This collection has been gathered for the purpose of facilitating research synthesis and for meta-analysis


51

in particular. However, the collection has hardly been used for this purpose as yet and one of the main reasons is that the measures of happiness used in the various studies differ too much. This study should also serve to resolve this problem. All the benefits mentioned above apply also for this problem of heterogeneity of measurement of happiness. Meta-analysis will benefit from more accurate estimates of happiness from the available data and from better comparability of responses to questions that differ in wording, number of response options and language. However these benefits can only be reaped if the full distribution of responses is available, which is not always the case with correlational findings. Still, the obtained weights can be used in secondary analysis of available datasets. Better Measurement of Happiness This study should improve the measurement of happiness. Ideally, the meaning of response options to a question is the same for all respondents. Yet in practice there are always differences in interpretations of words and some words give rise to more differences than others. The use of such words must be avoided and therefore it is worth knowing which words cause confusion. In this study we can identify such words using the standard deviation of the ratings. For example, if our English respondents differ more in their ratings of the term ‘rather happy’ than of ‘fairly happy’ while the midpoints are the same, future researchers should better avoid the former term.

4.4

Method

As noted above, this study is about survey questions on happiness using verbal response options. Since the main aim is to improve comparison of happiness across nations, we restrict to such questions as those that have been applied in studies of general populations in nations. These survey questions are specified on the ‘item list’ on Scheme 4.2.

Assessment Native speakers will be asked to consider questions separately and estimate the degree of happiness denoted by the different response options provided in their language. This will be done on a bar scale, ranging from 10 to 0. The native speaker’s task is to partition the scale into sections that correspond with the meaning denoted by the words used to qualify happiness. The native speakers will be asked to do this for each of the response options of several questions.

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Scheme 4.2 Questions on happiness involving verbal response options, ever used in general population surveys Item codea

Survey program in which question was used

2-Step verbal happiness (Table 111A in Happiness in Nations) O-HL/u/sq/v/2/a The Netherlands, NIPO survey 1947 3-Step verbal happiness (Table 111A in Happiness in Nations) O-HL/c/sq/v/3/aa Australian National Science Survey 1984, South Korean National Survey 1980, Polish Surveys 1991–2000, Spanish CIRES Survey 1985, US General Social Survey since 1957 O-HL/c/sq/v/3/ab Euro-barometer (periodical multi-nation survey) bi-annual 1975–1986 O-HL/c/sq/v/3/ah US General Social Survey since 1957 O-HL/g/sq/v/3/a US Incidental Gallup polls 1947–1990 O-HL/g/sq/v/3/d International Gallup/Kettering World Survey 1975, US Gallup polls 1975–2004 O-HL/g/sq/v/3/f International Gallup World Survey 3, 1965 O-HL/g/sq/v/3/g US Gallup polls 1956, 1957 O-HL/g/sq/v/3/j International Gallup World Survey 1946–48 (probably nr 1) O-HL/g/sq/v/3/k USA Gallup pollw 1995 O-HL/g/sq/v/3/l USA Gallup polls 1948, 1956 O-HL/g/sq/v/3/i USA Gallup polls 1948, 1956, 1966, 1970 O-HP/u/sq/v/3/a Netherlands, NIPO Survey 1948 O-HP/u/sq/v/3/b Germany, Allensbacher periodical polls 1954–1992 0-H?/?/sq/v/3/a Japan Periodical Life in Nations Surveys, International Gallup poll 1970 4-Step verbal happiness (Table 111B in Happiness in Nations) O-HL/c/sq/v/4/a Scandinavian one-time Welfare Survey 1972, German Wohlfahrt surveys 1980, 1984, 1988, 1990, 1993, 1998 O-HL/c/sq/v/4/f International Gallup Survey 1946, ISSP 1991, Polish GSS 1992, 1993, US GSS 1998, 2002 O-HL/c/sq/v/4/g International Euromodul 1999, Former communist countries LLH Survey 2001, Hong Kong and Taiwan Social Trends 2000 O-HL/c/sq/v/4/h Russian panel study RUSSET 1993–1999 O-HL/c/sq/v/4/o Poland periodical Social Diagnosis Survey 1993, 2003 O-HL/c/sq/v/4/p World Value Survey (Japanese version) 1980, 1990, 1996, 2000 O-HL/g/sq/v/4/b USA Gallup polls 1946–1956 O-HL/g/sq/v/4/f International Latino Barometro 2002 O-HL/g/sq/v/4/g Brazil 2001 (ISSP) O-HL/g/sq/v/4/h Ireland 2001 (ISSP) O-HL/ly/sq/v/4/a South Korea one-time Social Development Surveys 1981, 2001 O-HL/u/sq/v/4/a International World Values Surveys 1980, 1990, 1996, 2000 O-HL/u/sq/v/4/c World Youth Surveys 1988, 1993 O-HL/u/sq/v/4/e Romanian Public Opinion Barometer 2005 O-HP/c/sq/v/4/a Canadian GSS 1986 O-HP/g/sq/v/4/b Canadian GSS 1985, 1989, 1990 5-Step verbal happiness (Table 111C in Happiness in Nations) O-HL/c/sq/v/5/e International Leisure Development Survey 1979 O-HL/c/sq/v/5/g South Africa periodical Quality of Life Surveys 1983–2003 O-HL/c/sq/v/5/m International Asia barometer 2003 O-HL/g/sq/v/5/b Sweden QOL Survey 1985 O-HL/u/sq/v/5/b Austria QOL Survey 1984 (continued)


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Scheme 4.2 (continued) Item codea

Survey program in which question was used

O-HP/u/sq/v/5/a Netherlands periodical QOL Survey since 1977 O-HP/u/sq/v/5/d Netherlands Dutch Household Survey, yearly panel since 1993 O-HP/u/sq/v/5/e Netherlands Cultural Change Survey 2004 7-Step verbal happiness (Table 111D in Happiness in Nations) O-HL/g/sq/v/7/a International periodical Social Survey Program (ISSP) 2003 2-Step verbal life satisfaction(Table 121A in Happiness in Nations) O-SLP/c/sq/v/2/a USA Gallup polls 2001–2004 O-SLP/g/sq/v/2/b USA Gallup polls 1973–2001 3-Step verbal life satisfaction (Table 121B in Happiness in Nations) O-SLL/c/sq/v/3/a USA, various surveys 1968, 1972, 1976 O-SLL/u/sq/v/3/a Canada various surveys 1968, 1974, 1977 O-SLL/u/sq/v/3/b Eastern Europe New Democracies Barometer 1991 O-SLS/c/sq/v/3/a International Tension Study 1948 O-SLW/c/sq/v/3/a Eastern Europe New Democracies Barometer Survey 1991 4-Step verbal life satisfaction (Table 121C in Happiness in Nations) O-SLL/u/sq/v/4/a Japan Life-in-Nation Surveys, yearly 1958–1963 O-SLL/u/sq/v/4/b Euro-barometer survey in all member states, since 1973 O-SLL/u/sq/v/4/c Japan Life in Nation Survey 1984 O-SLL/g/sq/v/4/d Romania, Public Opinion Barometer, bi-annual since 1996 O-SLP/c/sq/v/4/a USA Gallup polls 2001–2004 O-SLP/u/sq/v/4/a USA Gallup poll 1991 O-SLP/?/sq/v/4/c Hong Kong and Taiwan periodical Social Trend Studies 2000 O-SLu/c/sq/v/4/e Japan Life-in-Nation Survey, yearly 1964–1983 O-SLu/c/sq/v/4/f Japan Life-in-Nation Survey, yearly 1980–1991 O-SLu/g/sq/v/4/b International Latino Barometro 1997, 2000 O-SLu/g/sq/v/4/c International Latino Barometro 2001, 2002, 2004 O-SLu/u/sq/v/4/b USA Gallup poll 2003 O-Slu/u/sq/v/4/c USA Gallup poll 2004 O-SLW/c/sq/v/4/b Canada Survey 1989 O-SLW/c/sq/v/4/c Former communist countries, LLH Survey 2001 O-SLW/c/sq/v/4/e Japanese Life-in-Nation Survey, periodical) since 1992 O-SLW/c/sq/v/4/f China Gallup polls 1997, 1999, 2004, US Gallup poll 2004 O-SLW/g/sq/v/4/b USA Gallup poll 1997 O-SLW/u/sq/v/4/b International Candidate Countries Euro-barometer 2001, 2002, 2003 O-SLW/u/sq/v/4/d Canadian GVP 1997, 2000 O-SLW/u/sq/v/4/e USA Gallup poll 1991 O-SLW/?/sq/v/4/b Finland, Survey 1960 O-SQL/u/sq/v/4/a Italian Barometro Sociale 1996 5-Step verbal life satisfaction (Table 121D in Happiness in Nations) O-SLL/c/sq/v/5/d Netherlands periodical QOL Survey since 1974 O-SLL/u/sq/v/5/a European Readers Digest Survey 1990 O-SLu/c/sq/v/5/a International Leisure Development Survey 1979 O-SLu/g/sq/v/5/c International IRMC Survey 1991 O-SLu/u/sq/v/5/a Polish Survey 1960 O-SLW/c/sq/v/5/b Austrian QOL Survey 1984 O-SLW/c/sq/v/5/g South Africa QOL Survey 1983, Spanish Survey 1993 O-SLW/c/sq/v/5/h Russia panel RLMS panel, 1992–2002, Kyrgyzstan KMPS 1993 (continued)

54 Scheme 4.2 Item codea

R. Veenhoven (continued) Survey program in which question was used

O-SLW/c/sq/v/5/k Japanese Future Life Surveys1995, 1997, 1999 O-SLW/c/sq/v/5/l Japanese Future Life Survey 2001 O-SLW/c/sq/v/5/o China Gallup Survey 1994 O-SLW/c/sq/v/5/p India, World value Survey 2002 O-SLW/u/sq/v/5/e Romania Diagnosis of Quality of Life surveys, since 1993 O-SLW/u/sq/v/5/g Japan Life Style Preference Survey, tri-annual since 1978 O-SLW/u/sq/v/5/m Candidate Countries Euro-barometer 2004.1 O-SLW/u/sq/v/5/h Japanese Life Style Preference Survey 2001 O-SL?/c/sq/v/5/a Taiwan Living Conditions Survey 1998 7-Step verbal life satisfaction (Table 121F in Happiness in Nations) O-SLW/c/sqt/v/7/a Sweden QOL Survey 1982 7-Step verbal delighted-terrible life (Table 141A in Happiness in Nations) O-DT/c/sq/v/7/aa Michalos’s International Student Survey 1985 O-DT/c/sq/v/7/ab Diener’s International Student Survey 1995 O-DT/u/sq/v/7/a Australian QOL Survey 1978, US QOL Surveys 1972, 1978 O-DT/u/sq/v/7/d USA Social Indicator Study 1972 8-Step verbal delighted-terrible life (Table 141B in Happiness in Nations) O-DT/u/sq/v/8/b Australian National Social Science Survey 1995 Affect A-AOL/m/sq/v/5/b Russia one-time Erasmus Survey 1991 A-AOL/md/sq/v/5/a USA one-time Gallup poll 2001 Contentment C-RG/ly/sq/v/4/b South Korea, Social Development Survey 1981and Democracy barometer 2001 Mixed items M-FH/u/sq/v/3/a Netherlands, NIPO 1988 M-FH/u/sq/v/3/d Netherlands, NIPO 1965, 1995 M-FH/g/sq/v/4/a Poland PGS-BS 1992, 1993 M-FH/cw/sq/v/6/a Romania Diagnosis of Quality of Life Surveys, annual 1993–1997 M-PL/c/sq/v/4/b South Korea, Social Development Survey 1981 and Democracy barometer 2001 M-TH/cm/sq/v/6/a Item in health inventory SF-36. Used in one-time surveys in Denmark 1994, Croatia 1999,2003 and Hong-Kong, Romania 1996 M-TH/g/sq/v/5/c Romania Diagnosis of Quality of Life Survey 1993 a The full text of the above mentioned questions on happiness can be found in the ‘Item bank’ of the World Database of Happiness (http://www1.eur.nl/fsw/happiness/hap_quer/hqi_fp.htm), using the item codes in the left column.

Instrument The assessments will be made on a computer screen, which displays the survey question and a vertical bar scale. Next to this will be the verbal response options, such as ‘very happy’ or ‘not happy’. On the vertical bar there will be horizontal


55

lines that can be moved by the cursor to section the bar. The user can move these lines up and down and thereby divide the bar into sections of different size. The response options next to the line will also move. The native speakers must shift the boundaries until they feel that the segments on the bar correspond with the meaning of the words as used for the response options. This tool is named a ‘Scale Interval Recorder’ and is available on request (Veenhoven & Hermus, 2006). An example of possible scores on this instrument is presented on Scheme 4.3.

The Judges University students will be invited to do this job. We opted for university students rather than ‘average citizens’, because the task requires a more than average verbal intelligence. We ignore that this may be at the cost of the validity, since the significance of words may be dependent on the subculture of their users. Recruiting Volunteers will be recruited though professors who participate in the study. Professors will explain the study to the students in class and then hand out a flyer with further details and a log-on code. Interested students can then do the assessments on a PC with Internet connection. This task is expected to take about 10 minutes per session, in which about 8 scales are judged consecutively.

Examples of three possible ratings A

B

C

Best Possible Life 10 9

Very

Very

Very

Fairly

Fairly

Fairly

Not too

Not too

Not too

8 7 6 5 4 3 2 1 0

Worst Possible Life

Scheme 4.3

Scale interval recorder

56

R. Veenhoven

Number Estimates will be more reliable the more judges are involved. We aim at a precision of 0.1 and a 0 to 10 scale in a 95% confidence interval, which will require about 200 student judges to participate per language/country.

Analysis The responses will be automatically recorded and transformed to an MS-Excel file. Using this file we will compute the average value allotted to each response option on a scale of 0 to 10. We will then use these scores to recalculate the means and standard deviations from distributional findings on happiness in nations already available in the section ‘Happiness in nations’ of the World Database of Happiness mentioned above. Example The response options with three response options were rated as follows in the Dutch language: 8.5 for ‘very happy’, 5.7 for ‘fairly happy’ and 2.5 for ‘not too happy’ (study dutch1). When used in a survey in The Netherlands in 1985 the frequency of responses to these options was respectively 71%, 27% and 2%. The values obtained were then used to compute a weighted average from these frequencies: 0.71 × 8.5 + 0.27 × 5.7 + 0.02 x 2.5 = 7.6. The ratings for the ‘same’ response options after translation into the English language were slightly different, 8.2 for ‘very happy’ and 2.6 for ‘not too happy’ (study english1). Given the same distribution of responses that would yield a slightly lower average: 0.71 × 8.2 + 0.27 × 5.7 + 0.02 × 2.6 = 7.4.

Validation The question then is: will these weighted averages provide a more accurate estimate of happiness in nations than the currently used unweighed means, which assumes equidistance and absence of language differences? To answer that question we will compare the performance of the calibrated and uncalibrated means in a crossnational analysis, to find out if objective country characteristics such as income per head correlate stronger with the former than with the latter. The data will also be used to calibrate standard deviations of happiness, which are used as a measure of inequality in nations (Kalmijn & Veenhoven, 2005)

4.5

Illustrative Result

One of the standard questions in the World Values Survey reads: Taking all things together, would you say you are…..? very happy, quite happy, not very happy or not at all happy? A Dutch version of that question figured in the 1999 survey in the


57

Scheme 4.4 Illustrative results Taking all things together, would you say you are…. Question

Mean

Very happy

Quite happy

Not very happy

Not at all Range happy 1–4

45.9

49.1

4.2

0.6

4 9.03

3 6.08

2 3.74

1 0.89

33.1

57.1

7.2

2.4

4 8.6

3 6.67

2 3.6

1 1.04

Range 0–10

Dutch Frequency of responses in % Standard rating Assessed ratings

3.40 –

8.00a 7.29

3.21 -–

7.37a 6.97

English Frequency of responses in % Standard ratings Assessed ratings a

After linear scale transformation

Netherlands and in that same year the English version was fielded in the UK. The observed frequency of responses to each of the answer options are presented in Scheme 4.4. Application of ratings from 1 for ‘not at all happy’ to 4 for ‘very happy’ results in a mean score of 3.40 in the Netherlands and 3.21 In the UK. This difference of 0.19 on the 1–4 scale is 6.3% of the scale range. Application of the method described in this paper yields a slightly different result. The numerical values assigned to the four response categories were not identical in the Dutch language (study dutch1 as in English language (study english1), the British judges give somewhat more weight to the lower categories. See Scheme 4.4. The resulting mean score are respectively 7.29 in the Netherlands and 6.97 in the UK, and the difference is now only 3.2% of the scale range. This preliminary result suggests that the difference in average happiness between the Netherlands and the UK is smaller than earlier findings on the basis of this question suggest.

4.6

Call for Cooperation

As noted above, this study aims to cover questions in 72 different languages and requires the participation of some 15,000 students. At this stage we have co-investigators for the following languages: Arabic, Chinese, English, Danish, Dutch, Portuguese, Spanish and Turkish. The latest update can be found on the web-site mentioned below. We welcome help from colleagues, especially in language areas not covered as yet.

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4.7

R. Veenhoven

Website

This study entirely web-based, Not only are the data gathered using a website, but also is all the documentation on the website, including the questionnaires and the findings. There is no paper archive in Rotterdam. So this research is entirely open to inspection. Anyone who may doubt the conclusions can check. The address of the study web site is: http://worlddatabaseofhappiness.eur.nl/scalestudy/scale_fp.htm

References Cummins, R.A. (1995) On the trail of the gold standard for subjective well-being. Social Indicators Research, vol. 35, pp. 179–200 Veenhoven, R (1993) Happiness in nations subjective appreciation of life in 56 nations 1946–1992, RISBO, Erasmus University Rotterdam. The Netherlands Kalmijn, W.M. & Veenhoven, R. (2005) Measuring inequality of happiness in nations: In search for proper statistics. Journal of Happiness Studies, Special issue on ‘Inequality of Happiness in Nations’, vol. 6, pp. 357–396 Jones, L.V. & Thurstone, L.L. (1955) The psychophysics of semantics: An experimental investigation. Journal of Applied Psychology, vol. 33, pp. 31–36 Smith, T.W., Mohler, P. Ph., Harkness, J. & Onodere, N. (2005) Methods for assessing and calibrating response scales across countries and languages. Comparative Sociology, vol. 4, pp. 365–415 Veenhoven, R. (2006) World Database of Happiness: Continuous register of scientific research on subjective enjoyment of life. Erasmus University Rotterdam, The Netherlands. Available at: http://worlddatabaseofhappiness.eur.nl Veenhoven, R. & Hermus, P. (2006) Scale Interval Recorder: Tool for assessing relative weights of verbal response options on survey questions. Web survey program, Erasmus University Rotterdam, Department of Social Sciences & Risbo Contract Research, The Netherlands Veenhoven, R. & Kalmijn, W.M. (2005) Measuring inequality of happiness in nations. In search for proper statistics. Journal of Happiness Studies, Special issue on ‘Inequality of Happiness in Nations’, vol. 6, pp. 357–396 World Database of Happiness, see Veenhoven (2006)

Chapter 5

More Than SF-36? Using Narratives to Elaborate Health and Well-Being Data in Recent Lower-Limb Amputees Narelle Warren*, Lenore Manderson and RoseAnne Misajon

Abstract Limited research has been conducted on the health-related quality of life of people who have undergone a major amputation. This paper explores the complexities of this population, through narratives elicited during in-depth interviews to elaborate data collected through administration of the SF-36 on self-reported health and well-being. Sixty inpatients aged 21–89 were recruited following the amputation of one or both lower limbs whilst at four (two rural, two urban) rehabilitation centres in Victoria, Australia. Results indicated a significant decrease in health-related quality of life in relation to the physical components of the SF-36. However, these limitations were viewed as temporary, and people anticipated a return to higher levels of physical functioning post-rehabilitation. No significant difference was found in regard to mental health (amount of time a person experienced feelings of nervousness, anxiety, depression and happiness) or the overall mental component summary scores, but participants scored significantly lower on three of the four mental components compared with Australian

* Corresponding author: N. Warren Research Fellow, School of Psychology, Psychiatry & Psychologiccal Medicine, Monash University (Caulfield), 900 Dandenong Rd, Caulfield East VIC 3145, Australia E-mail: [email protected] L. Manderson Professor, School of Psychology, Psychiatry & Psychological Medicine, Monash University, 900 Dandenong Road, Caulfield East, Victoria, 3145. E-mail: [email protected] R. Misajon Lecturer, School of Political and Social Inquiry, Monash University (Caulfield), 900 Dandenong Rd, Caulfield East VIC 3145, Australia E-mail: [email protected] V. Møller and D. Huschka (eds.) Quality of Life and the Millennium Challenge, © Springer Science + Business Media B.V. 2009

59 59

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population norms. Qualitative data indicated that participants experienced feelings of social isolation, hopelessness, and grief following their amputation, all impacting significantly on their mental health. Our results highlight the limitations to using the SF-36 as a stand-alone instrument to assess quality of life in a mostly elderly, ill population. Keywords Amputation, Australia, qualitative research methods, quality of life

5.1

Introduction

Assessing the impact on quality of life of medical and surgical procedures is important when planning rehabilitation and clinical practices. These are commonly used to measure the progress of individual patients and to assess the efficacy and success of particular approaches and programs (Bak et al., 2006). The SF-36 is one of the most commonly used instruments for this purpose. Our interest in the use of validated scales has two dimensions. One relates to the appropriateness and interpretation of results in a diverse population. We were interested in the relevance of the questions asked according to patients’ age and general health status, the comprehensibility of questions in relation to idiomatic expressions (“pep,” “blue,” etc., a concern also noted by Mallinson, 2002) especially for patients from diverse cultural backgrounds (Maramaldi et al., 2005), and the adequacy of questions and responses as measured by their concordance or discordance with other, qualitative data. Assuming validity and congruence, we were also interested in differences by gender, age and ethnicity (Lacey & Walters, 2003; Sin et al., 2004; Wee et al., 2006). Our population focus was on a diverse population with lowerlimb amputation. Amputation is performed for various reasons, often correlating with life stage: traumatic amputations occur most often in young to mid-age adults (see Hagberg & Branemark, 2001); amputation due to osteosarcoma in adolescents (Wittig et al., 2002); and dysvascular amputation in elderly patients (Dillingham et al., 2002; Cumming et al., 2006), who report a positive psychosocial response post-amputation (Harness & Pinzur, 2001). Older people with amputation typically present with various co-morbidities, with the amputation a reflection of their poor general health. Many young people who have had amputation may, in contrast, have had good health prior to trauma, although the few who have amputations following drug or alcohol related injuries or self-harm often have poor mental health. As a result, questions of quality of life, as captured by the SF-36, are a “blunt” instrument of the well-being of individuals. As Hendry and McVittie (2004) suggest for older people, the results of responses to such instruments may not truly reflect experiences. In addition to the extent to which responses are subject to homeostatic effects, expectations about health and activity levels affect the validity of conclusions about well-being, quality of life and the suitability of aggregate measures

5 More Than SF-36?

61

(Clavarino, 1999; Cummins, 2003). Problems encountered by individuals when completing measurement instruments can further complicate results and their interpretation (Mallinson, 2002; van der Schans et al., 2002: 434). As noted above, we conducted our research in a sample of rehabilitation inpatients who had had an amputation of either or both lower limbs, through the ankle or higher. Both Mallinson (2002) and Hendry and McVittie (2004) argue that qualitative methods enable detailed understanding of the nuances of factors impacting upon quality of life and provide clarification of problems involved in measurement instruments. In this study, we employed iterative, qualitative methods, particularly open-ended, unstructured interviews which invited participants to describe how they felt and to interpret their responses, to examine the complexities associated with health-related quality of life. These findings were compared with generic health-related quality of life data (collected via the SF-36) to explore the utility of this measure in our population. While we were interested in documenting response differences according to instrumentation, and specifically to contrast the SF-36 with data generated, we anticipated that the two approaches would allow for triangulation, but did not expect a discrepancy in self-reports. The emergence of discordance raised questions of the utility of a structured instrument. In exploring the implications of this finding, we argue that the results are important because they emphasise the need to take account of context, including cultural, personal and structural factors, in assessing individual well-being. The results raise questions about the timing of the evaluation of patient wellbeing, about the factors that influence responses, and about how such responses might be used to inform general programs and individual welfare. Quality of life and well-being following amputation and, by implication, in other contexts, involves more than the SF-36 response. In this paper, following a brief discussion of methods, we present the findings across the various items and domains of the SF-36, and use excerpts from research participants to elaborate on key findings as well as to highlight contradictions. We then return to the literature to tease out the implications of the findings from this study, and identify areas for further research.

5.2

Methodology

Sixty men and women were recruited using non-random theoretical sampling from four rehabilitation clinics in regional and urban Victoria, Australia, with multiple clinics selected to ensure diversity of participants by age, gender, ethnicity and socio-economic status. Rehabilitation consultants identified potential participants during case meetings; exclusions, determined by consultants, occurred due to severe psychiatric morbidity (n = 1) or where informed consent could not be obtained due to cognitive impairment (n = 2). Eligible patients were approached until 15 were recruited from each clinic; 4 declined to participate. Interested patients were introduced during clinical ward rounds and physiotherapy sessions to

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the first mentioned author, who provided detailed information about the research aims and protocol, and obtained informed consent. Participants were interviewed by the first named author for 45 to 80 minutes whilst inpatients, 13 to 138 days (mean = 46.9) post-amputation(s). Using openended interview guidelines, participants were invited to tell their stories in their own words, ensuring that they felt comfortable in raising issues pertinent to their experience and could direct their stories in ways they desired. Of nine participants from non-English speaking backgrounds, four required translators (Italian, Macedonian, and Mandarin). At the end of each interview, in the participant’s preferred language, the researcher verbally administered the SF-36 (Ware & Sherbourne, 1992), which provided self-reported health-related quality of life information. Verbal administration was appropriate due to high levels of vision impairment amongst participants (n = 41); it also enabled participants to explain their responses and clarify their understanding of items. The data from the interviews and questionnaires were supplemented by contextual data gathered from inpatient clinic observations, while co-morbidity and functional data (not reported in this article) were obtained from medical records. Interviews were audio-taped, transcribed and imported from word documents into Atlas-ti (2004) text format, for coding and narrative and thematic analysis. The first two authors coded the interviews independently, and discussed themes and sub-themes to check for concordance and possible interpretation. In this paper, we present excerpts of interviews for illustrative purposes, and to ensure confidentiality, we use pseudonyms when specifically referring to individual experiences or directly quoting from interviews. Quantitative data were analysed using SPSS (2005) by the third author, and consisted of descriptive analyses and one-sample t-tests for comparisons between the current study and the general Australian population. Where relevant, in our analysis of each scale, individual t-scores are indicated in parentheses.

5.3

Results

Thirteen participants (9 male, 4 female) did not complete the SF-36, citing lack of applicability or difficulties in relating the instrument to the complex impact of their current health concerns on their lives. Those who did not complete it tended to be older (mean age 72.2 years) than the remaining participants (see van der Schans et al., 2002). Four of these participants were from non-English speaking backgrounds, and lack of cultural salience or familiarity with such instrumentation may have played a role in non-completion. Key socio-demographic information for the remaining 47 participants is shown in Table 5.1. Our sample consisted of three times more men than women, reflecting amputee inpatient populations. Participants were mostly elderly, with 59.6% aged over 70 years (mean 67.8 ± 14.0 years) and retired from paid employment. Over half were married or had a partner, but almost a quarter were divorced. Several lived

5 More Than SF-36? Table 5.1

63

Socio-demographic profile of study participants (completed SF-36) N

Total N Age Mean & SD (67.8 ± 14.0) Range (21–82 years) – about 2,909)

Mean

SD

Mean

SD

t

48.73 52.30 49.44 61.84 47.73 55.62 50.84 54.59 46.06 37.38 34.37 31.43 36.03

29.77 21.10 28.37 30.37 27.29 30.41 29.38 30.11 27.54 26.19 17.43 22.79 25.76

61.90 64.22 60.45 71.89 56.05 65.68 68.77 68.64 58.69 53.10 46.52 42.33 47.42

24.01 15.30 24.01 23.22 25.51 25.86 24.82 24.97 25.77 27.94 18.35 23.51 25.82

15.60a 20.97a 13.31a 12.01a 09.83a 11.31a 20.94a 16.19a 14.77a 17.71b 20.73b 14.45b 13.61b

32.41 29.94 37.09 39.32

22.58 23.79 24.91 25.54

39.81 45.21 47.13 57.28

22.50 26.77 24.46 25.76

10.13b 18.24b 12.58b 21.57b

126

3.

4.

5.

6.

H. Tiliouine

(Table 8.3). The main findings concerning PWB are that of a reversed trend, but no significance is noticed in favour of males in S2. A consistent finding in both surveys concerns the domain of Standard of Living, which is scored significantly higher by females compared to males. A reversed trend, but one that is not significant is noticed in the domains of Health, Personal Security, and Future Security. In the domains of Life Achievements, Personal Relationships, and Belongingness to society the trend, though not significant was consistently in favour of males. In NWI, all comparisons are in favour of females, and discrepancies in Business and Life in Algeria are significantly higher in the same direction. Differences between survey mean scores are all higher in the second survey. With regard to comparisons between PWI and NWI across age sub-groups, it is apparent from Table 8.4 that the PWB of the age range 36–45, followed by the 26–35 has been more subject to change than the eldest and youngest group. The youngest group followed by the 36–45s scored the largest mean differences in NWB. So, this latter does not seem to follow the same trend. When the same indexes have been compared across education groups, the results reveal that the least affected group in terms of PWB is the ‘no formal education’ group. The most affected are the medium and secondary levels. NWB of primary followed by university levels have been the more affected. Although both surveys generally show that higher education groups have higher PWB, these have lower NWB scores (Table 8.5). As far as marital status is concerned, Table 8.6 shows that the main groups, the single and married ones, have an equal SD but the mean gains of the married group are much higher than those of the singles, with married persons having significantly higher PWB in S2. Finally, with relation to the four income groups which are created on the basis of the official National Minimum Salary in Algeria, both surveys indicate higher PWI in higher earning groups. Although the trend is not significant, the least earning group has the highest NWB in both surveys (Table 8.7). It has been argued earlier that in Algeria major economic indicators have shown significant improvements compared to 2003. In order to explore whether the population perceives a change in its financial situation, PWI and NWI means are calculated on the basis of the 5-response categories (Table 8.8). It could be noticed that 37.31% (N = 1,080) of 2895 respondents declared that their financial situation has either ‘improved’ or ‘greatly improved’, compared to the remaining 28.43% (N = 823) respondents who choose the opposite response direction. Yet, 34.27% of the sample perceives no change in this respect. When PWB means are compared, it is apparent from F-values that the differences are significantly higher in favour of the groups who perceive an improvement in their financial situation. The same trend is noticed in NWB means, but no significance beyond the ‘no change’ in the finance group. As a summary, it should be stressed that considerable gains in both measures have been found in S2. This is consistent across all the researched domains. In addition, females have lost the PWB advantage of S1, with some variations

Social conditions

Environment

Economic situation

NWI

Life as a whole

Future security

Belongingness

Personal security

Personal relationships

Life achievements

Health

Standard of living

PWI

Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male

Gender

708 709 708 709 708 709 708 709 708 709 708 709 708 709 708 709 708 709 708 709 708 709 708 709 708

N 50.55 54.06 45.27 53.61 59.24 64.44 47.95 47.50 56.40 54.84 49.74 51.93 51.13 58.05 44.10 48.02 46.45 51.00 33.69 35.05 31.43 31.44 35.90 36.16 32.00

Mean (20.89) (21.18) (28.00) (28.15) (30.55) (29.99) (27.33) (27.27) (29.25) (31.53) (29.11) (29.63) (30.06) (29.78) (27.46) (27.49) (29.84) (29.53) (17.28) (17.57) (22.63) (22.96) (25.37) (26.16) (21.93)

SD

Table 8.3 Comparisons of mean scores of the two surveys (S1 and S2) S1

−0.19

−0.01

−1.47

−2.89b

−2.69a

−4.36b

−1.40

.97

.30

−3.24b

−5.59b

−3.42a

t 1404 1421 1442 1460 1437 1460 1440 1453 1440 1449 1440 1454 1437 1460 1436 1457 1441 1458 1426 1447 1439 1459 1444 1461 1440

N

S2 64.46 63.98 57.35 63.52 72.52 71.27 57.31 54.80 67.94 63.44 69.26 68.29 68.50 68.79 59.13 58.26 62.17 61.63 44.66 48.35 40.47 44.17 45.93 48.90 38.27

Mean (15.29) (15.31) (23,90) (23,73) (22,87) (23,55) (25,13) (25,82) (23,83) (27,55) (25,10) (24,55) (25,59) (24,36) (26,22) (25,32) (24,35) (23,66) (18,61) (17,91) (24,00) (22,86) (26,18) (25,38) (22,84)

SD

−3.10b

−4.26b

−5.41b

.60

.90

−.31

1.05

(4.70)b

2.65a

1.45

−6.98b

.22

t

S2-S1

(continued)

13.91 (−5.6) 9.92 (−5.87) 12.08 (−4.1) 09.91 (−4.42) 13.28 (−7.68) 06.83 (−6.44) 09.36 (−2.2) 07.30 (−1.45) 11.54 (−5.42) 08.60 (−3.98 19.52 (−4.01) 16.36 (−5.08 17.37 (−4.47) 10.74 (−5.42) 15.03 (−1.24) 10.24 (−2.17) 15.72 (−5.49) 10.63 (−5.87) 10.97 (1.33) 13.3 (0.34) 09.04 (1.37) 12.73 (−0.1) 10.03 (0.81) 12.74 (−0.78) 06.27 (0.88)

Mean score difference

8 Stability and Change in National and Personal Wellbeing in Algeria 127

b

p < .05, p < .005

a

Life in Algeria

National security

Business

Government

Table 8.3 (continued)

N

709 708 709 708 709 708 709 708 709

Female Male Female Male Female Male Female Male Female

S1

Gender 32.82 28.84 31.03 35.37 38.81 38.60 40.04 35.67 39.10

Mean (23.22) (23.75) (23.79) (24.26) (25.43) (25.36) (25.72) (25.59) (26.67)

SD

−2.47a

−1.06

−2.61a

−1.73

−0.68

t

S2

1459 1442 1457 1441 1457 1443 1461 1440 1454

N 41.34 42.34 48.06 44.57 49.65 56.29 58.25 50.78 55.40

Mean (22,06) (26,94) (26,31) (24,18) (24,47) (25,71) (25,78) (28,78) (26,90)

SD

−4.46b

−2.05a

−5.62b

−5.78b

08.52 (−0.56) 13.5 (3.19) 17.03 (2.52) 09.20 (−0.08) 10.84 (−0.93) 17.69 (0.35) 18.21 (0.06) 15.11 (3.19) 16.30 (0.23)

−3.68b

S2-S1 Mean score difference

t

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8 Stability and Change in National and Personal Wellbeing in Algeria

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Table 8.4 Age subgroups and wellbeing mean scores in the two surveys S1 Age PWI 18–25 26–35 36–45 46+ NWI 18–25 26–35 36–45 46+

S2

N

%

Mean SD

690 425 215 87 690 425 215 87

48.7 30.0 15.2 6.1 48.7 30.0 15.2 6.1

53.57 50.08 51.55 54.99 34.27 33.96 33.88 38.41

N

%

Mean SD

S2-S1 mean score difference (SD)

21.30 1,251 44.3 64.55 15.19 10.98 (−6.11) 21.79 806 28.6 63.00 16.07 12.92 (−5.72) 20.09 456 16.1 65.52 15.01 13.97 (−5.08) 17.49 312 11 64.13 13.88 09.14 (−3.61) 17.64 1,271 44.2 47.53 18.19 13.26 (0.55) 17.36 817 28.4 44.04 18.61 10.08 (1.25) 17.38 464 16.2 46.25 18.51 12.37 (1.13) 15.94 321 11.2 49.23 17.44 10.82 (1.5)

S1: PWB by age differences (F (3, 1413) = 3.06, p = 0.02); NWB by age differences (F (3, 1413) = 1.70, p = 0.16); S2: PWB by age differences (F(3, 2821) = 3.019, p = 0.029; 36–45 > 26–35, p = 0.025). NWB by age differences (F (3, 2869) = 8.669, p = 0.000; 18–25 > 26–35, p = 0.000; 46= > 26–35, p = 0.000)

Table 8.5 Education levels and wellbeing mean scores in the two surveys S1 N

S2 %

Mean SD

N

PWI Not been to 38 2.7 55.56 20.76 180 school Primary 48 3.4 49.38 22.54 151 Middle 166 11.7 47.44 20.59 448 Secondary 532 37.5 52.02 22.08 914 University 633 44.7 53.85 20.11 1,132 Total 1,417 2,825 NWI Not been to 38 2.7 38.29 16.12 182 school Primary 48 3.4 41.15 19.42 155 Middle 166 11.7 37.26 19.18 451 Secondary 532 37.5 34.59 17.54 932 University 633 44.7 32.68 16.53 1153 Total 1,417 2,873

%

Mean SD

6.4

58.14 14.86 02.58 (−5.9)

5.3 15.9 32.4 40.1

62.19 62.77 64.48 65.82

6.3

49.55 16.66 11.26 (0.54)

5.4 15.7 32.4 40.1

48.87 49.98 48.13 43.08

14.36 15.07 15.75 14.91

17.25 18.52 18.74 17,82


12.81 (−8.18) 15.33 (−5.52) 12.46 (−6.33) 11.97 (−5.2)

07.72 (−2.17) 12.72 (−0.66) 15.85 (1.2) 10.40 (1.29)

S1: Significant differences in PWB according to education; F(4,1412) = 3.55, p = .007 (Post Hocs: University > Middle school, p = .005); Marginal significant differences in NWB according to education; F(4,1412) = 4.99, p = .001 (Post Hocs: Middle School > University, p = .021; Primary school > University, p = .010); S2: PWB Significant differences in PW according to education; F(4,2820) = 12.11, p = .000 (Post Hocs: Medium > none, p = .005; Secondary > none, p = .000; University > none, p = .000; University > primary, p = .046; University > medium, p = .003. Significant differences in NWB according to education: F(4,2868) > 18,239, p = .000(Post Hocs: None > university; p = .000; Primary > university, p = .002; medium > university, p = .000; Secondary > university, p = .000)

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Table 8.6 Marital status and wellbeing mean scores in the two surveys S1

PWI Single Married Widowed Divorced Total NWI Single Married Widowed Divorced Total

S2

N

%

Mean SD

N

%

Mean

SD


915 473 24 5 1,417 915 473 24 5 1,417

64.6 33.4 1.7 0.4

52.85 51.61 43.81 58.29

21.49 20.17 23.31 19.04

61.8 34.7 2.1 1.4

63.71 65.73 58.21 58.46

15.73 14.41 14.95 13.52

10.86 (−5.76) 14.12 (−5.76) 14.40 (−8.36) 0.17 (−5.62)

64.6 33.4 1.7 0.4

34.24 34.49 32.08 50.67

17.51 17.30 14.97 16.44

1,745 980 60 40 2,825 1,776 995 61 41 2,873

61.8 34.6 2.1 1.4

46.28 46.58 49.02 51.79 46.52

18.48 18.52 13.49 13.96 18.35

12.04 (0.97) 12.09 (1.22) 16.94 (−1.48) 01.12 (−2.48)

S1: No PWB differences between married/single: t(1386) = 1.04, p = .299;S2: Significant PWB differences between married/single: t(2723) = −3.32, p = .001

Table 8.7 Income level and wellbeing mean scores in the two surveys S1

PWI <MS* Up to Twice MS Up to 3 times MS > 4 times MS Total NWI <MS* Up to twice MS Up to 3 times MS > 4 times MS Total

S2

N

%

Mean

SD

122 412

16.7 56.4

48.89 51.80

20.98 553 20.93 708

35.7 61.50 15.30 12.61 (−5.68) 45.8 65.78 15.11 13.98 (−5.82)

113

15.5

49.17

20.51 227

14.7 67.65 13.64 18.48 (−6.87)

84

11.5

56.21

21.44 59

3.8

731 122 412

16.7 56.4

36.94 35.16

1,547 19.51 562 35.7 47.54 18.80 10.6 (−0.71) 17.48 720 45.8 43.50 18.18 08.34 (0.7)

113

15.5

31.70

15.82 229

14.6 45.75 18.43 14.05 (2.61)

84

11.5

36.75

15.60 61

3.9

1,417

N

%

Mean SD


67.55 14.79 11.34 (−6.65)

44.64 17.55 07.89 (1.95)

1,572

MS* = Official minimum salary guaranteed;S1 (2003): Marginal significant differences in PWB according to income: F(3, 727) = 2.54, p = .05 (Post Hocs: No significant differences in NWB: F(3, 727) = 2.15, p = .09; S2 (2005): Significant PWB differences: F (3, 1543) = 13.29, p = .000 (Post Hocs: Up to Twice MS > < MS, p = .000; Up to three times MS > < MS, p = .000; > 4 times MS> < MS, p = .017). Significant NWB differences: F (3,1568) = 5.14, p = .002 (Post Hocs: < MS < Up to twice MS, p = .001)


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Table 8.8 Well-being scores and the self-perceived change in the financial situation over the last two years PWI

NWI

N

%

Mean

SD

Mean

SD

Greatly decreased Decreased

239 584

8.26 20.17

15.90 15.13

992

34.27

Improved

933

32.23

Greatly improved

147

5.08

39.38 (N = 234) 45.68 (N = 574) 47.06 (N = 983) 47.95 (N = 922) 48.64 (N = 146) 11.44a

18.20 18.35

No change

55.43 (N = 236) 62.78 (N = 564) 63.48 (N = 969) 67.21 (N = 899) 70.76 (N = 146) 38.75a

F

15.15 14.10 14.73

17.71 18.37 19.85

a

P < .000; Post Hocs: PWI: Decreased > G. Decreased, P = 0.000; No Change > G. Decreased, p = 0.000; Improved > G. Decreased, p = .000; Improved > Decreased, p = 0.000; Improved > No Change, p = .000; G. Improved > G. Decreased, p = .000; G. Improved > Decreased, p = .000; G. Improved > No Change, p = .000; NWI: Decreased > G. Decreased, P = .000; No Change > G. Decreased, p = .000; Improved > G. Decreased, p = .000; Improved > G. Decreased, p = .000

concerning individual items. But, NWI does not follow the same trend. Generally, data indicate that with regard to education levels comparisons follow the same line. Here, people with higher education are more satisfied with personal domains, but not with societal ones. Furthermore, all marital status groups registered higher gains in S2 in both measures, with singles losing the PWI advantage of S1. Data confirm that the higher personal income group is more satisfied with their personal life. These are also more significantly satisfied with the societal domains in S2. Besides, further support has been brought to the idea that recent changes in the country are accompanied by positive perceptions of a high percentage of people of their financial situation. Comparatively, the groups perceiving positive changes in this respect score higher means in both WB measures. In the following part, some of the psychometric properties of IWI are compared. Our emphasis is not only on PWI as in previous studies, but on both measures of IWI. 7. Reliability While Cronbach alpha for NWI shows a remarkable stability with 0.83 in S2 and 0.81 in S1, that of PWI has decreased from 0.85 in S1 to 0.73 in S2. Their PWI equivalents in Hong Kong and Australia have been respectively 0.73 and 0.80. Altogether, these figures bring further support to the reliability of both sub-scales. In the same direction, all item-total correlations have been found significant in both surveys (Table 8.9), but a small decrease in PWI is noticed in S2, and a relatively marginal increase in NWI. All inter-item correlations are positive and significant. But while those of NWI are generally comparable across the two surveys, those of PWI have been

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Table 8.9 Item-total correlations in the two surveys Item total correlations of PWB

Item total correlations of NWB

Items

S1 (2003)

S2 (2005)

Standard of living Health Achievements Personal relations Personal security Belongingness Future security Economy Environment Social conditions Government Business Nation security

0.71 0.75 0.72 0.72 0.72 0.74 0.72 0.72 0.64 0.71 0.79 0.75 0.71

0.57 0.49 0.64 0.58 0.65 0.66 0.70 0.76 0.8 0.74 0.80 0.76 0.71

All correlations are significant at the 0.001 level (two-tailed).

reduced. In 2003, they ranged between .37 and .75, but in 2005 their range was between .16 and .66. 8. Validity The coherence of the two sub-scales has been tested through a Principle Component Factor Analysis of the 13 domains for each survey. The two factors solution has been further reinforced but reduced loadings on the first component in S2 are found (Table 8.10). Similarly, the total percentage of explained variance has been slightly lower in the same survey for both factors (about 46% in S2 compared to 53% in S1). 9. Shared contribution of individual Domains to satisfaction with life-as-a-whole From the figures displayed in Table 8.11, it could be noticed that in both surveys the seven domains correlate significantly with the general item of Life-as-a-whole. But, in S1, they ranged from 0.43 to 0.65 and in S2 their range is from 0.30 to 0.47. For instance, the correlation with the Health item has been reduced to half, from 0.60 to 0.30. This echoes what has been noticed as far as factor loadings on PWB are concerned. Concerning societal domains, it could be noticed from Table 8.12 that overall correlations between individual items and the general item of Life in Algeria and interdomains correlations are comparable across the two surveys. Consistently, all domains made a significant contribution to the general satisfaction variable in both surveys, except ‘Business’ which has a marginal negative contribution in S1 but this negative contribution has been larger in S2. So, this domain needs to be further explored. To sum up, confidence in the psychometric performance of IWI has been confirmed. The sensitivity of the measure to the changing context of the research has been also reinforced through empirical evidence. The reduced level in PWI inter-item correlations and the weaker loadings of the items on the PWB Factor in S2 could be explained by the fact that the sample has been experiencing a new climate of better


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Table 8.10 Orthogonal factor analysis of personal and national domains in the two surveys S1

S2

Item

Component 1

Health Personal relationships Achievements in life Community connectedness Standard of living How safe you feel Future security Government Economic situation Business Social conditions National security State of the environment % of variance explained Eigenvalues

0.77 0.72 0.70 0.70 0.69 0.69 0.66

Component 2

Component 1 Component 2 0.47 0.60 0.65 0.64 0.53 0.60 0.67

0.82 0.75 0.72 0.68 0.67 0.56 15.57% 2.02

37.45% 4.87

0.80 0.74 0.80 0.72 0.68 0.64 13.62% 1.77

32.71% 4.25

Table 8.11 Regression of personal domains on satisfaction with life as a whole in the two surveys Variable S1 1. Standard of living 2. Health 3. Achieve in life 4. Perso. Relationships 5. Safety 6. Comm. Connect 7. Future security S2 1. Standard of living 2. Health 3. Achieve in life 4. Perso. Relationships 5. Safety 6. Comm. Connect 7. Future security

Life as a whole

1.

0.65a 0.60a 0.51a 0.47a

0.54 0.46 0.37

2.

3.

0.48 0.49 0.50

4.

5.

6.

B

β

Sr2

0.37* 0.23* 0.10* 0.08*

0.35 0.24 0.09 0.09

0.27 0.18 0.07 0.07

0.00 0.09 0.13 0.30 0.13 0.18 0.09

0.00 0.07 0.10 0.28 0.12 0.15 0.08 0.06 0.07 0.09

0.43a 0.48a 0.50a 0.47a 0.30a 0.40a 0.30a

0.42 0.39 0.45 0.25 0.28 0.22

0.42 0.38 0.42 0.00 0.45 0.42 0.45 0.50 0.09* 0.38 0.47 0.39 0.51 0.51 0.14* 0.30* 0.13* 0.20 0.17* 0.16 0.34 0.08*

0.31a 0.32a 0.37a

0.22 0.23 0.28

0.22 0.26 0.24 0.07* 0.07 0.17 0.29 0.26 0.41 0.08* 0.09 0.17 0.37 0.26 0.44 0.45 0.10* 0.11

a

Significant at the 0.001 level; S1: Unique variability = 0.13; shared variability = 0.44; R2 = 0.57; Adjusted R2 = 0.57; S2: Unique variability = 0.14; shared variability = 0.22; R2 = 0.36, Adjusted R2 = 0.36

security and better future prospects. So, their ranking of priorities in life has been altered compared to the prevailing situation in 2003. In this respect, the importance of Health has been reduced along with Standard of living.

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Table 8.12 Regression of national domains on satisfaction with life in Algeria in the two surveys Variable S1 1. Economy 2. Environment 3. Social cond. 4. Government 5. Business 6. National security S2 1. Economy 2. Environment 3. Social cond. 4. Government 5. Business 6. National security

Life in Algeria

1.

0.50 0.33 0.42 0.45 0.34 0.40

0.32 0.44 0.55 0.46 0.38

0.55 0.34 0.41 0.44 0.33 0.36

0.42 0.53 0.53 0.49 0.41

2.

0.47 0.33 0.31 0.32

0.47 0.38 0.40 0.36

3.

0.46 0.40 .34

0.50 0.48 0.38

4.

0.56 0.51

0.58 0.50

5.

B

β

Sr2

0.49

0.33a 0.08b 0.18a 0.14a −0.03 0.16a

0.29 0.08 0.16 0.13 −0.03 0.15

0.23 0.07 0.12 0.09 −0.02 0.12

0.48

0.44a 0.07a 0.12a 0.17a −0.07b 0.11a

0.37 0.07 0.10 0.16 −0.06 0.10

0.28 0.05 0.08 0.11 −0.05 0.08

S1: R2 = 0.35; Adjusted R2 = 0.34 S2: R2 = 0.35, Adjusted R2 = 0.35, ap < 0.005; bp < 0.05

10. The contribution of the new “spare time item” to PWI Two main considerations have been observed in the construction of the PWI (Cummins et al., 2003). The first one is in relation to the theoretical rationale behind its construction. So, all of the seven constituent domains represent a first level deconstruction of the general item of Satisfaction with Life as a Whole (LAW). The second one is empirical. So far, the seven retained domains have been extensively put under empirical scrutiny, and proved to make a satisfying contribution to the general item. Aware of these two considerations, we attempt here to test the possible addition of the domain of ‘spare time use satisfaction’ in order to see whether the shared variability between the domains increases, as this latter has been judged lower than it should be. The wording of the proposed domain is as follows: How satisfied are you with your spare time use? This item is somewhat different from those used by Cummins (2006). He researched two aspects of satisfaction with leisure time. One is satisfaction with the amount of leisure time and the second is in connection with satisfaction with the way this time is spent. So, our wording seems more general because spare time (at least as used in our Arabic questionnaire) implies free time, time when one is not carrying out a formal work activity compared to the word leisure which may consider only time spent in pursuing fun, distraction, and entertainment. Future research in this area may produce very important information on the way different cultural settings perceive and provide for people’s free time, knowing that due to technological advances modern life is differently shaped compared to the past. So, theoretically, satisfaction with the spare time use item seems reasonable, though no details could be given here for space restrictions. However, our data indicate that this item has the lowest mean compared to other PWI items (Mean: 49.73, SD: 25.87) which may indicate that many people are not satisfied with the way they spend their free time. This item correlates significantly


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Table 8.13 Regression of individual domains on satisfaction with life as a whole β

Sr2

0.30a

0.30

0.27

Health

0.13

a

0.12

0.12

Achievements

0.15a

0.16

0.14

0.07

a

0.08

0.08

Personal security

0.06

a

0.07

0.06

Belongingness

0.07a

0.08

0.07

Future security

0.09

a

0.10

0.08

0.58

a

0.06

0.06

B Standard of life

Personal relationships.

Spare time use a

p < 0.005, p < .05 R2 = 0.37, Adjusted R2 = 0.36

with PWI (r = 0.41). Factor Analysis shows that its loadings on the PWI factor reached 0.6, which is higher than that of Health, Personal Security, and Belongingness items. Besides, it makes a significant contribution to life as a whole (Table 8.13).

8.5

Discussion

It has been argued that the case of Algeria can be used as an example of developing countries which are in the process of a significant recovery after harsh security and economic difficulties. Therefore, the conclusions may be applicable to a wide range of Third World societies. In Algeria, despite the significant increases in PWB and NWB from 2003 to 2005 for the whole studied population and its categories, the results indicate that the country continues to lag behind the developed world in these aspects. This is congruent with international research (cited in our introduction). The recent positive developments in terms of political stability, the significant improvement of security and rising economic prospects may explain the gains in both PWB and NWB. This has been evidenced through domain comparisons in which it has been found that higher figures are registered in the domains of Personal Safety, Community connectedness and Future Security. In NWI, it is respectively the domains of National Security, Government, and Economy that have recorded higher increases. A supplementary argument could be drawn from Table 8.7 in which the people who have felt an improvement in their earnings have significantly higher Personal and NWB. As for the question of which category of the population reacts more positively in terms of PWB and NWB to such changes, comparisons on the basis of demographic characteristics are very informative. Between-surveys comparisons prove that in S2 females lost their PWB advantage over males. This result leads us to suppose that in male dominant

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societies an increasingly stable context is more favourable to males to carry out their normal life. With security problems, they are more exposed to dangers as they drive outside cities, travel and work at night, and so on. Societal domains do not seem to follow the same trend, as women keep up their advantages across all NWI and its individual components with a much larger difference in S2. Although, there is no plausible explanation for why women are more satisfied with societal domains, it is worth mentioning that the largest difference in S2 concerns the Government item. This may indicate that women have more sympathy with the government efforts made in their favour, such as in employment. Furthermore, there might be some susceptibility to official media that takes the form of organised propaganda, or even a particular tendency in women to express positive views on their societal situation. This might be an interesting subject for future research. In terms of age, results are less conclusive. It has been found that the youngest and the oldest groups’ PWB accumulated the lowest increases across the two surveys. This may mean that they are the least affected by the changes occurring in the country, but this needs further analysis on an individual domains basis. Highest gains on the societal wellbeing scale are registered by the youngest group. In accordance with most international research findings, higher education groups experience higher personal satisfaction in both surveys. Meanwhile, they are the least satisfied with national domains. This may be in relation to the diversification of their sources of knowledge of the situation of their underdeveloped country. So, governmental propaganda is not their main source of information. Furthermore, when compared to singles, married persons recorded higher mean gains across the two surveys, and have significantly higher PWI score in S2. These findings lead us to suppose that a stable context is more profitable to family heads to carry out their normal lives. In this respect, international research suggests that, in general, married persons are happier than other individuals. But, in the more troubled situation of 2003 (S1), they had relatively lower PWI mean than their counterparts. The trend has been reversed in the recovering situation in 2005 (S2). In NWI, means are comparable, which may generally suggest that satisfaction with societal domains has little to do with marital status. In both surveys higher personal income groups have generally higher IWI scores. This brings more support to the idea that in developing countries income is an important predictor of satisfaction in life. Financial means in such societies, where basic life facilities are deficient, enables one to meet the growing needs of life with no major difficulties. This may have also lead to a positive perception of societal domains. One of the main aims of this paper has been to further explore IWI characteristics as this measure is enjoying growing interest by international researchers (McAllister, 2005). A large section of this paper has been devoted to its psychometric properties. The results indicate that in terms of reliability both measures continue to score satisfactory levels. All item-total correlations are consistently


137

significant, though they have registered generally small decreases in PWI and a generally marginal increase in NWI in S2. The same trend is noticed as far as factor loadings are concerned. The clear two-factor solution has been solidly confirmed, with a slight reduction of the total explained variance (about 53% in S1 and 46% in S2). Further, regression analysis of the specific domains against the more general satisfaction item in 2005 has yielded a significant contribution in PWI of all items including Personal Safety which has no such contribution in S1. In NWI, the negative weight on the measure of the domain of Business needs to be further explored. One reason may be that our translation of this word into Arabic gives it the meaning of “commercial relationships”, which is more specific than intended. So, emphasis seems to be made on the evaluation of relational aspects of business rather than the whole aspect of trade and commerce in the country. But even in this case further research is needed to clarify this issue. On the whole, the International Wellbeing Index (IWI) has been proved a valuable tool to monitor changes in societal aspects and needs further consideration by the research community. IWI has been sufficiently sensitive to the contextual changes in the country. Yet, we believe that there is room for PWI enrichment. The possible addition of the item of ‘spare time satisfaction’ has been presented. Its contribution to the performance of the measure has been proved positive. But, more research evidence is needed before any step is taken to enlarge the index. Acknowledgments I would like to thank Professor Robert Cummins for his contribution in this research, and the members of Labo-PECS in Oran University who assisted in field work, mainly: Abbes Belgoumidi, Larbi Ghrib, and Mokaddem Sahil, and to L’Agence Nationale de Recherche en Santé (ANDRS), Oran, for partly financing our 3rd survey (Project: 01/14/00/04/082).My deepest gratitude goes to all the colleagues of the School of Psychology, University of Deakin, Australia for their help while I was a visiting scholar, and to Ann-Marie James for her assistance in the preparation of the revised copy of this manuscript.

References Baltatescu, S. & Cummins, R. A. (2004, November 10–14). Subjective Wellbeing in a Post Communist Country Romania’s International Wellbeing Index. (Paper presented at the 6th ISQOLS Conference, Philadelphia, USA) Biswas-Diener, R. ‘ Diener, E. (2001). Making the best of a bad situation: Satisfaction in the slums of Calcutta. Social Indicators Research, 55, 329–352 CIA Word Fact Books (2006). Retrieved May 20, 2007, form (https://www.cia.golibrary/publication/the-word-factbook/docs/profileguide.html) CNES (Conseil National Economique et Social) (2003a). Rapport sur la conjoncture économique et social du 2ème semestre 2003. Alger: CNES CNES (Conseil National Economique et Social) (2003b). Rapport sur la conjoncture économique et social du 1èmeme semestre 2003. Alger: CNES Cummins, R. A. (February 2002). International Wellbeing Index, Version 2. Retrieved August 8, 2007, from (http://www.acqol.deakin.edu.au) Cummins, R. A., Hunter, B., Davern, M., Eckersley, R., Kai, S., & Okerstrom, E. (2003). The Australian Unity Wellbeing Index: An overview. SINET, 76, Fall November.

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Cummins, R. A. (March, 2006) Fifth Anniversary Special Report — Summarising the Major Findings. Australian Centre on Quality of Life. Retrieved August 8, 2007, from (http://www. deakin.edu.au/research/acqol/index_wellbeing/index.htm) Diener, E. & Seligman, M. E. P. (2004). Beyond money: Toward an economy of well-being. Psychological Science in the Public Interest, 5(1), 1–31 Donovan, N. & Halpern, D. (December 2002). Life Satisfaction: The State of Knowledge and Implications for Government, Analytical paper, Strategy Unit, UK Estes, R. (2005). Global change and social indicators. In M. Weil (Ed.), Handbook of community practice. Thousand Oaks, CA: Sage Hadjadj, D. (2007). Algeria a future hijacked by corruption. Mediterranean Politics, 12(2), 263–277 Hagerty, M. R. & Veenhoven, R. (2003). Wealth and happiness revisited: Growing wealth of nations does go with greater happiness. Social Indicators Research, 64, 1–27 Helliwell, J. F. & Putnam, R. D. (2006). The social context of well-being. In F. A. Huppert, N. Baylis & B. Kevern (Eds.), The science of well-being. Oxford: Oxford University Press International Wellbeing Group (2005). Personal Wellbeing Index. Melbourne: Australian Centre on Quality of Life, Deakin University. ISBN No: 1 74156 048 9. Retrieved May 20, 2007, from (http://www.deakin.edu.au/research/acqol/instruments/wellbeing_index.htm.) Joffé, G. (2002). The role of violence within the Algerian economy. Journal of North African Studies, 7(1), 29–52 Lau, A. L. D. & Cummins, R. A. (2005). An investigation into the cross-cultural equivalence of the personal wellbeing index. Social Indicators Research, 72, 403–432 McAllister, F. (December 2005). Wellbeing concepts and challenges. Discussion paper prepared for the Sustainable Development Research Network Ministère de la santé, de la population et de la réforme hospitalière. (2004). La santé des Algériens et Algériennes. Alger: Ministère de la santé, de la population et de la réforme hospitalière Moller, V. (2004, July 2–4). Researching Quality of Life in a developing country: Lessons from the South African case. (Paper presented at the international workshop on researching wellbeing in Developing countries. Hanse Institute for Advanced Study, Delmenhorst, Germany) Moller, V. (2007). Quality of life in South Africa - The first ten years of democracy. Social Indicators Research, 21, 181, 2001 OCDE (2005/2006). Perspectives économiques en Afrique 2005/2006- Etudes par pays Schyns, P. (2002). Wealth of nations, individual income and life satisfaction in 42 countries: A multilevel approach. Social Indicators Research, 60, 5–40 Tiliouine, H, Cummins, R.A., & Davern, M. (2006). Measuring wellbeing in Developing Countries: The case of Algeria, Social Indicators Research, 75: 1–30 Tiliouine, H., Cummins, R.A., & Davern, M. (in preparation). Islamic religiosity, wellbeing and health factors World Health Organisation (WHO) (2006). Neurological disorders: Public health challenges. Geneva: WHO CIA World fact Books. (2006), Retrieved May 20, 2007, from. http://www.cia. gov/library/publications/the-world-factbook/docs/profileguide.htm.

Chapter 9

‘All That Glitters Is Not Gold’: Johannesburg and Migrant Access to Social Services Rodreck Mupedziswa

Abstract South Africa is the economic powerhouse of Africa. Consequently the country has attracted large numbers of forced migrants particularly in the post1994 period when the new democratically-elected government took over the reins of power. By 2003, an estimated 85,000 refugees and asylum seekers had found their way into the country, and the figures have continued to swell. While on paper the South African Constitution is inclusive in terms of access to social services, it would appear forced migrants residing in that country have been short-changed as the country seems to be sinking into the quick-sands of a new brand of “apartheid” – inequitable access to social services. Indeed while the pre-1994 apartheid system played out in the form of “ (white) citizen against fellow (non-white) citizen”, the post-1994 form of ‘apartheid’ appears to be presenting in the form of “nationals versus non-nationals” often (irrespective of the citizenship status of the non-nationals) with the latter on the receiving end. Research has shown that the situation appears particularly desperate in the city of gold – Johannesburg. Many migrants that had been lured to this city by tales of abundant opportunities, have upon arrival in Johannesburg, to their disappointment, discovered that “all that glitters is not gold”. Indeed the forced migrants have quickly learnt that while Johannesburg may on the surface appear a glittering, cosmopolitan city full of opportunities for self improvement, there are, in fact, no easy “gold deposits” (in the form of greater employment and related opportunities) for the picking on the part of the average migrant. Indeed, all that is available – the forced migrants have belatedly discovered – are extremely difficult lifestyles predicated on the notion of “survival of the fittest”. Social services including health facilities, housing, education and social welfare, are not readily accessible. The paper examines the challenges associated with migrant access to social services in the city of Johannesburg in South Africa.

R. Mupedziswa Ph. D. Associate Professor, Faculty of Social Sciences, University of Botswana Private Bag, UB 00705 Gaborone Botswana. E-mail: [email protected] V. Møller and D. Huschka (eds.) Quality of Life and the Millennium Challenge, © Springer Science + Business Media B.V. 2009

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Keywords Forced migrants, social services, Johannesburg, xenophobia, access, refugees, challenges

9.1

Introduction

During the apartheid era, South Africa was a refugee-generating country; but since 1994, the country has essentially become a refugee-receiving destination. There is no doubt that the dismantling of the apartheid dispensation was accompanied by a new wave of immigration – in particular made up of forced migrants (i.e. refugees and asylum seekers) mainly from African countries. Consequently, the country as at 2003 was playing host to between 70,000 and 85,000 refugees and asylum seekers, and of this figure an estimated 53,000 were asylum seekers whose applications for refugee status had yet to be determined. The population of forced migrants in South Africa, who are largely urban based, was expected to have risen to around 100,000 by 2004 (UNHCR, 2002) – a development that, in the view of many, was bound to further strain the limited resources at the country’s disposal. Forced migrants continue to enter South Africa in large numbers in the process of fleeing dangerous political situations and abuses in their home countries, and also in search of new socioeconomic opportunities. South Africa is one of a few democratic and socially and politically stable countries within the African continent. Unlike other African countries, South Africa does not employ encampment asylum policies and this policy does contribute towards making it a natural destination for many exiles, particularly those from urban environments. Encampment essentially involves placing refugees in settlements (camps) that are usually fenced off to restrict their movement. In many instances the camps would be situated in remote rural parts of a given host country, far away from social and economic life of the particular country, where they do not interact easily with the host population. This decision, ostensibly, is taken for their own safety. Encampment could be said to be the opposite of spontaneous settlement, which involves refugees settling wherever they please, among locals, within the given country. Thus South Africa has allowed refugees to self-settle, and the vast majority are based in urban, and not rural areas. The relative economic wealth of South Africa strengthens its appeal as a land of milk and honey, an inaccurate image of course, which quickly wears off once the exiles become conscious of the harsh reality of trying to make a living in a foreign country (Moret et al., 2005: 43).The unprecedented influx of refugees and asylum seekers has created a major stress economically, socially and culturally for refugees and asylum seekers (flooding into the country) on the one hand, and sections of the host community on the other. Many of the forced migrants hailed from countries to the north of South Africa that are among the major refugee-sending states on the continent, including the DRC, Angola, Rwanda, Burundi and Somalia. Apart from political migrants, thousands of economic migrants – both legal and illegal – have also swelled the country’s

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population over the years – often severely testing the patience of the host population in the process. Zimbabwean migrants, in particular “border jumpers” from that country, top the list in this regard. But undocumented migrants have also come from other countries within Africa and beyond. Upon arrival in South Africa, many forced migrants have settled in Johannesburg – or Igoli, the city of gold (Nkosi, 2004), as the city is affectionately called. Naturally they have done so with expectations for a better life, but the bulk of the forced migrants – because they fall outside the guidelines and often unwritten policies set out by the South African authorities – have found the environment suffocating. The many migrants that have been denied refugee status in particular, have had no claim or access to any state-managed services. Even those with status have struggled to access the country’s social services.

9.2

Challenges Faced by Forced Migrants in Exile

Forced migrants everywhere face a plethora of challenges in host countries, and a good number of the hardships revolve around questions of social, political, cultural and economic needs. They often have specialized needs, particularly around psychological support in coping with trauma (Pursell, 2005). Other needs revolve around nutritional concerns or even complex health-related conditions, e.g. tropical diseases that might be uncommon in the host country. Studies have shown that refugees were vulnerable to many health problems because of their difficult flight experiences and the squalid living conditions they have to contend with in the host country. In many instances refugees and asylum seekers would have fled their countries of origin, leaving behind all their possessions, including their person-hood (Mupedziswa, 2001, 2003). Accessing social services such as health care, housing, and education would therefore constitute important items on their agenda in an effort to cope physically, mentally and otherwise. And yet the conditions are such that they often face formidable challenges in accessing social services. With respect to mental health, forced migrants generally tend to be heavily traumatized, such that they end up having to deal with feelings of alienation, social isolation and stress which may precipitate mental illness or disorders (Grondin, 2004). In some instances they have even arrived in the host country suffering from poor health, making access to health care a priority. Often existing health problems are exacerbated by poor housing conditions, poor sanitation, and an unsafe environment with little hope of employment (Mupedziswa, 1993, 2001, 2003). In short, access to social services is a major challenge. These occurrences are usually a function of either existing policies of host governments or ineptitude in implementation of well-meaning policies by the same governments. Perhaps the most critical question that ought to be surveyed at this point is: What is the South African government’s policy on migrant access to social services?

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Forced Migrants and South Africa’s Social Services Policy

It is common course that because of the severe financial crises bedevilling many developing countries today – and South Africa is no exception – governments face numerous challenges in delivering social services to their people (Mupedziswa, 2001, 2003). The concept of “equal access for all” in respect of social service delivery, pursued by many governments, albeit in principle, however rests on the notion that what is available to some groups in the population ought to be available to all; that access to social services (such as health and shelter) constitute a right and not a privilege (Palmer & Short, 1998). As Gifford (1986) has argued, this social justice philosophy gives priority to the interests of the most disadvantaged in society (this includes forced migrants) and guarantees them basic rights to such social services as health care and shelter. In the context of South Africa, the challenges around access to social services have been enormous. During the apartheid era, (i.e. prior to 1994) social services had been primarily targeted at the white population and the rest of the population groups were very poorly serviced. South Africa’s health policy and practices, for example, were at the time, determined primarily by ideological agendas, rather than by the needs of those requiring the services. The same policies and practices applied to shelter and education, among other social services. As Baldwin-Ragaven et al. (1999) note in respect of access to health care, during the apartheid period social services were manipulated for political purposes, given that situations of conflicting loyalties to patient/client, to profession, to police, and to self, were commonplace. The authors further note that it was essentially in this “grey zone” that most violations of human rights took place in South Africa. The statement would be essentially true in respect of access to a whole host of social services. South Africa’s democratic Constitution has been hailed as one of the most progressive the world over. Blake (1998) has explained that the South African Constitution’s Bill of Rights is in fact considered to be one of the most progressive in the world essentially because access to such basic services as health care, housing, education, etc. is acknowledged as critical. The democratic Constitution therefore was designed to afford all in the country’s borders, certain fundamental rights, including the right to access social services. The ushering in of a democratic political dispensation in South Africa was marked by the advent of large-scale reforms across sectors, to streamline and restructure (social) services to better cope with the increased demands placed on the system. This was a result of the crisis of expectation triggered by the euphoria associated with the new sociopolitical dispensation. In the context of social services provision, the new government set about restructuring the (various) sub-sectors. In the area of health care, for instance, these efforts are succinctly captured in two important documents on health matters – the White Paper on the Transformation of the Health Sector (1997) and the Strategic Framework for Health Care (1999). The documents show that the government had committed itself to the provision of health care, among other social services, to all that required such a service. As for education, Section 5 (1) of the country’s


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Schools Act 84 of 1996 declares that “a public school must admit learners and serve their educational requirements without unfairly discriminating in any way”. Consistent with the provisions of the democratic Constitution, the South African government proceeded to craft legislation meant to deal specifically with issues relating to forced migrants. In September, 1993, the government signed an agreement with UNHCR concerning refugee affairs, and this marked the beginning of a relationship in the management of refugee-related issues. The agreement committed the South African government to open the country to refugees. The following year (1994) democracy was ushered in, and a few years later (1998) the Refugee Act was passed. Among other things, this (Refugee) Act symbolised the South African government’s commitment to the provision of basic social services including health care, shelter, etc. to refugees (Nkosi, 2004; Pursell, 2005; CASE, 2003a). According to Section 27 of the Refugee Act (1998) of South Africa which incidentally came into force only in 2001, a person who is afforded refugee status is entitled to not only an identity document, but perhaps more importantly, to the same basic social services that the inhabitants of the Republic receive. However while the Act does not make similar provisions for asylum seekers, Section 38 (e) does allow the responsible Minister to make regulations governing the conditions of sojourn in the Republic of an asylum seeker while their application for status is under consideration (Moret et al., 2005). Thus there is an abundance of relevant legislation in South Africa to support issues of access to social services for refugees and asylum seekers within the country’s borders. Article 27 (G) of the Refugees Act states that “Refugees as well as refugee children are entitled to the same basic health services and basic primary education which the inhabitants of the republic receive from time to time”. Provisions like these clearly showed that South Africa had, at least on paper, set about not only building a ‘rainbow nation’, but accommodating forced migrants from far and near. However, as the next section will show, there is incongruence between the law and its actual implementation, enforcement, protection and provision of these rights (Moret et al., 2005).

9.4

Refugee Access to Social Services in South Africa: The Reality

While on paper South Africa’s social services policy might appear inclusive of refugees (and asylum seekers), in practice there are serious barriers that make accessing social services a major challenge for this population group. The country’s Constitution states that every person is entitled to welfare rights, but in reality this tends to refer mainly to permanent residents (Moret et al., 2005). In all fairness it ought to be pointed out that many South African citizens lack access to even the most basic of rights, freedoms, and services, and it would therefore be unrealistic to imagine that forced migrants would fare any better in accessing these services (Moret et al., 2005).

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South Africa adopted in June 1996, a neo-liberal economic ideology predicated on the Growth, Employment and Redistribution (GEAR) strategy. Ten years after GEAR, the country has witnessed the economy growing at a remarkable 5% (Manuel, 2006). However, empirical evidence suggests large-scale destruction of local industries which had provided livelihoods for entire generations. While South Africans have increasingly been able to access social grants and also previously inaccessible welfare services, the country’s macro-economic policy has had harmful consequences for welfare service delivery (Maseko & Sewpaul, 2006). Presently unemployment stands at 42%, water, telephone and electricity cut-offs (due to nonpayment stemming from unaffordability), have been the order of the day, affecting over 10 million people (Maseko & Sewpaul, 2006). Diseases such as diarrhoea, tuberculosis (TB) and AIDS, have continued to ravage the country, with more than 1,700,000 AIDS-related deaths having been recorded as at February 2006. A drug-resistant strain of TB has been diagnosed in some parts of the country. A study by CASE (2003b), for instance, highlighted problems that local people face in accessing social grants, adequate housing and ARV treatment. Raniga (2006) too has observed that welfare service expenditure has, over the last few years, grown only marginally. Apparently human and material resources have been spread increasingly thinly, as welfare services have broadened out throughout the country. Thus admittedly the country faces a huge challenge, with many of its own people being poor. Even so, refugees and asylum seekers do face a number of critical hurdles that local South Africans do not. Landau (2006: 319) has eloquently argued, “A combination of inadequate documentation, ignorance and outright discrimination ensures that many refugees are denied rights to critical social services”. Some of the critical hurdles, including policy loopholes, xenophobia and prejudice, will now be reviewed.

9.4.1

Policy Loopholes as a Barrier to Access to Social Services

The South African refugee project run by UNHCR is said to be the largest urban refugee initiative in the world. Yet the plight of forced migrants living in South Africa continues to be an issue of particular concern especially where access to social services is concerned. The South African government has been accused of lacking a clear and definite strategy to accommodate refugees and asylum seekers flooding the country. Critics have attributed this failure to loopholes supposedly in the existing policy framework and concomitant legislation. It is pertinent to appreciate that no permit is granted until the first interview, and hence asylum seekers remain ‘prohibited persons’ under the Aliens Control Act before the first interview. This puts them at a disadvantage from the outset. Lodging an application with the Department of Home Affairs (DHA) can be a nerve-wracking experience, with officials in this Department limiting the numbers of applicants processed each day, at times refusing potential applicants entry into


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relevant buildings, or demanding bribes from asylum seekers. (This issue is discussed in greater detail later.) To make matters worse, whilst the asylum application is being processed – which can be several months or even years – no subsistence or welfare support is provided (either by UNHCR or the South African government) (Moret et al., 2005). Very often, there are also challenges associated with interpretation of existing legislation. For instance the Constitution’s reference to “right to access to health care services” as opposed to “health care” per se is a factor which, in the view of critics, has put the onus on individuals to prove eligibility for this important social service, rather than on the state (Centre for Human Rights, 2000). Perceived ambiguities in the social service policies (e.g. health) have thus fuelled confusion in this regard. The point of contention is essentially that the right of access to social services ought to refer to an obligation on the part of the state to make the necessary social services accessible and available to all concerned, irrespective of whether they are nationals or non-nationals. Policy implementation structures in place in South Africa have also been blamed for serving as a barrier to accessing social services (Moret et al., 2005). In South Africa responsibility for social services such as health and education rests with local government authorities, who themselves have been accused of being unsure of what their responsibilities ought to be (Palmary, 2002). Employees in other arms of government that deal with forced migrants, have equally been found wanting, in respect of their general competence. In a study by Davids et al. (2005), 40% of officials indicated that they were “unfamiliar” with the Immigration Act of 2002; and of this figure, 66% had been employed by the DHA for six or more years. But the policies themselves have also been blamed for ambiguity. For instance it has been argued that no clearly identified protocol and procedures were in place for dealing with refugees and asylum seekers who may present for such social services as health care. A related concern has been the observation that while the Refugee Act, in which the rights of refugees are stipulated, was crafted at a national policy level, implementation and administration of same has occurred at local government level, allowing for confusion to reign around demarcation of responsibilities and poor levels of knowledge of refugee rights among local government officials (Palmary, 2002). Thus on paper, recognised refugees are entitled to services offered at municipal level such as safety, housing, health, libraries, etc. But in reality, “not only is there a lack of awareness at the local government level of the rights of refugees, but there appears to be no plans for ensuring that services are extended to refugees” (Moret et al., 2005: 11). In a study conducted by CASE (2001) there was consensus among health providers, for example, that there was lack of a coherent government policy specifically addressing issues of health care of forced migrants. The same could be said in respect of access to other social services. As far as the authorities were concerned, there had hardly been a ‘flood’ of refugees to social services facilities and the matter had therefore not been regarded as a priority. The fact that this might

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have been a result of barriers to access, appeared to have escaped the authorities. Indeed the fact that many refugees and asylum seekers have been inadvertently turned away from seeking health care at public health facilities due to the absence of interpreters etc, has not been appreciated by the authorities. Such policy-related barriers, which include the above-identified concerns, have led many observers to conclude that in spite of the escalating numbers of refugees and asylum seekers in Johannesburg and elsewhere, the South African government does not seem to have proper strategies to accommodate these flows as it has been using a skewed ‘touch and go’ approach to refugees issues (Magardie, 2000).

9.4.2

‘They Just Speak Their Language’: Xenophobia and Prejudice as Barriers

Xenophobia and prejudice have been identified as critical barriers that have added to the challenges faced by refugees and asylum seekers (Wyss, 1999). Xenophobia – hatred of foreigners – is an issue of considerable concern throughout South Africa, and there is no doubt that where it happens, xenophobia infringes upon the human rights and dignity of those subjected to it. Increasingly large numbers of forced migrants in the country have had to live within the “xenophobic wave” (Roll Back Campaign, 1999). The findings of a recent study by Grossberg et al. (2006) appear to substantiate claims of increasing levels of antipathy among ordinary South Africans to migrants (See Table 9.1). The study found that 34% of South Africans would welcome only some immigrants to South Africa, while 32% stated that they would generally welcome no immigrants to South Africa. The study further established that xenophobia was mostly directed at African migrants, with 28% of the respondents stating that they would least welcome African migrants to their country. While Johannesburg is essentially cosmopolitan, the problem of xenophobia still rears its ugly head. Moret et al. (2005) note that xenophobia and discriminatory behaviours are in fact becoming more frequent, if not more pronounced. Documented cases include an incident in which foreign nationals were thrown off a moving train, and another in which a foreign national had acid thrown at him. Certain authorities in government, including ministers, have been accused of fanning xenophobia through reckless statements.

Table 9.1 Perceptions of xenophobia (Grossberg et al., 2006) Generally welcome all immigrants to South Africa Generally welcome some immigrants to South Africa Generally welcome no immigrants to South Africa Total

%

Base

34 34 32 100

835 830 794 2,452


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The South African press too has been accused of perpetuating xenophobia through reinforcing stereotypes and unsubstantiated myths about immigrants (Krochmal, 2001; Geddo, 2002). Stories about the ‘burden’ that ‘illegal aliens’ place on South Africa’s economy are frequent. According to McDonald et al. (2000: 169) “The popular press in South Africa overflows with stereotypes about migrants, based on little more than interviews with a handful of people, secondhand evidence and/or hearsay”. In South Africa, xenophobia has been expressed in many ways, ranging from mere use of derogatory terms like ‘makwerewere’ to more serious expressions, including physical harm. Terms such as aliens, foreigners, and illegal immigrants are often used to describe non-nationals, with little regard to their legal status in the country. The derogatory labels and negative associations are dehumanising and tend to encourage intolerance on both sides, making interaction between forced migrants on the one hand and the host society on the other, particularly difficult and consequently creating much unnecessary tension (Roll Back Xenophobia, 1999). All this has impacted negatively on refugee and asylum seeker access to social services. It has also been observed that often local people tend to not appreciate the difference between refugees and other categories of non-nationals, such as immigrants and economic migrants (CASE, 2003a; Mupedziswa, 2005). In many instances the situation has been exacerbated by the fact that there is often confusion in the minds of the local population regarding the difference between foreigners who are in South Africa illegally, and refugees and asylum seekers who are in the country legally (Mupedziswa, 2005). Not that this categorisation ought to be viewed as critically important. On the contrary, people ought to be accepted as human beings living within the borders of South Africa, and in most cases making a meaningful contribution to the socioeconomic development of the country. It is disturbing to note that more often than not, citizens have, due to unfortunate errors of judgement, wrought their frustrations against all foreign nationals including those whose papers are impeccably regular and thus who have every right to be in the country. As Roll Back Xenophobia (1999) has noted, broad generalization and “branding” of foreigners does not show understanding of the different reasons, rights and plight associated with each (non-national) group. The authors could well have added that such a development (i.e. the painting of every foreigner with one brush) does not augur well for the socioeconomic development of South Africa, particularly given that some refugees and asylum seekers possess critical skills that have played a major part in the socioeconomic advancement of the country. It is, however, disturbing to note that xenophobia and prejudice are sometimes perpetrated by, among others, government officials tasked to assist the forced migrants. Research by McDonald et al. (2000) revealed that some women had been raped either in the course of their flight into exile, or upon arrival in South Africa. In some cases the rape had actually been perpetrated by security forces assigned to protect the same vulnerable groups. In a documented case in South Africa, a woman was reportedly raped by a police constable after she had gone to the police station to lodge an assault charge (McDonald et al., 2000: 181).

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The negative attitudes are particularly prevalent where health personnel are concerned (McLeod & Bywaters, 2000). Health personnel, among other social service providers, constitute a group of citizens who are supposed to be custodians of fair play and altruism. Yet often times they have faltered with dire consequences for forced migrants. The negative attitudes and perceptions of some health personnel have resulted in health care services being inaccessible to vulnerable forced migrants. What is equally worrying is the insidious cancer of corruption in the social services sector. Refugees and asylum seekers have often been obliged to give bribes to government officials in order to access certain social services, including health care. Crush (2000) and the South African Human Rights Commission have both stressed that although the reality on the ground might be different, the South African Constitution does give assurances of equal access to social services. Yet such practices (as corruption) have made it extremely difficult, if not impossible for many refugees and asylum seekers to access social services in Johannesburg in particular and South Africa in general.

9.4.3

Other Barriers to Accessing Social Services

Several other barriers have been identified (Forced Migration Studies Programme, 2003). For example, language, as a medium of communication, has been identified as a major barrier among forced migrants as it makes it difficult for them to communicate their needs and wishes. As the results of the FMSP (2003) Johannesburg research project established, a large number of refugees and asylum seekers in Johannesburg hailed not from Anglophone, but from Francophone and Lusophone countries. In such circumstances, government officials have been unable to respond appropriately to the needs of such groups given that in South Africa social services delivery personnel conduct business essentially in English (although Afrikaans and vernacular languages also feature). Often no interpreters have been available to assist refugees and asylum seekers express their needs. The situation has been particularly critical in the health sector. Communication as a barrier is more problematic in relation to access to health than with other social services, given that patients have to explain their ailments for health personnel to respond appropriately. The study conducted by CASE (2001) revealed that language indeed constituted one of the key barriers to accessing social services (especially health care). Government officials (in particular health providers) tended to get very impatient in the event of unclear communication, resulting in them not giving their undivided attention to the particular client/patient. The study by CASE further revealed that health personnel often failed to differentiate between groups of foreigners in hospitals and to appreciate the rights of each with regard to accessing health care. Consequently key personnel often did not distinguish between legal and illegal migrants, or even refugees (with status) from asylum seekers (whose status was still to be determined). The resultant prejudicial


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attitude of government officials has, of course, had the effect of creating a barrier to accessing social services on the part of forced migrants. Lack of access to employment too has been identified as a barrier to accessing social services. Moret et al. (2005) noted that asylum seekers in South Africa, because they are not allowed to work, have to rely on friends, relatives and their social and religious community networks for assistance. Apart from the fact that employment is, as a rule, denied refugees at least in the first few months of their stay in South Africa (while their papers are being processed), getting a job even after the lapse of the restriction period, has remained a major challenge for many forced migrants. The legal rights of refugees as spelt out in existing legislation thus tend to complicate matters in that their circumstances do not allow them to work in the first few months, and yet they are expected to pay for such services as shelter, education and health care. Landau (2006: 231) has observed that, “As they receive almost no material assistance from the South African government or UNHCR, this only heightens their vulnerability”. Forced migrants may not access social services during the (restriction) period, and in essence this implies they struggle to survive. Although in theory, forced migrants may be entitled to look for employment and access social services such as education and health care after the few months (prohibition) period has lapsed (with their application still pending), the reality has been completely different. Many institutions will not entertain refugees, let alone asylum seekers whose documents are not (yet) in order. In any event, the proviso in the legislation – that refugees can look for a job after the stipulated period of waiting for a response has lapsed – has apparently never been sufficiently publicised as many refugees have remained in a limbo for long periods (CASE, 2003a). Obviously their social well-being is negatively impacted as a consequence of the (restrictive) stipulation on employment. The circumstances of asylum seekers are even less encouraging than those of refugees (with status) as the situation of the former will often remain exceedingly desperate until such time that they have been granted status. Thus refugees and asylum seekers in South Africa will continue to struggle to access social services because they lack social, political and economic ‘clout’ (Timngum, 2001). It has been observed that a further complicating factor is that in many instances, government officials have a poor awareness of documentation and forms of identification issued to refugees and asylum seekers; suggesting that very often officials are unaware of the different statuses and the meaning of each status category, and indeed the rights accompanying each status (CASE, 2001, 2003a). In other words, they are often unable to tell the difference between the privileges and rights associated with being a refugee from those of being an asylum seeker. In addition, government officers have also been accused of holding the view that the ‘right to access for everyone’ as stipulated in the South African Constitution encourages abuse of social service, in particular health services (Peterson & Judge, 2002). It must also be pointed out that there is growing conflict between the conceptions of clients/patients and those who control the bureaucracies that serve them (Lewis et al., 1978), and in the context of South Africa, this has presented as a further barrier in terms of access to social services. There have been disturbing reports

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about personnel in South African health institutions (Magardie, 2000) who tend to hold the preconceived notion that many forced migrants make their way to South Africa to access health treatment, particularly free antiretroviral treatment which South Africa started rolling out in 2006. It is unfortunate that even medical doctors promoted this myth. In reality forced migrants flee to South Africa not because of health reasons, but essentially for political and economic reasons, to escape the hardships and dangers in their own countries (Moret et al., 2005). Not surprisingly, the negative attitudes have created much tension in South Africa, between some locals on the one hand, and refugees and asylum seekers on the other. Added to this, fees are routinely levied both in government and private hospitals throughout the country, creating a serious barrier because many refugees and asylum seekers do not have a steady source of income, often due to their legal status in the country, but also because South Africa has a high rate of unemployment. These developments have hit asylum seekers the hardest as they are not allowed to seek gainful employment (or study) while their refugee status is being determined. This has been the position since the adoption of the Refugees Act of 1998, and the introduction of the Section 22 asylum seekers’ permit (CASE, 2001). The prohibition on asylum seekers to work highlights the added importance of availing them access to social services, such as health and housing, since they normally have no other survival means. Otherwise it is difficult to conceive how forced migrants could sustain themselves if they were not allowed to do so through work opportunities. While it might be true that forced migrants in South Africa have tended to settle among their own nationals – which tendency might provide a support function since it helps new arrivals in particular – the fact remains that refugees and asylum seekers in South Africa struggle to meet the basic necessities of life, social welfare facilities and health care included (Moret et al., 2005). To state that existing arrangements leave much to be desired, would be an understatement. Their quality of life is generally poor. The following section briefly surveys the situation of forced migrants based in the city of Johannesburg with regard to accessing social services.

9.5

Forced Migrants and Social Service Provision in Johannesburg

It is incontrovertible that Johannesburg – the city of gold – is one of the most challenging urban areas to live in, on the entire African continent. One key explanation might relate to its cosmopolitan complexion. Like New York City in the USA, Johannesburg is in many ways considered a “melting pot”. While it presents a façade of glitter, there is a dark side to this city. As one study noted, “Johannesburg is cited as the nexus of the most dramatic and pressing concerns… … ” (Moret et al., 2005: 42). Various studies done on forced migrants in Johannesburg (e.g. Peberdy &


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Table 9.2 Priority needs of forced migrants in Johannesburg (CASE, 2003a) Priority

Frequency

%a

Employment opportunities Documentation Education for asylum seekers/refugees themselves Housing/shelter Education for children of asylum seekers/refugees N = 391; aMultiple responses

221 202 188 157 66

57 52 48 40 17

Majodina, 2000; CASE, 2001, 2003a, FMSP, 2003; Moret et al., 2005) have all revealed that migrants tend to struggle to survive in the concrete jungle that is Johannesburg. Ironically many forced migrants would have passed through a number of less hostile cities such as Lusaka, Nairobi, Harare, Maputo, etc. to seek refuge in Johannesburg only to meet with formidable challenges. In the study by CASE (2003a) Johannesburg-based forced migrants were inter alia, asked to mention the most important basic need that they required assistance with, and Table 9.2 summarizes their responses. The issue of documentation was identified among the thorny and contentious issues. As noted earlier, in South Africa, the Department of Home Affairs (DHA) is responsible for issuing documentation to forced migrants, but many have been short-changed. For instance, the DHA has been accused of undue delays in processing papers, and of demanding bribes. A study by Davids et al. (2005) noted that inter alia, the DHA had been plagued by a number of incidents of corruption and mismanagement. The study further noted that several incidents had been reported that suggested there was significant tension between the then Home Affairs Minister and the Director General of Home Affairs, giving the impression that the Department was indeed in disarray, and had not made any significant progress in improving its ability to deliver services efficiently. In the same vein, the Southern Africa Migration Project (SAMP), in the context of its Services Quality Survey project, found that people that did business with the DHA had numerous complaints, including office locations that they felt were inaccessible, infrastructure and physical conditions which they adjudged poor, and resources, in terms of facilities and available equipment, that they felt were limited. Lack of good customer service, often linked to negative attitudes of officers, was also highlighted as an issue of concern (Davids et al. (2005). The DHA had also been accused of recklessness in conducting its work. In one particularly poignant example, the DHA had wrongly deported three people in 2003. It is because of such blunders that the DHA had been taken to court on numerous occasions. According to Crush (2000), in a succession of court challenges over a period spanning five years (to 2000), for example, foreign citizens had won virtually every case against the DHA. The Johannesburg office of the DHA has historically been the busiest of all the centres that issue documents to forced migrants. Landau (2006) has observed that in spite of being the busiest, sadly the Johannesburg facility also happens to have one of the most significant obstacles to refugees regarding not only their stay in

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South Africa, but indeed, translating legal rights into entitlements. In this and sister offices scattered across the country, vices such as extortion and exploitation have been noted. The wheels of service tend to turn very slowly in the Johannesburg office of the DHA. For example, although the Refugee Act says that adjudication of asylum claims should be completed within six months, some asylum seekers using this office have been obliged to wait for years, during which period they have remained in a limbo (Landau, 2006; Moret et al., 2005). In Johannesburg, forced migrants have found it difficult to access social welfare services although this item might not have featured in the top five priority areas identified by forced migrants interviewed in the context of the CASE (2003a) study (See Table 9.2). Many refugees and asylum seekers based in Johannesburg often went without meals, and lacked other basics such as a change of clothing. In respect of food, the study by CASE (2003a) revealed that some 44% of the respondents could afford only one meal per day – usually of poor quality at that. Interestingly, however, only 14% of respondents had reported ever receiving any food aid from NGOs working in this city, such as the Jesuit Refugee Services (headquartered in Johannesburg), and Refugee Pastoral Care, among others. This shows the kind of desperate living conditions that forced migrants living in South Africa in general and Johannesburg in particular have faced. Of the various social services, the subject of shelter is often an emotive one, as it in many ways defines one’s quality of life. The study conducted by Peberdy & Majodina (2000) as well as that by CASE (2003a) both established that many forced migrants based in Johannesburg struggled to secure a roof over their heads. Research conducted by the Forced Migration Studies Programme (FMSP, 2003) of the University of the Witwatersrand (in the context of its Johannesburg Research Project) also arrived at virtually similar conclusions. In the CASE (2003a) study, out of a nationwide sample of 1,501, only 5% did not pay rent, either because they lived with relatives or friends, or stayed in churches, had occupied empty buildings or simply did not have a place to stay. The vast majority struggled to find money for rent. In Johannesburg and also in other major South African cities, overcrowding was observed to be a major and perennial problem. The study by Peberdy & Majodina (2000), referred to earlier, established that 7% of forced migrants in their sample shared a room with 10 or more other people. Many had no roof above their heads. In the Johannesburg area in particular, the homeless, forced to remain on the streets, were often exposed to attacks and harassment (Moret et al., 2005: 42). Conditions were such that the forced migrants shared many services in ways that could only be said to be unhealthy (see Table 9.3). As Table 9.3 shows, 93% of men shared toilets (compared to 73.6% of women), 87.8% shared bedrooms, while 80.3% shared washing facilities. The conditions were clearly unhygienic, and poor hygiene has (negative) implications for an individual’s state of health. Focusing on health care, forced migrants in South Africa in general and Johannesburg in particular faced enormous and insurmountable challenges. In South Africa, health care provision presents an interesting case study of disparities between the law and its implementation. On paper the idea of ‘health for all’ is valued, with the notion of ‘for all’ featuring as “everyone” in Section 27 (1) in the Bill of Rights


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Table 9.3 Proportion of sharing of facilities with non-family members in Johannesburg (Peberdy & Majodina, 2000) Sharing facility Bedroom Cooking facilities Washing facilities Toilets

Men % 87.8 71.4 80.3 93.0

Women % 73.6 44.2 41.4 86.8

Total % 81.1 57.8 60.7 89.8

enshrined in the Constitution of this “rainbow nation”. Access to health care services therefore is adequately covered, while Section 27(2) of the Constitution obligates the state to “take reasonable legislative and other measures within its available resources” to ensure the progressive realisation of this right (i.e. the right to access health care). This notion is buttressed even further in Section 27(3) which inter alia, states that no one shall be refused emergency medical treatment. Yet the reality on the ground tends to be different. Various health services, including emergency services, primary health care and reproductive health, have all been exceedingly difficult to access by forced migrants. For example, the CASE (2003a) study established that some two-thirds of the respondents in the study had never accessed emergency health services even though they had wanted to. Often times refugees are charged the fees levied on other non-citizens, while in other instances they are made to wait longer than South African citizens before being attended to. A quote from an interviewee in Johannesburg was most revealing, “At the hospital, they see you very late. You have to wait and the doctors ignore you. Even if you are almost dying they just leave you. They ask you to come back two months later, even if you don’t feel well. They just speak their language. They give you problems because you don’t speak English (Angolan man in Johannesburg, quoted in CASE, 2003a: 144). Anecdotal evidence suggests that in some cases refugees have been denied full courses of medication at health centres, simply because of their alien status (Landau, 2006). Education too has been difficult to access both for forced migrants themselves and their children. The study by Peberdy & Majodina (2000) showed that many forced migrants and their children had to struggle against enormous odds to get an education. This finding was corroborated by the CASE (2003a) study, which for instance found out that up to 26% of primary school age children were not going to school. Reasons proffered included the fact that they could not afford school fees; the children had been refused admission because their parents could not afford school fees (34%); the schools were full; or the school did not accept asylum-seeker permits. Focusing on refugee access to education, Landau (2006: 319) has strongly argued that the de facto requirement that immigrants pay school fees is the most obvious barrier. He further explains that this in fact contradicts a prohibition on refusing admission to public schools based on parents’ inability to pay. Other barriers in this regard included arbitrary denial of access to school due to factors like language skills, age, etc. In a few cases South African government schools, which happen to be less expensive, unfortunately tend to be too far away for some of the

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children. In addition to prohibitive costs for transportation, costs of books and uniforms are a further source of exclusion (Landau, 2006). There have also been reports of refugee school children being ridiculed by local children, forcing them to abandon school.

9.6

Discussion: The Way Forward

It is an open secret that in South Africa public discourse has typically portrayed refugees and asylum seekers as a drain on public resources and a principal cause of crime, infrastructural dysfunction and declining business and property values within cities such as Johannesburg, Cape Town, etc. (FMSP, 2003). In some cases migrants have even been portrayed as the source of the spread of certain diseases, including the dreaded AIDS. This has heightened xenophobic tendencies that legitimise the often hardened attitudes of many officials in various institutions, including the South African Police Services (SAPS), the Ministry of Home Affairs, private business and city officials – let alone ordinary citizens – towards the vulnerable populations that include refugees and asylum seekers. Refugees and asylum seekers come from many different backgrounds and many find themselves in a setting completely unlike that which they were used to (Mupedziswa, 2001, 2003). Major problems stem from a tendency on the part of the authorities to look at migrants as “different” and thus placing them into categories. What is needed is for the authorities to look at all people within the borders of South Africa as being under the protection of the country’s much acclaimed democratic Constitution and therefore eligible for a variety of rights, including rights in terms of accessing social services. There is something worrying about a policy which, for instance focuses on promoting shelter for nationals only, at the same time consigning non-nationals to a life in shacks and slums, with no proper facilities like running water or sanitation. When that happens disease-outbreaks emanating from living in squalid conditions will spread, and sadly these outbreaks do not discriminate against locals. Similarly an (unwritten) health policy that promotes health for locals at the expense of that of refugees and asylum seekers is likely to be eternally doomed, as again disease does not discriminate. There is therefore value in promoting health for all, irrespective of legal status – as long as people happen to be living inside the borders of South Africa (Mupedziswa, 2005). Officials in the various cities of South Africa are therefore urged to consider this matter very carefully and seriously, as there are enormous gains to be derived from an inclusive social services delivery policy. Resource scarcity aside, of major concern has been the observation that no clear efforts appear to have been made by the authorities to promote social services for all, resulting in refugees and asylum seekers, in particular, losing out. Focusing on health for example, poor health for refugees and asylum seekers will at least in the long term, inevitably translate into poor health for all. In any event, healthy migrants are bound to make a meaningful contribution to the development of the city of Johannesburg and of course the entire country.


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A few authorities in South Africa, including the state president, have acknowledged that migrants bring a variety of useful skills, and that they therefore need support, not only on the economic front, but perhaps more importantly in respect of accessing social services. It would appear that this positive attitude and stance adopted by the country’s president, has began to “rub off” on some of the top officials in government. The fact that the government installed a new Director General of Home Affairs in 2003 and a new Minister in 2004, suggests seriousness of purpose on the part of the government in efforts to improve service delivery and accountability, and hence it ought to be commended. Again the fact that the government had resolved to introduce a new document – the ‘smart card’ (Landau, 2006) – for use by refugees to curb corruption, also suggests a willingness on the part of the South African government to improve conditions among the refugee population in the country. Recently there have been further encouraging developments, particularly with particular reference to the situation of forced migrants in Johannesburg itself. These have presented in the form of a variety of tangible attempts to improve the situation of forced migrants on the ground. For example, the moves by the DHA to open a new office to process documents, in the Crown Mines area in the wake of complaints by the local community of noise and disturbance at the existing offices, is particularly welcome. Other positive developments have been linked with the office of the executive mayor of Johannesburg. In an article titled, “Jo‘burg aims to make migrants welcome’, newspaper reporter Chantelle Benjamin (Business Day, 13 April 2007: 3) stated that, “Johannesburg, which has experienced the largest influx of migrants in SA, has set up a help desk to advise them (i.e. migrants) on how to access services and get information on economic opportunities, social networking, counselling, legal advice, and shelter”. The same newspaper report quoted Johannesburg mayor Amos Masondo as stating that, “It was time to accept that migrants had been the livelihood of the city since it was founded, and that they had been found to help stimulate economies, and the transfer of technology and capital in cities all over the world”. Many critics will heave a sigh of relief. The report further explained that a help desk, which would provide information for asylum seekers, community networks and government services, would also be expected to deal with issues of violation of migrant rights and harassment. In a follow-up article titled, “Jo’burg mayor launches migrant help desk” (Business Day, 18 April, 2007: 3), reporter Chantelle Benjamin explained that Johannesburg was to launch a campaign to make the public more aware of the important part played by migrants, foreign nationals and illegal migrants in the development of urban areas worldwide. The mayor of Johannesburg was this time quoted as stating that Johannesburg was adopting a progressive approach with regard to ensuring that migrants of this city feel that they are part of an ‘inclusive’ city. While these developments are most welcome, only time will tell how much of this rhetoric will be translated into tangible programmes of action. Recognition that diversity is a source of the city’s strength and enrichment rather than a problem, is welcome and indeed a step in the right direction. If properly executed, the new policy will promote equity and facilitate enhanced participation on the part of forced migrants in the affairs of this cosmopolitan city. The report further noted that the

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city of Johannesburg planned an internal campaign involving departments dealing with migrant affairs. It would appear that there is a sudden realization that there are enormous benefits to be reaped by not only the city of Johannesburg, but the country at large from taking a route that promotes a progressive vision. All concerned ought to counter the negative discourse that has promoted social exclusion of refugees and asylum seekers. It is pertinent to appreciate that rights of refugees can only be promoted in South Africa when nationals – both their leaders and ordinary citizens – recognize both their moral duty to provide sanctuary to refugees and asylum seekers, and the economic and social benefits that might flow from such action. The South African government in particular has to acknowledge that it has an obligation to promote and fulfil the right of access to social services for all in the country’s borders, and this includes refugees and asylum seekers. It is therefore encouraging that some in South Africa are beginning to talk in terms of revisiting the issue of migrant welfare in the country, with a view to ensuring refugees and asylum seekers do not continue to be prejudiced, as the consequences for South Africa in general and Johannesburg in particular, of continuing on such a flawed route would be disastrous.

9.7

Concluding Remarks

It is obvious from the discussion that forced migrants in South Africa face numerous challenges in accessing social services in that country in general and Johannesburg in particular. South African government officials in their capacity as bearers of the rights of the forced migrants, ought to feel obliged to protect these vulnerable groups and ensure that they are aware of their rights. Particularly important, in addition, is the need to promote vigorously, efforts aimed at “rolling back” xenophobic attitudes that have fuelled negative behaviour towards foreign nationals within the borders of South Africa. Landau (2006) has warned that failure to overcome these obstacles can have dire consequences for South Africa. Within the context of this debate, certain commentators have posited that rolling back the negative attitudes of the general South African population will depend to a large extent, on the degree to which the South African government is able to address the needs of its own citizens, and especially the poor, in respect of accessing basics such as social grants, employment opportunities, housing, etc. It is equally important to appreciate that forced migrants too have certain entitlements, in accordance with the law. It has been argued that true entitlements rest on people’s actual ability to claim that to which they are legally entitled. As Landau (2006) notes, if this is true for South African citizens, it ought to be true for forced migrants within the country’s borders. This is so because in constitutional terms the South African government is obliged to promote the rights and dignity of all its ‘legal’ residents, and this would include forced migrants (Landau, 2006). This is how things ought to be. Anything short of


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this would be tantamount to allowing a new form of apartheid to take root – a type based not necessarily on the colour of one’s skin, but rather on one’s nationality. Only in this way, can the concept of a truly “rainbow nation” become a living reality. Recently, authorities in the city of Johannesburg appear to have, in this regard, ‘smelt the coffee’, and hence seem to have begun to take meaningful measures to move in the right direction where promotion of the rights of forced migrants is concerned, and these efforts ought to be applauded for their progressive nature.

References Baldwin-Ragaven, L., Grunchy, J. & London, L. (1999). An Ambulance of the wrong Colour: Health Profession, Human Rights and Ethics in South Africa. (Cape Town: University of Cape Town Press). Benjamin Chantelle (2007). ‘Jo’ burg mayor launches migrant help desk. Business Day 13 April 2007, p3. Blake, M. (1998). Rights Up Your Street: A Guide to Human Rights in South Africa. (Cape Town: National Association of Democratic Lawyers). CASE (2001) Realising Rights: The Development of Health and Welfare Policies for Asylum Seekers and Refugees in South Africa. Research conducted for UNHCR. CASE (2003a) National Refugee Baseline Survey: Final Report. Researched for Japan International Cooperation (JICA) and UNHCR. November 2003. CASE (2003b) Socioeconomic Impact of the Three Constitutional Court Cases. Grootboom, TAC and Welfare. Commissioned by CIDA. Centre for Human Rights (2000) Report on the Realisation of Socio-Economic Right. Centre for Human Rights, University of Pretoria. Crush, J. (2000) The Dark Side of Democracy: Migration, Xenophobia and Human Rights in South Africa. International Migration, 38(6): 5–12. Davids,Y.D., Lefko-Evertt, K. & Williams,V. (2005) The quality of migration services delivery in South Africa. Cape Town: SAMP. Migration Policy Series, No 41. Series Editor Jonathan Crush. Forced Migration Studies Programme (FMSP) (2003) Human Displacement, Survival, and the Politics of Space: Preliminary Survey Results. University of the Witwatersrand, Johannesburg. Forced Migration Studies Programme. (Raw data for report). Geddo, B. (2002). Durable Solutions to the Refugee Problem: UNHCR’s Regional Strategy for Southern Africa. Retrieved from: http://www.lhr.org.za/projects/refugee/publications/ perspectfull/geddo.htm. Gifford, S. (1986). Better Health for Groups at Risk Special Needs or Basic Rights? Community Health Studies, x:411–414. Grondin, D. (2004) Well managed migrants’ health benefits all. Bulletin of World Health Organisation, 82(8): 561. Grossberg, A., Struwig, J. & Pillay, U. (2006) Multicultural, national identity and pride. (in U. Pillay, B. Roberts & S. Rule (Ed.). South Africa Social Attitudes: Changing Times and Diverse Voices; pp 54–75.Cape Town: Human Science Research Council). Krochmal, R. (2001) The Current Refugee Situation in South Africa: Cause of Concern. Retrieved from: http://www.academy.umd.edu/education/SouthAfrica/SA2001/article_krochmal.htm Landau, L.B. (2006) Protection and dignity in Johannesburg: Shortcomings of South Africa’s refugee policy. Journal of Refugee Studies, 19(3): 308–327. Lewis, C., Fein, R. & Mechanic, D. (1978). A Right to Health: The Problem of Access to Primary Medical Care. (New York: Wiley).

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Magardie, K. (2000). New Hope for Asylum Seekers in South Africa. Retrieved from: http://www. queensu.ca/samp/migdocs/New.htm Manuel, T. (2006) quoted in Maseko, DH & Sewpaul, V. (2006) Ethics as a site of resistance: the tension between social control and critical reflection. (In N. Hall (Ed.). Social Work; Making a World of Difference. pp 173–194. Berne: IFSW and FSFO). Maseko, D.H. & Sewpaul, V. (2006) Ethics as a site of resistance: the tension between social control and critical reflection. (In N. Hall (Ed.). Social Work; Making a World of Difference. pp 173–194. Berne: IFSW and FSFO). McDonald, D., Mashike, L., and Golden, C. (2000) The lives and times of African migrants and immigrants in post-apartheid South Africa. (In D. McDonald (Ed.). On Borders. pp 168–195. New York: St Martins Press). McLeod, E. & Bywaters, P. (2000). Social Work, Health and Equality. (London: Routledge). Moret, J., Baglioni, S. & Efionayi-Mader, D. (2005) Movements of Somali refugees and asylum seekers and states’ responses thereto. Final Report – Draft. (Geneva: Swiss Forum for Migration). Mupedziswa, R. (1993) Uprooted: refugees and social work in Africa. (Harare: JSDA Publications). Mupedziswa, R. (2001). Africa’s refugee crisis. (In A. Rwomine (Ed.). Social Problem in Africa. pp 191 – 208. London: Praeger). Mupedziswa, R. (2003) Africa’s refugee crisis: implications for socioeconomic development. (In K.K. Prah & T.Tegegne (Eds.). Chasing Futures: Africa in the 21st Century: Problems and Prospects. pp 239–276. Cape Town: CASAS Book Series No 33). Mupedziswa R. (2005, October) Migration and health: universal challenges. Plenary paper presented at the International Diversity in Health Conference, Melbourne. Nkosi, G. (2004) Influences of xenophobia in accessing health care for refugees and asylum seekers in Johannesburg. Dissertation, University of the Witwatersrand. Palmary, I. (2002) Refugees, Safety and Xenophobia in South African cities; the role of Local Government. Research conducted for Centre for the Study of Violence and Reconciliation. Palmer, G.R. & Short, S.D. (1998). Health Care and Public Policy: An Australian Analysis. (Melbourne: Macmillan Education). Peterson, I. & Judge, K. (2002). Equality of access to health care. (In J. Mackenbch & M. Bakker (Eds.). Reducing Inequalities in Health: A European Perspective. pp 119–137. London: Routlegde). Peberdy, S. & Majodina, Z. (2000) Just a roof over my head? Housing and the Somali Refugee Community in Johannesburg. Urban Forum, 11(2): 273–288. Pillay, U., Roberts, B. & Rule, S. (2006). South Africa Social Attitudes: Changing Times and Diverse Voices. (Cape Town: Human Science Research Council.) Pursell, R. (2005) Access to health care among Somali forced migrants in Johannesburg. Dissertation, University of the Witwatersrand. Raniga, T. (2006) quoted in Maseko, D.H. & Sewpaul, V. (2006) Ethics as a site of resistance: the tension between social control and critical reflection. (In N. Hall (Ed.). Social Work; Making a World of Difference. pp 173–194. Berne: IFSW and FSFO). Refugee Act 1998; No 19544, Section 27. Government of South Africa, Pretoria. Roll Back Xenophobia (1999) Roll Back Xenophobia Campaign. (Materials). Johannesburg. Timngum, D.A., (2001). Socio-economic experience of Francophone and Anglophone refugees in South Africa: a case of Cameroon Urban Refugees in Johannesburg. Dissertation, University of the Witwatersrand. The Constitution of the Republic of South Africa (1996). Pretoria, Government Printers. UNHCR Africa Fact Sheet- June 2002. Wyss, K. (1999) Health provision of migrants in the African context: if nobody really cares. Bulletin Medicus, 74: 23–47.

Chapter 10

Trust and Life Satisfaction in Eastern and Western Europe Georg P. Mueller

Abstract Comparative international surveys consistently show differences between Eastern and Western Europe with regard to the perceived trustworthiness of state agencies like courts, police, or civil services. This article explores the consequences of these differences for the life satisfaction of the common citizen. The analysis concentrates on the one hand on the hypothesis that a lack of trustworthiness of state agencies implies the risk of the abuse of power by these institutions, which has among others also direct negative consequences for the life satisfaction of the citizens. On the other hand, the article also pursues the hypothesis that trustworthy state institutions may buffer the citizens’ risk of being deceived by non-trustworthy fellows, which obviously has an indirect positive impact on life satisfaction. Using secondary analysis of survey data from the European Values Study (EVS), the article shows that the mentioned effects of institutional trustworthiness on life satisfaction differ by institution. It seems that the trustworthiness of the police mainly matters for the direct effects of the abuse of state power, whereas the trustworthiness of the civil service is relatively important for the buffering of distrust in fellow citizens. Based on quantitative information about these empirical regularities, the article finally makes conditional forecasts about the effects of changing trustworthiness of state agencies on the future life satisfaction in Eastern and Western Europe. Keywords Life satisfaction, trustworthiness of state agencies, buffering of distrust, abuse of state power, Eastern/Western Europe, European Values Study

G. P. Mueller Maıˆtre d’Enseignement et de Recherche (Senior Lecturer), Dept. of Social Science, University of Fribourg, Switzerland E-mail: [email protected] V. Møller and D. Huschka (eds.) Quality of Life and the Millennium Challenge, © Springer Science + Business Media B.V. 2009

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10.1

G. P. Mueller

An Introductory Overview of the Research Questions

In the social sciences there is currently a growing literature about various types of trust together with their preconditions, causes, and consequences. Part of this literature is based on international values surveys (Eurobarometer, 2006; World Values Survey, 2005; European Values Study, 1999/2000) and focuses on the international differences between countries with regard to generalized trust in fellow citizens and political or social institutions (Mishler & Rose, 1997; Catterberg & Moreno, 2005). Among other aspects, this literature points to the fact that most forms of trust are lower in the Eastern European countries than in the Western ones. Another part of the literature deals with the psychological, cultural, and social causes of trust (e.g. Brehm & Rahn, 1997; Delhey & Newton, 2003, 2005). This literature is especially useful with regard to the question of how to promote and build trustworthy political and social institutions (Kornai et al., 2004; Kornai & Rose-Ackerman, 2004). Finally there are large number of publications about all kinds of consequences of trust, for example with regard to political legitimacy or the functioning of democratic institutions (e.g. Braithwaite & Levi, 1998; Warren, 1999). Within this category of literature, however, there are only few papers dealing with the influence of interpersonal or institutional trust and distrust on life satisfaction (e.g. Bjornskov, 2003 or Hudson, 2006). The present article attempts to fill this gap with an empirical investigation of the country-specific impact of generalized distrust in others on personal life satisfaction. The article hypothesizes that this impact is negative (see Fig. 10.1, relation 1). However, it is assumed that this negative impact can be buffered through law enforcement by appropriate state agencies, which control and prosecute the abuse of trust (see Fig. 10.1, relation 2). Finally, the paper also considers that a trustworthy commitment of the state to the rule of law prevents government from abusing its power and thus has a positive and direct effect on the life satisfaction of its citizens (see Fig. 10.1, relation 3). The empirical analyses presented here will show, whether the relations hypothesized in Fig. 10.1 genuinely exist. The answer to this question will further be differentiated according to the particular law enforcing institution such as the civil service, the police, or the justice system. Since Eastern and Western Europe have

Trustworthiness of state agencies

− Interpersonal distrust

− (1)

(2)

(3)

+

Life satisfaction

Fig. 10.1 Overview of the main hypotheses

10 Trust and Life Satisfaction in Eastern and Western Europe

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different institutional and political histories, there is a further question as to whether the strength of the relations postulated is different for these two groups of countries. The results of the empirical analyses will not only be used for hypotheses testing but will also allow conditional forecasts about the future of life satisfaction in Eastern and Western Europe. We will present a number of different scenarios for prospective life satisfaction, in which the East and the West of Europe converge or diverge with regard to the trustworthiness of their political institutions. These scenario-based analyses will help to answer the question whether the currently observed differences in life satisfaction between Eastern and Western Europe are the result of cultural factors or more political and institutional ones.

10.2

Theoretical Considerations About Trust and Life Satisfaction

Trust is the personal belief that another actor will stick to his or her commitments and will not suddenly defect from a formal or informal agreement for purely egoistic reasons. Hence, trust is one of the beliefs which make life easier and more comfortable. In the case of mutual trust between two actors trust reduces the transaction costs of mutual agreements since no formal contracts are needed (Yamagishi, 2001: 139 ff.). In a situation of trust there is reduced uncertainty about the future since it is assumed that the other party will stick to the commitments (Gundelach & Kreiner, 2004: 368). Finally, trust also opens up the possibility to reduce the control of compliance with an agreement. This is not only advantageous in terms of reduced transaction costs. It also implies reduced suspicions about the breaking of agreements, which are often a source of interpersonal conflict (Yamagishi, 2001: 139 ff.). In sum, we hypothesize that generalized trust in others increases the life satisfaction of the trust giver, mainly due to increased certainty about the future and a reduction in transaction costs, interpersonal suspicions, and conflicts. Consequently it is assumed that distrust in others has a negative effect on the life satisfaction of the person concerned (hypothesis 1). For reasons of simplicity this relationship is represented in Fig. 10.2 by a straight line with a negative slope and not by a general monotonic function. This simplification facilitates the statistical analysis for the testing of hypothesis 1 with empirical data (see section 10.3). In addition, by assuming linearity the relation between distrust and life satisfaction is described by only two parameters a and b, which can further be interpreted and explained. The constant a obviously describes life satisfaction for the case of zero distrust in others (see Fig. 10.2), whereas the coefficient b refers to buffering mechanisms: the closer the negative slope b is to zero, the lower the impact of distrust in others on life satisfaction. According to the intellectual tradition of Thomas Hobbes (1991 (1651)), the state claims a monopoly of legitimate physical power in order to prevent a virtually endless internal war of all against all. The regulatory function of state agencies is especially important in situations, where there is a great deal of mutual distrust among citizens. By enforcing social order, the state ensures that citizens stick to

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G. P. Mueller LifeSatisfaction S D=1

Trustworthiness T

b

S=a+b*D with b3

1.19

3

1.23

3

1.31

10

5.73

1

0.77

>

0.64

Concept

Operationalization

Trustworthiness T of civil service

Mean West

Variable names: See European Values Study (1999/2000). Significance: All differences between means for East and West are significant at p = 1% (1-tailed t- tests). Country values: See appendix of this article. Sample size: East: N = 14; West: N = 19

state agencies in Eastern Europe is still significantly lower than in the West. A similar gradient between the two groups of countries is in Table 10.1 also visible for general distrust in others.

10.3.2

Hypothesis 1: The Impact of Distrust on Life Satisfaction

On the grounds of the theoretical considerations set out so far (see section 10.2) we postulate a negative impact of distrust on the life satisfaction of the person concerned. To test this hypothesis we can obviously use the original interview data at the individual level of aggregation in order to make country specific estimates of the parameters a and b in the equation Life satisfaction S = a + b * Distrust D If hypothesis 1 is true, only parameter estimates with values b < 0 should be observed. As Fig. 10.3 with the frequency distribution of the parameter estimates of b demonstrates, European reality is quite close to our theoretical model: with the exception of two countries, i.e. Spain and Turkey, 31 out of 33 countries have indeed the expected negative signs and thus confirm earlier empirical results by Bjornskov (2003: 9) and Helliwell (2006: C40). However, according to Table 10.4 in the appendix of this article, Iceland, Portugal, and Romania are three other countries with b-values, which are in fact negative but at the level of α = 5% statistically not really different from zero. It could be argued that these countries are cases with a nearly perfect buffering of the negative impact of distrust and thus do not represent


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20

Abs. frequencies

15

10

5

0

−.90

−.70

−.50

−.30

−.10

.10

Values of the coefficients b

Fig. 10.3 The frequency distribution of the coefficients b of the impact of distrust on life satisfaction

real falsifications of hypothesis 1. Alternatively, these countries could be considered as additional counter-evidence against hypothesis 1, which increase the share of falsifying cases from 2/33 = 6.1% to 5/33 = 15.2%. This would still be an acceptable result, which would corroborate hypothesis 1, even when making allowance for the possibility that life satisfaction is not only influenced by distrust but in turn also actively influences distrust. The already mentioned arguments concerning the conflict and transaction costs of distrust (see section 10.2) make it a statistical predictor of life satisfaction which is for these theoretical reasons at least as plausible as the possibility of the reverse causal relationship.

10.3.3

Hypothesis 2: The Buffering Effect of the Trustworthiness of the State

Hypothesis 2 postulates that the higher the trustworthiness T of the state, the closer to zero is the negative impact b of distrust in others (see Fig. 10.2). In order to test this buffering effect of trustworthiness, we have to switch from individual to aggregated national data such that country specific b-values can be compared with the trustworthiness of selected state agencies. More precisely, we consider these b-values as the dependent variable and attempt to explain them with statistical regression by varying sets of explanatory variables about institutional trustworthiness (see appendix, Table 10.4). Model 1 in Table 10.2 presents the results of the regression analysis for a full model, which uses the trustworthiness of the police, the justice system, and the civil

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Table 10.2 Regression parameters of the effects of the trustworthiness T of the state on the impact coefficient b Trustworthiness T

Model 1

Model 2

Model 3

Model 4

T of police T of justice system T of civil service T of civil service * East

[0.128] [0.053] [0.323] -.--

-.--.-0.503** -.--

-.--.-0.628* [-0.280]

-.--.-0.658*** -.--

Constant East (= 0–1-dummy)

-1.196*** -.--

-1.155*** -.--

-1.301** [0.273]

-1.369*** -.--

Adjusted r-square 0.226** 0.241** 0.325** 0.332*** N of observations 31 31 30 30 Dependent variable: Country specific coefficient b of the equation Life satisfaction = S = a + b * Distrust D (see Fig. 10.2). Significance (1-tailed t- and F-tests): ***: p ≤ 0.1%, **: p ≤ 1%, *: p ≤ 5%, []: Not significant. Models 1 – 4: Excluding Spain and Turkey, due to b > 0. Models 3 – 4: Excluding the deviant case Greece (see Fig. 10.4, no. 26). Other symbols: -.--: Variable not used

service as explanatory factors and which does not distinguish between countries in Eastern and Western Europe. Using a reanalysis which discards step by step the least significant explanatory variables, model 1 is transformed into model 2 with a much simpler structure. The relatively small explanatory power of this model (see adjusted r-squares in Table 10.2) is partly due to an outlier country, represented in Fig. 10.4 by the data-point no. 26 for Greece. Since the data for this country are described as non-representative in the codebook of the European Values Study (1999/2000), they have not been used for the estimation of the parameters of the models 3 and 4 in Table 10.2. However, the small r-square of model 2 could also be caused by the different institutional history of Eastern Europe. Thus, in order to make allowance for the special situation of these formerly communist Eastern states, model 3 in Table 10.2 includes two additional variables: the 0–1-dummy East, by which the global constant may be modified, and T of civil service * East, by which the effect of the global trustworthiness T of civil service can be adapted to the situation in Eastern Europe. As none of the two variables displays statistically significant effects, they are omitted in the final model 4 in Table 10.2. In sum, there is finally only one variable which has a buffering effect on the impact coefficient b: the trustworthiness of civil service, which in both Eastern and Western Europe has exactly the same quantitative effect. However, according to Table 10.2 the police and the justice system, which are designed as institutions for prosecuting deviance from public order, have no such buffering effect. This is in so far quite plausible, as the control function of the public service creates a certain degree of compliance with public order and is thus a primordial element against the chaos of an internal war of all against all (Hobbes, 1991 (1651)). If the rules of this order are commonly agreed, the police and the justice system are only for regulating residual cases of deviance from these norms. Consequently, law enforcement by police and justice is less important for buffering distrust in others than the control function of a trustworthy public service.


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0.0

Coefficient b

−.2

−.4

26

−.6

−.8 East West

−1.0 .6

.8

1.0

1.2

1.4

1.6

1.8

Trustworthiness T: Civil service

Fig. 10.4 Scatterplot of the trustworthiness T of the civil service and the impact coefficient b

10.3.4

Hypothesis 3: The Direct Effect of the Trustworthiness of the State

The third hypothesis developed in section 10.2 refers to the abuse of state power and postulates that the trustworthiness of state agencies has a positive direct effect on the life satisfaction of the citizens, other factors such as distrust in others being constant. In order to test this hypothesis, we present in Table 10.3 the results of three regression analyses of the aggregated data in the appendix of this article, each of them explaining the constant a, which measures life satisfaction if distrust in others were totally absent (see Fig. 10.2). Model 1 uses trustworthiness in the police, the justice system, and the civil service as three explanatory variables. However, for the latter two variables, Table 10.3 displays no significant results. After discarding these two variables and keeping only trustworthiness of police as an explanatory factor, the model was run another time and produced relatively good results, presented in Table 10.3 in the column entitled model 2. However, the visual representation of the relationship between trustworthiness of police and the dependent constant a in Fig. 10.5 displays two irregularities. The first refers to the data point no. 33 for Turkey, which lies far outside the general pattern of the scatterplot. As Turkey is the only Islamic country in the sample and may thus be a “special case”, this outlying data point no. 33 was discarded before calculating the final model 3 (see Table 10.3). The second irregularity refers to the lack of homogeneity of the data points of the Eastern- and the Western-European countries, which are not optimally represented by one single regression line: model 3 thus introduces two

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G. P. Mueller Table 10.3 Regression parameters of the effects of the trustworthiness T of the state on the satisfaction constant a Trustworthiness T

Model 1

Model 2

Model 3

T of justice system T of civil service

[-0.611] [-0.145]

-.--.--

-.--.--

T of police T of police * East

2.826*** -.--

2.411*** -.--

1.173* 2.078*

Constant East (= 0–1-dummy)

3.618*** -.--

3.240*** -.--

5.756*** -3.812**

Adjusted r-square N of observations

0.462*** 33

0.489*** 33

0.732*** 32

Dependent variable: Country specific constant a of the equation Life satisfaction = S = a + b * Distrust D (see Fig. 10.2). Significance (1-tailed t- and Ftests): ***: p ≤ 0.1%, **: p ≤ 1%, *: p ≤ 5%, []: Not significant. Other symbols: -.--: Variable not used. Model 3: Excluding the deviant case Turkey (see Fig. 10.5, no. 33)

9.0 8.5 8.0

Constant a

7.5 7.0 6.5 6.0 5.5 33

East

5.0

West 4.5 .8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

Trustworthiness T: Police

Fig. 10.5 Scatterplot of the trustworthiness of the police and the satisfaction constant a

additional independent variables, i.e. a 0–1-dummy East and the product T of police * East, by which the general effect of the trustworthiness T of police can be adapted to the special historical situation of the ex-communist East.


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According to Table 10.3, these modifications are quite successful, insofar as the resulting final model 3 explains about 74% of the total variance and yields – without exception – statistically significant parameter estimates, which point to the importance of the institutional history of Eastern Europe. Whereas in the West the influence of the trustworthiness of the police has a value of only 1.173, the effect in the East is much higher: summing all the relevant terms yields an expected increase in life satisfaction of 1.173 + 2.078 = 3.251 scores per additional unit of trustworthiness. Similarly, the total lack of trustworthiness of the police corresponds in the West to a life satisfaction equal to the regression constant 5.756. In the ex-communist East, however, the summing of the relevant terms yields for this situation an expected life satisfaction of only 5.756 - 3.812 = 1.944. In sum, due to its totalitarian political history, the East is much more sensitive to the behavior of the police than the West. However, the two other institutions, i.e. civil service and justice, seem to have no direct effect on the life satisfaction of the citizenry, neither in the East nor in the West: the corresponding regression coefficients in Table 10.3 are obviously not significant. As hypothesis 2, which is being tested in this section, refers to the impairment of life satisfaction by the abuse of state power, this finding is not so unexpected. From the perspective of the common citizen power abuse by the police has more serious personal consequences than similar cases of misconduct by most other state agencies. Consequently, trustworthiness of the police has a much higher impact on life satisfaction than other institutions of the state.

10.4

Prospects for Future Life Satisfaction

The trustworthiness of state agencies has changed in the past (Catterberg & Moreno, 2005) and will probably continue to change in the future. Since the trustworthiness of the police and the civil service have direct and indirect effects on the life satisfaction of the national populations concerned, the dynamics of the trustworthiness of these institutions also matters for the future of life satisfaction in Eastern and Western Europe. Based on the final regression model 3 in Table 10.3, Fig. 10.6 gives an overview, of how future changes of the trustworthiness of the police will directly influence life satisfaction under the ceteris paribus assumption of a total lack of general distrust. Similarly, Fig. 10.7 uses the regression estimates of the final model 4 in Table 10.2 to display the functional relationship between the future trustworthiness of the civil service and the decrease in life satisfaction which results from a change in distrust D from 0 to 1. Figures 10.6 and 10.7 can only be used for prospective analyses of life satisfaction in East and West if one previously defines scenarios for the future trustworthiness of the state agencies represented by the horizontal axes in these figures. In this article we will analyze the following scenarios, which are either theoretically or empirically of special interest:

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G. P. Mueller Life satisfaction if distrust D = 0

10

East

9

D6

West Current level West

D5

8 D2 7

D3

6

D4 Current level East

D1

5 4 3 2 T = Trustworthiness of police

1 0.5

0

Min

Mean 1.5 East

Mean 2 Max West

Fig. 10.6 Life satisfaction for distrust D = 0, by scenario for future trustworthiness of the police

0

Min

Mean Mean 1 East West Max

0

d5 −0.5

d2

d3

d4

2

Trustworthiness T of civil service

Current level West Current level East

d1 −1.0

−1.5 Change in life satisfaction if D=0 –> D=1

Fig. 10.7 Decrease in life satisfaction due to changes of distrust D = 0 − > D = 1, by scenario for the buffering effects of future trustworthiness of the civil service


173

(a) Leveling down of the East to the current international minimum of trustworthiness of police and civil service, combined with the maintenance of the current levels of trustworthiness in the West. In view of the empirical data of the last ten years, indicating a stagnation of confidence in state agencies in the West and a deterioration of the corresponding figures in the East (Catterberg & Moreno, 2005), the scenario represents a relatively plausible future. According to Fig. 10.6 it implies a lowering of life satisfaction in the East by D1 units, which would further increase the gap to the current level of life satisfaction in the West. This scenario would also decrease the buffer effect of the Eastern civil services by d1 units (see Fig. 10.7) such that the currently rather small difference between the East and the West with regard to the effects of distrust would substantially increase. (b) Adaptation of the East to the mean level of trustworthiness in the West. This scenario corresponds to the political program of the EU, targeted at the integration and Westernization of the East. According to Fig. 10.6, this program would indeed be successful as it means an increase in Eastern life satisfaction by D3 units, which will indeed annihilate the difference in life satisfaction between the East and the West. Similarly, Fig. 10.7 shows that for this scenario the buffering of distrust will slightly increase in the East by d3 units and consequently reach the current mean level of the West. (c) Adaptation of the West to the mean level of trustworthiness in the East. Due to the general crisis of confidence in politics, this scenario could become an unintended consequence of European unification. It means a reversal of the preceding scenario, however its consequences are less serious than one might expect: in this case Western life satisfaction would only slightly decrease by D2 units (see Fig. 10.6) and the considerable gap between Eastern and Western life satisfaction would consequently continue to exist. Similarly, the buffering effect of Western civil service would also only marginally decrease by d2 units (see Fig. 10.7) and consequently adapt to the current level in the East. (d) Upgrading of the East and the West to the current international maximum of trustworthiness of police and civil service. This scenario means an adaptation to the best practice of European state agencies, which is however not perfect, neither in terms of the resulting life satisfaction nor in terms of the buffering of distrust, since it does not reach the respective maximum values of 10 and 0. For the West, this scenario implies only a small increase in life satisfaction by D5 (see Fig. 10.6) and an improvement in buffering by d5 units (see Fig. 10.7). However, for the East, life satisfaction would substantially increase by D4 + D5 + D6 units (see Fig. 10.6) and buffering would also be considerably above the current level by d4 + d5 units (see Fig. 10.7). In sum, whatever may happen in the future, the analysis of the preceding four scenarios clearly reveals that changes of institutional trustworthiness have more consequences for life satisfaction in Eastern Europe than in the West. Moreover, the currently observed differences in life satisfaction between

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Eastern and Western Europe are not only the result of structural factors in terms of different mean values of the trustworthiness of the state. They are also a consequence of differences in political culture, which are best represented by the two different regression lines in Fig. 10.6 , one for the East and an other one for the West.

10.5

Summary of the Main Findings

This article has focused on the theoretical and empirical question of how the trustworthiness of a state influences the life satisfaction of the citizens of this state. In the theoretical part of the paper, two mechanisms were identified: a direct one, based on the deterioration of life satisfaction as the result of the abuse of state power and an indirect one, where the state buffers the negative impacts from dishonest fellow citizens by enforcing social order. In its empirical re-analysis of the European Values Study (1999/2000), the article distinguishes between the effects of three types of state agencies, i.e. the civil service, the police, and the justice system. In addition, it also differentiates between Eastern and Western countries with different political cultures. The data analyses not only corroborate the hypothesized negative impact of distrust on life satisfaction, they also confirm the buffer-hypothesis about the indirect effects of the trustworthiness of state agencies. However, they do so only for the civil service and not for the police and the justice system: the control of the citizen’s compliance with the social order seems to be more important than coercive rule enforcement by police and justice. The indirect effects observed are relatively weak. But they are quantitatively identical for the Eastern and Western countries of Europe (see Fig. 10.7). The hypothesis about the negative direct effects is also confirmed, but again only for one state agency, the police. Because of its institutional nature, the police is probably perceived as the most repressive of the three analyzed institutions, with a much higher potential for power abuse than the civil service and the justice system. This interpretation is consistent with the empirical finding, that the Eastern countries are more sensitive to changes in the trustworthiness of the police than the countries of the West (see Fig. 10.6). It seems that their citizens have preserved a part of their political culture from the authoritarian communist past and closely monitor the potentially abusive behavior of the police. Consequently, the scenario analysis in the previous section of this article reveals an asymmetry between the East and the West. Whereas possible future changes in the trustworthiness of the state have only limited effects on the life satisfaction of the citizens in the West, life satisfaction in the East will change more profoundly, independently whichever scenario will ultimately prevail.


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References Barrera, M. (1988). Models of Social Support and Life Stress: Beyond the Buffering Hypothesis. (In L. H. Cohen (Ed.), Life Events and Psychological Functioning (pp. 211–236). Newbury Park, CA: Sage) Bjornskov, Ch. (2003). The Happy Few: Cross-Country Evidence on Social Capital and Life Satisfaction. Kyklos, 56, 3–16 Braithwaite, V. & Levi, M. (Eds.) (1998). Trust and Governance. (New York: Russell Sage Foundation) Brehm, J. & Rahn, W. (1997). Individual-Level Evidence for the Causes and Consequences of Social Capital. American Journal of Political Science, 41, 999–1023 Catterberg, G. & Moreno, A. (2005). The Individual Bases of Political Trust: Trends in New and Established Democracies. International Journal of Public Opinion Research, 18, 31–48 Delhey, J. & Newton, K. (2003). Who Trusts? The Origins of Social Trust in Seven Societies. European Societies, 5, 93–137 Delhey, J. & Newton, K. (2005). Predicting Cross-National Levels of Social Trust: Global Pattern or Nordic Exceptionalism? European Sociological Review, 21, 311–327 Eurobarometer (2006). From http://www.gesis.org/en/data%5Fservice/eurobarometer/. (Cologne: Zentralarchiv fuer Empirische Sozialforschung) European Values Study (1999/2000). Codebook and Data on CD-ROM, Release 1. (Cologne: Zentralarchiv fuer Empirische Sozialforschung) Gundelach, P. & Kreiner, S. (2004). Happiness and Life Satisfaction in Advanced European Countries. Cross-Cultural Research, 38, 359–386 Hardin, R. (2002). Trust and Trustworthiness. (New York: Russell Sage Foundation) Helliwell, J. F. (2006). Well-Being, Social Capital and Public Policy: What’s New? The Economic Journal, 116, C34–C45 Hobbes, T. (1991 (1651)). Leviathan. (New York: Cambridge University Press) Hudson, J. (2006). Institutional Trust and Subjective Well-Being Across the EU. Kyklos, 59, 43–62 Kaufmann, D. et al. (2004). Governance Matters III: Governance Indicators for 1996–2002 (= World Bank Policy Research Working Paper 3106). (Washington, DC: World Bank) Kornai, J. & Rose-Ackerman, S. (Eds.) (2004). Building a Trustworthy State in Post-Socialist Transition. (New York: Palgrave Macmillan) Kornai, J. et al. (Eds.) (2004). Creating Social Trust in Post-Socialist Transition. (New York: Palgrave Macmillan) Mishler, W. & Rose, R. (1997). Trust, Distrust and Skepticism: Popular Evaluations of Civil and Political Institutions in Post-Communist Societies. Journal of Politics, 59, 418–451 Mueller, G. P. (2006). Conflict Buffers and Marital Satisfaction: On the Effects of Different Forms of Social Support. Journal of Happiness Studies, 7, 499–515 Myers, R. H. (1990). Classical and Modern Regression with Applications. (Pacific Grove: Duxbury) Warren, M. E. (Ed.) (1999). Democracy and Trust. (Cambridge: Cambridge University Press) World Values Survey (2005). From http://www.worldvaluessurvey.org/ (Ann Arbor: World Values Survey-Organization) Yamagishi, T. (2001). Trust as a Form of Social Intelligence. (In K. S. Cook (Ed.), Trust in Society (chap. 4). New York: Russell Sage Foundation)

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Appendix Table 10.4 The data used for testing the hypotheses 1 to 3 Coefficient b

Eastdummy

Trustworthiness T by state agency

Country

Constant a

Police

Justice

Civil service

Austria Belarus Belgium Bulgaria Croatia Czech Rep Denmark Estonia Finland France Germany Greece Hungary Iceland Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands N. Ireland Poland Portugal Romania Russia Slovakia Slovenia Spain Sweden Turkey Ukraine United Kingdom

8.148 5.214 7.929 6.061 7.121 7.483 8.436 6.362 8.123 7.338 7.816 7.068 6.124 8.118 8.346 7.540 5.686 5.673 8.207 8.590 7.933 8.304 6.574 7.100 5.617 5.075 6.662 7.953 6.993 7.749 5.062 5.206 7.688

-0.185 -0.766 -0.676 -0.694 -0.542 -0.547 -0.584 -0.597 -0.584 -0.420 -0.604 -0.475 -0.428 [-0.133] -0.201 -0.537 -0.503 -0.609 -0.517 -0.479 -0.217 -0.478 -0.460 [-0.078] [-0.429] -0.518 -0.737 -0.904 [0.164] -0.289 [0.027] -0.894 -0.416

.00 1.00 .00 1.00 1.00 1.00 .00 1.00 .00 .00 .00 .00 1.00 .00 .00 .00 1.00 1.00 .00 .00 .00 .00 1.00 .00 1.00 1.00 1.00 1.00 .00 .00 .00 1.00 .00

1.93 1.28 1.51 1.41 1.41 1.28 2.16 1.24 2.19 1.70 1.77 1.08 1.33 2.03 2.19 1.77 1.27 1.12 1.79 1.77 1.70 1.73 1.64 1.73 1.40 1.03 1.34 1.51 1.54 1.86 1.84 1.07 1.80

1.78 1.44 1.19 1.07 1.15 1.09 1.92 1.21 1.74 1.32 1.58 1.33 1.33 1.88 1.62 1.18 1.40 0.93 1.62 1.34 1.45 1.43 1.39 1.28 1.30 1.16 1.19 1.40 1.37 1.64 1.57 1.10 1.42

1.42 0.95 1.35 1.02 1.22 1.11 1.54 1.33 1.35 1.33 1.28 0.78 1.42 1.58 1.70 1.22 1.41 1.00 1.58 1.41 1.32 1.51 1.22 1.50 1.07 1.22 1.27 1.09 1.33 1.46 1.42 1.26 1.41

Variable definitions: Trustworthiness T by state agency: see Table 10.1; East-dummy: value 1 for Eastern and value 0 for Western countries; Constant a: see section 10.3.2; Coefficient b: see section 10.3.2. Significance of coefficient b: []: Error probability of b < 0 is greater than 5% (one-tailed t-test); other cases: negative sign of b is significant at level α = 5%

Chapter 11

Quality of Life in Cities: A Question of Mobility and Accessibility Giampaolo Nuvolati

Abstract Contemporary cities are characterized by an increasing concentration of populations (inhabitants, commuters, tourists) using a limited set of services and resources. Accessibility of services can be evaluated according to educational, cultural and economic disparities, but also in terms of traffic, transport systems and other issues concerning urban mobility. The first part of the paper deals with the concept of accessibility as a crucial aspect to examine in order to evaluate quality of life in the metropolitan areas as well as in the medium cities and small towns. This part is developed according to a theoretical framework based on Amartya Sen’s categories of functionings and capabilities. In the second part of the paper survey data regarding the accessibility of services in Italy are analyzed in order to test similarities and disparities among cities of different size. Keywords Quality of life, mobility, accessibility, urban size

11.1

Quality of Life and Mobility

Starting from the traditional distinctions between primary and secondary needs (Maslow, 1954), material and post-material values (Inglehart, 1977), objective and subjective dimensions (Allardt, 1976; Campbell et al., 1976; Andrews & Szalai, 1980; Zapf, 1984), cognitive and affective components (Bradburn & Caploviz, 1965; Cantril, 1965), individual well-being and collective welfare (Drewnowski, 1974), quality of life has been extensively conceptualized and studied in the last decades. In particular, when we deal with quality of life in the urban context classic

G. Nuvolati Department of Sociology and Social Research, University of Milan Bicocca, Via Bicocca degli Arcimboldi 8, 20126 Milano, Italy [email protected] V. Møller and D. Huschka (eds.) Quality of Life and the Millennium Challenge, © Springer Science + Business Media B.V. 2009

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issues emerge like criminality, poverty, traffic and pollution, social polarization, loss of identity, and weakening of social relations. Yet, job opportunities, highly sophisticated services and cultural events are still concentrated in the largest cities. However, “quality of urban life, as measured across non economic dimensions seems to decline as urban scale increase and the extent to which this quality of life difference is acceptable seems to depend largely upon economic trade-offs” (Elgin et al., 1974: 16). Several scholars analyzed the relationships between quality of life and urban size and density (Cicerchia, 1996; Cicerchia, 1999; Cramer et al. 2004; Royuela & Suriñach, 2005), starting from the so-called optimal city size theory (Fig. 11.1) here depicted and tested through empirical studies. According to this model the optimal size for a city is the one in which the positive difference between benefits and costs is higher. Normally transport and/or mobility are issues considered in the multidimensional model finalised to monitor and compare urban quality of life (Population Crisis Committee, 1990; Center for Urban Policy Research, 1998; European Commission-Eurostat, 2006) or to develop local studies (Santos & Martins, 2007). The management of a well-organized transport system is crucial in defeating pollution and improving urban safety, health, people’s daily mobility, and exploitation of all the available services. Of course transport is not the only item to look at in order to study the urban quality of life, nevertheless it has an increasing importance. The time we spend daily on travelling to work or study is increasing. According to the data collected by TTI (Texas Traffic Institute) in the Urban Mobility Report, 2005, in the United States the travel time index is continuously growing in the large as well as in the medium and small metropolitan areas, even if the situation is still better in the smaller areas (Table 11.1). These trends testify to a general loss of

The optimal city sized theory Costs

Benefits

Best size

Fig. 11.1 The optimal city sized theory

Urban size

11 Quality of Life in Cities

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Table 11.1 Travel time index trend in United States by Metropolitan area size (TTI – Urban Mobility Report, 2005) 1982

1993

2003

Metropolitan areas Very large = more than 3 million 1.18 1.38 1.48 Large = 1 million to 3 million 1.07 1.19 1.28 Medium = 500,000 to 1 million 1.05 1.11 1.18 Small = less than 500,000 1.03 1.06 1.10 1.12 1.28 1.37 Total The travel time index is a ratio of average peak period to freeflow travel. A value of 1.30 that indicates a free-flow trip of 20 minutes takes 26 minutes in the peak due to heavy traffic demand and incidents.

mobility with possible consequences in terms of quality of life, even if mobility is only one aspect of personal well-being which also includes housing, public safety, health, leisure, social relationships, and so on. People’s mobility, on the other hand, is not only the consequence of the quality of the transport system but is also based on a set of personal and family resources and tools, space morphology, location and organization of services (Nuvolati, 2006: 58). Sen’s concepts can be very useful for modelling and analyzing quality of life in such a perspective. According to Sen (1993: 31) “functionings represent part of a state of a person – in particular various things that he or she manages to do or be in leading a life. Capabilities of a person reflect the alternative combinations of functionings the person can achieve, and from which he or she can choose one collection”. Therefore, functionings deal with human activities while capabilities are more related to the concept of freedom. Mobility could be considered as a functioning of individuals based on the transformation of available resources (having) in real conditions (being or doing) according to a specific set of opportunities the individual can choose. In the more industrialized society the percentage of families owning one or two cars is very high, nevertheless the functioning of mobility is quite reduced because of the traffic. Sometimes traffic flow in the city is more fluid because of the improvement of the infrastructure of public transport, but this do not really increase the quality of life of the people who, for example, would like to travel by bicycle. In this perspective and in order to contrast both the utilitarian and the neocontractualist approaches, quality of life is therefore mainly considered as people’s being and doing and not only as being satisfied or having commodities. Regarding the utilitarian view, “It is quite easy to be persuaded that being happy is an achievement that is valuable, and that in evaluating the standard of living, happiness is an object of value. The interesting question regarding this approach is not the legitimacy of taking happiness to be valuable, but its exclusive legitimacy. Consider a very deprived person who is poor, exploited, overworked and ill, but who has been made satisfied with his lot by social conditioning (through, say, religion, or political propaganda, or cultural pressure). Can we possible believe that he is doing well just

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because he is happy and satisfied? Can the living standard of a person be high if the life that he or she leads is full of deprivation? The standard of life cannot be so detached from the nature of the life the person leads. As an object of value, happiness or pleasure (even with a broad coverage) cannot possibly make a serious claim to exclusive relevance”. (Sen, 1987: 8) The failure of utility to get very far leads to a more objective consideration, for example toward the establishment of a minimum standard of living by the definition of “primary goods” as in the Rawlsian theory of social justice (Rawls, 1971). However, this approach partially failed by neglecting the absolute and the relative nature of the standard of living (Sen, 1987: 17). “Sen’s argument against the primary good metric was simple but powerful. It was that differently constructed and situated people require different amounts of primary goods to satisfy the same needs” (Cohen, 1993: 16). Daily mobility could be analyzed by simply looking at car availability, but the validity of this indicator could be influenced by necessity or desire to use other means of transport; daily mobility could be measured considering the level of satisfaction of the population for the transport system or for their personal mobility, but such satisfaction could be affected by the level of expectation or information. Therefore, more objective and appropriate indicators of mobility could consider speediness of traffic (controlled by accidents), length of journey to go to work, to study or to access services (Table 11.2). Mobility is not only a functioning by itself, but can also improve a set of other functionings strictly connected with mobility. A recent study (Nitta & Inoi, 2005), which applies Sen’s categories to the analysis of the quality of life in Japan (the case study is Suita-city, Osaka), clearly shows that efficient public transport (community bus) can improve the accessibility to a wide set of services and therefore can enhance living conditions in terms of people’s functionings (Table 11.3).

Table 11.2 Indicators of mobility Resources and services

Satisfaction

Functionings

Cars per 100,000 inhabitants Percentage of road miles served by public transport Percentage of public expenditures on transportation Percentage of people satisfied with the transport system Percentage of people satisfied with mobility Miles per hour in rush hour by car Miles per hour in rush hour by public transport Average time to go to work or to school Average time to access services


181

Table 11.3 Achievement opportunity of functionings (Nitta & Inoi, 2005) Without With community community bus (%) bus (%) Hospital Shopping Municipality and bank Haircut School Walking and hiking Visiting a cemetery Meeting with family and friends Travel Dining and celebrations Viewing art and sports Playing sports Working and volunteering

11.2

63 73 68 83 36 47 44 42

87 87 85 85 51 48 44 42

39 38 36 17 12

41 38 36 22 18

Accessibility in Large and Small Cities

Commodities, functionings and capabilities, constitute the coordinates along which it is possible to compare quality of life by size of the city. The specific hypothesis to be tested here is that large and small to medium-sized cities differ in terms of amount of resources (goods and services), functionings and capabilities. Normally, large cities are characterized by the availability of a huge amount of resources from a quantitative and qualitative point of view, and by a high degree of personal freedom – freedom in terms of real opportunities that people have regarding the life they may lead, but also in terms of reduced social control. Yet, in the large cities what seems to be problematic is the transformation of resources in functionings, even in a context of a high number of resources and high-level capabilities. The small- or medium-sized cities are the opposite. Only few resources exist, but these are immediately utilizable because of the more limited number of users. The level of resources and capabilities is therefore quite low, but all of the limited resources available are easily transformable in functionings. Of course, functionings are still more achievable in the large cities, but simply because of the large initial amount of resources available and not because of the capacity of the city to improve accessibility (Table 11.4). Nowadays, local communities are much more unstable and open entities than in the past. Cities interact constantly with different populations coming from different places, and having different potentials. The metropolis, in particular, is currently characterized by the growing presence of different “user populations”: commuters, tourists and metropolitan businessmen, competing in the processes of accessing, controlling and using resources and services (Martinotti, 1999; Nuvolati, 2003a, 2006).

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Table 11.4 From resources to functionings and capabilities by city size Resources: goods and services Level of transformation of resources in functionings Functionings Capabilities

Large cities

Small and medium cities

High number and variety Low level

Low number and variety High level

High level High number of alternatives

Medium level Low number of alternatives

Therefore, in order to study quality of life, problems and opportunities in the communities must be analyzed according to the daily flows of people using resources and services located in the city, and not only considering the ratio between resources and local population. The natural and artificial morphology of the city, the not un-limited amount of resources available, the problematic accessibility of the services generate contrasts in the short as well as in the long run, among populations with different status, culture and mobility but all similar in concentrating in the same space. According to this approach, we can more appropriately define the instruments and the circumstances that can improve quality of life in the city by increasing the level of functionings. In other words, community quality of life can be enhanced in big cities if the problem of service accessibility is resolved. Conversely, community quality of life in small cities and towns can be enhanced by increasing the number and variety of services. Accessibility of course can be described along different paths: spatial and temporal mobility, economic, cultural and technological resources and instruments. Traditionally, the sociological approach focuses on the last three dimensions pointing out the economic polarization and digital divide between groups of population in accessing and using resources. Disparities in economic resources, uneven levels of knowledge in using technological devices and different information and education still remain crucial issues in favouring or limiting accessibility. But nowadays the attention on the more physical components of accessibility is increasing among sociologists as well. To consider spatial and temporal accessibility, and not only socio-economic accessibility, as elements which generate inequalities means to underline the importance of space and time in shaping living styles and quality of life and the renaissance of a modern urban sociology as a key discipline for interpreting the contemporary complexity. The debate about the objects of urban sociology (Saunders, 1981), about the importance of urban space as an independent variable generating particular kinds of social events and arrangements (and not only vice versa), could be revitalized by the concepts of functionings and capabilities as far as these dimensions, more or less directly, also relate to the spatial and temporal constrains in using the city (Fig. 11.2). Data regarding the availability of services in a city are no longer useful for analyzing living conditions if not combined with information regarding time and transport means that are necessary in order to quickly and properly access and utilize the


183

Perspective A

Perspective B

Accessibility of the place

Reach of the individual

I I I I I

P P P P P

I I I I I

I I P I I

I I I I I

I I I I I

P P P P P

P P I P P

P P P P P

P P P P P

I = Individual P = Place-services Fig. 11.2 Accessibility and reach (Elaboration on Dijst et al., 2002)

services and, therefore, in order to transform available resources in functionings. Such a perspective involves a shift in the analysis of the quality of urban life: from the city – in terms of the ratio between services and users (Perspective A) – to the individual – in terms of the typology of places-services he/she can reach and use in a limited time (Perspective B). To evaluate the quality of life (more specifically, a part of it) in terms of ease of access to a set of services or resources for each individual, contributes to define the concept of reach of each individual. Reach could be considered as the complex of habits, competences, information and practices experimented and performed by the individual in order to access services spatially distributed at an acceptable cost (in terms of time and money). Reach is therefore not exclusively based on the territorial distribution of services, but it is also something the individual can build up as far as people develop alternative and complex strategies in accessing resources. Of course, to focus on the time and space accessibility does not mean to reduce the importance of socioeconomic and cultural variables, but to underline that disparities are multilayered and present different sources also related to physical and organizational aspects. It means also the necessity to combine the analysis of sociological characteristics of the city with the analysis of the everyday spatial and temporal strategies adopted by individuals in order to deal with urban complexity.

11.3

Services Accessibility in Italy

In order to test our hypothesis about city size and services accessibility in this section some survey data regarding Italy will be presented and discussed. The sources are two very large national surveys: the Italian Multipurpose Surveys on Families, performed by Istat, Istituto Nazionale di Statistica, in 1998 (77,443 cases) and 2003 (53,708 cases) (Table 11.5) – face to face interviews with samples randomly selected in the municipalities register lists – and presenting identical questions about accessibility of some type of basic services and about opinions concerning time schedules.

184

G. Nuvolati Table 11.5 Questions from the Istat surveys (Multipurpose Surveys on Families, 1998, 2003) “In general, does reaching the following services create problems or difficulties for your family?” 1. No difficulties 2. Some difficulties 3. Many difficulties 4. Do not know “How do you judge the time schedule (of register offices, of health administrative offices, of post offices)?” 1. Very convenient 2. Sufficiently convenient 3. Not very convenient 4. Not convenient at all 5. Do not know

Table 11.6 Percentage of people with “no difficulties” in reaching services, Italy, 1998, 2003 (Ranked by 2003 values) (Istat, Multipurpose Surveys on Families) Garbage containers Small shops, markets Pharmacies Post offices Pre-schools Elementary schools Supermarkets, malls Middle schools Public offices Police stations Kindergartens Hospitals/emergency Local gas offices/windows Local electricity offices/windows

1998

2003

Var.

78.9 78.9 75.8 70.8 71.6 67.4 66.2 63.1 63.3 55.8 51.1 41.5 30.8 26.8

78.3 78.1 74.7 71.9 71.7 68.5 65.9 64.7 64.1 57.3 53.8 41.2 29.0 23.6

−0.6 −0.8 −1.1 1.1 0.1 1.1 −0.3 1.6 0.8 1.5 2.7 −0.3 −1.8 −3.2

The level of accessibility is perceived as quite high for every type of service for 1998 and 2003 excluding hospitals (emergency ward), local gas and local electricity offices/windows that present percentages lower than 50% of users without difficulties. The most accessible services in 2003 are garbage cans and small shops/markets (more than 78%). Kindergartens show the largest positive increment during these five years (2.7%), local electricity offices the largest negative variation (−3.2%). This result is probably due to the fact that people pay directly through their bank for gas and electrical utilities. However, in general the level of accessibility over the time remains quite stable (Table 11.6). Data do not show very large differences by city size and also remain quite stable between 1998 and 2003. However, towns with 2,000 or less inhabitants score first


185

for three items in 1998 and for four items in 2003 (+1): post offices, public offices, pre-schools, and elementary schools. Towns with 2,001–10,000 inhabitants score first position for two items in 1998 and for one item in 2003 (−1): police stations. Towns with 10,001–50,000 inhabitants score first position for one item in 1998 and for four items in 2003 (+3): local gas offices, local electricity offices, hospital/emergency, and kindergartens. Towns with more than 50,000 inhabitants score first position for four items in 1998 and for one item in 2003 (−3): garbage cans. Hinterlands never score first position. Metropolitan cores score first position for five items in 1998 and for four items in 2003 (−1): pharmacies, middle schools, supermarkets and malls, small shops and markets. Data do not present a clear relationship between city size and services accessibility, nevertheless it is interesting to notice that all the best variations take place in the towns with 2,000 or less inhabitants or in the towns with 10,001–50,000 inhabitants, showing a positive trend for medium-sized towns. Hinterlands, moreover, constitute the more problematic areas in terms of services accessibility (Table 11.7). If we consider the average of the percentages of people with no difficulties in reaching different services (Table 11.8), in 2003 the more problematic situations are found in the very small towns as well in the largest cities and their metropolitan areas, while medium-sized cities score better values. But considering the percentage variations between 1998 and 2003, the towns with 2,000 inhabitants or less display an improvement in service accessibility, the more urbanized areas get worse, and the medium-sized towns confirm or reinforce their position. Such findings are confirmed by the total sum of the percentage variations (1998–2003) of people with no difficulties in reaching fourteen types of services for each city size. Very small and medium-sized towns show positive or stable trends, while the metropolitan cores and the hinterlands are suffering (Table 11.9). According to these data the negative relationship between city size and services accessibility seems to be clearer and confirms our hypotheses. If we consider service accessibility from the point of view of their time schedule, it emerges quite clearly that the general opinion is not very positive and in any case the percentages of people that judge the time schedule of register offices, health administrative offices and postal offices to be very convenient is diminishing, even if the situation still seems better in the small and medium-sized cities with 50,000 inhabitants or less (Table 11.10). Services considered in this analysis are so-called basic services. Looking at more sophisticated services like museums, theatres and galleries could strongly modify the results. But in which directions? If it is true that such rarer resources are mainly located in the largest cities, it is also factual that more selective and international people access them, generating overloading effects in terms of congestion, forms of exclusion for the rest of the residential population. “Large cities concentrate city-effects (superior urban functions and opportunities) and often act as powerful magnets in attracting commuters and new residents from surrounding areas, where city-effect is weaker. But when concentration goes beyond a certain threshold, overburdened cities pay for their city-effect in terms of decreasing liveability” (Cicerchia, 1999: 273).

72.8

76.9

- Towns 10,001–50,000 inhab. 71.0

79.9

75.8

86.6

75.8

- Towns more 50,000 inhab.

- Hinterlands

- Metropolitan cores

Total

51.1

Total

53.8

52.6

49.6

47.0

58.0

51.6


60.5

59.6

- Towns 10,001–50,000 inhab. 51.1

- Hinterlands

50.9


41.7

31.0

2.7

−7.9

2.6

6.4

8.5

1.3

10.7

2003 Var.

67.4

69.6

63.5

62.8

68.6

69.6

66.3

68.5

66.9

61.9

66.9

69.0

69.0

78.2

2003

1998

41.2

49.7

26.9

45.7

52.0

35.2

25.8

1998

41.5

48.8

347

50.1

47.0

34.1

21.7

Pre-schools

−1.1

−0.8

−5.4

−3.0

1.8

0.8

2.4

Kindergartens

74.7

85.8

- Towns 2,001–10,000 inhab. 49.6

- Towns ≤ 2,000 inhab.

73.9

- Towns 2,001–10,000 inhab. 73.1

70.4

69.5

67.1


2003

1.1

−2.7

−1.6

4.1

0.4

−0.6

11.9

Var.

−0.3

0.9

−7.8

−4.4

5.0

1.1

4.1

Var.

71.9

70.5

60.8

71.7

69.2

75.7

80.2

71.6

74.0

69.8

70.6

71.2

72.0

72.0

1998 75.5

71.7

72.4

66.5

71.0

71.6

57.3

56.4

50.1

50.5

61.9

62.4

49.6

2003

0.1 63.1

−1.6 67.7

−3.3 61.2

0.4 60.0

0.4 63.6

0.6 66.4

3.5 46.2

1998

64.7

68.5

61.6

66.3

63.4

65.7

60.2

2003

Middle schools

1.1 55.8

0.9 56.4

−1.9 53.3

0.5 53.1

2.0 58.9

−0.7 60.1

2003 Var. 72.6

1998

Police stations

0.0 37.0

2003 Var.

Elementary schools

70.8

69.6

62.7

71.2

67.2

76.4

80.2

1998

1998

1998

2003 Var.

Hospitals (emergency wards) Post offices

Pharmacies

1.6

0.8

0.4

6.3

−0.2

−0.7

14.0

Var.

1.5

0.0

−3.2

−2.6

3.0

2.3

12.6

Var.

64.1

48.9

58.1

51.8

63.3

73.8

82.9

2003

0.8

−1.7

−5.7

−3.6

1.6

0.9

0.4

Var.

78.9

83.6

78.4

84.1

77.0

76.1

72.3

1998

78.1

82.3

76.2

81.0

78.7

75.8

75.0

2003

−0.8

−1.3

−2.2

−3.1

1.7

−0.3

2.7

Var.

Small shops, markets

63.3

50.6

63.8

55.4

61.7

72.9

82.5

1998

Public offices

Table 11.7 Percentage of people with “no difficulties” in reaching services, Italy by city size, 1998, 2003 (Istat, Multipurpose Surveys on Families)

186 G. Nuvolati

66.2

Total

65.9

78.1

67.5

68.4

75.9

77.2


75.3

72.9

- Towns 10,001–50,000 inhab. 68.0

- Hinterlands

59.6


31.9

33.1

- Towns 2,001–10,000 inhab. 58.3


−0.3

2.8

−0.9

−1.3

4.9

1.3

−1.2

78.9

80.0

78.2

81.8

76.6

78.1

82.7

78.3

80.9

75.4

81.6

77.6

76.6

79.4

2003

1998

1998

2003 Var.

Garbage cans

Supermarkets, malls

−0.6

0.9

−2.8

−0.2

1.0

−1.5

−3.3

Var.

30.8

15.4

32.4

33.8

38.6

33.2

19.4

1998

−1.1 35.1

2.9 31.6

−5.6 26.0

−0.3 19.9

1998

29.0

12.3 −1.8 26.8

−3.1 16.3 23.6

12.4

14.6

29.3

32.0

22.2

17.6

2003

−3.2

−3.9

−10.0

−5.8

0.4

−3.8

−2.3

Var.

Local electricity offices/ windows

20.9 −11.5 24.6

32.7

41.5

27.6

19.1

2003 Var.

Local gas offices/ windows

11 Quality of Life in Cities 187

188

G. Nuvolati Table 11.8 Mean of the percentage of people with “no difficulties” in reaching services, Italy by city size, 1998, 2003 (Istat, Multipurpose Surveys on Families) - Towns ≤ 2,000 inhab. - Towns 2,001–10,000 inhab. - Towns 10,001–50,000 inhab. - Towns more 50,000 inhab. - Hinterland - Metropolitan core Total

1998

2003

Var.

52.2 60.4 60.9 61.9 58.1 61.0 60.1

56.2 60.1 63.3 61.4 54.3 59.8 60.2

3.9 −0.4 2.4 −0.5 −3.8 −1.2 0.1

Table 11.9 Sum of the percentage variations (1998–2003) of people with “no difficulties” in reaching 14 types of services, Italy by city size (Istat, Multipurpose Surveys on Families) - Towns ≤ 2,000 inhab. - Towns 2,001–10,000 inhab. - Towns 10,001–50,000 inhab. - Towns more 50,000 inhab. - Hinterland - Metropolitan core Total

55.2 −4.9 33.4 −7.4 −53.3 −16.7 0.8

Table 11.10 Percentage of people considering the time schedule of services “very convenient”, Italy by city size, 1998, 2003 (Istat, Multipurpose Surveys on Families)

- Towns ≤ 2,000 inhab. - Towns 2,001 –10,000 inhab. - Towns 10,001 –50,000 inhab. - Towns more 50,000 inhab. - Hinterlands - Metropolitan cores Total

Register office

Health administrative office Post office

1998

2003 var.

1998

2003

var.

1998

2003

var.

38.0

28.9

−9.1 10.4

10.0

−0.4

23.0

20.0

−3.0

28.5

21.5

−7.0 9.9

10.2

0.3

19.6

15.6

−4.0

22.2

15.9

−6.3 10.6

11.1

0.5

18.6

16.7

−1.9

18.5

10.8

−7.7 11.5

9.0

−2.5

17.0

12.6

−4.4

21.8 11.2 22.9

16.3 7.3 17.0

−5.5 9.7 −3.9 7.2 −5.9 9.9

8.7 6.8 9.7

−1.0 −0.4 −0.2

15.5 9.0 16.9

15.5 8.7 15.0

0.0 −0.3 −1.9

Finally, research topic and methodological issues should be addressed to evaluate accessibility in a more objective way. As a matter of fact, subjective perception is still negatively influenced by people’s level of information and expectations and therefore it does not always correspond to the real situation. Time studies concerning mobility practices for different purposes constitute an important sector to be


189

developed in order to investigate in a more objective, systematic and comparative way the level of spatial and temporal accessibility of services and activities. Of course, many disciplines like planning, geography and transport sciences promoted much research oriented to study accessibility from a more physical point of view. For example, amenities and services are often a function of the geographic (and not only population) size of cities and towns; in some countries cities are very dispersed, making the provision of an efficient and effective public transport system, expensive and difficult. In general, a more fruitful combination between the sociological and material aspects of services accessibility would be welcome. Moreover, multivariate analysis should be performed in order to understand how much urban size matters in determining service accessibility, how much the space and time characteristics of the context contribute to limit or reinforce disparities in using the city based on more classic variables like age, gender, social class and education. Also local specificities in terms of the natural and built environment, social networks, administrative traditions, and innovative policies, could add new elements in creating positive or negative conditions in accessibility. However, the results presented in the paper give us some starting points for further research.

11.4

Preliminary Conclusions

New urban disparities can be analysed not only by considering the distribution of the resources (having) but also by evaluating the distribution of space and time which are necessary today in order to access and use the services (being and doing). To transform resources and services in concrete functionings is not an immediate process. Especially in the large cities, where many people, residents and nonresidents, concentrate, a large gap between the availability of the resources and their friendly exploitation exists, while in the small and medium-sized towns resources, even if limited, can be easily accessed. Survey data about spatial and temporal accessibility to services in Italy confirm these hypotheses, although differences in service accessibility by city size remain quite small. Moreover, on average more than 60% of the people in Italy declare “no problem” in accessing services, with a quite high stability over time. These findings are strictly connected to the features of the Italian urban system. Historically Italy has been characterized by a multicephalic process of urbanization, based on the presence and everlasting importance of medium-sized cities (Nuvolati, 2003b) which generate a very balanced distribution of resources and services. Even the more innovative public policies oriented to improve the accessibility of the services – for example the time policies and e-government policies – have recently undergone experiments especially in the medium-sized cities, producing a general improvement of the quality of life. Time policies are very useful instruments aimed at improving living standards in the local community with the specific objective of integrating the individual needs of the populations, both resident and non-resident, with the time schedule of public and private services. Several admin-

190

G. Nuvolati

istrative practices of time policy implementation have been built up over the last decade in many European cities, Italian in particular (Boffi & Nuvolati, 2002). Large cities that had experienced de-industrialization and transformation of lifestyles were the first to develop time policies geared to deal with gender issues; but in a second phase time policies became more popular in the medium-sized communities where many innovative and wide-ranging experiments were progressively performed and favoured by local administrations characterized by a reduced segmentation of roles and responsibilities. But, in order to solve problems linked to accessibility, innovative policies have been developed, which also consider the diffusion of technological devices and individual competences. Information and Communication Technologies (ICT) are now so widespread that they affect every aspect of our daily life. Working, shopping, traveling, banking, receiving services from our local council, going to the hospital or to the cinema are all activities that involve contact with ICT to a greater or lesser extent (Craglia et al., 2004). In Italy, during the last decade not only large cities but also small and dispersed local communities are showing a large interest in this kind of accessibility. Italian metropolitan areas, of course, are not losing their leading role and still are the places where resources and services are concentrated in order to meet the increasing requirements of resident and non-resident populations. This is particularly true for the more sophisticated supply in cultural and leisure sectors. Nevertheless, the growing phenomena of traffic, congestion and the everyday presence of external populations are gradually making the usability of the city more complex. New urban public policies are needed in order to contrast disparities in accessing and using resources and services by different groups of population. Also the everyday living strategies aimed to improve quality of life are changing according to the capacity of individuals to deal with complexity, to rationalize mobility and other activities in relation to a set of resources and services specifically distributed and accessible in the urban space.

References Allardt, E. (1976). Dimensions of Welfare in a Comparative Scandinavian Study, Acta Sociologica, 19, 227–239 Andrews, F. & Szalai, A. (Eds.) (1980). Quality of Life: Comparative Studies. (London: Sage) Boffi, M. & Nuvolati, G. (2002). Time, Mobility and Urban Governance: The Case of the Metropolitan Area of Milan. (In M. Dijst, W. Schenkel & I. Thomas (Eds.), Governing Cities on the Move (pp. 113–133). Burlinghton: Ashgate) Bradburn, N. & Caplovitz, D. (1965). Reports on Happiness. (Chicago, IL: Aldine) Center for Urban Policy Research (1998). State of the Nation’s Cities. (New Brunswick, NJ: Rutgers, The State University of New Jersey) Campbell, A., Converse, P. & Rodgers, W. (1976). The Quality of Life: Perceptions, Evaluations and Satisfaction. (New York: Russell Sage Foundation) Cohen, G. A. (1993). Equality of What? On Welfare, Goods, and Capabilities. (In M. Nussbaum & A. Sen (Eds.), The Quality of Life (pp. 9–29). Oxford: Clarendon)


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Cantril, H. (1965). The Patterns of Human Concerns. (New Brunswick, NJ: Rutgers University Press) Cicerchia, A. (1996). Indicators for the Measurement of the Quality of Urban Life: What Is the Appropriate Territorial Dimension?, Social Indicators Research, 39, 321–358 Cicerchia, A. (1999). Measures of Optimal Centrality: Indicators of City Effect and Urban Overloading, Social Indicators Research, 46, 273–299 Craglia, M., Leontidou, L., Nuvolati, G. & Schweikart, J. (2004). Towards the development of quality of life indicators in the “digital” city, Environment and Planning B: Planning and Design, 31, 51–64 Cramer, V., Torgersen, S. & Kringler, E. (2004). Quality of Life in a City: The Effect of Population Density, Social Indicators Research, 69, 103–116 Dijst, M., Jayet, H. & Thomas, I. (2002). Transport and Urban Performance. Accessibility, Daily Mobility and Location of Households and Facilities. (In M. Dijst, W. Schenkel & I. Thomas (Eds.), Governing Cities on the Move (pp. 19–39). Burlington, VT: Ashgate) Drewnowski, J. (1974). On Measuring and Planning the Quality of Life. (Paris: Mouton) Elgin, D., Thomas, T., Logothetti, T. & Cox, S. (1974). City Size and the Quality of Life. An analysis of policy implications and continued population concentration. National Science Foundation – Research Applied to National Needs Program. (Stanford: The Stanford Research Institute) European Commission-Eurostat (2006). Urban Audit, Bruxelles http://www.urbanaudit.org/index. aspx Inglehart, R. (1977). The Silent Revolution: Changing Values and Political Styles Among Western Publics. (Princeton, NJ: Princeton University Press) Istat (1998). Multipurpose Surveys on Families. (Rome: Istat) Istat (2003). Multipurpose Surveys on Families. (Rome: Istat) Maslow, A. (1954). Motivation and Personality. (London: Harper & Row) Martinotti, G. (1999). A City for Whom? Transients and Public Life in the Second-Generation Metropolis. (In R. A. Beauregard & S. Body-Gendrot (Eds.), The Urban Moment. Cosmopolitan Essays on the Late-20th-century City (pp. 155–184). London: Sage) Nitta, Y. & Inoi, H. (2005). The Planning of the Community Transport from the Viewpoint of Well-Being: Appling Amartya Sen’s Capability Approach. Proceedings of the Eastern Asia Society for Transportation Studies, 5, 2330–2341. Nuvolati, G. (2003a). Resident and Non-resident Populations: Quality of Life, Mobility and Time Policy, Regional Analysis & Policy, 33, 67–83 Nuvolati, G. (2003b). Socioeconomic Development and Quality of Life in Italy. (In M. J. Sirgy, D. Rahtz & A.C. Samli (Eds.), Advances in Quality-of-Life Theory and Research (pp. 81–98). Dordrecht, The Netherlands: Kluwer) Nuvolati, G. (2006). Commuting and Quality of Life: The Italian Case. (In R. Estes (Ed.), Advancing Quality of Life in a Turbulent World (pp. 55–66). New York: Springer) Population Crisis Committee (1990). Cities, Life in the World’s 100 Largest Metropolitan Areas. (Washington, DC: Population Crisis Committee) Rawls, J. (1971). The Theory of Justice. (Cambridge, MA: Harvard University Press) Royuela, V. & Suriñach, J. (2005). Constituents of Quality of Life and Urban Size, Social Indicators Research, 74, 549–572 Santos, L. D. & Martins, I. (2007). Monitoring Urban Quality of Life: The Porto Experience, Social Indicators Research, 80, 411–425 Saunders, P. (1981). Social Theory and Urban Question. (New York: Holmes & Meier) Sen, A. (1987). The Standard of Living. (Cambridge: Cambridge University Press) Sen, A. (1993). Capabilities and Well-Being. (In M. Nussbaum & A. Sen (Eds.), The Quality of Life (pp. 30–53). Oxford: Clarendon) Texas Transport Institute (2005). Urban Mobility Report. (College Station: Texas A&M University) Zapf, W. (1984). Individuelle Wohlfahrt: Lebensbedingungen und wahrgenommene Lebensqualität. (In W. Glatzer & W. Zapf (Eds.), Lebensqualität in der Bundesrepublik. Objektive Lebensbedingungen und subjektives Wohlbefinden (pp. 13–26). Frankfurt: Campus)

Chapter 12

The Main Determinants for Subjective Well-Being: A Quest for the Holy Grail? Can Governments Enhance the Perceived Quality of Life? Dries Verlet and Carl Devos* Abstract Governments consider the enhancement of the quality of life as an implicit touchstone of the effects of their policies. Whether and to what extent the quality of life is improved through government intervention is a question that’s rather difficult to answer. The two main reasons for this are, on the one hand, the measurement of policy effects, and on the other hand, the interpretation of the concept “quality of life”. In our contribution, we focus on the use of subjective indicators, i.e. the study of the “perceived quality of life” or the “subjective well-being”. We used the framework of resource-theory on subjective well-being as a basis for our analysis of the main determinants of the general subjective well-being, people’s evaluation of life as a whole. In order to study this, we set up a face-to-face survey research design. More specifically, our analysis applies to the empirical data of 1873 adult citizens spread over the three biggest Flemish cities (Antwerp, Ghent and Bruges). In order to find these main determinants of the general subjective well-being, we took a wide range of variables into account and, applying a multivariate regression analysis, we tried to determine their relative importance. The main objective of our enquiry was to investigate to what extent government policy can enhance the perceived quality of life. Keywords Subjective well-being, determinants, resource theory, government, Flanders (Belgium)

D. Verlet Advisor Policy Evaluation, Research Center of the Flemish Government and visiting professor at the Department of Business Administration and Public Administration, University College Ghent Research Center of the Flemish Government, Boudewijnlaan 30-bus23, B-1000 Brussels, Belgium E-mail: [email protected] C. Devos Associate professor, Department of Political Sciences, Ghent University, Universiteitstraat 8, GENT, B-9000, Belgium E-mail: [email protected] V. Møller and D. Huschka (eds.) Quality of Life and the Millennium Challenge, © Springer Science + Business Media B.V. 2009

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Introduction

A government has as its implicit most important objective to make policies which benefit its inhabitants (Andrews, 1974; Milbrath, 1979). Therefore, it is important not only to take into account economic and social indicators, because restricting the investigation to these objective indicators of the quality of life would mean the loss of valuable information, particularly the evaluation of life conditions by the inhabitants themselves (Diener & Suh, 1999; Milbrath, 1979). In the process of defining a policy, it is therefore important to have an adequate view of the situation of the local community and how this community experiences this situation. Moreover, it is also important to scrutinise the needs and requirements of this population. In other words, policy-making must take into account the way in which daily life in the community is experienced. Our present research focuses on the identification of this aspect of the quality of life, the subjective well-being. Characteristic of the research concerning the quality of life is the multitude of approaches and the lack of a common theoretical framework. All too often one employs solely economic indicators to deduce the well-being of a society. However, this economic approach has a number of limitations. Firstly, it emphasises, by definition, those aspects of life which can be traded on a market. Other ‘goods’, e.g. friendship, content, trust, are thus disregarded. Secondly, such an approach starts from the premise that individuals mainly attempt to maximise their own utility. According to the critics, there is an exaggerated perception of people as a so-called homo economicus. Thirdly, economists employ indicators which can only indirectly measure subjective satisfaction (Diener & Suh, 1997: 191–192). A second line of research emphasises social indicators. These are societal standards which reflect the objective circumstances of the inhabitants of a geographic and cultural unit. Characteristic of this approach is its reliance on objective, quantitative indicators rather than on individual perceptions of the social environment. Its most important limitation is, arguably, the fact that one cannot surmise whether those objective indicators also offer an accurate account of the subjective experience of the inhabitants (Diener & Suh, 1997). A third approach is the defining and measuring of the quality of life in terms of subjective well-being. In this approach, it is the evaluation of the individual’s life which is highlighted, both in the sense of the evaluation of contentment (the cognitive aspect) and in the sense of affective reactions (state of mind and emotions). The term ‘subjective well-being’ thus refers to the evaluation people make of their own lives. If an individual puts that (s)he is content with her/his life, that (s)he frequently enjoys pleasant experiences and encounters few unpleasant ones, we can conclude that this person has a high level of subjective well-being. In other words, three of the crucial components which constitute subjective well-being are: a general contentment with life, the frequent occurrence of agreeable experiences and the rarity of negative feelings (Kahneman et al., 1999; Diener & Lucas, 2000). Taking into consideration the respective strengths and weaknesses of these outlined approaches, we ideally employ a combination of the economic, social

12 The Main Determinants for Subjective Well-Being

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and subjective approach. Their complementarity allows us to provide an accurate definition of the quality of daily life on the level of citizens’ experience. In this contribution, the emphasis lies on the subjective evaluation by the inhabitants and we focus on the different measures of subjective well-being, also called ‘the perceived quality of life’ (Andrews, 1974). Because of the limited number of cities in our empirical analysis, we concentrate on the use of subjective indicators. Research concerning the subjective well-being clearly rises above the domain of political science. Established lines of thought and research have been developed in the context of predominantly the (socio) psychological and sociological sciences (Kahneman et al., 1999). The present political science approach is therefore also an important complementation of existing points of view, methodology and empirical results. For a long time, governments stuck to economic indicators as the principal signs of the quality of life in a society. In their logic, giving people a job and an income, was equal to an increase of life quality. Later on, policy-makers became aware that (other) social indicators were important too in order to map the quality of life. Finally, so-called subjective indicators were also taken into consideration in the study of quality of life. Objective indicators of an environment as such, are no indications to us of the experience of this condition (Milbrath, 1979). Early quality-of-life based on subjective indicators was mainly focused on basic research. However, there is also room for applied research. One of the possible applications of subjective well-being research is a policy application. Policy-makers made progressively more use of subjective indicators in, for example, the formation of their social policy (Davis & Fine-Davis, 1991). Results from quality-of-life studies were also being used in other policy fields such as spatial planning, geographical spacing of service, liveability, population compactness and social impact of economic policy (e.g. Cicerchia, 1996, 1999; Cohen & Felson, 1979; Chan, 1999). In such policy applications both subjective and objective indicators are being used. Another topic in applied research is the comparison of living conditions in the city with those in the country (e.g. Mookherjee, 1992) and the relation between the size of the municipality or city and the satisfaction concerning local services (e.g. Wasserman, 1982). Probably one of the biggest policy advantages of the use of subjective indicators is their contribution to the reconstruction of the ‘cognitive and affective map of society’ of policy-makers (Campbell et al., 1976). In other words, research that focuses on the actual perception of the inhabitants can assist policy-makers to see what is going on in a society. This can be a slow and difficult process, but as Campbell et al. already stated in 1976 about the impact of social research in the United States: ‘… we have witnessed in the last 25 years convincing examples of changing perceptions of social reality and consequent changes in social institutions and public behaviour. Public policies toward our most basic social problems, poverty and racial segregation, have changed dramatically during that time, and no doubt exists in my mind that social science have contributed significantly to these changes.’ (Campbell et al., 1976). More than 30 years later, this general conclusion still holds.

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In general, the measurement of subjective well-being can fulfil two important functions for governments and their policy. First of all, it can indicate to policy agents the need to improve subjective well-being. Secondly, it can also be a way to examine the effectiveness of the pursued policy by means of an increase in subjective well-being (Yardley & Rice, 1991). In this study we have opted for the resource theory as an overall theoretical framework to study the general subjective well-being. This approach is used to look for sources or conditions which contribute to a higher or lower subjective well-being (Schulz, 1995: 157). Applied to our research design, the several sources or conditions are the independent variables we found in the literature on this subject. More specifically, we can divide the independent variables into two general groups: one group consists of variables concerning the measurement of the satisfaction with specific life domains, and the other group has variables which apply to other characteristics of the respondents. The different scales to measure the general subjective well-being are the independent variables. An alternative theoretical approach for studying the general subjective wellbeing is the multiple discrepancies theory of Michalos. In this theory, the central point of attention is the generation of the general subjective well-being as such. Therefore he takes into account several comparison processes in order to come to a judgement of life (concerning a specific aspect of life or in general).1 A possible problem with such models to explain subjective well-being is, however, that one explains subjective well-being by something similar (Schulz, 1995: 156). Although this is a valuable approach, one can say that too little attention is paid to the living conditions (or “sources”) that are – in their turn – the basis for those comparison processes which result in levels of general subjective well-being. The research set-up is simple by nature. We study to what extent the independent variables in our research (i.e. the different sources or conditions) can help to explain the differences in the dependent variables (i.e. the general subjective well-being). This way we can get an overview of the main determinants of the general subjective well-being. In our contribution, we also take satisfaction with specific life domains into account in order to give a complete overview of the subjective well-being of our respondents (cf. infra). However, the focus is on the general subjective well-being. The main objectives of our study are to discuss the following questions: 1. How can we measure the subjective well-being? 2. What are the main determinants of the general subjective well-being? 3. Can governments increase the general subjective well-being? This discussion is covered in the conclusion of this article

1 In total, he distinguishes seven comparisons: ‘self now/others now’, ‘self now/self are appropriate best’, ‘self now/self expected by now’, ‘self now/self expected in future’, ‘self now/self deserves’, ‘self now/self needs’ and ‘perceived self now/wants’ (Michalos, 1985: 347–357).


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Because our article is essentially an empirical study, we first discuss the data-collection and methodological aspects.

12.2

Data, Methodology and Representativeness

The empirical verification is based on a questionnaire used in a representative sample survey of people entitled to vote during the local election in Ghent, Bruges and Antwerp. Those three cities are the biggest within the Flemish region of Belgium. This study reports data from a survey of the Department of Political Sciences of the Ghent University on political attitudes and subjective well-being which was carried out in March 2003. The questionnaire had already been tested through a representative survey of inhabitants of Ghent enfranchised since 2000 and preliminary research in 1999. The discussed survey was constituted on the basis of a literature study and the preceding surveys of 1999, 2000, 2001 and 2002 (see for example Verlet et al. 2002, 2005). The data are drawn from face-to-face interviews within a planned random sample of 4,652 enfranchised citizens of the cities of Ghent, Bruges and Antwerp. Respondents were interviewed in person in their own homes. Answer Cards were used showing relevant response categories. This was done in order to speed up the interviews and to minimise the effect of the order of the answer options.2 To increase the response and to legitimate the visit of one of the interviewers to the respondents, all the respondents received an invitation in advance to cooperate with the research. After the necessary quality controls,3 the actual sample contained data from 1,873 resident voters, the actual realised sample of our research. This means that the response-rate was 40.3%. Given the size of the survey, this response can be considered normal.4 An important issue is the representativeness of the sample. A generally known fact in survey research is that there exists no such thing as a sample which is a perfect reflection of the population from which it is drawn. Because the non-responses can be differential, the representativity of the actual sample was examined with the Chi-squared test. We checked the variables of residence (operationalised on the basis of the postal code of the district in which the interviewee was living at the time), sex

2

When answer categories are read, the respondents tend to remember the last options (Robinson et al., 1990: 43; Segers, 1999).

3

Both during and after the data-collection, we have organised an additional quality control, next to the internal quality control of the fieldwork company. Such a thorough monitoring and verification is important to safeguard the quality of the data. For example, unfinished questionnaires were dropped. Those questionnaires do not count as a response in the calculation of the general response.

4

The survey contained 26 pages; the average duration per interview was about 60 minutes.

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and age. These checks showed that there were no significant problems with the representativity concerning the district where people lived.5 In addition, the representativity was tested for the combined variables of sex and age.6 This analysis showed that the actual realised sample is also in this respect a good sample of the target population.7 So with respect to geographical background, gender and age, we can conclude that our sample is a satisfactory reflection of the “universe” we intended to study.

12.3

Variables Used in the Questionnaire

A large number of different aspects is measured in the survey. The present contribution offers only a selection. We can make a distinction between dependent and independent variables, given our research design. The central dependent variables in this study are those concerning the subjective well-being. It is obvious that, compared to some objective variables, the operationalisation of these subjective factors is not straightforward.8 Hence the use of various operationalisations is recommended. This constitutes the central part of our research. The study of the subjective well-being benefits from the use of a number of different indicators. We also note the difference between the cognitive and affective dimension of the subjective well-being. Moreover, we have made the essential distinction between positive and negative affect. This distinction has been highlighted by Bradburn in his pioneering study concerning the structure of the psychological well-being (Bradburn, 1969). In its empirical study, he found that the answers with a positive undertone have no

5

Concerning the comparison of the actual sample and the target group (i.e. all voters of Ghent, Bruges and Antwerp) Chi-squared values of respectively 13.3; 2.8 and 32.2 were obtained. The number of degrees of freedom is respectively nine, three and thirteen with accompanying p-values of 0.150; 0.431 and 0.002. 6 Also for the combined variables of sex and age, the representativity was tested with Chi-square. Concerning the comparison of the actual sample and the target group for Ghent, Bruges and Antwerp, Chi-squared values of 12.6; 17.3 and 30.1 were found, each time with 11 degrees of freedom and a p-value of respectively 0.028, 0.100 and 0.002. 7 Ideally, more variables are included to check the representativity of the actual samples. The problem that arises here is that there is a lack of comparable data for the target population concerned, i.e. the resident voters of Ghent. 8 The measurement of objective factors is not always straightforward though, especially not in comparative research (Carley, 1981; Cohen, 2000; Cutter, 1985; Drewnowski, 1980; Jacob & Willits, 1994; Johnston, 1979). In this context, we can question the straightforwardness of the distinction between so-called “objective” and “subjective” measures of the quality of life (Andrews & Withey, 1976; Campbell, 1980; Cummins, 2000). For a recent analysis concerning the use of objective and subjective indicators and their interrelationship, see for example McCrea et al. (2006).


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explanatory value in relation to answers to questions which were formulated negatively. In addition, the two dimensions of positive and negative affect each correlated with other factors. Past research already illustrates the value of employing both positive and negative indicators for affect in order to come to a general view of the subjective well-being (Andrews & McKennell, 1980; Bradburn, 1969; Diener & Iran-Nejad, 1986; Kozma et al., 1990; Michalos, 1991; Thomas & Diener, 1990). The operationalisation of the different components of the subjective wellbeing will be treated as dependent variables in our research design. Although general indicators of subjective well-being can be useful, more specific indicators bring out more pertinent information since so many elements contribute to the level of subjective well-being. Hence the surveying of more specific indicators, such as the contentment with one’s neighbourhood, one’s professional situation and health is recommended. Those measures about rather specific domains of daily life are important variables in our research design. We treat them as independent variables because we focus on measures of general subjective well-being as our dependent variables. We will also use other variables to detect the main sources of the subjective wellbeing. Based on a comprehensive review of the literature, we use a wide range of variables in our empirical study. Those variables can be placed in different groups. The survey measured first of all socio-demographic variables. Then, there are several variables concerning attitudes toward others (e.g. trust in fellow man, social integration, social support, frequency of and experience of the contact with different groups), living in the neighbourhood and membership of diverse organisations. Other variables in the questionnaire concern the following subjects: perception of social class, feeling secure in the city, individualism, self-esteem, authoritarianism and postmaterialism. We also asked the respondents to compare their own situation with the situation of their parents and the situation at the beginning of their occupational life.9 Finally, a number of political attitudes of the respondents were measured by the survey. We can consider all those characteristics as independent variables in our research design. In this contribution, we discuss the link between the independent variables on the one hand and the operationalisations of the subjective well-being on the other. Doing so, we can give an overview of the characteristics, traits and circumstances going together with high levels of subjective well-being (Myers, 2000). Based on a correlation- and ANOVA-analysis we can focus on the relations between the independent and dependent variables. However, this kind of analysis, tells us little about the explanatory value of the independent variables for the general subjective wellbeing. In order to do this, regression analysis was used. In that way, we could assess to what extent the knowledge of several types of independent variables contributes to the explanation of subjective well-being.

9

The unemployed and students, for example, cannot always judge their current situation compared with the situation at the beginning of their occupational life. Therefore, the answer options of “don’t know” and “not applicable” were added.

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So, to express the strength of the association between the independent variables on the one hand and the satisfaction with the policy on the other (multiple) regression-analysis was used. That technique makes it possible to indicate what proportion of the variance in a dependent variable (e.g. general satisfaction with life), can be explained by the independent variables (e.g. the socio-demographic variables). Moreover, multiple regression allows – to a certain extent – that independent variables correlate with each other and with the dependent variable to varying degrees.10 The higher the proportion explained variance, the stronger the explanatory value of the independent variables. As a parameter for the proportion explained variance, the “adjusted R2” or the “adjusted coefficient of determination” is used in the analysis. This parameter takes the number of independent variables into account. The interpretation of the “adjusted R2” is similar to the interpretation of the conventional R2. The parameter “adjusted R²” can range from 0 to 1 (or from 0% to 100%). The higher the proportion explained variance, the stronger the association. The “adjusted R2” is also called a “pseudo-R2” (Hair et al., 1998; Neter et al., 1996). It is important to remind ourselves that regression analysis cannot prove the causality of the associations. The forthcoming associations are not causal relationships ipso facto. They only denote to what extent the variance in the assumed dependent variables can be explained by the knowledge of the independent variables in the analysis. A causal relationship implies that we have different measurements from the same respondents throughout time (McClendon, 1994). In short, the present study is not a panel study (Mannheim et al., 2002).

12.4

Measures of Subjective Well-Being

Subjective well-being is an attitude, and it is widely accepted that attitudes include at least two basic components: cognition and affect (Guttman & Levy, 1982; Veenhoven, 1984). The cognitive component of the subjective well-being refers to the rational or intellectual aspects of subjective well-being, i.e. how people think about their subjective well-being. On the other hand, there is the affective component of subjective well-being. The latter component involves emotional aspects, how people feel about their lives. It has proven useful to make a distinction between positive and negative affect (for example Heady et al., 1993; Horley & Little, 1985). Bradburn’s scales (1969) have quite often been used as being relatively pure measures of these concepts. A somewhat puzzling result in this area of research is that the positive affect dimension and negative affect dimension are relatively independent of each other. In the empirical analysis, we use both the measure for negative affect and positive affect as two separate dependent variables in order to measure

10

Nevertheless, we also checked for multicollinearity using the tolerance and VIF statistics.


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(aspects of) the general subjective well-being. Besides, we also – as Bradburn did – compose the Affect Balance Scale based on the scores for positive affect and negative affect. Bradburn’s Affect Balance Scale is one of the most widely used measures of subjective well-being (Suh et al., 1998). Measures of the concept “happiness” have been shown to reflect relatively large amounts of affect, positive affect in particularly, but relatively little cognition. In contrast, measures of satisfaction reflect cognition to a greater extent. But satisfaction measures do not seem to be pure measures of the cognitive component of subjective well-being. They include some positive and negative affect as well (Andrews & Robinson, 1990: 61–114). To remedy this shortcoming Diener et al. developed a multi-item scale to measure life-satisfaction as a cognitive-judgemental process (Diener et al., 1985; Pavot & Diener, 1993). In sum, because of the different aspects of the rather vague concept of subjective well-being, the following different scales are used: the Satisfaction With Life Scale of Diener et al., the general satisfaction with life measure (a single-item scale with a response scale ranging from 0 to 10), a single-item happiness scale (a seven-category response scale) and Bradburn’s multi-item scales of negative and positive affect.11 It is important to note, however, that none of those scales are really pure measures of e.g. affect of cognition. However, we can place them on a continuum ranging from the most cognitive to the most affect-loaded scales to measure subjective well-being (cf. Fig. 12.1). Those measures are treated as dependent variables in our analysis. Besides the distinction between the various measures of subjective well-being according to the level of affect and/or cognition they measure, we also had to make a distinction along the object of measurement. The above mentioned scales are general, they consider life-as-a-whole. But we can also assess more specific life concerns (sometimes called “domains”), such as the evaluation of the family, the personal financial situation etc. In his analysis Cummins distinguished seven domains: material well-being, health, productivity, intimacy, safety, place in the community and emotional well-being. Although Cummins states that those domains are comprehensive, in

COGNITION

AFFECT

1. Satisfaction With Life Scale

2. General lifesatisfaction

3. Happinessscale

(Dieneret.al. 1985)

(e.g. Robinson, Shaver (e.g. Michalos, & Wrightsman, 1990) 1991)

4. Positive affect 5. Negative affect 6. Affect balance scale (Bradburn, 1969)

Fig. 12.1 Positioning of the different measures for subjective well-being on the affect-cognition dimension 11 Concerning the choice between, for example, 11-point scales or 7-point scales, we have used the most frequently-used format in the literature.

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his work he also mentioned some additional domains. Those domains are: leisure, spiritual well-being and (local) politics. Although, he stated that their added value is rather limited, we also used those additional domains in order to cover the whole range of life domains. The satisfaction on these domains is measured by a score on the seven-point delighted-terrible scale (Cummins, 1997). As a result of an explorative research we also developed an own scale for the measurement of the different domains. The scale measures the satisfaction on eight items. On the one hand there are two items which are rather general, namely the satisfaction as a human being as such and the satisfaction with life in our society. On the other hand there are five more specific items: current professional situation, financial situation at home, the life at home, the neighbourhood and the local government. We also bring a time aspect into account in our scale. In doing so, we ask the respondents to express their satisfaction with their current situation in comparison with their situation of four or five years ago. For all the items, the respondents were asked to give a score on a scale ranging from zero to ten. As with most of subjective well-being scales a response category “don’t know” was also provided. It is clear that there is a certain amount of overlap between the scale of Cummins and the one we developed. The measures for the specific domains of daily life are entered as independent variables in our analysis.

12.5 12.5.1

Results Global Subjective Well-Being Measures

So far, we have discussed the different global measures with different loadings on the affect and cognition dimension. In general, the respondents report high mean levels of subjective well-being. Based on the order of the variables used in Fig. 12.1, the overall mean scores are the following: 5.11 on the SWLS (a 7 point scale), 7.37 for the general life satisfaction scale (on a 11 point scale from 0 to 10), 5.73 for the scale measuring happiness, resp. 3.32 and 1.55 for positive affect (scales ranging from 0 to 5) and 6.77 on the Affect Balanced Scale (operationalised as a score on a scale ranging from 0 to 10). We also note very low levels of missing values for the different measures (ranging from 0.1% for the scale measuring negative affect to 3.0% for the most cognitively loaded scale (SWLS). We can conclude, conforming with earlier research, that people don’t find it difficult to judge their general subjective well-being (Andrews, 1974). In Table 12.1 the Pearson correlations give us a view of the intercorrelation between the general subjective well-being measures.12

12 The layout of these figures tells us something about the corresponding significance levels. The values in bold and italic have p-values which are smaller or more equal to 0.001. The corresponding significance level for values in italics is larger than 0.001 but smaller than 0.050.


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Table 12.1 Correlations between the different measures for global well-being SWLS

Gen. LS

Happ.

PA

NA

ABS

SWLS Gen. LS Happ. PA NA ABS

1.000 0.555 1.000 0.517 0.468 1.000 0.306 0.364 0.261 1.000 -0.313 -0.311 -0.257 0.002 1.000 0.439 0.477 0.370 0.707 -0.706 1.000 SWLS = Satisfaction With Life Scale, Gen. LS = General Lifesatisfaction, Happ. = Happiness, PA = Positive Affect, NA = Negative Affect and ABS = Affect Balance Scale

We see that the measure for general satisfaction, for happiness and the SWLS strongly mutually correlate, ranging from 0.468 to 0.555. Bradburn’s negative affect dimension correlates moderately and negatively with measures for the SWLS, the scale for general satisfaction and the happiness scale. The positive affect dimension correlates also moderately with those three other measures but in a positive way. All these correlations were significant at the 0.001 level. As we can expect based on the literature, there is no significant correlation between the dimension for positive and negative affect. So it is important to make a distinction between these two measures. Experiencing high or low levels of positive feelings, do not go together with the same levels of negative affect. Besides this bivariate analysis, we also used a multivariate method, more specifically a principal component analysis. This was done in order to detect how many latent dimensions or factors can be found in those general subjective well-being measures. If we only use the Kaiser criteria (1959, source: Tacq, 1992), stating that only factors with a eigenvalue higher then 1 must be taken into account, two factors are detected. Looking to the rotated component matrix (after using varimax rotation) we found that there is a clear distinction between the mainly cognitive loaded measures of subjective well-being and the measure of negative affect. The eigenvalues produced in the extraction were examined on a scree plot and this failed to reveal a clear cut-off point. The eigenvalue of the third factor is only slightly lower then 1 (0.984). Allowing three factors, we see a clear distinction between one for the most cognitively loaded measures, one for positive affect and one for negative affect. The factor loadings after varimax rotation for both factor solutions are shown in Table 12.2. Although there is a clear intercorrelation between different measures of the global subjective well-being, we will use the different measures as separate dependent variables in our analysis. Doing so, we can give an overview of the explanatory value of the different independent variables for each of six measures for general subjective well-being. In this way we can see if the same main determinants come forward. For a start, we begin by linking the satisfaction with the specific domains in life.

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Table 12.2 Analysing latent factors in the scales measuring general subjective well-being: factor loadings after varimax rotation when taking into account two or three factors

SWLS General lifesatisfaction Happiness Positive affect Negative affect Affect Balance Scale

12.5.2

Two component solution

Three component solution

1

2

1

2

3

0.682 0.706 0.632 0.820 −0.090 0.644

0.304 0.278 0.240 −0.147 −0.990 0.604

0.811 0.740 0.821 0.193 −0.188 0.271

0.175 0.181 0.091 −0.020 −0.981 0.687

0.150 0.259 0.065 0.978 0.029 0.671

Life Domains

As already mentioned, we have made a distinction concerning satisfaction on various life domains. To do so, we used the domains that Cummins used in his “comprehensive measure of quality of life” (Cummins, 1997). Those domains are: material wellbeing, health, productivity, intimacy, safety, place in the community and emotional well-being, leisure and spiritual well-being. Additionally, the satisfaction about several other aspects of the daily life of the respondents was measured by items in our own scale for subjective well-being. The domains used in this scale are the following: satisfaction as human beings, with the life in our society, current professional situation, financial situation at home, the life at home, the neighbourhood and the local government and satisfaction compared with the recent past. Whereas Cummins’s response scales are seven-points scales, the ones we have used for our own scale range from zero to ten in order to maximize the variation and because of the comparativeness with other measures (Andrews & Withey, 1976; Andrews & McKennell, 1980; Headey et al., 1984; Veenhoven, 1984). If we look only to the mean scores for the total realised sample for the items of Cummins we find the highest satisfaction for material well-being, intimacy and emotional well-being (respectively 6.05, 5.85 an 5.83 on a 7 point scale). The lowest mean satisfaction was for safety (5.31) and spiritual well-being (5.06). In our own scale the highest mean score was found for satisfaction with the situation at home and satisfaction as a human being (respectively 7.88 and 7.46). The relative lowest satisfaction we found is the satisfaction in comparison with the near past (6.31) and the local government (6.01). Yet, we notice that all the mean satisfaction scores are situated on the positive side of the continuum. In that sense ‘most people are happy’ (Diener & Diener, 1996). Several models are put forward to study the relationship between satisfaction with domains of life and general subjective well-being (for an overview see Leonardi et al., 2005; Moller & Saris, 2001; Rojas, 2006). A basic distinction can be made between “top down” and “bottom-up” models. A top down model is based on the assertion that a central subjective well-being exists that has an influence on more specific domains of life which are of a lower level. Thereby one assumes a


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causal influence from the central subjective well-being to the satisfaction with specific domains of life. On the other hand, there is the bottom-up model. As the denomination of the model already indicates, here one assumes a reversed causality. In this view, people come to their level of general subjective well-being, based on the satisfaction concerning specific domains of life. As noted, in our study, the satisfaction with specific life domains can be seen as independent variables when we study the general subjective well-being. First of all we’ve studied the plain correlations between the scores on the various domains and the different global measures of subjective well-being. A general conclusion is that the domain satisfaction scores correlate overall rather weakly with the positive and negative affect dimension and to a lesser extent rather weakly with the general happiness dimension. The correlation with the general satisfaction measure and particularly the SWLS is relatively stronger if we compare them with other measures of subjective well-being. The reasoning behind that conclusion is quite evident since the domain satisfaction measures do measure satisfaction, which is by definition a rather cognitive evaluation of the subjective well-being. Measures that tend to measure a similar aspect correlate in a higher extent with each other. If we focus on the strength of the correlation of the several specific domains with the various global measures we see that the correlations are relatively strong for the domains productivity (made operational by the measurement of the satisfaction with the things people achieved in life), emotional well-being, satisfaction with the life at home, satisfaction as human beings and the satisfaction with the personal financial situation. The lowest correlations were found with the domains spiritual well-being and the satisfaction with the local government. To determine which domains are the most powerful statistical predictors of global well-being a multiple regression analysis was performed for the six different global measures of subjective well-being with the variables about the domain satisfaction as independents. In Table 12.3 we give an overview of the explanatory value of the satisfaction with the specific life domains for the several measures of general subjective well-being. In this table the results of the regression analysis are displayed. We display the explanatory value of the satisfaction with the separate life domains. The results of the regression analyses show that 51.1% of the variance in the most cognitively loaded measure for general subjective well-being (SWLS) can be explained by the inclusion of the variables concerning the various life domains in the regression model. The strongest predictor is the satisfaction as a human being. The various measures of satisfaction concerning the specific domains account for 49.3% of the total variance in the measure for general life satisfaction. The most predictive domains for that dependent variable are the satisfaction as a human being, the satisfaction with life at home and – as Cummins called it – the emotional well-being. They are respectively responsible for 33.3%, 29.2% and 29.1% of the variance. Concerning the measure of general happiness, 37.5% of the variance can be “predicted” by the satisfaction on several domains. For that measure the domain satisfaction with the emotional well-being has the highest explanatory value (25.1%). This is not surprising because the emotional well-being was measured by

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Table 12.3 Overview of the explanatory value of the satisfaction with specific facets of life for the general subjective well-being measures18 Material well-being Health Productivity Intimacy Safety Place in the community Emotional well-being Leisure time Spiritual well-being Local government Total (Cummins, 1) Societal life in Belgium Regard to the past As human being Work situation Financial situation Home situation Neighbourhood Local policy Total (own scale, 2) Overall total (1 and 2)

SWLS

Gen. LS

Happ.

PA

NA

ABS

10.2% 14.6% 25.5% 9.4% 5.0% 7.7% 34.7% 11.5% 1.0% 3.1% 43.1% 10.1% 8.3% 28.8% 11.3% 17.7% 26.3% 6.8% 3.0% 39.8% 51.1%

7.7% 12.4% 18.0% 6.8% 5.1% 7.0% 29.1% 9.3% 0.7% 2.9% 35.1% 11.3% 12.1% 33.3% 11.5% 19.2% 29.2% 9.2% 3.4% 44.9% 49.3%

6.1% 9.4% 15.2% 4.4% 2.9% 3.9% 25.1% 6.8% 0.3% 1.8% 28.1% 7.9% 6.0% 19.3% 5.0% 12.9% 19.9% 9.5% 2.3% 28.5% 37.5%

0.2% 5.6% 4.3% 3.7% 2.7% 5.1% 7.9% 2.3% 0.4% 0.7% 12.2% 1.6% 3.0% 7.3% 3.6% 3.5% 4.8% 2.6% 0.4% 10.2% 13.7%

2.1% 5.2% 6.6% 2.6% 1.2% 0.8% 9.5% 3.9% 0.5% 0.6% 12.1% 1.6% 1.2% 8.9% 4.2% 5.1% 8.0% 1.5% 0.3% 10.8% 13.8%

1.9% 10.8% 11.0% 6.2% 3.8% 5.1% 17.5% 6.2% 1.0% 1.3% 23.0% 3.2% 4.1% 16.6% 8.1% 8.5% 12.6% 4.1% 0.7% 21.7% 27.5%

18

Again, the layout of these percentages tells us something about the corresponding significance levels. The values in bold and italics have p-values which are smaller or more equal to 0.001. The corresponding significance level for values for adjusted R² printed in italics is larger than 0.001 but smaller than 0.050.

the extent that people are satisfied with their own happiness. The proportion of the variance explained concerning the positive and negative affect dimension is relatively low, respectively 13.7% and 13.8%. The most important variables in predicting positive affect are the satisfaction as human beings (7.3%) and the emotional well-being (7.9%). The variables explaining the highest amounts of variance in the measurement of negative affect are the emotional well-being (9.5%), the satisfaction as human beings (8.9%) and the satisfaction with the home situation (8.0%). Those domains are also responsible for the highest explained variance for the Affect Balance Scale (resp. 17.5%, 16.6% and 12.6%). As noted, this Affect Balance Scale of Bradburn is a combination of the scales of positive affect and negative affect. All the domains together can explain 27.5% of the variance in this scale. Although this scale is disputed as a measure of general subjective well-being (because of the alleged independence of positive and negative affect, Benin et al., 1988; Brenner, 1975) in this analysis, this scale is doing quite well. The fact that the satisfaction measures for the various specific life domains are rather weak in predicting the positive and negative affect dimension, just as it was for the general happiness measure, can be interpreted as that the specific domains


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of life-satisfaction measure another dimension, i.e. the cognitive component of subjective well-being. The results of our analysis confirm the finding that the assessment of specific life concerns (the so-called domains), are rather powerful statistical predictors of global well-being. The finding in previous research that the domains with the strongest links to global well-being generally concern domains about the self and home is also confirmed by our analyses. More remote concerns as satisfaction with the local government, for example, have much smaller contributions to explain global subjective well-being (Andrews & Robinson, 1990; Andrews & Inglehart, 1979). As was already mentioned, a large amount of the variance in the general subjective well-being measures can be explained by the satisfaction with more specific aspects of life. Although the inevitable random errors and the so-called “noise” in such regression models must be taken into account (Saris & Scherpenzeel, 1995), there is still an important amount of variance left unexplained. This may imply that some important domains of life were not questioned. This, however, is not very plausible. Yet, it may be the case that some other factors, which are exogeneous to subjective well-being, must be included in the analysis of the determinants of the general subjective well-being. In a way, one can discuss to what extent it is legitimate to explain general subjective well-being by the use of other measures for specific aspects of this subjective well-being, as domain satisfaction scores. Therefore it is important to study the explanatory value of the several other characteristics of the respondents. Doing so, we can make a more global overview of the main determinants of the general subjective well-being. We examined to what extent several other characteristics of the respondents, so-called independent variables in our research design, can contribute to explain the differences in the general subjective well-being levels. The same characteristics/ independent variables were linked to the six different measures for general subjective well-being. As noted, a (somewhat arbitrary) distinction of several (groups of) independent variables has been used: socio-demographic characteristics, attitudes towards others, the frequency and experience of the contact with several groups of others, variables concerning living in the neighbourhood, membership of associations (involvement in social life), perception of social class, feeling secure in the city, utilitarian individualism, self-esteem, authoritarianism, post-materialism, variables concerning political attitudes and the comparison of the own situation to those of the parents and at the beginning of the professional life. For each of those (groups of) independent variables, we examine to what extent they can contribute to explain the differences in the general subjective well-being. As noted above, regression analysis has been used. In Table 12.4 an overview of the results of those regression analyses is given. Some categories contain several variables, others only one. Therefore we mention the number of variables in Table 12.4. We will now consider in some detail (groups of) variables that contribute significantly to explain the differences in the general subjective well-being. In the discussion of the results of our analysis, we focus on those independent variables that contribute

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Table 12.4 Overview of the explanatory value of the independent variables for the general subjective well-being Socio-demographic characteristics (12) State of health compared to peer groups Attitudes towards others (5) Frequency of the contact with others (9) Experience of the contact with others (9) Neighbourhood (5) Involvement with social life (5) Perception of social class (1) Feeling secure in the city (1) Utilitarian individualism (1) Self-esteem (1) Authoritarianism (1) Post-materialism (1) Political attitudes (18) Comparison to parents situation and beginning of occupational life (2)

SWLS

Gen. LS

Happ.

PA

NA

ABS

11.0%

9.6%

11.7%

9.0%

10.3%

6.0%

10.1%

6.8%

6.7%

4.0%

4.2%

8.5%

14.8% 6.6%

15.1% 4.9%

13.2% 6.4%

13.7% 8.9%

8.7% 8.4%

16.2% 6.5%

9.3%

7.6%

9.0%

9.1%

6.8%

6.8%

7.4% 1.4% 1,5% 2,2% 1.5% 10.4% 0.1% 0.0% 1.8% 12.7%

9.7% 0.5% 1.2% 2.9% 2.2% 11.0% 0.2% 0.0% 2.8% 10.0%

10.5% 0.3% 0,9% 2,3% 1.3% 8.0% 0.3% 0.0% 1.6% 8.6%

4.5% 3.1% 3.5% 2.3% 3.6% 3.9% 3.3% 3.1% 6.5% 3.3%

2.9% 0,0% 0,1% 0,2% 0.6% 9.9% 1.2% 1.0% 6.8% 4.0%

6.2% 1.8% 1.7% 1.9% 2.2% 12.0% 0.3% 0.2% 4.2% 5.9%

to a strong significant proportion of explained variance (i.e. p < 0.001). Nevertheless, it is important to stress that there are no considerable differences in the subjective well-being depending on the level of authoritarianism and post-materialism. In general those attitudes of people tell us little about their level of general subjective well-being. Those variables have some explanatory value only for the measures for positive and negative affect. More specifically, we have found that there is a positive correlation between post-materialism on the one hand and both positive and negative affect on the other. People with a more post-materialistic attitude tend to experience higher levels of both positive and negative affect. It is important to note that younger voters have a more post-materialistic attitude. A further analysis shows that the effect of post-materialism can be explained by the effect of age (cf. infra). Besides, people with a high level of authoritarianism also experience less positive and more negative feelings. Partly because of the ongoing popular and important debate concerning “social capital” (see for example Putnam, 1995), we asked the respondents about their membership of a political party and/or a union. Furthermore, we asked for the membership of other organisations, and activities in social life and volunteer work. Those variables can be situated under the denominator of the so-called structural social capital or the involvement in social life (Lelieveldt & Van der Kolk, 2002). In Table 12.4 they are displayed under the heading “involvement with social life”.


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An important conclusion is that there are no great differences according to those variables. The structural social capital has no noticeable explanatory value for the general subjective well-being. We only found that people active in social life and volunteer work do experience more positive feelings. Traditionally, a lot of attention is paid to the socio-demographical characteristics and their explanatory value for the general subjective well-being. Therefore we discuss them in more detail. The explanatory value of each of those independent variables is portrayed in Table 12.5, while in Table 12.4 we give only a general overview of those socio-demographical variables. There is almost no difference in the level of subjective well-being of male and female respondents. Also we don’t find noticeable differences in subjective wellbeing according to religious beliefs. Contrary to the difference along the sex and religion of the respondents, there were significant differences among the age of the respondents if we look to the mean scores for positive and negative affect. A classification in six age categories was used (18–24, 25–34, 35–44, 45–54, 55–64 and 65+). A remarkable conclusion is that the younger citizens (i.e. younger than 45 year) experience both more negative affect and positive feelings. They seem to experience a more active emotional life regarding both positive and negative affect.13 In general there were rather small differences in the subjective well-being depending on one’s educational level. ANOVA-analyses show us strongly signifi-

Table 12.5 Overview of the explanatory value of socio-demographical characteristics for the general SWB SWLS Sex Age Professional status Paid job? Reason why no job Fear of unemployment Last main occupation Education Civil status and social situation Civil status Social situation Household income Monthly household income Income sufficient for expenses? Religious beliefs Total

Gen. LS

Happ.

PA

NA

ABS

0.0% 0.2%

0.0% 0.0%

0.0% 0.0%

0.1% 4.7%

0.4% 5.0%

0.5% 0.2%

0.2% 4.0% 0.5% 1.1% 0.6%

0.2% 2.7% 0.2% 0.9% 0.5%

0.8% 2.2% 0.4% 0.5% 0.8%

2.1% 4.2% 0.4% 2.7% 4.4%

0.0% 3.5% 0.4% 0.5% 0.3%

0.7% 2.2% 0.2% 0.9% 1.0%

3.7% 2.6%

2.0% 1.1%

5.4% 4.8%

1.8% 0.9%

3.8% 3.6%

1.3% 1.4%

1.4% 5.3% 0.4% 11.0%

1.2% 6.3% 0.8% 9.6%

2.8% 5.7% 0.9% 11.7%

2.2% 1.8% 0.4% 9.0%

0.5% 2.0% 0.3% 10.3%

1.5% 3.8% 0.1% 6.0%

13 As such, the variables concerning the job situation have some explanatory value for the measures for positive effect. However, this effect we found can be explained by the association between those variables on the one hand and age on the other.

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cant difference when positive affect is measured (p = 0.001). The higher the educational level, the higher the mean score on positive affect. When we look at the mean scores of the citizens according to their civil status, we found that the married citizens experience a higher level of subjective wellbeing (cf. earlier research, for example Argyle, 1987; Campbell, et al., 1976; Mastekaasa, 1993; Veenhoven, 1983). The last socio-demographical characteristic concerns the net monthly income of the respondents. First of all, there is the net income, divided into three categories (low, medium, high).14 Although it is a well-known saying that money doesn’t make one happy, there is a progressive increase of the subjective well-being when the income level increases. We have also asked the respondents to what extent this monthly income is sufficient for the expenses of the household. Also for this variable we have found an increasing subjective well-being when the income converges with the actual needs of the household. To some extent, one of the surprising conclusions in the research on subjective well-being has been the general weakness of relationships between different measures of well-being and standard demographic variables such as sex, age, education, civil state and income. Even taken together, such demographic variables rarely explain more than about 5–10% of the variance in respondents’ measures of satisfaction with life (e.g. Andrews & Withey, 1976; Davis et al., 1982; Michalos, 1985). We can confirm the foregoing conclusion. About 10% of the variance in the different measurements can be “predicted” by demographic variables. This is not to say, however, that there are no relationships between global subjective well-being measures and demographic variables. Nevertheless we can conclude generally that the socio-demographic variables have a rather low predictive value for the different measures of subjective well-being, especially when we compare them with other variables in our research. In Table 12.4 we see that the perception of one’s state of health has an important explanatory value for the general subjective well-being. It is a one-item variable asking people how they evaluate their own state of health in comparison to peer groups. The more positive the evaluation one makes, the higher the subjective well-being. We take into account different variables concerning the attitudes towards others. This group of variables constitutes five more specific variables. Because of their considerable explanatory value, it is important to elaborate on this. The specific variables concerning the attitudes towards others and their explanatory value are displayed in Table 12.6. Not all the variables have a high explanatory value. In Table 12.6 we see that the explanatory value of the variables concerning trust and the attitude towards migrants is limited or non-existent (especially for negative affect). If significant, we see a higher subjective well-being when people trust their fellow man and have a positive attitude towards migrants.

14

Low: up to 1,500 EUR a month, medium: 1,500–2,500 EUR and high: +2,500 EUR.


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Table 12.6 Overview of the explanatory value of attitudes towards others for the general SWB SWLS Most people to trust? Scale trust in fellow man Social integration Social support Attitude towards migrants Total

1.8% 2.1% 11.8% 5.7% 0.3% 14.8%

Gen. LS 0.7% 3.0% 12.4% 6.1% 0.8% 15.1%

Happ. 1.3% 1.7% 10.6% 5.7% 0.4% 13.2%

PA 3.3% 4.4% 5.5% 6.6% 5.0% 13.7%

NA

ABS

0.0% 0.5% 8.2% 0.8% 0.0% 8.7%

2.4% 4.0% 12.6% 5.5% 2.0% 16.2%

However, in Table 12.6 we see that other variables are far more important to explain the subjective well-being. More specifically, the measure of social integration (Bharadwaj & Wilkening, 1980; Ponjaert-Kristoffersen et al., 1995) and social support have a high explanatory value. Both variables are multiple-item scales. The one measuring social support, is the one that Michalos has used in his empirical study to validate his multiple discrepancies theory (Michalos, 1985).15 Both scales can explain a considerable proportion of the variance in the subjective well-being measures. More specifically, the more people feel integrated in the society and the more social support they experience, the higher the subjective wellbeing. So, although the formal membership of organisations in social life does not explain much of the variance, the more subjective feeling of being integrated and supported within a community is crucial in our search for determinants of subjective well-being. So, it is important to take into account the so-called social context of well-being (Helliwell & Putnam, 2004). Beside the more general measures about attitudes towards others, we have also taken into account both the frequency and the appreciation of the contact with specific groups of others. Those groups of significant others are diverse, namely children, grandchildren, brothers/sisters, parents, other members of the family, friends, volunteers, professional social workers and colleagues. The appraisal of the frequency lies with the respondents themselves: every individual has his or her own notion of what frequent contact may entail. In general, there is only a slight increase in the subjective well-being as people have more frequent contact with others and experience those contacts more favourably. Furthermore, some of the independent variables concerning the neighbourhood can contribute significantly to explain the differences in the levels of subjective well-being. The more specific variables under this denominator are listed in Table 12.7. The proportion of explained variance ascribed to the variables about the neighbourhood, chiefly reflects the positive correlation between the satisfaction with the neighbourhood on the one hand, and the measures of general subjective well-being on the other.16 The more satisfied people are about their neighbourhood, the higher

15 The scale on social support refers to the degree in which significant others grant positive attention, affection and attention and validate this individual’s feelings (Abbey & Andrews, 1985). 16 The correlation with the scale for Negative Affect is negative.

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Table 12.7 Overview of the explanatory value of the variables concerning the neighbourhood for the general SWB Satisfaction with the neighbourhood Involvement with the neighbourhood Judgment of the involvement with the neighbourhood Frequency of the contact with the neighbours Experience of the contact with the neighbours Total

SWLS

Gen. LS

6.8%

9.2%

0.5%

Happ.

PA

NA

ABS

9.5%

2.6%

1.4%

4.0%

0.8%

0.2%

2.0%

0.0%

1.5%

0.4%

0.4%

0.5%

0.3%

0.5%

0.5%

1.5%

1.5%

1.7%

1.4%

1.4%

2.6%

1.9%

2.0%

2.0%

0.7%

1.4%

2.2%

7.4%

9.7%

10.5%

4.5%

2.9%

6.2%

their subjective well-being. In addition to this, the subjective well-being increases slightly as people have more frequent contact with people in the neighbourhood and judge that contact positively. Another variable within our survey is the perception of social class. More specifically, we have asked the respondents in what social class they situate themselves: the working class, the lower middle class, the higher middle class and the upper class.17 The explanatory value of this variable is displayed in Table 12.4. The highest subjective well-being levels were found in the groups situating themselves within the higher middle class and the upper class. As we can deduct from the proportions of explained variance in Table 12.4, there is a strong correlation between the variable concerning feeling secure in the city on the one hand and the general subjective well-being on the other. The stronger the perception of security in the city, the higher the subjective well-being. It is thus clear that the government has to pay attention to the (by definition subjective) feeling of safety in order to enhance the subjective well-being. The explanatory value of the extent of utilitarian individualism is distinct. Nevertheless, the more utilitarian individualistic people’s disposition, the lower the levels of subjective well-being. A considerable proportion of the variance in the subjective well-being levels can be ascribed to the level of self-esteem. Rosenberg’s measure for self-esteem was used to measure this aspect. The measure of self-esteem seems to have an important impact on the measures of subjective well-being. High levels of self-esteem go together with high levels of subjective well-being. In our search for the main deter-

17 In our operationalisation, we prefer the subjective class identification by the respondents. An alternative is a classification by means of objective variables (as income, profession or other socioeconomic characteristics). However, past studies have shown that both operationalisations lead to similar conclusions (Veenhoven, 1984).


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minants of subjective well-being, it is therefore important to incorporate personality-related characteristics like Rosenberg’s measure of self-esteem. Those finding support previously established results within other populations (e.g. Lyubomirsky et al., 2005; Prince & Gerber, 2005). Several variables concerning politics and attitudes towards this aspect of life were measured in our survey. There is scant research that links political characteristics with subjective well-being at the micro level, i.e. the individual level (for an overview see Radcliff, 2001). The overall explained variance of those variables is rather limited. Nevertheless, some of the variables under this heading tells us something about the subjective well-being of the respondents, especially the more affective loaded measures. The interest people take in politics in general and in the ins and outs of the local policy particularly does have some explanatory value for the level of positive affect. More specifically, the higher the general interest in politics, the higher the levels of positive affect. The people with no interest at all concerning the ins and outs of the local policy reported less positive feelings. The extent of political powerlessness also tells us something about the subjective well-being in general and the positive affect more specifically. The higher the level of political powerlessness, the lower the reported subjective well-being. Finally, people were also asked about their feelings when thinking of politics. They could answer with eight negatively or positively loaded feelings. People associating politics with a negative feeling are also people with lower mean levels of general subjective well-being. We have to stress, however, that attitudes towards politics as such is only loosely related to the general subjective well-being. The last two independent variables in the research design relate to the comparison of the respondents’ own situation with the parents’ situation on the one hand and with their own situation at the beginning of their occupational life on the other hand. Those two variables together explain a considerable amount of variance in the general subjective well-being. The comparison to the beginning of occupational life has a specially important explanatory value. The respondents who evaluate their own present situation as unfavourable compared to their parents’ and to the situation at the beginning of their professional life, have a markedly lower level of subjective well-being. Finally, in Table 12.8 we give an overview of the five independent variables with the highest explanatory value for each of the six measures of general subjective well-being. Those variables can be considered as the main determinants of the general subjective well-being. First of all, we mention the strong explanatory value of social integration and – to a lesser extent – social support, both for the more cognitively and affectively loaded scales for general subjective well-being. In this respect, we can stress the importance of informal social relations in the study of the subjective well-being (cf. Altergott, 1990; Frick, 1986; Lane, 2000; Parmentier, 1994; Ryan & Deci, 2001). The relevance of the social integration is also reflected in the explanatory value of the way people evaluate the life in their neighbourhood. Another general finding is

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Table 12.8 Overview of the independent variables with the highest explanatory value for the general SWB SWLS

Gen. LS

Happ.

Social integration (11.8%) Self-esteem (10.4%)

Social integration (12.4%) Self-esteem (11.0%)

Social integration (10.6%) Satisfaction with neighbourhood (9.5%) Self-esteem (8.0%)

State of health compared to Satisfaction with peer groups (10.1%) neighbourhood (9.2%) Comparison to the beginning Comparison to the beginning State of health compared to peer of occupational life (9.1%) of occupational life (8.6%) groups (6.7%) Comparison to parents State of health compared Comparison to the beginning of situation (7.3%) to peer groups (6.8%) occupational life (6.7%) PA

NA

ABS

Social support (6.6%) Social integration (5.5%) Attitude towards migrants (5.0%) Age (4.7%)

Self-esteem (9.9%) Social integration (8.2%) Age (5.0%)

Social integration (12.6%) Self-esteem (12.0%) State of health compared to peer groups (8.5%) Social support (5.5%)

Education (4.4%)

State of health compared to peer groups (4.2%) Civil status (3.8%)

Comparison to the beginning of occupational life (5.2%)

the crucial role of self-esteem. People with high levels of self-esteem, also experience high levels of general subjective well-being. The way people perceive their own health condition in comparison with peer groups is also an important element in our quest for the main determinants of subjective well-being. Especially for the most cognitively loaded subjective well-being scales, it is important to take into account the comparison of the respondent’s own situation relative to the situation of their parents and to the situation at the beginning of their occupational life. Finally, some determinants are only relevant when looking to positive and negative affect. In this respect, age is an important determinant for the levels of positive and negative feelings that people experience. The youngest people in our survey (18–24) reported both more positive and negative feelings. Besides, we found that the attitude towards migrants and one’s educational level only tells us something about the level of positive affect. People with a positive attitude towards migrants and the highly-educated respondents reported more positive feelings, but not fewer negative feelings.

12.6

Conclusion: What Can Governments Do to Enhance General Subjective Well-Being?

The primary aim of our study was to explore the different aspects of the daily life of the citizens in general and their subjective well-being in particular. We focus on those aspects that can tell us more about the level of general subjective well-being.


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Doing so, we can give an overview of the main determinants of the subjective well-being. It is quite evident that the satisfaction with some specific aspects of life has an important explanatory value for the general subjective well-being. It seems rather important to consider the different “loading” of the measures concerning the affectcognition dimension. The satisfaction measures concerning specific domains have the strongest predicting value, they explain from 13% to 50% of the variance of the different global measures for subjective well-being. They are strong predictors, especially for the more cognitively loaded measures of well-being. Moreover, it is the domains closely related to the personal life of the interviewees that are very influential. However, there were some other important differences in the well-being of the interviewees depending on their specific characteristics. It seems to be important to take these other indicators into account, especially the measures of self-esteem, social integration and the evaluation of health. To what extent can the government influence the level of subjective well-being? First of all, there are some indications of powerlessness. Those aspects of the evaluation of life, seem strongly correlated with the satisfaction about rather personal domains of life. As a government, it is not easy to influence in a direct way the experience of the private sphere. Nevertheless, a government can influence the context of the daily life we live. Doing so, a government can shape conditions in which subjective well-being flourishes. Another indication of powerlessness is the importance of the personality, as revealed by the correlation with self-esteem. It is also not evident that a government can influence the personality of people. What about enhancing material conditions? Although there are some indications that a higher income corresponds with a higher level of well-being, we had to take into account a more long-term vision. Processes of adaptation to existing situations are strong mechanisms and tend to “normalize” the augmentation of subjective well-being (Diener & Suh, 1997; Inglehart & Rabier, 1986; Glatzer & Mohr, 1987; Rodgers & Converse, 1975; Stutzer, 2004). However, we have not yet mentioned the most important independent variables of our model, namely social integration and social support. People who are strongly integrated and feel a strong social support, experience high levels of general subjective well-being. This is where the important but difficult task of the government can be situated. Nevertheless, governments are able to influence the feelings of integration and social support. For example, initiatives can be taken to stimulate the participation in social life and neighbourhood activities. Doing so, governments can build up the social networks of individuals and groups in the society. In our study we focus on the subjective experiences of the daily life of citizens. In addition to the fact that a considerable part of the existing research virtually concerns itself exclusively with economic and social indicators, there is the problem of the scale of the research. Most comparisons are only made between countries or between regions within countries, taking into account their general characteristics. As a consequence, these approaches leave less room for context-specific differences at a more local level. In this respect, it would be interesting to pay more

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attention to such differences between localities or between neighbourhoods within those localities. For this reason, in a further stage of our research not only inter- but also intra-local geographical differences will be studied in more detail.

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Chapter 13

The Vicious Circularity of Mental Health Effects of HIV/AIDS: Symptom and Cause of Poor Responses to the Epidemic Kevin Kelly1, Melvyn Freeman, Nkululeko Nkomo and Pumla Ntlabati

Abstract In this paper we consider the possibility that psychosocial effects of the HIV/AIDS epidemic may have acted to sustain and entrench the epidemic. After reviewing the evidence for an association between HIV/AIDS and psychological dysfunction in the form of breakdown of coping responses to the point of psychiatric disorder, we suggest that it is not inevitable that this should have happened. We argue that these effects are partially created and certainly sustained by the manner in which the epidemic has been responded to. Reviewing findings from our previous research on mental health effects of HIV/AIDS and analysing interviews conducted with HIV positive respondents, we describe psychological responses to HIV infection and their possible epidemiological consequences. We argue that these have acted with vicious circularity, undermining responses to the epidemic and compounding the predisposing psychosocial vectors of HIV infection. In closing we suggest that particular intervention strategies need to be much more carefully thought through and we make some recommendations regarding the need to respond to the mental health dimensions of HIV/AIDS. Keywords Mental health, HIV/AIDS, epidemiology, South Africa, well-being, psychosocial support

1 Corresponding author: Kevin Kelly - [email protected] - is a director of CADRE, a Rhodes University-based NGO focused on supporting HIV/AIDS responses through research; Melvyn Freeman is an independent consultant and specialist in mental health issues from a public health perspective; Nkululeko Nkomo lectures in the Psychology Department at the University of the Witwatersrand; Pumla Ntlabati was a researcher in CADRE at the time of writing.

K. Kelly Centre for Aids Development Research & Evaluation (CADRE), Rhodes University, South Africa E-mail: [email protected] V. Møller and D. Huschka (eds.) Quality of Life and the Millennium Challenge, © Springer Science + Business Media B.V. 2009

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Introduction

HIV/AIDS is by now widely recognised by developing country governments, international funders and the scientific community, as an obstacle to socio-economic advancement in sub-Saharan Africa and a major humanitarian crisis. There has been a massive commitment of new funds to the development of a comprehensive response to HIV/AIDS, by governments of affected countries and the international community. Advances have been made in understanding the virology and epidemiology of HIV. Treatments are becoming more effective and more affordable, and most countries have or are instituting national antiretroviral treatment programmes (ART). National strategies and the development of governmental and civil society structures for responding to HIV/AIDS have been established. Populations in areas heavily affected by HIV/AIDS have time and again been shown to be aware of the threat of HIV infection and of how to avoid it. There have been some encouraging outcomes of these developments. Rates of infection are declining in some countries, and HIV infection levels in many high risk populations appear to have reached a plateau. ART is proving effective in curbing mortality of those infected, although many country programmes are rolling out very slowly on the back of massive skills deficits in the health field, poor health services and formidable infrastructure challenges. In some respects it comes as no surprise that successful responses to HIV/AIDS have been slow to develop and were initially less than hoped for. This is especially true in countries where there are multiple social and health challenges, weak or conflicted governments and poor infrastructure, and where the majority of citizens are poorly educated, poverty-stricken and hungry. Yet there are exceptions such as South Africa, Swaziland and Botswana, which cause us to look deeper at why responses have been slow to develop or at least initially ineffective. There have been numerous attempts to understand this. Much effort has been focused on understanding the conditions under which HIV has thrived, and why some countries or localities have been worse affected. It has been thought that by better understanding the drivers of country-level epidemics we may improve our ways of responding to them. Migrancy, urbanisation, impoverished living conditions, gender inequality and domination, cultural practices, income inequality, and patterns of sexual mixing attending all of these, are some of the many social epidemiological vectors associated with high prevalence. In general, success in responding to HIV/AIDS epidemics has been hard won. Researchers have responded by digging ever deeper into socio-economic and context-specific vectors to identify apparent missing links in understanding the spread of HIV, but with diminishing returns. Others have focused on understanding the ingredients of success where this is in evidence, with early successes in Uganda having created the hope that with the right intervention approach the drivers of HIV infection might be rolled-back. In this paper we cross between epidemiology and response analysis. We consider the possible influence on the epidemic of a complex set of psychosocial factors which are a by-product of how HIV/AIDS responses have been conceived and managed.

13 The Vicious Circularity of Mental Health Effects of HIV/AIDS

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After outlining the extent of the HIV/AIDS epidemic in South Africa and its impacts, we focus on mental health dimensions of the epidemic. We begin by providing evidence for a mental health epidemic which has accompanied and is related to the HIV/AIDS epidemic. We suggest that for the most part, mental health sequelae of HIV infection are a symptom of the manner in which the epidemic has been responded to, rather than an inevitable psychiatric effect of the viral infection. We suggest that these mental health outcomes are not only symptoms of the ways of responding to the epidemic, but in a viciously circular way have entrenched and exacerbated it. They have undermined the effectiveness of the very strategies which have shown positive responses to the epidemic, and have compounded the predisposing psychosocial conditions or vectors of HIV infection.

13.2

HIV/AIDS in South Africa

South Africa is in the grip of a ‘generalised’ epidemic, no longer confined to specific high risk groups of population. In 2006, HIV seroprevalence in public sector antenatal clinic attendees (DOH, 2007) was 28.6%. This means that more than one in four pregnant women in 2006 was HIV-positive. One in nine (11.4%) South Africans over the age of two years were estimated to be HIV positive at the end of 2007.2 Although fewer than 3 in 100 South Africans aged 10–14 years are infected with HIV, at current infection rates more than 20% will be infected by the time they turn 25 years old. The total number of new HIV infections in 2007 is estimated at 512,931 which translates to 1,405 new infections every day. The ASSA Model predicts 38,510 babies infected at or before birth in 2007, and 25,705 babies infected through mother’s milk. This amounts to a total of 64,215 HIV positive infants in 2007, or 176 new HIV positive babies a day. AIDS deaths were estimated at 360,689 in 2007 (988 per day) and the accumulated number of AIDS deaths to mid-2007 is 2,168,836. Life expectancy at birth has fallen from 56.7 years in 2000 to 50.6 years in 2007. By the end of 2007 there was an estimated 1.2 million maternal orphans (children under 18 years old who have lost a mother or both parents) due to AIDS. This amounts to about 14% (1 in 7) of children between the age of 2 and 18 becoming maternal orphans. A total of 537,803 people in South Africa in mid-2007 were in need of antiretroviral therapy but were not receiving it, and a further 4,589,436 were HIV positive but in the pre-AIDS phase of illness progression, and will be needing ART in future.

2

Unless otherwise stated, data presented in this section is extracted from the Actuarial Society of South Africa’s ASSA2003 modelling instrument released in 2005 and updated in 2006. Data sources used to build the instrument include annual large-scale antenatal surveys conducted by the Department of Health as well as data from independent nationally representative HIV seroprevalence studies. ASSA is considered the most inclusive and reliable source of estimates relating to a range of HIV/AIDS prevalence and impact indicators in South Africa.

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About one in six public school educators were HIV positive in 2005 (Shisana et al., 2005a) and a similar situation prevails in the health sector, undermining the society’s capacities to respond to the epidemic. This situation prevails despite the existence, over the past 20 years, of both the information and the technology to prevent most new infections. Since 2004 the public health system in South Africa has been committed to the provision of antiretroviral therapy, and if comprehensively done this would prevent the majority of current AIDS deaths.

13.3

Mental Health Correlates of HIV Infection

Studies of the mental health status of people infected with HIV have consistently found higher prevalence of mental health problems than is found in general community or clinic samples (Catalan, 1999; Cournos & Forstein, 2000; Green & Smith, 2004). Reasons for the higher prevalence of mental health problems in HIV infected populations include: premorbid mental conditions which predispose people to infection, the effects of the virus on the central nervous system, the psychological impacts of living with HIV/AIDS, side-effects of medication, and results of social stigma and discrimination (Freeman et al., 2005). Whilst there have been some advances in understanding the mental health sequelae of HIV infection and the mental health support needs of those with HIV/AIDS, until recently there has been very little research conducted in developing country contexts, where HIV/AIDS is most prevalent. We know relatively little about the levels of mental health problems amongst HIV positive populations in those countries most affected by the epidemic. A study conducted by the authors (Freeman et al., 2008) describes the prevalence of mental disorder in people living with HIV/AIDS in South Africa in a sample of 900 HIV positive people, using a cross-culturally validated diagnostic instrument and a structured socio-demographic and health information questionnaire. We found a prevalence of one or more diagnosable mental disorders in 43.7% of respondents, which is significantly higher than the prevalence of mental disorder in the South African population. A general population stress and health study conducted at about the same time (Williams et al., 2007) provides a standard of comparison, with 16.5% reported as having a diagnosable mental disorder. In our survey of HIV positive people, depression was the most common disorder (29.9% of which 11.1% was major depression), followed by alcohol abuse disorder (12.4%). By comparison, in the general population (Williams et al., 2007) major depressive disorder was found in 4.9% of the population and a1lcohol abuse disorder was found in 4.5% of the population. This confirms in a South African context what has already been shown in countries which have more localised or concentrated epidemics; that HIV infection is associated with much higher levels of mental disorder, especially depression and alcohol abuse. Presence of (any) mental disorder was significantly associated with the clinical stage of progression of HIV/AIDS. In other words, progression leads to greater


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levels of mental disorder and most significantly depression, from stage one (39.8%) to stage four (full-blown AIDS) at 68.8%. It is notable that 18% of the sample were on ART, and this did not prove to alter the likelihood of mental disorder. Males were more likely than females to experience a mental disorder. This is a reflection of higher levels of alcohol abuse amongst the male population, as in all other categories of mental disorder there was no significant gender difference. Unemployed people were more likely to experience any mental disorder and have particular susceptibility to depression and alcohol abuse compared to their employed counterparts. It should be noted that poverty and HIV prevalence are related in South Africa, and that poverty and mental health disorders are also related (Hargreaves, 2002; Shisana et al., 2005; Patel & Kleinman, 2003). It may be the case that an elevated prevalence of mental disorders amongst HIV positive people is a consequence of poverty rather than HIV specifically. However, given that other mental health prevalence studies have found much lower rates than this HIV focused study, it is likely that poverty and HIV/AIDS exacerbate each other and in combination impact on mental health, leading to levels of mental disorder higher than are expected for other very poor people or those who have HIV but are not poor. This vicious circle may be further exacerbated by the possibility that poor mental health can be both a risk factor for poverty and HIV/AIDS as well as a consequence of both of them. High unemployment, HIV/AIDS and mental health are likely intertwined in a complex relationship of mutual causality. Those with children were more likely to experience mental disorder, but having children is not related to the presence of any particular disorder. It seems likely that problems associated with caring for children and worries about what will happen to the children with disease progression and possibly death of parents, results in raised mental disorder. Furthermore, the financial burden of caring for children and associated stress may lead to higher levels of disorder. The origin of HIV infection was shown to be associated with both depression and alcohol use. Respondents who said they did not know how they were infected were more likely to suffer from depression than those who knew – no matter how they were infected. On the other hand a diagnosis of alcohol abuse was often associated with having been infected by a casual partner. The pathway through which the person discovered their HIV positive status was related to alcohol abuse only. Respondents who fell ill and were tested as part of a medical investigation were more likely to have an alcohol abuse disorder than those who discovered their status by other means, such as voluntary counselling and HIV testing or testing for insurance purposes. Given that the stage of progression of HIV/AIDS is an independent predictor of mental disorder we cannot eliminate biomedical reasons for mental disorders. However, the significance of the other independent predictors points to the need for a psychosocial as well as neurological understanding of the findings. To study the influence of psychosocial factors further we identified associations between the presence of mental disorder in people with HIV and a range of independent variables, defined as psychosocial supports. The results are reported in Freeman et al. (2007).

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Eighty seven percent of interviewees had received some pre-test counselling and 78% post-test counselling. The vast majority found the pre-test counselling to be either very helpful (71.7%) or somewhat helpful (13.4%), while 78.1% found the post-test counselling to be very helpful and 10.7% found it to be somewhat helpful in coping with their positive diagnosis. Fifty one percent of people were counselled by a lay person and 38% by a nurse. The remainder were counselled by a doctor (5.3%), a social worker (2.4%) or a psychologist (0.4%). Thirty five percent of people saw the counsellor only once, when they were given their results, while 39% saw the counsellor 2–3 times, 11% of people 4–10 times and 14.4% saw a counsellor more than 10 times. Interestingly, no significant differences were found between people diagnosed with a mental disorder in terms of whether they had counselling (pre- or post-test), who they had seen for counselling nor how many sessions they had with the counsellor. There were also no significant differences in mental disorder between those that found the counselling to be helpful and those that did not. Whether someone had pre- and post-test counselling was not related to mental disorder; nor were the number of sessions of counselling, the professional status of the counsellor and the perceived helpfulness of counselling. So the actual event of counselling at the time of discovering HIV positive status was not independently associated with mental disorder. It is thus likely that the events that transpired after finding out their HIV status had the greater influence on development of mental disorder. Half the interviewees joined a support group for people with HIV after receiving their positive diagnosis. Of these 43% were still part of such a group at the time of the interview. Eighty seven percent felt that the group had been very helpful and 5.2% somewhat helpful in coping with being HIV positive. People who had been part of a support group were significantly less likely to have a diagnosis of mental disorder than those that had never been part of a group. However, the number of times a person attended a group or whether they were still in the group at the time of the interview were not significantly correlated with mental disorder. It seems that knowledge of available support gained through having attended support groups at some point, makes some difference, rather than the actual effects of ongoing attendance of a group. The majority of respondents had informed one or more people outside of the clinic that they were HIV positive (85%) and 44.5% reported that they were fully open about their status. Although most of those who disclosed their HIV status found the experience helpful, there was a significant positive association between the presence of a mental disorder and having disclosed HIV positive status. This is interesting and important, as it suggests that disclosure and openness does not necessarily buffer against development of psychological problems although, by the accounts of respondents, disclosure provides emotional support, but was not really helpful at the level of informational support. Eighty percent of people were in a relationship/married at the time of hearing their HIV status and 72.6% informed their partner of their positive status. Of these 40% felt that it has made the relationship stronger, 17% reported that it made the relationship difficult but they were still together, 14% said it made no difference and in 27% of cases the marriage/relationship broke up.


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Twenty three percent of interviewees said that they had been discriminated against or had had negative reactions due to their positive status. This correlated strongly with the presence of mental disorders amongst the interviewees. The discrimination mainly took the form of being blamed for the infection and name calling by members of the community and family. Twelve percent of respondents said that they had been isolated as a result of their positive status. This too correlated significantly with the existence of a mental disorder. Fifty nine percent of respondents said that they were very religious, 19% were somewhat religious, 12.7% a little and 9.2% were not religious. Religious status had no significant correlation with a diagnosis of mental disorder. However, 70% said that their faith had been very helpful in helping them to cope with their status, 15% found it to be somewhat helpful, 8.4% said it helped a little, 4.4% found religion no help at all and 2.3% said that religion had made things worse for them. More than half of the respondents (57%) had had someone close to them die of AIDS. Those that had had a close person die from AIDS were significantly more likely to have a mental disorder than those that did not. Seven percent had had a child die, 20.5% a friend, 1.6% a parent, 10.3% a partner, 12.2% another relative and 18% a sibling. Twenty six percent of respondents had experienced other major losses due to non-AIDS related deaths in the year prior to the interview. This included deaths of children, spouses, parents, siblings and friends. Deaths due to other causes did not correlate with the presence of a mental disorder.

13.4

Psychological Responses to Discovering HIV Status

To gain further understanding of how the determinants of mental health correlate with HIV infection we now discuss hitherto unpublished work which documented the experiences of 19 persons diagnosed HIV positive. These respondents were interviewed in order to better understand the results of the survey discussed above and to make sense of them in the context of South African HIV/AIDS response. In particular the individuals’ experiences were analysed in an attempt to understand their reactions to discovering their HIV status and the factors that influenced their changing experiences thereafter. The results show a remarkable range of ways in which people interpreted and responded to their HIV positive diagnosis, contingent on their preexisting ways of coping with adversity and on the degree and quality of support within their immediate social environment. The ways in which the meaning of, and response to, the diagnosis took shape, was a product of the ways in which each individual had previously learned to engage with adversity and the convergence of this with their perceptions of what being HIV positive means. But as importantly, sequences of responses were shaped by perceptions relating to the consequences of HIV/AIDS and perceptions related to the responses of others to whom they had disclosed this HIV positive status. However, our concern here is not so much to distinguish what leads people to differ in responses to HIV, but rather to explore the commonalities of response. We are

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interested in how the environment in which they struggle to discover positive responses, shapes their experiences. We are then interested in discovering whether the consequences of these ‘common’ responses may have epidemiological significance. Focusing on the personal experience of being HIV positive we have considered the ways in which the outcomes of an HIV positive diagnosis are shaped. It is apparent that the initial discovery of HIV positive status tends to be met with a sense of shock, and often even disbelief. How long this period lasts, its severity and whether an individual is able to pass through it, depends on various factors both internal and external to the person. For example how one comes to know one’s status, prior psychological state and seeing the effects of HIV/AIDS on others. But whatever the starting point the mediating influence of various supports available makes a significant difference. The flow chart summarises how opportunities for support and assistance profoundly influence how people react and eventually adapt to their diagnosis (Fig. 13.1). The initial reality of being HIV positive corresponds to what Ezzy (2000) calls a polyphanous reality. It is oriented to multiple fragments of understanding about what it might mean to be HIV positive, rather than to a coherent framework for understanding or responding to HIV. The truncation of the promise of a future and feelings of alienation from others unsurprisingly tended to lead the respondents to a sense of despair and hopelessness. At the point of first hearing about their positive status respondents tended to be consumed by thoughts about death and dying, and attuned to the negative ways in which they imagined others reacted to their status. A number of respondents contemplated suicide and engaged in self-destructive behaviours. One respondent described her experiences in the months following discovery of her HIV positive status thus: “I told myself that I was going to die. I was too scared to hang myself

CRISIS

DYSFUNCTION • Denial • Avoidance • Depression • Suicide • Fatalism • Alcohol abuse

• Perceived fatal condition • Infectivity • Expectations of stigma

MANAGING HIV/AIDS • Health management • Communication • Personal growth

Fig. 13.1 Experiences following discovery of HIV-Positive status

SUPPORT • Resources • Informational • Emotional • Community • Spiritual


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or to shoot myself. Drinking was an easier option; I would drink myself to death. I stopped looking after myself and kept drinking. My physical state deteriorated, I couldn’t care less, I was dying anyway but I couldn’t commit suicide: alcohol would do it for me”. In response to the constructions of meaning of being HIV positive which they had prior to learning of their status, many felt intense disappointment, a sense of having lost all hope for the future. Some respondents felt so depressed or angry that they engaged in destructive and fatalistic behaviours such as abusing alcohol and knowingly engaging in unsafe sex. To a large extent the meaning of HIV/AIDS was often not based on experience of the responses of others or experience of the effects of HIV/AIDS, but on the prevailing image of HIV/AIDS as a death sentence and the expectation of experiencing stigma and isolation during a slow and inexorable process of deterioration and disease. This is not surprising given what is known about the effects of media depictions of HIV/AIDS in South Africa (Connelly & Macleod, 2003). This is also unsurprising given the lack of treatment options for most in South Africa at the time and to this day, where only about one in three of those needing ART are receiving it. For some respondents the equivalence of HIV/AIDS and death was transformed as they realised that the continuity of their lives had not been permanently disrupted, that they could manage their condition and that rejection was not inevitable. Such transformation was largely a consequence of the availability of various support mechanisms. For others though, the same “recovery” did not take place. Those who coped best managed to piece together ways of engaging with the reality of being HIV positive. They discovered for themselves how to survive the damning social image of the condition and the perceived fatalism of its consequences. The process of adapting to one’s HIV positive status does not appear to follow discernible stages or time frames. Some respondents were able to rapidly adapt by either adopting or constructing meaningful ways of engaging with their HIV positive status. This however sometimes provided only temporary solace, and the process of finding a meaningful relation to their HIV status was an ongoing challenge. Three main domains of meaning, each associated with an external reality, were identified: having a chronic and possibly fatal medical condition; being infective to others; and the realities of preconceptions of others and society about what it means to be HIV positive. Each domain has consequences which almost any HIV positive person needs to orient to. Having a chronic and likely fatal condition means a possibly shortened life and hence radical challenges to current goals in all areas of life. It has implications for relationships, it implies illness and the need for care, it has financial implications and so on. The fact of being infective to others implies the need to consider at least selective disclosure, a limitation in possible future relationships, a changed relationship to child bearing and need for use of protective measures during sex. The fact that others (be they intimate friends and family, or strangers) have preconceptions about the meaning of being HIV positive, often leads the HIV positive person to project such preconceptions onto his/her own identity – at least at the

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level of how they see themselves in the context of relationships with others. This is sometimes termed ‘self-stigma’. The way in which respondents progressed in engaging with knowledge of their status and coping with this knowledge in their own thoughts, feelings and actions, depended in part on their own individual predispositions, but it was also significantly mediated by external factors. While some respondents felt that open disclosure was a precondition to self-acceptance and living a positive life, others felt that it would lead to further pain and hurt and assessed the risk to be too high. In reality the disclosure experience was predominantly positive, though for a few, initial experiences of negative reactions seemed to vindicate a “non-disclosure” position. Nonetheless most who chose not to disclose felt isolated and continued their psychological battle not only to deal with the magnitude of their situation but of whether or not to disclose. The same could be said of all of the challenges faced. Progress was hard won, and required the seizure of small opportunities to work through the difficulties faced. These included issues related to having a serious medical condition, being infective to others and the realities of how others and the society in general perceive HIV positive people. These challenges all involve encountering and having to overcome specific externalities, and involve considerable adjustment and courage. Many do not confront these realities and have few personal or external skills and opportunities for achieving this. They experienced anxiety, depression, alcohol abuse, hopelessness and self-destructiveness. They also posed an epidemiological risk.

13.5 13.5.1

Epidemiological Consequences Treatment Compliance

Baingana et al. (2005) review research which shows that psychological, psychosocial and psychiatric factors play a significant role in how well people comply with antiretroviral treatment (ART). Interestingly factors such as age, education, employment, religious support and perceived quality of life are not specifically correlated with adherence to ART, but adaptive coping ability and level of depression are. Depressed subjects with poor support adhere to ART only about half as frequently as non-depressed subjects with good social support (Gordillo et al., 1999). “Because of the strong correlation between mental health disorders and noncompliance with treatments, addressing mental disorders within the HIV epidemic is critical for preventing drug-resistance. ” (Baingana et al., 2005: 16). It is of utmost importance that strong measures be taken to secure compliance with HIV treatment regimens once these have started, to avoid an equivalent risk of the development of particularly virulent and non-treatable forms of the virus, such as has been the case in the development of multiple drug resistant-tuberculosis (MDR-TB).


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The South African national treatment (DOH, 2004) guidelines recommend that untreated active depression or alcohol abuse should be considered as contraindications in assessing eligibility for ART. Mental stability, sobriety and emotional robustness are necessary to endure the first few months of treatment in particular, where treatment side-effects tend to be experienced. Any kind of psychological instability threatens ART adherence at the 95% level needed to prevent resistance. We have reported above on the high levels of mental disorder, and in particular depression and alcohol abuse, in HIV positive people in South Africa. Short of excluding them, ART services in the country have a major challenge in managing the mental health of their clients. This problem has yet to be confronted and could have a significant epidemiological consequence if not addressed.

13.5.2

HIV Infection Risk

One of the core psychological challenges for participants arose with the realisation that being HIV infected, they might infect others. This was not always an immediate realisation, but when it inevitably dawned it had significant consequences leading to, for example, the risk of termination of relationships, unlikelihood of forming new relationships and a permanent change in sexual practices. “I revealed my result certificate and she saw that I was positive and ended the relationship on the grounds of my status and expressed that she loved me but could not continue with me, as I was HIV positive. I was hurt. ” (study participant) In the words of another respondent in our qualitative study: “Then I did not use condoms or anything of that nature. I just engaged in sex without using a condom, ‘flesh to flesh’ . The thought of spreading the infection never came to my mind. ” Others may not deny the obvious fact that they are infective but avoid communicating it to their partners. It must be appreciated that the mental state of people who have recently discovered their HIV status is fractured, chaotic and often lacking in the resolve to raise and discuss the consequences of what it means to be infective. As one respondent reported, “Everything happened very fast. I was really scared, this was weighing heavily on my mind and I couldn’t confront him about it…. We stayed this way for about a year. ” She subsequently attempted suicide and separated from her partner, but never confronted him with the fact that she was HIV positive. It must be appreciated that beyond people knowing their HIV status, there is a great and largely unaddressed challenge, in assisting people to constructively engage in safe sex practices. The once-off nature of HIV counselling and testing does little to manage the complexities of prevention, especially since it is done in the immediate context of people learning of their HIV status for the first time. This situation plays out also in the context of mother-to-child HIV transmission, giving rise to tens of thousands of infants becoming HIV infected either during the birthing process or through breastfeeding practices.

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The epidemiological consequences are obvious and much more thought must be given to how to support HIV positive people through the process of learning their status, such that prevention outcomes are likely to ensue. Unless voluntary counselling and testing procedures are optimised in the interests of prevention, current efforts to promote the population knowing their HIV status will come to little, and may have negative consequences for the epidemic. Amongst the respondents, the experiences of feeling stigmatised, whether imagined or based on actual responses of others, created an aversion to being open about their HIV status, and this effect of stigma thus also has epidemiological consequences. A further infection risk issue is posed by the possibility that people with patterns of alcohol abuse may be at higher risk for HIV/AIDS infection as a result of impaired judgment. One might speculate about the risks of other mental disorders, but we have little evidence at hand about HIV sexual risk behaviour related to mental disorders. This is an area worth investigating.

13.6

Recommendations

We now outline what we believe are priority actions that need to be taken to address the mental health dimensions of HIV/AIDS. These, we believe, would help to curtail the epidemiological risks described above, as well as improve the health, quality of life and psychological adjustment of HIV positive people.

13.6.1

Re-categorising HIV/AIDS

For many years HIV/AIDS was spoken about in the media, in communication campaigns, and in popular discourse, as a death sentence. It is now a treatable condition with HIV positive people able to live happy and productive lives. HIV/AIDS needs to be redefined as a chronic, serious illness condition, which is preventable and treatable. It appears that much of the mental health mayhem that infuses the experience of learning about one’s HIV positive status is a product of the aura of AIDS, which has been ‘exceptionalised’ amongst other chronic and serious health conditions. HIV/AIDS is shrouded in secrecy and whilst concerns about confidentiality relating to the condition may be justified given the realities of stigma surrounding the condition, they also feed it. We believe that if routine (provider initiated) HIV testing were introduced as a part of medical services it would pose some risks in the current environment. Evidence for this is the emotional turmoil of those who discover their HIV positive status. Yet if routinisation were gradually introduced in an environment which brands HIV/AIDS as a manageable condition, the fear and stigma would reduce correspondingly.


13.6.2

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Expanded Counselling and Support

HIV/AIDS impact mitigation is usually separated as a programme area from HIV/ AIDS prevention. Yet by diminishing the mental health impacts on HIV positive people, disclosure and discussion of HIV status, and hence prevention purposes, can be better served. Currently HIV testing and counselling services are hopelessly inadequate for supporting people through the emotional turmoil of discovering their HIV status. Once-off post-test counselling, sometimes lasting as little as 20 minutes (Magongo et al., 2002) is clearly inadequate and it is of critical importance, even at an epidemiological level, that attention be paid to extending services. This needs to include emotional support, informational support and instrumental support, in other words, practical assistance (cf. Kalichman et al., 1996). Currently South Africa supplies cash support to HIV positive people in the form of a disability grant. While this may provide some relief at a financial level, there has been little justification for this as a response strategy aimed at supporting health adjustment to living with HIV and preventing infection. A portion of the significant resources currently deployed in this programme would be much more usefully deployed in an expanded programme of counselling and support. There is ample international evidence to support the value of investing in support programmes (Kalichman et al., 1996). Key issues that need to be addressed in developing programmes of post-HIV testing support are: disclosure of status; dealing with stigma; support in solving relationship problems; prevention as a concern of HIV positive people; and meeting of information needs relating to management of the disease condition.

13.6.3

Mental Health Integrated into Treatment and Support Programmes

Improving the mental health of HIV positive people is likely to lead to reduced possibilities of them infecting others, greater involvement in building awareness of the HIV epidemic, reduced morbidity because of access to health and support services, and greater ART compliance. It is also likely to lead to a greater reduction in stigma, thus leading to a reduction in fear about knowing and communicating HIV positive status, which also has prevention value. Mental health services need to become a central part of comprehensive HIV/ AIDS support, care and treatment programmes. Mental health interventions have not been systematically integrated into HIV/AIDS care and treatment programmes in most developing countries, including South Africa (WHO, 2005; Baingana et al., 2005; Freeman et al., 2005). Important reasons for this include a lack of resources for effective interventions, poor identification of mental disorders, stigma, and a low prioritisation of mental health in health services generally. Critically, planners of HIV/AIDS programmes in developing countries appear unaware of HIV-AIDS/

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mental health co-morbidity and of the possibilities of improving physical and mental health through mental health treatment.

13.7

Conclusion

Evidence has been presented that severity of stress and mental disorders experienced by HIV positive people is not surprising given the way in which the epidemic has been managed. There has been a fundamental failure within society to create a positive environment for responding to HIV, and poor mental health in HIV positive people is a consequence of this. Furthermore, mental health concerns have barely featured in HIV/AIDS response strategies, except as an addendum. Addressing mental health issues is often regarded as a desirable, but not essential or necessary, element of HIV/AIDS intervention programmes. We have presented evidence that there are strong mental health correlates of HIV infection, and that there are significant epidemiological risks if we continue to overlook these in responding to the epidemic.

References Baingana, F., Thomas, R. & Comblain, C. (2005). HIV/AIDS and Mental Health. Washington, DC: World Bank. Catalan, J. (1999). Mental Health and HIV Infection. Psychological and Psychiatric Aspects. London: UCL Press. Connelly, M. & Macleod, C. (2003). Waging war: Discourses of HIV/AIDS in South African media. African Journal of AIDS Research, 2(1), 63–73. Cournos, F. & Forstein, M. (eds.) (2000). What Mental Health Practitioners Need to Know About HIV and AIDS. San Francisco, CA: Jossey-Bass. DOH (2004). National Antiretroviral Treatment Guidelines. Pretoria: National Department of Health. DOH (2007). National HIV and Syphilis Antenatal Seroprevalence Survey in South Africa – 2007. Pretoria: Department of Health. Ezzy, D. (2000). Illness narratives: time, hope and HIV. Social Science and Medicine, 50(5), 605–617. Freeman, M.C., Patel, V., Collins, P.Y. & Bertolote, J.M. (2005). Integrating mental health in global initiatives for HIV/AIDS. British Journal of Psychiatry, 187, 1–2. Freeman, M., Nkomo, N., Kafaar, Z. & Kelly, K. (2007). Factors associated with prevalence of mental disorder in people living with HIV/AIDS in South Africa. AIDS Care, 19(10), 1201–1209. Freeman, M., Nkomo, N., Kafaar, Z. & Kelly, K. (2008). Mental disorder in people living with HIV/AIDS in South Africa. South African Journal of Psychology. in press. Gordillo, V., del Amo, J., Soriano, V. & Gonzalez-Lahoz, J. (1999). Sociodemographic and Psychological Variables Influencing Adherence to Antiretroviral Therapy. AIDS, 13, 1763–1769. Green, G. & Smith, R. (2004). The psychosocial and healthcare needs of HIV positive people in the United Kingdom: A review. HIV Medicine, 5(1), 5–46.


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Hargreaves, J.R. (2002). Socio-economic status and risk of HIV infection in an urban population of Kenya. Tropical Medicine and International Health, 7, 793–802. Kalichman, S.C., Sikkema, K.J. & Somlai, A. (1996). People living with HIV infection who attend and do not attend support groups: A pilot study of needs, characteristics and experiences. AIDS Care, 8 (5), 589–599. Magongo, B., Magwaza, S., Mathambo, V. & Makhanya, N. (2002). National Report on the Assessment of the Public Sector’s Voluntary Counselling and Testing Programme. Durban: Health Systems Trust. Patel, V. & Kleinman, A. (2003). Poverty and common mental disorders in developing countries. Bulletin of the World Health Organisation, 81(8), 609–615. Shisana, O., Rehle, T., Simbayi, L.C., Parker, W., Zuma, K., Bhana, A., Connolly, C., Jooste, S. & Pillay, V. (2005). South African National HIV Prevalence, HIV Incidence, Behaviour and Communications Survey, 2005. Cape Town: HSRC Press. Williams, D.R., Herman, A., Stein, D.J., Heeringa, S.G., Jackson, P.B., Moomal H. & Kessler R.C. (2007). 12-Month Mental Disorders in South Africa: Prevalence, Service Use and Demographic Correlates in the Population-Based South African Stress and Health Study. Psychological Medicine (Oct), 1–10. World Health Organisation (2005). Mental Health and HIV/AIDS. Organisation and Systems Support for Mental Health Interventions in Anti-retroviral (ARV) Therapy programmes. Johannesburg.

Chapter 14

Universal Coverage but Unequal Access? Experiences of Health Care in Northeast and South Thailand Laura Camfield

Abstract Thailand’s rapid economic growth has brought health challenges as well as benefits, namely a rise in life expectancy to 6.5 years above the global average, and an ‘epidemiological transition’ from infectious and deficiency diseases, to chronic non-communicable diseases such as diabetes. Previous research in Northeast and South Thailand by the Wellbeing in Developing Countries ESRC Research Group (WeD) demonstrates the importance of health to people’s subjective quality of life and wellbeing, and suggests that ill health is a significant problem – nearly a fifth of households in WeD sites experienced severe health-related ‘shocks’ during the past five years, and a third of household heads defined themselves as chronically ill. In 2001 the Government of Thailand introduced the Universal Health Coverage scheme (UHC) to offer near-universal health care coverage. However, while this has reduced ‘out of pocket’ expenditures for healthcare and impoverishment through ‘catastrophic expenditures’, the perceived quality of its services mean it is in danger of becoming little more than a safety net and failing to ameliorate existing inequalities. This proposition is explored using the results of large-scale qualitative health study carried out by WeD with 245 men and women from different age groups and socioeconomic statuses in Northeast and South Thailand, supplemented by WeD household survey data. The paper is divided into three parts; the first briefly introduces Thailand and the WeD sites, and describes the sampling and methodology. It also reviews current discourses about health and health issues in Thailand, and outlines the context to health and health services. The second presents data from the qualitative health research covering health risks, and the incidence and impacts of chronic illness and disability. The final section looks at the health seeking behaviour of people in the WeD sites (illustrated with case studies), focusing particularly on use of the UHC and traditional medicine.

L. Camfield Wellbeing in Developing Countries ESRC Research Group University of Bath, BA2 7AY, UK E-mail: [email protected] V. Møller and D. Huschka (eds.) Quality of Life and the Millennium Challenge, © Springer Science + Business Media B.V. 2009

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Keywords Thailand, health, universal health insurance, wellbeing Thailand’s rapid economic growth has brought health challenges as well as benefits (Wibulpolprasert, 2005), namely the rise in life expectancy to 6.5 years above the global average and an ‘epidemiological transition’ from infectious and deficiency diseases, to chronic non-communicable diseases such as diabetes. Previous research in Northeast and South Thailand by the Wellbeing in Developing Countries ESRC Research Group (WeD)1 demonstrated the importance of health to people’s subjective quality of life and wellbeing (Jongudomkarn & Camfield, 2006). Data from WeD’s Resources and Needs Questionnaire (RANQ) and qualitative interviews suggest that ill health is a significant problem – nearly a fifth of households experienced severe health-related ‘shocks’ during the past five years (rising to a quarter in two sites in the Northeast), and a third of household heads defined themselves chronically ill. In addition to the experiential dimension, health was seen as an important economic and social resource, and its absence often lead to financial and psychological stress. In 2001 the Government of Thailand extended healthcare coverage to 18.5 million people who were previously uninsured. The Universal Health Coverage scheme or ‘Golden Card’ was a central plank of Thai Rak Thai’s election manifesto,2 and was designed to provide most curative and preventative health services for a fee of 30 THB per visit. The main reported benefit of UHC was the security it offered by covering healthcare costs for most chronic conditions, and reducing ‘catastrophic health expenditures’. A recent report by EQUITAP confirmed this, demonstrating that UHC had succeeded in reducing the inequity of ‘out of pocket’ expenditures for healthcare and halved the incidence of impoverishment through catastrophic expenditures (2006). Possibly for this reason chronic illness and disability appeared to have little effect on household resources or needs satisfaction for WeD respondents, although there were differences in asset holdings which are explored later. EQUITAP also observed that “better physical and cultural access, better perceived quality of care, and adequate financing of the scheme would potentiate the pro-poor nature of the scheme” (2006: 13), and this proposition forms the main topic of the paper. The paper presents the results of large-scale qualitative health study carried out by WeD with 245 men and women from different age groups and socio-economic statuses in Northeast and South Thailand. It is divided into three parts; the first briefly introduces Thailand and the WeD sites, and describes the sampling and methodology. It also reviews current discourses about health and health issues in Thailand, and outlines the context to health and health services, using data at

1 The Wellbeing in Developing Countries ESRC Research Group (WeD) studies poverty, inequality and quality of life in developing countries—see www.welldev.org.uk. 2

Thai Rak Thai was led by Thaksin Shinawatra, a wealthy telecommunications entrepreneur who capitalised on the growing antagonism between GoT and the rural electorate, and the frustration of small business owners.

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national, regional, and local levels.3 The second part presents data from the qualitative health research covering health risks, and the incidence and impacts of chronic illness and disability. The final section looks at the health seeking behaviour of people in the WeD sites (illustrated with case studies), focusing particularly on use of the UHC and traditional medicine.

14.1

Context

Thailand is situated in the heart of the Southeast Asian Mainland; its total population is 64.2 million, at least six million of which live in the capital city of Bangkok, which is one of the busiest and most densely populated cities in Asia. The majority of people live in rural areas (68 percent), however, only 42 percent work in agriculture, and the annual per capita income (78,783 THB/ $2,462) compares favourably to other countries in South East Asia. The national ethnic identity is Thai, but there is some regional identification and large ethnic groups in specific locations, which tend to have poorer access to healthcare (for example, Melayu speaking Muslims in the three Southernmost provinces) (NESDB, 2004). Thailand’s rapid growth during the last 45 years led to substantial improvements in infrastructure, social development, and political reform. GDP per capita also rose, alongside employment opportunities in cities, factories, and the emerging service sector, and the incidence of poverty fell dramatically. However, the picture was not universally positive as emerging disparities were observed in key areas such as income, education and health, partially due to differential access to health services and educational institutions. For example, half the households in the Northeast are classified as living in slum conditions, compared to 27 percent nationwide, and maternal mortality per 100,000 births in the South is double the figure in other regions (UNDP, 2003). Annual per capita income in Bangkok is also three times that of the rest of the country and nearly ten times the figure in the Northeast (234,398 THB vs. 26,755 THB). The Wellbeing in Developing Countries ESRC Research Group (WeD) is working in seven rural, peri-urban, and urban communities in the Northeast and South of Thailand, which illustrate some of the challenges presented by rapid and uneven development (see Table 14.1 for a summary of the research sites). The complete WeD research methodology includes analysis of international and national policy regimes; community level profiles; the RANQ household level survey of resources and needs; in-depth qualitative and quantitative studies of particular households and themes; and the development and application of a measure of subjective quality of life (McGregor, 2007). This data provided a context for the qualitative health 3

The quantitative primary data is predominantly from RANQ, supplemented with statistics from the qualitative study. Secondary data is drawn from recent reports on Human Development and the Millennium Development Goals, and a volume of provincial and regional statistics compiled by WeD.

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research, which involved in-depth semi-structured interviews with 24 people in each site. Respondents were sampled according to gender, age, wealth status, and religion (in the South). A further eight interviews were carried out with people with severe illness or disability, and up to five with workers at the local health centre, Village Health Volunteers, and traditional healers. The interviews explored (1) how respondents understand ‘health’ and relate it to wellbeing, (2) what they do to keep healthy, and (3) what they do when things go wrong (for example, ‘self-care’, and use of traditional and modern medicine).

14.1.1

Current Discourses in Thailand about Health

On an international level, health has been defined in increasingly all-encompassing terms, to the extent that it is almost indistinguishable from wellbeing (for example, the World Health Organisation’s definition of health as a “state of complete physical, mental, and social well-being not merely the absence of disease” [WHO, 1946]). This criticism has also been made of measures of ‘health-related quality of life’, which by conflating the concepts make it difficult to measure the effect of health on quality of life, and may consequently underestimate the quality of life of people with chronic illnesses and disabilities (Michalos, 2004; Albrecht & Devliger, 1999). Health is so important in modern Western society that its pursuit has become the pursuit of moral personhood; “a healthy body has become a sign of individual achievement […] the mark of distinction that differentiates those who deserve to succeed from those who fail” (Crawford, 1980). This is reflected in Thai public health discourses, where health appears to be equated with modernity, despite the prevalence of ‘diseases of modernity’. The focus is on “unhealthy [consumption] behaviours” like over or under-eating, which increase people’s vulnerability to costly chronic illnesses.4 This focus risks overstating people’s agency, and encapsulates the cultural and economic tension between “control” and “release” which Crawford argues is inherent in capitalist societies (1984). An example of this would be models of ‘patient compliance’ now being applied in developing countries, which ignore the “radical differences in the ability of different populations to comply with demanding therapies, […for example] exhortations to take a year’s worth of several drugs” (Farmer, 1997). While these debates are not universally salient (despite the influence of global health discourses), ‘healthism’ and ‘victim blaming’ are already part of Thai health discourses, even in the concept of ‘holistic health’ (Wattanachai, 20055). Holistic health is translated in Thai as ‘whole in one’ (a concept with Buddhist resonances), and spans four levels: (i) individual, which contains physical, mental (cognitive and

4

See, for example, the Thai Health Promotion Foundation at http://www.thaihealth.or.th/. Professor Wattanachai is a privy Councillor who was proposed as interim Public Health Minister (Bangkok Post, Sept.2006).

5

36 km Highland, in National Park

770 (173) 3.1

Distance to town Landscape

Population (hh) Population density (rai per head) % Aged 20–60 Main employment

107,240 THB ($3,351) -

57 Rice farming, primarily for household Gathering wild products, homework from clothing factory, cultivating fish, basket weaving, livestock 388,513 THB ($12,141) -

9 km Forest & seasonal marshland, on flood plain 407 (67) 10.3

Noreastville_ near

492,983 THB ($15,406) 70

26.2 Agriculture, primarily rubber, some chillies Factory work, civil service, state enterprises

4 km Lowland with small hills & forests 1,849 (369) 1.9

Southville

348,865 THB ($10,902) -

Home work from fishing industry, labouring, trading, livestock

59.1 Agriculture, primarily rice

17 km Mostly highland, some paddy 935 (175) 1.9

Noreastville_ peri

1,317,125 THB ($41,116) 50

52.4 Agriculture (rubber, some rice for household) Factory work, labouring, trading, service sector

10 km Plateau (forest) & lowland (paddy) 1,733 (479) 3.6

Southville_peri

WeD-Thailand I&E data analysis, June 2007. The national average reported in UNDP 2003 was 143,856 THB ($4,496)

a

Annual household incomea % Muslim

62.3 Agriculture (cassava, some rice for household) Other employment Gathering wild products, petty trading, labouring, cattle rearing, rubber tree cultivation

Noreastville_far

Site

Table 14.1 Description of the sites (Summarised from the WeD Community Profiles)

NK Service industries

West: residential. East: slum on railway land 7,120 (1,188) 0.007

Southurban

159,747 THB ($4,992) -

506,696 THB ($15,834) 30

Selling prepared Labouring, food, work in drying fish, factories, shops, market trading and on building sites

46 Manual labour

800 (163) 0.009

Slum on railway land

Noreasturban

243

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emotional), social, and spiritual; (ii) household; (iii) community-country (reflecting a conception of Thailand as a giant Baan [village]), and (iv) international (Jongudomkarn, 2006). It emphasises firstly, people’s relationship to nature, which was a source of concern for many respondents (for example, use of chemicals in agriculture); and secondly, their use of self-care to maintain balance in their lives, and ‘manage’ thoughts and feelings. Holistic health fits with the Thai Buddhist emphasis on selfresponsibility; for example, a traditional healer in the Northeast described how “when you are born you have both your happiness and your suffering with you”, and likened building health to farming rice: “if you grow a lot of rice sprouts, you would get a lot of rice crops. It depends on each person’s Karma”. It also fits with traditional health beliefs in Northeast Thailand, which recognise three levels of causation: natural, preternatural (for example, use of ‘black magic’), and supernatural, albeit that illness explanations usually operate on the first level (Nilmanat & Street, 2004). The surprising consonance between core Thai values, and hegemonic Western health discourses, has led to their enthusiastic adoption by GoT. For example, the ninth NESDP6 (2002–2006) aimed for a holistic and person-centred approach to health development, rather than a sectoral one, which combined the use of the whole of the health system with the encouragement of individual self-sufficiency. An explicit aim was that every person “should have access to resources to achieve good health, develop the abilities to adapt to change, and practice high moral standards and social responsibility” (http://www.nesdb.go.th, 5/07/2005). The plan focuses on ‘health building’ rather than ‘health repairing’ as a more efficient use of public funds, which would discourage dependency. Its aim was “absolute health management” to reduce the ‘causal’ factors of poverty; isolation; obesity; sexual promiscuity; addiction to alcohol, drugs, nicotine, and gambling; and other ‘man-made illnesses’ (for example, traffic accidents) (Wattanachai, 2005). Despite the discourse of holism, the majority of these focus on individual behaviours, have a moral tone, and are stripped of social context (for example, the current drive towards car ownership as a sign of prosperity and modernity). The focus on the individual has enabled what Jongudomkarn (2006) calls ‘commercial holistic health’ where people are persuaded to purchase the missing elements in their lives, rather than look for the root of the problem in the demands of their daily lives and environment.

14.1.2

Background to the Provision and Use of Health Services in Thailand

The ninth plan also promised an ‘equitable and efficient’ healthcare system, and in 2001 GoT established the Universal Health Coverage scheme to supplement the two employment related schemes, the Civil Service Medical Benefit Scheme (CSMBS), which covers government employees and their dependents (approximately seven 6

NESDPs are five-year development plans that are created, implemented, and monitored by the National Economic and Social Development Board.


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million people, non-contributory), and the Social Security Scheme (SSS), which covers all employees in the formal sector (approximately ten million people, costs shared between employee, employer, and government). The UHC replaced two existing risk protection schemes – the non-contributory Medical Welfare Scheme or Low Income card (people with low incomes, people under 12 or over 60, people with disabilities, monks, and local government officials), and the contributory Voluntary Health Card Scheme or 500 THB card (farmers and informal sector workers), which cost 500 THB per year. It originally came in two forms: UH exempt where treatment is free, and GC-co-payment where users are charged 30 THB per visit; however, the 30 THB fee has now been removed. The covers most curative and preventative health services, with the exception of road traffic accidents, which are covered by compulsory vehicle insurance paid on vehicle registration. Some high cost therapies such as chemotherapy are only partially covered. Health insurance coverage has greatly increased since the introduction of the scheme; one national survey conducted in 2002 found only nine percent of respondents didn’t have any health insurance (uninsured respondents were typically young and poor, with little or no education) (Suraratdecha et al., 2005). The figure from the WeD qualitative health research was four percent, reflecting the time elapsed since Suraratdecha’s survey, and were usually older people who had been unable to register as they did not have a birth certificate. Five to six percent of people with a UH had previously had no health insurance and 73 percent of holders previously had Low Income cards, suggesting that the UH is effectively targeting the poor. Nonetheless, a survey shortly after its introduction suggested that those in the lowest income quintile were still spending 7.5 percent of their income on healthcare, compared with an average of 1.6 percent and 0.1 percent respectively for people in SSS and CSMBS (HSRI, 2002 in Towse et al., 2004). Similarly, Mee-Udon’s survey of two Northeastern villages (2006) found that in the more remote village six percent of respondents perceived their expenditure had increased, although this may be due to transport costs incurred by greater use of healthcare facilities. Another initial concern was that while ‘compliance’ figures from 2004 suggest that poor people are more likely to use the card than richer ones, indicating effective targeting, even in the lowest income quintile usage was not universal, as only 74 percent of cardholders use outpatient services, and 86 percent use inpatient. Usage figures then decline proportionate to salary so only 19 percent of those earning over 15,000 THB use outpatient services, and 40 percent inpatient, which suggests that the ‘universal’ health service is becoming a safety net rather than a choice. The increase in coverage also necessitated changes in health care delivery; for example, GoT redirected funding from provincial and teaching hospitals (located in the main urban centres), towards district hospitals and local primary healthcare centres, in the expectation that this would increase the benefit derived by poorer people (Hanvoravongchai et al., 2003 in Towse et al., 2004). Prior to this primary healthcare was predominantly delivered by hospital outpatient departments, or government doctors working ‘after-hours’ in private clinics (Mills & Bennett, 2002), and consequently had a popular reputation for poor quality treatment and care. Golden card holders can now access healthcare through their ‘contractor unit’, which comprises a

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Table 14.2 Facilities reported by respondents to the qualitative health research, WeD 2005 (percentage of respondents reporting use of these facilities) Site

Government health centre

Noreastville_ far

2 (next villages) (40%)

Noreastville_ near

2 (next village, Roi Et) (44%)

Noreastville_ peri Noreasturban

1 in next village (55%) 4 nearby (61%)

Southville

2 (next village & district town) (27%)

Southville_peri

1 in village, 35%

Southurban

2 (own & next ∼6 (1 local community) (30%) & nearby) (82%)

Clinics 2 (in village & next district) (24%) 1 in Roi-Et (22%) ∼10 (next villages) (61%) ∼5 nearby (33%) ∼4 (district town & Hat Yai) (58%) ∼2 (Hat Yai) (50%)

Government hospital

Private hospital

1 district, 1 provincial (74%) 1 district, 1 provincial (50%) 2 district, 1 tertiary (49%) 1 provincial, 1 tertiary (61%) 1 district, 1 provincial, 1 tertiary in Hat Yai (85%) 1 district, 1 provincial, 1 tertiary (both Hat Yai) (74%) 1 district, 1 provincial, 1 tertiary (61%)

1 in next district (24%) 1 in Roi-Et (25%) 2 in Khon Kaen (9%) 2 nearby (3%) 2 in Hat Yai (9%)

2 in Hat Yai (15%) 3 nearby (12%)

district hospital and related primary healthcare centres, and is funded through ‘capitation’.7 While it is possible to be referred to other services such as teaching hospitals, respondents described this as a time-consuming and bureaucratic process. People are reluctant to ‘self-refer’ as unless they hold a CSMBS or SSS card they are required to pay their costs. In contrast, SSS card holders can use any public and private service at ‘registered hospitals’ within their ‘provider network’, and CSMBS holders and their dependents can use any service, anywhere. In fact Pannarunothai (1993) estimated that a quarter of the income of private hospitals came from CSMBS. The most recent information on the effects of the UH on health seeking behaviour comes from the 2002 survey conducted by Suraratdecha et al. (2005). This found that for non-hospitalised illness, self-care (traditional remedies or pharmaceuticals), or use of traditional healers was still the most common method of care for 42 percent of respondents, including those entitled to free care. This was also true in WeD sites where one poor villager spent 2,500 THB per month on Chinese medicine for his wife’s diabetes. Only 33 percent of Suraratdecha’s respondents used government health services, while 18 percent used private clinics. The main reasons given for not

7

Capitation is a fixed prepayment, per patient covered, to deliver medical services to a particular population.


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using government services was that (i) the illness was not serious, (ii) purchasing drugs was easier, (iii) the respondent didn’t want to take leave from work, (iv) the facility was too far away, (v) the attitude or behaviour of the healthcare workers was unsatisfactory, or (vi) the medicine or treatment was perceived as poor quality. The next section outlines the extent of formal healthcare provision at provincial and local levels. To simplify this, we have only reported figures for provinces containing WeD sites.

14.1.2.1

Government Health Services at Provincial and Local Levels

The impression given by local and migrant respondents of better health services in the South is supported by the ratios of population per doctor and per bed, which in Songkhla province were considerably better than the mean across the three WeD provinces: population per bed 424 (mean 643), and per doctor 3,301 (mean 6,204). While respondents from all sites have access to a range of facilities, there are some important differences between rural, peri-urban, and urban sites (see Table 14.2). For example, Noreastville_far has access to a primary healthcare centre (PHC)8 in the next village (9 km from the farthest end of the village), but for serious conditions villagers need to travel 38 km to the District hospital. They also have access to fewer private facilities (a private hospital and clinic in an adjacent district) although in 2005 a Public Health Officer at the PHC started an inexpensive private clinic in his home in the village. Currently Southville doesn’t have a PHC, although the local government officer is campaigning for one as residents of the Muslim half of the village have to use the PHC in the district hospital (residents of the Buddhist half are in the catchment area of the PHC in the next village). Noreastville_peri has access to a PHC in the next village, and is relatively close to a modern Hospital that used to be private, which also provides an ambulance service. Southville_peri has a popular new Primary Care Unit (PCU), but is far away from the District Hospital, which also doesn’t have provision for Muslim patients (for example, Halal food stalls). The city hospital is easier to access, but unfortunately isn’t within the residents’ catchment area. The two urban sites are the best provided for: the PHC in Noreasturban has closed, but residents have easy access to municipal health centres and hospitals in the city, while residents of Southurban can use a PHC, a PCU in the next community, an inexpensive private clinic, or nearly 20 other municipal health services. Southurban also has access to at least 173 private clinics and four private hospitals in the city. These often take patients from Malaysia, indicating that ‘health tourism’ isn’t confined to Bangkok.

8

A PHC is the lowest level of formal healthcare; usually staffed by Community Health Volunteers, it only gets weekly or monthly visits from a doctor. A Primary Care Unit will have resident nurses, a doctor, and occasionally even a dentist.

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14.1.2.2

L. Camfield

Use of Health Services

However, availability of government facilities is no guarantee of use: according to the RANQ a fifth of people who were sick in the two weeks preceding the survey had not sought treatment for this, and this was more common in the Northeast (28 percent) than the South (10 percent). Across all sites between 39 and 73 percent of respondents to the qualitative health research had never used government primary care services, and between 15 and 51 percent had never used a government hospital. The lowest usage for government primary care was in the South (a third of respondents, compared to a half in the Northeast),9 while only half the respondents in Noreastville_ near and Noreastville_peri used government secondary care. The main health service used in rural and urban sites was the hospital, and in nearly 90 percent of cases this was used under the UHC scheme. The remaining percentage had either used a private hospital, or used a government hospital but needed to pay because it was out of their catchment area, and/or they hadn’t obtained a referral from their district hospital (the head of the contractor network). Peri-urban sites were more frequent users of primary care: either a PHC or PCU under the Universal Health Coverage scheme (67 percent), or a private clinic (33 percent). The difference between site types may reflect either a different pattern of healthcare use where people in rural and urban sites self-treat unless the illness is serious, when they go straight to the hospital, or ‘over-counting’ arising from the location of many rural PHCs in hospitals. Formal traditional medicine use was minimal (less than two percent), but self-treatment with traditional remedies was relatively common among older adults, especially in Noreastville_far. People in the South were more likely to have used a private service for a recent specified illness (28 percent, compared to 20 percent in the Northeast), and much less likely to use government health services in the past year (a third, compared to three quarters in the Northeast). Although the rate of satisfaction with government health services was slightly lower in the South, both regions recorded satisfaction rates of over 90 percent, which suggests relatively low expectations. Respondents from Southville reported the lowest level of satisfaction with government services, which may be due to the poor quality of services at the district hospital, which was also the nearest PHC for Muslim residents. Few people in Noreastville_far reported using a private service for a ‘recent specified illness’, possibly because until recently the nearest was a private hospital in the district town. Southurban presents an interesting contrast: because there was an inexpensive clinic within the community, people were more likely to use this than either of the two local health centres (45 percent private, compared to 39 percent government). NGO health service use was minimal as they only provide support in a few of the study sites. Only a quarter of household heads in the South thought their family healthcare was inadequate, compared to a third in the Northeast. There were also marked dif9

There can be some confusion between these categories as government primary care facilities are often sited in hospitals, for example, Southville, which may account for the fact that 85 percent of respondents in Southville said they used secondary care, but only 27 percent used primary.


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ferences between rural, peri-urban, and urban sites, as rural household heads were twice as like to perceive their family’s healthcare as inadequate as urban ones (38 percent rural, 27 percent peri-urban, 18 percent urban). Household heads in Noreastville_far were least satisfied, which is not surprising considering the distance to the nearest health service. In contrast, respondents in Noreasturban had a good choice of local providers, but were much less likely to use the health services (over a third of people with a recent illness didn’t seek treatment). The main reason given was a preference for self-medication, possibly because attending government health services would cause them to lose a day’s paid labour. Economic considerations, as well as more extensive choice, may explain why 90 percent of people sought treatment in the South, compared to only 72 percent in the Northeast. Respondents to the qualitative health research perceived changes in people’s attitudes to health, for example, an increased confidence about using government services, especially hospitals and vaccinations. The Southville_peri Public Health Officer described how Previously when you were sick someone else brought you to the doctor, you were usually too afraid to come! People would only come when they were going to die, now they come as soon as they realise they’re sick, they try to protect themselves.

Paradoxically, some respondents felt doctors’ knowledge had reduced, one attributing this to fewer ‘foreign’ doctors in hospitals, and another to the reduction in tertiary care funding. This suggests that the shift of focus to primary care may not have been universally popular. Being economically poor was perceived as a big health risk, for example, (i) people were unable to take time off to exercise or see the doctor, (ii) took jobs that exposed them to health risks, (iii) had a history of ‘over-work’, and (iv) often did a ‘double day’ of work and child-care. Specific health risks were associated with different occupations; for example, (i) making fishing nets at home (poisoning from the lead weights and chemicals on the net, pain in knees from sitting cross-legged for long periods), (ii) rice growing (Weil’s disease, leeches, chemicals from the rice), and (iii) working in a factory (standing for long periods doing ‘quality control’, exposure to fumes, chemicals, and dust). However, these were often traded off against improved income and/or autonomy. For example, cutting rubber, while physically demanding, was as lucrative as factory work and enabled cutters to manage own time: “It isn’t good for my health because I don’t have enough time for sleep; however, it’s worth it because to get money you have to spend health” (young Buddhist man, Southville_peri).

14.2 14.2.1

Outcomes Contemporary Health Risks

Over the past 30 years Thailand has experienced a classic ‘epidemiological transition’ from infectious and deficiency diseases, to chronic non-communicable diseases. For example, in 2003 the combined mortality rate for three of the most

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common conditions in developing countries (malaria, dengue fever, and diarrhoea) was only 1 per 100,000 people (Wibulpolprasert, 2005). WeD data provided less support for an epidemiological transition, as the most common condition was for all age groups was pain in joints and muscles (14 percent of chronic illness overall, 23 percent for over 65s). In fact, WeD found higher than average incidences of both ‘traditional’ and ‘modern’ health problems, for example, the combined incidence of malaria, dengue fever, and diarrhoea was 4.8 per 1,000 people, compared to 1.7 per 1,000 nationwide, and the incidence rate for cancer was 2.4 per 1,000 people, compared to 0.9 percent nationwide. The main causes of lost Disability Adjusted Life Years10 nationwide were non-communicable diseases (twice as many as were lost to communicable), namely: i) Conditions affecting the circulatory system, particularly stroke (19 percent), which relate to smoking, drinking, and obesity ii) Cancer, mainly liver and lung (16 percent), which relate to smoking, and drinking iii) HIV and HIV-related tuberculosis (16 percent) and iv) Road traffic accidents (12 percent), especially among young men, three-fifths of which are alcohol-related (Wibulpolprasert, 2005). The causes highlight five public health risks that GoT is attempting to deal with (smoking, drinking, obesity, HIV/AIDS, and car use), despite their integration into Thai society, and even into what people understand as modernity. For example, 46 percent of men are classified as having ‘drinking problems’ and 10 percent of women (Kittirattanapaiboon, 2006), and a similar percentage are smokers (3 percent of women). While GoT has not attempted to reduce car use (annual purchases of new cars are now approaching pre-economic crisis rates of 600,000), it has intervened to reduce drinking, smoking, and obesity, even including them as indicators in the annual Basic Minimum Needs household survey. Tobacco and alcohol advertising has been banned, cigarettes are no longer on public display, and licensing hours are limited. The government recently launched an anti-alcohol television campaign to suggest that by giving up drinking, a man could turn his family into a happy, healthy, and well-dressed one (‘stop drinking for your economic health’), although ironically, the campaign’s slogan ‘poor, stressed, and drunk’ has become a popular ‘toast’ while drinking! Diet has proved an easier target: in 1995 40 percent of the population aged 40 to 49 was overweight, increasing their risk of coronary heart disease and diabetes (Wibulpolprasert, 2005). Hospital admission rates for these conditions were 397 and 381 per 100,000 population respectively, and only half of those admitted with diabetes had been diagnosed (ibid.). Obesity was found to be highest in Bangkok and other urban areas, and lowest in rural, due to its positive correlation with socioeconomic status. Sixteen percent of children aged 6 to 12 were overweight in 2003

10

The DALY is calculated at the population level, and is the sum of years of life lost due to premature mortality, plus the ‘healthy life years’ ‘lost’ through disability.


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(14 times as many as in 1973) [WHO, 2003], and according to Sakamoto et al. (2001) the figure was even higher among urban pre-schoolers (23 percent were clinically obese, compared to 7 percent of rural). At the same time 12 percent of primary school children were underweight in 2001, and 11 percent of school children in the Northeast were malnourished; a striking illustration of uneven development in Thailand (UNDP, 2003). Drugs control is also a national priority; however, due to the savagely punitive nature of recent campaigns,11 it is difficult to get accurate figures of the number of users. In 2002 70,000 people were registered at drug treatment centres nationwide, half of who were new users. Estimates of intravenous drug use (IDU) range from 100,000 to 250,000; however, use of methamphetamines (yaa baa or ‘crazy medicine’) is estimated to be ten times higher, and concentrated among young people. Intravenous drug use is the main risk factor for HIV/AIDS in Thailand: HIV prevalence among IDUs is 50 percent, and they account for a quarter of new infections (UNDP, 2004). The estimated number of HIV infections since the start of epidemic is less than one million, 460,000 people have died (53,000 in 2003), and the number of PLWHA in 2003 was 604,000, 12,000 of whom were under 15. Consequently, Thailand is considered an HIV/AIDS ‘success story’ as while the annual infection rate peaked at 143,000 in 1991, it fell to 19,000 in 2003, making it one of only a handful of countries to reverse a serious epidemic. The estimated adult prevalence rate is 1.5 percent; however, this conceals disparities between different groups and regions. For example, only 7 to 12 percent of brothel-based commercial sex workers are infected due to the success of the “100 percent condom programme” (signs appeared over bar doors after the start of the campaign saying “No condom, no sex, no refund!” [Beyrer and Suwanvanichkij, 2006]). However, the rates for ‘men who have sex with men’ and intravenous drug users are much higher (15 and 50 percent, respectively), and high rates have also been recorded among pregnant women in the South (UNDP, 2004). Economic migrants (and their wives) and ‘indirect’ commercial sex workers are at risk, especially in border provinces such as Mukadaharn (Lyttleton & Amarapibal, 2002). Additionally, the concentration of AIDS deaths among people aged 20 to 49 years old has enormous socio-economic implications, for example, the effect on poor households of losing a working adult (Knodel & Im-Em, 2004), and caring for ‘AIDS orphans’ (Safman, 2004). Participants in the WeD qualitative health research also identified environmental risks relating to climate (fever and respiratory problems from cold weather, exacerbated by poor quality housing), transport (pollution and accidents), and water quality. Urban environments were particularly unhealthy because of over crowding; rubbish; large, young families; and transient populations who didn’t respect the environment. In Southurban the village health volunteer claimed that “in the past

11 In February 2003, the Thaksin government instructed police and local officials that persons charged with drug offences should be considered “security threats” and dealt with in a “ruthless” and “severe” manner. The first three-months of this campaign resulted in 2,275 extra-judicial killings (Human Rights Watch, 2004).

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everywhere was cleaner” but now “people are drying fish, and there is goat shit and cow pats everywhere. These kinds of business belong to the gangsters so no one can complain about it, even if they don’t feel happy about the smell!”

14.2.2

Chronic Illness and Disability

14.2.2.1

Incidence of Disease

The incidence of disease in the four provinces where the WeD sites are located compares well to national averages as for all conditions, except cancer, the figures are significantly lower (see Table 14.3).12 The wealthier provinces of Songkhla and Khon Kaen have high levels of heart disease, hypertension, and road traffic accidents (MoPH, 2003), and hypertension was the most common condition in Southern, and urban WeD sites. Unfortunately diabetes has not been recorded in Khon Kaen or Songkhla (anecdotal reports suggest it is endemic), however, nephritis and cerebrovascular conditions are common sequela to diabetes. The high rate of cancer in Khon Kaen and Roi Et is largely accounted for by alcohol-related liver cancer, as Khon Kaen has the highest international incidence, 90 percent of which is caused by liver fluke from eating raw fish and meat while drinking (Vatanasapt et al., 2002). The prevalence of ‘pain in joints and muscles’ in Northeastern and rural WeD sites suggests that chronic illness is strongly influenced by socio-economic status and occupation (for example, pain is presumably caused by prolonged physical activity in the fields, or as a daily labourer). The main problem in WeD peri-urban sites was respiratory disorders, which may also be occupational as a sixth of the population work in factories, or as motorcycle taxi drivers. Pain was the condition

Table 14.3 Incidence of disease: national and regional (MoPH, 2003; WeD Northeast and South Statistical Booklets, 2005) National and regional—per 100,000 people Cancer Heart disease Diabetes High blood pressure & cere brovascular conditions Rate of illness—overall

National

Khon Kaen

101.7 451.5 380.8 389.8

125.9 58.0 NA 47.8

17.4 28.2 4.1 2.4

109.3 16.1 16.6 2.3

38.2 58.1 NA 34.5

1,845.0

575.0

256.0

155.0

603.1

Mukdaharn

Roi Et

Songkhla

Bold = higher than national average

12 These have been recorded for the four conditions that the government considers to be current priorities.


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with the highest incidence overall, accounting for 14 percent of reported sickness, and experienced by 3 percent of the population. The next were ‘other respiratory conditions’, for example, coughs or asthma, diabetes, high blood pressure, and gastritis. These figures were supported by the WeD qualitative health study where the most common health problems were also ‘pain in joints or muscles’, diabetes, fatigue, hypertension, and respiratory conditions.13 During the previous year 10 percent of households had members who were too sick to perform their usual activities and a quarter of these were sick for more than a month (30 percent in Noreasturban). The persistence of sickness in WeD sites may be explained by the fact that only 28 percent of people who were sick in the two weeks preceding the RANQ had sought treatment for this (the figure ranged from 12 to 44 percent in different sites), something which is explored further in the following sections.

14.2.3

Impacts of Ill Health

Scores from the RANQ Household Resources and Needs Deprivation Indices (McGregor et.al., 2007) suggest that chronic illness and disability have little effect on household resources or needs satisfaction. However, there are some differences in asset holdings, with people with disabilities having the smallest mean score on the Asset Index14 (2.67, SD 1.4), followed by people with chronic illnesses (3.32, SD 1.4), and ‘healthy’ people (3.39, SD 1.4). The reason why the Asset Index is affected rather than the other indexes may be firstly that chronic illness is associated with age, which is positively associated with resources and need fulfilment, and secondly, that the index focuses on material resources, rather than say social or cultural, which are less affected by ill health. The exploratory quality of life research suggests that prolonged illness has a pronounced effect on household finances, for example, a middle-aged woman with renal failure described having to borrow from moneylenders to meet her medical bills (“I have spent more than 100,000 Baht over the years. I don’t know how I will ever have the money to pay them back”). Another, who was being tested for cervical cancer, was worried because “my family would suffer a lot if I get sick—I don’t have money for transportation to the hospital as I can barely feed my family” (Jongudomkarn & Camfield, 2006). Many respondents talked about the effect of ill health on self respect; namely not being able to feel proud of themselves or look ‘elegant’, being ‘gossiped’ about, and being weak and dependent, rather than strong and self sufficient. A poor old man from Noreastville_far explained “if you’re weak it doesn’t matter how rich you

13 Sixty-three percent of respondents to the health study reported health problems, from cancer to work-related stress. However, there was an inherent bias as a quarter of the sample had been selected because they were chronically ill or disabled. 14 See Clarke 2006 for a description of the Asset Index methodology.

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are, if you have a million THB you can’t do anything if you’re sick, but if you’re poor and healthy it’s a treasure”. In fact a common saying is ‘you cannot buy good health, but have to practice it’ (‘Sukha-pap Dee Mai, Mee Khai Tha Yak Dai Tong Tam Eng’). Health was also discussed in terms of capability, being able to “do anything, go anywhere” and seemed to be a fungible resource that could be used for work and income generation, and to visit a sick friend, play football with friends, and “plan good things for your life” (rich middle-aged Muslim man from Southville). A wealthy Buddhist from Southville described what he saw as the connection between health and wellbeing: If I am strong and have a rubber garden I can cut two to three rai per day, if I am weak I can only cut one rai. […] When you are healthy you can work in your garden and earn lots of money, which gives you wellbeing.

The alternative picture was of someone who had to stay at home, possibly even in bed, and was therefore in an unbalanced relationship to the rest of society and denied opportunities for social participation. Illness could cut people off from sources of self-esteem such as being able to help others, and do “good things” (for example, being the Vice President of your community—an example given by a middle-aged man with diabetes in Southurban). It also endangered people’s moral and spiritual health (“if you are not healthy you will become lazy”, young woman from Noreast_peri, employed in a garment factory). For example, ill health could mean that they didn’t have the strength to fast and pray during Ramadan, or money left to tam bhun (make merit15) after expenditure on healthcare. Ill health was an important source of stress, people worried about the effect of everyday activities on their health, how their condition was affecting their family, and, ultimately, their own mortality (“Health makes you happy and able to go anywhere, sickness makes you afraid of death”, elderly woman from Noreast_near). It also placed a tangible financial burden on families as sick people couldn’t earn money, and needed to “waste” what money they had on medicine and travel to healthcare facilities. There was also the cost of food in hospital (for patient, family, and visitors), and extra expenses such as x-rays. Fear of physical and financial dependency was a persistent theme, for example, having to depend on external others (for care, agricultural labour, or money), or engage in relationships of dependency within the family, although paradoxically “mutual care” and receiving good care from others was also a signifier of a good family. Respondents talked about having freedom from the demands of an unhealthy body; for example, having to see the doctor regularly “without any sign of a cure” (something that was resented by respondents with diabetes), and their “dependency” on medicine, which was symbolised by “having to carry it around with them”.

15 Merit enables Thai Buddhists to reduce the accumulated karma, or traces of previous existences, which can hold them back from enlightenment.


14.3

255

Health Seeking

The section on health seeking begins with five case studies to draw out key themes. It then briefly explores experiences of using the UHC scheme, and traditional medicine, which expresses many of the contradictions of modernity Thai-style. The case studies were chosen to represent a range of experiences across key dimensions of location, socio-economic status and/or type of health insurance, age, and gender. Salim is a relatively wealthy Muslim man in his thirties who lives in Southville, and has worked as a driver for a factory for ten years. He describes his health as ‘70 percent’ as he doesn’t have much time for exercise (playing football with his friends), and has chronic back pain from driving. He has numerous cards—SSS from the factory, a local government officer’s card,16 and golden card, which he never uses. When he’s in pain he buys medicine from a general store, which only takes “three minutes” compared to a whole day to get equivalent medicine from the doctor. He prefers the shop to hospital, as although the latter is free (medicine from the shop costs 50 THB), you can spend a lot of time waiting and just get paracetamol. He sometimes uses the district or provincial hospitals, but they’re very busy and the ‘officials’ are often rude and abusive, and don’t seem motivated to serve people. He also uses a private clinic, because it’s faster than the hospital, buys traditional medicine in ‘modern’ capsule form, and has regular traditional massages. He feels that Good health is very important to my life because if you have good health you can plan good things for your life, it’s easy to sleep. […] You can work hard and aren’t easily tired […] you’re not anxious, not serious. If you’re sick you need to spend a lot of money to go to the doctor, and become anxious about spending this money, you’re not happy.

He looks after his health by taking care over what he eats, for example, growing organic vegetables or washing non-organic thoroughly to remove toxins, and drinking milk. Mai is a relatively wealthy Buddhist woman in her twenties who lives with her parents in Southville_peri. She described her health as ‘90 percent’, because she rarely goes to the doctor, however, she has worked at a factory making rubber gloves for eight years and worries that the chemicals might have affected her. She links good health to wellbeing because If you have good health you can work for your family; I don’t need to worry about anything because I work and earn money for my family so they don’t need to borrow from other families.

She explains that she keeps healthy by eating food from the “five food groups”, but doesn’t have time to exercise because she works late shifts. She also has fun with her friends, and gets good advice from her parents. When she feels ill, she usually takes paracetamol, and if she doesn’t get better goes to the new PCU or a clinic where she can use her SSS card. She doesn’t use the hospital (it’s too far away and the queues are long), or traditional medicine. 16 Elected local officials (for example, the village head) are not paid, but receive free government healthcare for themselves and their family.

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Noi is a poor Buddhist woman, also in her twenties, who lives with her motherin-law and young baby in Noreastville_far. She describes her health as ‘50 percent’ because she always has fevers, exacerbated by the leaky roof, and gets stomach pain because she doesn’t eat regularly. Although she has a golden card, she has to pay travel costs, which in Noreastville_far are fairly high. She regards sickness as normal (“it’s natural; the Lord Buddha told us”), but feels that “if we are healthy we are strong, we have wellbeing”. She keeps healthy by walking every day, praying, and trying to eat well, although their monthly household income is only 200 THB. She also boils fresh herbs to strengthen her body, which are collected for her by an old man who lives near the forest. If she is very sick, she goes to the PHC or hospital, but finds the staff uncommunicative (“he just gave us medicine, he didn’t ask what happened”), although the treatment is usually effective. She has also been to a private hospital about her stomach pain, which cost 500 to 600 THB for medicine and 140 THB for travel. Although the medicine was effective, she felt pain when she ate chilli while taking it, which was a problem as their diet is primarily nam prik and kao niaw (fermented chilli paste and glutinous rice). Mai Bhun is also from Noreastville_far, and is a medium-poor Buddhist woman in her late forties. She has low blood pressure, which she treats with herbs. This is her main form of healthcare; she boils them to drink, inhale, and bathe in. She massages herself with muscular balm when she feels tired, and has purchased Chinese medicine for her daughter from a mobile vendor. She also eats local and natural foods like bamboo shoots, fish, and vegetables, and takes Newpharmavit vitamin B complex, which her son sends from Bangkok. Mai describes health as good because “you eat well, sleep well, and your food tastes better”. She had a golden card (the staff at the PHC asked her to get it) but it expired, as she never used it. She doesn’t like the district hospital because it’s slow, the medicine is poor quality, and the doctor speaks rudely to her and isn’t interested in her sickness. Neighbours have also had bad experiences; “here they don’t call it the hospital but Long Pan [ruined place]”. Instead she uses Inter private hospital, paid for by her children. She used the PHC once, but wasn’t happy with the injection she was given, so afterwards got a healer to ‘blow’ on the area (this is a popular traditional treatment used for measles and herpes where the healer blows or sometimes spits betel nut juice over the affected areas and says a prayer). Pi Pek is a medium-poor Buddhist man in fifties, who lives in Northurban and works as a sweeper. He gives himself ‘70 percent’, as while his health is good, he gets very tired because he goes to work at four am and then takes care of his grandchildren. He has chronic leg pain, which he treats by buying painkillers every two days from the general store, and an itchy rash on his arms. He has a free golden card and SSS but doesn’t use them for himself, and nurses from the local PHC visit his grandchildren every month. Last year he was knocked unconscious in an accident and was taken to Sringarind hospital, which isn’t covered by either of his cards17.

17 In fact, Pi Pek could have used either card in this situation, however, the point of the story is that neither he nor the attending healthcare workers were aware of this, and this caused him much subsequent distress.


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The mistake cost him 1,800 THB, which he is paying off at 100 THB per month, and he’s not sure if he’ll be able to get it back in the end. He has never used private healthcare, although his SSS card would cover it, as he can’t afford unexpected expenditures. Health is important to him because “if our body isn’t good we can’t think; if we have good health we can think and stay in a good mood”. He keeps healthy by exercising, eating good food, and drinking filtered water (previously they purchased bottled). He also takes coffee as a supplement and Red Bull while he’s sweeping. He has never used traditional medicine or massage. The five case studies suggest a number of themes, for example, mixing of traditional and modern (even within ‘traditional’ medicine), widespread use of nonprescription painkillers,18 and low opinions of UHC services. They also demonstrate the linkage of health with occupational and environmental problems, for example, tiredness and working a ‘double day’, headaches and chemical inhalation, and fevers and leaky roofs. Health is clearly important to work and fulfill family responsibilities, but has an equally valuable experiential dimension. The next section looks at the 30 THB health scheme in more detail, beginning with a brief description of how health status, SES, and type of coverage affect the main source of people’s healthcare. Responses from the qualitative health research were coded and analysed with SPSS to produce a more detailed picture of people’s health care use, which is reported below and in Table 14.4 (unfortunately the sample was too small and unevenly distributed to allow more sophisticated statistical analysis). ‘Healthy’ people are mostly likely to use self-care as their main source of healthcare, while people with disabilities are unlikely to use private services, probably due to the

Table 14.4 Percentage of respondents describing this as their main source of healthcare (WeD qualitative health research, 2005) Main source of healthcare

Self-care

Trad. Med

Govt. Primary

Priv. Primary

Govt. Secondary

Priv. Secondary

‘Healthy’ (n = 165) Chronic Illness (n = 47) Disability (n = 27)

54 32

3 6

16 21

18 21

9 19

1 -

58

8

19

8

8

-

Poor (n = 99) Medium (n = 55) Rich (n = 85)

56 42 48

4 7 1

18 11 20

13 18 21

8 18 8

1 1

Nothing (n = 8) GC (n = 181) SS (n = 16) CSMBS (n = 18)

75 49 38 56

4 -

13 20 19 11

15 31 28

13 12 13 6

1 -

18

In 2002, drug consumption accounted for over a third of national health expenditure, compared to 10 to 20 percent in industrialized countries. A quarter of this was unsupervised consumption from general stores, as described above (Wibulpolprasert, 2005).

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cost (they are also slightly more likely to use traditional medicine, which may be related to their age). Poor people are also most likely to use self-care, and less likely to use private, but the difference is not as large as might be expected. This may be because poor people often have access to their children’s health insurance; however, the differences in the main source of healthcare by health coverage are not large either. The small percentage of people without coverage are most likely to self-treat, and don’t use private care. People with SSS and CSMBS are most likely to use private primary care, but almost no-one uses private secondary care as their main source of healthcare. A further analysis explored whether type of coverage affected simultaneous use of government and private health services. Type of coverage seemed to have little effect on simultaneous use (11 percent of people with a GC were simultaneous users, compared to 13 percent with CSMBS). However, people with SSS and CSMBS were more likely to only use private services than people with a GC (CSMBS 44 percent, SSS 31 percent, GC 24 percent). The percentages for private secondary care were too small to draw any conclusion; however, the experience of using government secondary care for someone with CSMBS is probably so different (respect from staff, private room, etc.) that it isn’t necessary to pay for a private provider. Many respondents reported substantial benefits from the 30 THB scheme, despite the problems described in the case studies and below. For example, the cost of medicine was covered for most chronic conditions, which was a great saving for respondents with hypertension or diabetes. It also reduced large and unpredictable healthcare expenses, with the exception of road traffic accidents. It appeared to have led to increased use of healthcare services, especially preventative, and older people felt gratitude towards the government, which was expressed in spontaneous donations (one elderly villager explained “I know I use a lot of money, maybe 1,000 THB, so I wanted to donate something”). Nonetheless, the use of catchment areas, which are required by a capitation-based scheme, was perceived as a significant limitation. This was because it reduced choice (for example, if a hospital that was well-known for a particular service wasn’t in the catchment area), and didn’t always make sense geographically. Rigid enforcement of the areas created problems for emergency treatment, and being treated out-of-area involved substantial bureaucracy. None of this was a problem for SSS and CSMBS card holders who had almost complete choice over provider and location, and were able to self-refer. A wealthy Muslim woman from Southville_peri described how before she left her job she always used Siantong hospital because “it’s clean and quick. […] I was very satisfied because every time I went there I got much better. With the GC there are always very many people and a long queue, but at Siantong there aren’t many people”. She concluded philosophically “when I used the social assurance card [SSS] it was good, but now I have no choice, so use the GC instead. It’s okay; I have no choice so I have to say it’s good”. Other respondents had difficulties registering (especially if their births had not been registered), transferring their registration on marriage or migration, and renewing expired cards. There were also exemptions for certain conditions and treatments, which made it difficult to calculate exactly how much an intervention would cost. For example, a wealthy garage owner in Southurban described how


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I would have been covered by the GC for the [eye] operation, but would have had to pay separately for the lens, and also for the medicine given during the treatment, which is imported and very expensive. The doctor said it depends on you which one you want to use but made it clear that I would be better off using my [daughter’s] private insurance.

The lack of clarity over coverage and cost (for example, whether it would cover cancer treatment for another respondent’s wife), and whether the scheme would be continued if Thai Rak Thai left power, reduced the potential psychological benefits from a ‘universal’ scheme. Other concerns related to the quality of the service, for example, the long queues (described in the case studies), the quality of care, and the quantity and quality of the medicine, compared to that offered by the other cards. A middle-aged truck driver in Noreasturban observed that while he would still go to the hospital if he had a golden card “the service might not be as good as with my social security card because you get a lot of medicine with the social security card and with the golden card you get less” (he also noted pragmatically that “it doesn’t matter because for 30 THB you can afford to go back and get more!”) This related to a general perception of inequity where services for rich and poor were ‘segregated’, for example, people with CSMBS would automatically have a private room. A concrete example of this is “private obstetric practice” in public hospitals (used in over a third of births), where for a fee of between three and five thousand THB, women could ensure continuity of care throughout their pregnancy (Riewpaiboon et al., 2005). This option was rarely taken up by poorer respondents, not just because of the cost, but because they felt their dissimilar backgrounds and relative position in the social hierarchy made it unlikely that they would ever have a ‘special relationship’ with their obstetrician, even if they paid for it. Respondents also mentioned the apparently arbitrary allocation of the two types of golden card (free and co-payment), which was a concern for people who had previously had a non-contributory Low Income card. One of the main cultural barriers to acceptance of the golden card was a general suspicion of anything free; a typical comment from a Muslim respondent in Southville was that while he personally didn’t have a problem with the golden card “if you want good service you need to pay for it, if you get it free it won’t be good”. Sequential and parallel use of different types of healthcare appears characteristic of Thai health seeking behaviour; for example, traditional medicine users described how they would get a diagnosis first, and then use both systems in parallel, or turn to traditional when conventional medicine had little to offer (e.g. after a stroke) (see also Nilmanat & Street, 2004). Traditional medicine has now entered the mainstream (for example, University centres of Thai Traditional Medicine), and many healthcare workers are attempting to record and conserve traditional knowledge (Del Casino, 2004). Similarly, while there was less enthusiasm for ‘traditional’ traditional medicine among younger people due to the difficulty of preparation and associated food restrictions, there was increasing interest in traditional medicines packaged like pharmaceuticals, or from other cultures. Although a few people talked about their medicine use in the context of traditional beliefs, for example, the need to balance fire, wind, and water in the body, and get 32 completed organs, most people used medicines independently of the associated medical system, whether traditional or biomedical.

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One benefit of traditional medicine, which is familiar from literature worldwide (e.g. Cant & Sharma, 1999), is improved communication. Many respondents described difficulty in communicating with healthcare workers because they were conscious of their low status, and lack of education, and felt kreng jai19 to ask for more information, even though this is now a statutory right (see also Riewpaiboon et al., 2005). Doctors who had been educated within a Western influenced health system found it difficult to relate to the beliefs and experiences of their patients, for example, one Muslim man from Southville described how he went to a healer three years ago because he was “afraid of everything around me”, and felt “anxious and very cold”. He initially went to a hospital but “I think the doctor didn’t understand my problem; he just gave me medicine to make me sleep, which I didn’t take”. Nonetheless, a few people felt that ‘the world moves too fast for herbs’, and that now there is a modern health system, people should use this instead, especially if they’ve moved to the city and adopted a ‘modern’ life style.

14.4

Conclusion

The discourse of holistic health extends the singular sukha-pap to a multiple sukha-pawa. While this transition could potentially aid our understanding of health as contextual and multiply determined, it could also have the reverse effect of individualising and disembedding our understanding of wellbeing. This is because contemporary health discourses are characterised by a focus on individual attitudes and behaviours (for example, raw fish consumption in the Northeast), which make little sense outside particular socio-cultural contexts. Redefining a social problem such as the high accident rate as a ‘risk factor’ effectively depoliticises it, and shifts the focus from the promotion of car ownership, to motorcyclists who fail to wear their helmets. It makes it possible to ignore the contradiction between on the one hand condemning drinking, and on the other promoting locally produced alcohol for export, and allowing an alcohol ‘free market’ to stimulate domestic demand (Thaksaphon Thamarangsi, 2006:.783). Similarly, poor diets can be attributed to individuals making the wrong choices, without acknowledging that choices are limited (it isn’t possible to ‘choose’ chemical-free vegetables), and constrained by lack of time and money. To most respondents, however, health was not intrinsically interesting, and a marker of good health was its invisibility. This suggests that the best health seeking strategy is one that is quick and effective, even if it costs more. As material and ‘time’ poverty usually go together, poor people are likely to continue using overthe-counter and private medicine in preference to the 30 THB services. While the healthcare reforms have greatly increased coverage, there is as yet little evidence that they have changed patterns of use, substantially reduced household expenditure, or increased satisfaction. For example, there were marked differences between the

19 Kreng jai is a very Thai concept that merges courtesy and consideration, with reserve, respect, and fear of giving offence.


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availability and quality of facilities in the WeD sites, and also a lack of capacity and confidence in primary care, which suggested that the shift to a primary-led service might have been premature (Towse et al., 2004). Further research on the meaning of health (not reported here) suggested that health also had multiple meanings for respondents—not only was it a basic capability and a resource that could be ‘spent’ to secure better economic outcomes, but it was also a precondition for community participation, and played an important role in attaining social, cultural, and spiritual wellbeing. Thailand is a country almost as well known for its inequality20 as its remarkable economic growth, and these inequalities affect both exposure to risk and access to health facilities (for example, regional differences in the numbers of doctors and available beds). Currently the Universal Health Coverage scheme is in danger of entrenching these inequalities rather than reducing them, partly due to people’s perceptions of the quality of its services. However, the international attention it has received suggests its future is relatively secure, and with a substantial increase in per capita funding (at least equivalent to that given to the CSMBS, which is likely to contain people with fewer health problems), it could begin to make a difference not only to people’s physical and material health, but also to their wellbeing. Acknowledgments The author would like to thank all our collaborators in Prince of Songkhla and Khon Kaen Universities, especially Dr. Sawitri Limchaiarunreoung, Aj. Malee Sabaiying, Aj. Darunee Jongudomkarn, and Fara Mee-Udon. As well as participating in the fieldwork, Aj. Darunee made helpful suggestions for analysis and read an early draft of this paper. Thanks also to Valerie Moller and an anonymous referee for their insightful comments.

References Albrecht, G.L., Devliger, P.J. (1999). The disability paradox: high quality of life against all odds. Soc Sci Med, 48, 977–988. Beyrer, C., Suwanvanichkij, S. (2006). A strategy that works. The New York Times, Sunday August 13, 2006, see http://www.iht.com/articles/2006/08/13/opinion/edbey.php. Cant, S., Sharma, U. (1999). A new medical pluralism?: Alternative medicine, doctors, patients and the state. (London: UCL Press). Crawford, R. (1980). Healthism and the medicalisation of everyday life. Int J health Servs, 10, 365–88. Crawford, R. (1984). A cultural account of “health”: control, release and the social body. In: McKinley, J.B. (ed.). Issues in the political economy of healthcare (pp.60–103). (London: Tavistock). Del Casino, VJ. (2004). (Re)placing health & healthcare: mapping the competing discourses & practices of ‘traditional’ & ‘modern’ Thai medicine. Health Place, 10, 59–73. Farmer, P. (1997). Social scientists and the new tuberculosis. Soc Sci Med, 44, 347–358.

20

For example, its GINI coefficient increased from 41.4 in 1962, to 53.6 in 1992, although it had educed to 43.2 by 2000 (a GINI coeffcient of 0 represents perfect equality, and of 100 perfect inequality).

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Hanvoravongchai et al. (2003). Paper presented at Manila meeting, May 2003, in Towse et al., 2004. Human Rights Watch (2004). Thailand. Not enough graves: The War on Drugs, HIV/AIDS, and Violations of Human Rights. June 2004, 16, 8. Jongudomkarn, D. (2006). Holistic health: methodology to people’s wellbeing study. Humanity & Social Sciences, 23, 58–79 (in Thai). Jongudomkarn, D., Camfield, L. (2006). Exploring the quality of life of people in North Eastern and Southern Thailand. Social Indicators Research, 78, 489–530. Kittirattanapaiboon, P. (2006). Alcohol and depression: the situation in Thailand. Abstract for presentation at ISBRA 2006 World Congress on Alcohol Research. (Thailand: Department of Mental Health, Ministry of Public Health). Knodel, J., Im-Em, W. (2004). The economic consequences for parents of losing an adult child to AIDS: evidence from Thailand. Soc Sci Med, 59, 987–1001. Lyttleton, C., Amarapibal, A. (2002). Sister cities & easy passage: HIV, mobility, & economies of desire in a Thai/Lao border zone. Soc Sci Med, 54, 505–518. McGregor, J.A. (2007). Researching wellbeing: from concepts to methodology. In: Gough, I., McGregor, J.A. (eds.). Wellbeing in developing countries: new approaches and research strategies. (Cambridge: Cambridge University Press). McGregor, J.A., Mckay, A., Velazco, J. (2007). Needs and resources in the investigation of wellbeing in developing countries: illustrative evidence from Bangladesh and Peru. Journal of Economic Methodology, 14, 107–131. Michalos, A.C. (2004). Social indicators research and health related quality of life research. Social Indicators Research, 65(1), 27–72. Mills, A, Bennett, S. (2002). Lessons on the sustainability of health care funding from low- and middle-income countries. In: Mossialos, E., Dixon, A., Figuras, J., Kutzin, J. (eds.). Funding health care: options for Europe (pp.206–225). (Milton Keynes: Open University Press). NESDB (2004). Thailand MDG Report 2004. (Bangkok: The Office of National Economic and Social Development Board). Nilmanat, K., Street, A. (2004). Search for a cure: narratives of Thai family caregivers living with a person with AIDS. Soc Sci Med, 59, 1003–1010. Pannarunothai, S. (1993). The Need for and the Use of Public and Private Health Services in an Urban Area in Thailand. Dissertation, University of London, London. Riewpaiboon, W., Chuengsatiansup, K., Gilson, L., Tangcharoensathien, V. (2005). Private obstetric practice in a public hospital: mythical trust in obstetric care. Soc Sci Med, 61, 1408–17. Safman, R.M. (2004). Assessing the impact of orphanhood on Thai children affected by AIDS and their caregivers. AIDS Care, 16, 11–19. Sakamoto, N., Wansorn, S., Tontisirin, K., Marui, E. (2001). A social epidemiologic study of obesity among preschool children in Thailand. Int J Obes Relat Metab Disord, 25, 389–394. Suraratdecha, C., Saithanu, S., Tangcharoensathien, V. (2005). Is universal coverage a solution for disparities in health care? Findings from three low-income provinces of Thailand. Health Policy, 73, 272–284. Thamarangsi, T. (2006). National alcohol experiences in Thailand: alcohol today. Addiction, 101(6), 783. Towse, A., Mills, A., Tangcharoensathien, V. (2004). Learning from Thailand’s health reforms. BMJ, 328, 103–105. UNDP (2003). International cooperation at a crossroads: Aid, trade and security in an unequal world. Human development report. UNDP (2004). Thailand’s response to HIV/AIDS: progress & challenges. Thematic MDG report. Vatanasapt, V., Sriamporn, S., Vatanasapt, P. (2002). Cancer Control in Thailand. Jpn J Clin Oncol, 32, S82–S91. Wattanachai, K. (2005). Matichon Daily News, 28(9838): 6 (in Thai). WHO Fact Sheet (2003). Children, adolescents and obesity. WHO, December 2003.


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World Health Organization, Constitution, World Health Organization, Geneva, 1946. Available online at http://www.searo.who.int/EN/Section898/Section1441.htm Accessed July 15, 2008. Wibulpolprasert, S. (ed.) (2005). Thailand health profile 2001–2004. Bureau of Policy and Strategy, Ministry of Public Health. http://www.moph.go.th/ops/health_48. World Health Organization, Constitution, World Health Organization, Geneva, 1946.

Chapter 15

Prospects for Community-Based Rehabilitation in the New Millennium Harry Finkenflügel

Abstract Community-based rehabilitation (CBR) is presented as an alternative or complementary approach to rehabilitation in institutions. In developing countries, these institutions are non-existent, or considered inadequate. In the CBR concept, rehabilitation of people with disabilities takes place in the community and relies explicitly on the involvement of lay people, i.e., family members, volunteers, schoolteachers and village community workers. Rehabilitation has gone through a paradigm shift from a medical to a human rights model. Disability is more and more perceived as an impoverishing condition in which the disability and poverty in sync deny people a decent life. Consequently CBR is described as a strategy to improve the socio-economic status of people with disabilities and to improve their quality of life. This article discusses the ‘state of the art’ of CBR and analyses shortcomings of current research in CBR. Evaluations and research rarely focus on outcomes related to community development or the Millennium Development Goals. It is argued that CBR needs interest from researchers from different disciplines and to use their instrumentation or develop it jointly. Quality of Life researchers are challenged to develop these tools with the main stakeholders in CBR. Keywords Community-based rehabilitation, disability, quality of life, millennium development goals

15.1

Introduction

According to early reports of the World Health Organization (WHO) (1976, 1981), 10 percent of the world’s population has disabilities and this causes serious social, economic, physical, and psychological problems not only for the person with a H. Finkenflügel Institute of Health Policy and Management, Erasmus MC University Medical Center, building/ room: L4-075, PO Box 1738, 3000DR, Rotterdam, The Netherlands E-mail: [email protected]

V. Møller and D. Huschka (eds.) Quality of Life and the Millennium Challenge, © Springer Science + Business Media B.V. 2009

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disability and her/his family but also for their communities and society. The assumption was made that at any time 1.5 percent of the population could benefit from rehabilitation and “ …thus 40 million disabled people in developing countries need rehabilitation”. It was emphasised that surveys showed that the quality of life of people with disabilities was low compared to other people in the same community. They mentioned that people with disabilities are more likely to suffer from poverty, are sick more often, have less opportunity to go to school or find a job, are excluded from a position of leadership, are often segregated, and suffer from negative attitudes and discriminatory behaviour. In addition, the effectiveness, impact, and coverage of institutions providing rehabilitation services in developing countries were heavily criticised. The main points of criticism were that these institutions are situated in towns and were practically inaccessible to people with disabilities living in rural areas, are often run by non-governmental organisations, are dependent on expatriate staff, and were not integrated with other health or social services. Although the percentages and numbers can be disputed the extent of the problem has been impressively put forward. To address this problem the WHO developed Community Based Rehabilitation (CBR) as a strategy to provide rehabilitation services for people with disabilities in low- and middle-income countries. In 1981, the WHO Expert Committee on Disability Prevention and Rehabilitation defined CBR as: Community-based rehabilitation involves measures taken at the community level to use and build on the resources of the community, including the impaired, disabled, and handicapped persons themselves, their families, and their community as a whole(WHO, 1981). The real move forward for CBR came with the active and wide distribution of the manual “Training Disabled People in the Community” (Helander et al., 1983) to policy-makers and rehabilitation workers in developing countries. This manual consisted of 32 training packages to be used by a family member of a person with a disability and separate guides for local supervisors, community leaders and schoolteachers. In these packages emphasis was given to problems experienced in activities of daily living and not to the underlying pathology or the medical condition. The basic idea of this manual was that the rehabilitation process can be broken down into steps-to-follow and can be explained to people without a professional background in rehabilitation, special education, vocational training, etc. Training packages consisted of a series of exercises that should be carried out by family members and volunteers with the person with a disability. At a first evaluation of nine CBR pilot projects in different parts of the world it was concluded that CBR had the following advantages: – Quality: Rehabilitation within ones’ own community makes it easier to participate in family and community life. – Coverage: Institutions, if existing at all, can only provide rehabilitation for a limited number of people with disabilities and/or certain types of disabled people. Through CBR it is possible to reach all people with disabilities.

15 Prospects for Community-Based Rehabilitation

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– CBR not only enables people with disabilities to develop their abilities but also influences attitudes and the physical environment. – CBR is far more cost-effective than rehabilitation in institutions (WHO, 1982). These ‘advantages’ mentioned above are in fact ‘claims’ that expressed great faith and optimism in the possibilities of changing attitudes towards people with disabilities, to mobilise communities, to formulate common objectives, to share economic resources and to refrain from individual gain. However, at this stage no substantial research to support these ‘advantages’ or ‘claims’ had been carried out.

15.2

The Development of CBR

With CBR, a formal system of rehabilitation has been introduced to developing countries as an alternative to, or alongside, rehabilitation offered in institutions. Institutions are absent or considered inadequate to meet the needs of people with disabilities. Increasing the capacity of institutions is not seen as a viable option because of the costs and the lack of professional rehabilitation workers. At the same time there were also ideological reasons to work on a different line of developing support services for people with disabilities. To understand the development of rehabilitation in low- and middle-income countries it is critical to realise that the shortage of formal rehabilitation services does not imply that rehabilitation is non-existent and that no support is given to people with disabilities. In any community, and at all times, people with disabilities have lived their lives and have (re)habilitated themselves in the absence of these services. They have done this often with the help of family and community members but sometimes even on their own or together with others with the same type of disabilities. Miles collected historical examples from African and Asian practices and illustrated how people with disabilities have been able to fulfil meaningful roles in their family and community (Miles, 1998, 2000, 2001, 2002, 2003). It must also be noted that special places and separate communities for people with disabilities existed long before Western missionaries and physicians started building institutions and providing a formal type of rehabilitation. These special places were meant to prevent contagion (e.g., leprosy) or to form communities where people with disabilities could live in a sheltered – or adapted to their needs – environment (e.g. people with visual or hearing problems). More recently, communities or self-help groups of disabled people like “Project Projimo” have been established (Werner, 1990). In developing countries, institutions for people with disabilities are a relatively recent phenomenon, mainly set up in the last century. Although early initiatives are known, for example in Zambia and Malawi schools for the blind started in the early years of the 20th century (Miles, 2001), most institutions were set up only in the second half of the century. In Zimbabwe, a “school for the deaf” started in 1947, the Jairos Jiri association (Children’s centres and sheltered workshops)

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began its activities in 1951, and only from 1954, were several medical and vocational rehabilitation centres established (Addison, 1986). To understand the development of CBR and the support it got, it needs to be related to ideologically-based developments in Europe and North America and the introduction of Primary Health Care (PHC). Up to the 1970s, it was common in Europe and North America to train and take care of people with disabilities (i.e. people with severe learning problems, mental disorders, or severe physical limitations) in institutions and to accommodate them for a certain period or even permanently. In the early seventies deinstitutionalisation, normalisation, and mainstreaming became leading concepts in the care of the disabled (Wolfensberger, 1980, 1985). It was argued that people with disabilities should live their lives with, and like, all other people, and that society has to adjust itself to people with physical limitations or to those who look different or behave differently. In the same time period the PHC approach was developed and promoted as the best way to improve health in developing countries (Walt & Vaughan, 1981). Fundamentally, PHC aims to make essential health care accessible to everybody. PHC and de-institutionalisation both stressed community involvement and included a change in the locus of control and the use of resources accessible to the community. This way of thinking appears to be most relevant in the discussion on CBR and geared towards the development of CBR. CBR is presented as part of PHC, and the PHC approach is “therefore…the general approach of WHO for preventing disability and providing rehabilitation” and the two principal strategies are prevention of disability and provision of essential rehabilitation care (WHO, 1981). Undoubtedly, the limited resources available for rehabilitation of people with disabilities in developing countries, combined with the assumed high number of people in need of help, have been of decisive importance in promoting CBR as the dominant model for rehabilitation in these countries. But the CBR model could only be developed because of the paradigm shift in organising support for people with disabilities in Europe and North America and the introduction of Primary Health Care.

15.3

Rehabilitation as Part of Community Development

Rehabilitation does not come out as a priority on the political agendas of the governments of developing countries. There are only few examples where governments, in the early years of CBR, made ‘disability’ a political issue and incorporated it in Health Care, Social Welfare, or Labour programmes. In Zimbabwe, an effort was made to rehabilitate disabled war veterans after the war ended in 1980. Rehabilitation units, orthopaedic centres, and vocational training centres offered medical rehabilitation, appliances, and vocational training for these people. However, in general, developing countries will concentrate on providing the basic needs for their people, and this does not appear to include rehabilitation services for people with disabilities. Even the loss of part of the working force due to disabling


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conditions is apparently not a political issue, probably because of the overall high unemployment rates in developing countries. The perceived dichotomy between community- and institutionally-based services has greatly influenced the discussion on CBR. In the 1989 edition of the manual (Helander et al., 1989) three approaches to rehabilitation were outlined; institution-based rehabilitation, outreach services for rehabilitation, and community-based rehabilitation. It was added that CBR “also includes referral services at district, provincial, and national levels”. As such, institution-based rehabilitation services were seen as a back-up service for CBR i.e. for people with disabilities with complicated problems and for training of personnel. Yet, this pragmatic and conciliating approach cannot disguise the different approaches to the needs of people with disabilities by, for example, social workers, physiotherapists, or human rights activists. The confusion about the ‘real interpretation’ of CBR can be described as the result of a conflict of interests (Wolffers & Finkenflügel, 1993). It is recognised that people involved in rehabilitation have different priorities and will use different terminology to put forward their point of view and to distinguish themselves and ‘their’ CBR-programmes from others. In 1994 three UN organisations published a ‘joint position paper’ and compromised on a new definition of CBR (ILO et al., 1994): Community-based rehabilitation (CBR) is a strategy within community development for the rehabilitation, equalization of opportunities and social integration of all people with disabilities. CBR is implemented through the combined efforts of disabled people themselves, their families and communities, and the appropriate health, education, vocational and social services. This new definition stressed that CBR is a strategy within community development. The former definition opened with “CBR involves measures …” and was formulated at an operational and tactical level. The new definition positions CBR in the field of community development without giving a direction to this development. Equalization of opportunities and social integration of people with disabilities became touchstones in the appreciation and evaluation of community development. The basic principle appeared to be that people with disabilities should take part in, and benefit from, community development. Whereas the former definition explicitly mentioned “community level”and “resources of the community” in the new definition this is rephrased as “combined efforts of …”. Although ‘ community ’ has not been defined in the former and new definition, the understanding of ‘ community ’ seems to have shifted. Originally, the community had been perceived as a relatively well-confined (geographical) entity. CBR was very much a model for rehabilitation of people with disabilities living in rural areas. The new definition allows CBR to be a pragmatic mix of rehabilitation in the community, through outreach or support services and in specialised centres. Community now seems to be used more in terms of groups of people who might live in proximity but can also be formed based on religion, descent, or a common interest. The new definition very much reflects the way CBR projects have actually been carried out (often as a combination of different types of rehabilitation services) and tries to meet the criticism that CBR was presented as an exclusive and prescriptive programme.

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However, this consensus definition masks what have been considered as key elements of CBR i.e. the involvement of lay people in the training of people with disabilities, the needs-driven approach, and the ownership of the programme.

15.4

Empowerment

In development issues ‘empowerment’ (originally meaning “to give lawful power or authority to act”) includes topics such as ‘participation’, ‘ownership’, ‘capacity building’, ‘self reliance’, and ‘human rights’. In rehabilitation, ‘empowerment’ seems to be reserved for the people with disabilities and their families (e.g. Helander, 1999; Stewart & Bhagwanjee, 1999). This is what Wolffers (Wolffers, 2000) called ‘personal empowerment’ which can be defined as making people aware of their skills and possibilities to improve their situation. In addition, he defined ‘community empowerment’ as strengthening the community as a whole to demand changes and call for a supportive environment and ‘social empowerment’ as claiming and exerting equal rights and recognition of special needs without being made exceptional or being stigmatised. In CBR, ‘empowerment’ is, in all three dimensions, used as a central element, and aim, for all stakeholders. The rationale for this is that CBR is seen as a process in which various stakeholders are empowered to exert their competency and to influence their position in the process. It could be argued that empowerment of community workers and rehabilitation workers is a means for empowering people with disabilities and not an end in itself. However, this relies too much on a perceived altruistic attitude of these stakeholders and tends to devalue their own interests. If CBR is to be seen as a ‘democratisation’ of rehabilitation services, the interests of the various stakeholders should be treated equally.

15.5

Challenging CBR

The conclusions of the WHO evaluation (WHO, 1982) have been challenged by professionals in the field of rehabilitation (e.g. programme implementers, rehabilitation workers, evaluators, anthropologists). In the past twenty-five years they have been engaged in a lively debate on the concept of CBR, implementation strategies, and the effectiveness of CBR programmes. In the 1990s people with disabilities themselves got increasingly involved in the debate. There appeared to be a consensus that people with disabilities did not get adequate support and that they, as well as their families, were highly at risk for impoverishment. CBR was promoted as an affordable and appropriate approach to address the needs of people with disabilities, but the relevance and effectiveness of the CBR approach has, however, been continuously queried, and the discussion has not yet ended. Some researchers and people involved in CBR projects go as far as saying that if CBR


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cannot provide better evidence of being an effective programme, policymakers and funding agencies might no longer be interested and CBR will fade out (Wirz & Thomas, 2002). The documented support of CBR consists of a wide range of sources, e.g. project reports, individual accounts of people with disabilities involved in CBR, conference proceedings, theoretical reflections on the concept of CBR, and evaluation studies of CBR projects. Most of the documentation allows a glimpse of a specific CBR project but does not contribute to the ‘evidence’ of CBR. Evaluation studies are generally concerned with the outcome of the rehabilitation process, e.g. functional progress of people with disabilities, the number of the people assisted by CBR, or the costs of rehabilitation per client. Due to methodological problems in the studies and the broad spectrum of CBR projects studied, generalisation of results and drawing conclusions that go beyond the particular project is hardly possible. In a systematic literature review, 128 articles on CBR that were published in international, peer-reviewed journals between 1978 and 2002 were analyzed (Finkenflügel, 2004; Finkenflügel et al., 2005). The overall conclusion of this review was that the evidence base for CBR is fragmented and incoherent, and for this reason the effectiveness of CBR cannot be established. Of these 128 articles, 64 could be categorised as an intervention, descriptive or case study (the others were theory and review papers). In these studies a variety of instruments was used to assess the CBR programme and its benefits to people with disabilities. Almost all studies make use of self-developed questionnaires. Only on the issue of identifying people with disabilities has an effort been made to develop and validate an instrument in different CBR programmes. The studies that have attempted to measure how people with disabilities benefited from the programme focused on functional progress (i.e., activities of daily living). No studies are available on the impact of the CBR programme and its role in, and effect on, community development and poverty reduction. The main reason for this limited scope of research is probably because CBR has branched off a medical type of rehabilitation. With the paradigm shift, the growing importance of the people with disabilities themselves in the programme and the emphasis on poverty reduction and the Millennium Development Goals, CBR is moving away from the medical discipline and heading towards an integrative programme in the community embedded in community work, social welfare, education, small business schemes and primary health care. CBR has now been taken up by Ministries such as the Ministry of Labour and Social Welfare, Ministry of Community Development and the Ministry of Education.

15.6

CBR in the New Millennium

At the start of the new millennium we have seen that various UN organisations have redefined CBR and have placed it prominently within the realm of the Millennium Development Goals. This does, however, not solve the problem of the weak evidence

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base of CBR. Although anecdotal evidence does come from enthusiastic CBR programme implementers all over the world we do not know if, or to what extent, CBR strategies to influence the lives of people with disabilities in the community are actually effective. It is argued above that the instrumentation has been feeble and patchy but the fear is that with the paradigm shift from a medical to a human rights model programme implementers, evaluators and researchers are left without any appropriate instrumentation. Two problems need to be identified here. The first is the lack of a sound methodology and indicators to be used to evaluate projects. This issue has been addressed by several researchers (McLaren & Phillpott, 1998; Boyce & Ballantyne, 2000; Cornielje et al., 2000; Boyce et al., 2001; Wirz & Thomas, 2002). They have argued that we need unambiguous indicators to assess CBR programmes and have come up with sets of indicators. The problem of approaching a CBR programme with long lists of indicators has been tackled by Velema et al. (Cornielje et al., 2000, 2002; Velema & Cornielje, 2003; Finkenflügel et al., 2008). They developed flow charts that would guide the evaluators through the programme and smartly address the most relevant areas and select the most significant indicators. However, this development in assessing CBR is only recent and not much experience has yet been gained with the use of indicators. The second problem to address here is that researchers in different disciplines still perceive CBR as a “disability programme” rooted in a medical type of rehabilitation. Up to now, CBR has benefited little from experiences and knowledge built in other disciplines such as community development, socio-economic research etc. This also applies to “Quality of Life” studies. The Quality of Life studies that do relate to people with disabilities are often disease specific (i.e., Stroke patients, Arthritis, and Amputations) and focus on emotional well-being and mobility and not on empowerment and socio-economic issues. Only one study could be found in which a general Quality of Life instrument has been used to assess the impact of different types of rehabilitation services in developing countries (Powell et al., 2002). In a review of CBR evaluations Mannan & Turnbull (2007) propose to use quality of life instruments such as the World Health Organization Quality of Life Assessment (WHOQOL) (The WHOQOL Group, 1995, 1998) and The Beach Center Family Quality of Life scale (FQOL) (Park et al., 2003; Summers et al., 2005) to gather evidence that CBR programmes do indeed improve the quality of life of people with disabilities. With only these two studies available there is a definite need to develop research in which Quality of Life instruments are used to evaluate CBR and to address disability in a community development context of a low- or middle-income country.

15.7

To Conclude

In order to develop CBR as a strategy within community development a combined effort from researchers from different backgrounds and with different instrumentation is needed. This includes Quality of Life researchers, especially those who take a


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special interest in the Millennium Development Goals (UN Millennium Project, 2005) and who do realise that large groups of people because of a disability – or because they take responsibility for a person with a disability – are not fully included in community development programmes. Together we can work on instrumentation to evaluate programmes, to provide evidence and to give direction to further developments.

References Addison, J. (1986). A historical survey of facilities for handicapped people in Zimbabwe. (Harare, NASCOH) Boyce, W. & Ballantyne, S. (2000). Developing CBR through evaluation. Asia Pacific Disability Rehabilitation Journal, Selected Readings in Community Based Rehabilitation, Series 1: CBR in Transition, pp. 69 – 83 Boyce, W., Broers, T. & Paterson, J. (2001). CBR and disability indicators. Asia Pacific Disability Rehabilitation Journal, 12, 3 – 21 Cornielje, H., Nicholls, P. G. & Velema, J. (2000). Making sense of rehabilitation projects: classification by objectives. Leprosy Review, 71, 472 – 85 Cornielje, H., Nicholls, P. G. & Velema, J. P. (2002). Avoiding misperceptions: classifying rehabilitation projects using letters rather than numbers. Leprosy Review, 73, 47 – 51 Finkenflügel, H. (2004). Empowered to differ. Stakeholders ‘ influences in Community-Based Rehabilitation. Dissertation, Vrije Universiteit Amsterdam. Retrieved June 4, 2007 from http:// www2.eur.nl/fgg/medbib/EUR-diss/040331_Finkenflugel_H/Finkenflugel_H.html Finkenflügel, H., Wolffers, I. & Huijsman, R. (2005). The evidence base for community-based rehabilitation: a literature review. International Journal of Rehabilitation Research, 28, 187 – 201 Finkenflügel, H., Cornielje, H. & Velema, J. (2008). The use of classification models in the evaluation of CBR programmes. Disability and Rehabilitation 30, 348–354 Helander, E. (1999). Prejudice and dignity. An introduction to community-based rehabilitation. (Geneva, United Nations Development Programme) Helander, E., Mendis, P. & Nelson, G. (1983). Training disabled people in the community. (Geneva, WHO) Helander, E., Mendis, P., Nelson, G. & Goerdt, A. (1989). Training in the community for people with disabilities. (Geneva, WHO) ILO, UNESCO & WHO (1994). Community-based rehabilitation for and with people with disabilities. Joint Position Paper (Geneva). Retrieved June 4, 2007 from http://whqlibdoc.who.int/ publications/2004/9241592389_eng.pdf Mannan, H. & Turnbull, A. P. (2007). A review of community based rehabilitation evaluations: quality of life as an outcome measure for better evaluations. Asia Pacific Disability Rehabilitation Journal, 18, 29 – 41 McLaren, P. & Phillpott, S. (1998). Indicators in disability research. (In: H. Cornielje, J. Jelsma & A. Moyo (Eds.) Proceedings of the workshop on research informed rehabilitation planning in Southern Africa (pp. 35 – 41) Harare, University of Zimbabwe) Miles, M. (1998). Professional and family responses to mental retardation in East Bengal and Bangladesh, 1770s – 1990s. International Journal of Educational Development, 18, 487 – 99 Miles, M. (2000). Disability on a different model: glimpses of an Asian heritage. Disability & Society, 15, 603 – 618 Miles, M. (2001). Deafness and blindness, disability and inclusion, in West African tradition and modernity: review of books and materials. Disability World, 7. Retrieved June 4, 2007 from http://www.disabilityworld.org/03-04_01/resources/bookreviews.shtml

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Miles, M. (2002). Children with Hydrocephalus and Spina Bifida in East Africa: can family and community resources improve the odds? Disability & Society, 17, 643 – 658 Miles, M. (2003). Knowledge and management of disabling conditions in South Asian histories: implications for leprosy futures. Indian Journal of Leprosy, 75, 153 – 167 Park, J., Hoffman, L., Marquis, J., Turnbull, A. P., Poston, D., Mannan, H., Wang, M. & Nelson, L. L. (2003). Toward assessing family outcomes of service delivery: validation of a family quality of life survey. Journal of Intellectual Disability Research, 47, 367 – 384 Powell, B. A., Mercer, S. W. & Harte, C. (2002). Measuring the impact of rehabilitation services on the quality of life of disabled people in Cambodia. Disasters, 26, 175 – 191 Stewart, R. & Bhagwanjee, A. (1999). Promoting group empowerment and self-reliance through participatory research: a case study of people with physical disability. Disability and Rehabilitation, 21, 338 – 345 Summers, J. A., Poston, D. J., Turnbull, A. P., Marquis, J., Hoffman, L., Mannan, H. & Wang, M. (2005). Conceptualizing and measuring family quality of life. Journal of Intellectual Disability Research, 49, 777 – 783 The WHOQOL Group (1995). The World Health Organization Quality of Life assessment (WHOQOL): position paper from the World Health Organization. Social Science and Medicine, 41, 1403 – 1409 The WHOQOL Group (1998). The World Health Organization Quality of Life Assessment (WHOQOL): development and general psychometric properties. Social Science and Medicine, 46, 1569 – 1585 UN Millennium Project (2005). Investing in development: a practical plan to achieve the millennium development goals. Overview. (New York, UNDP). Retrieved June 4, 2007 from http:// www.unmillenniumproject.org/documents/overviewEngLowRes.pdf Velema, J. P. & Cornielje, H. (2003). Reflect before you act: providing structure to the evaluation of rehabilitation programmes. Disability and Rehabilitation, 25, 1252 – 64. Walt, G. & Vaughan, P. (1981). An introduction to the primary health care approach in developing countries. A review with selected annotated references. (London, Ross Institute of Tropical Hygiene, publication 13) Werner, D. (1990). Project Projimo. CBR News, 4, 9 – 10. WHO (1976). Disability prevention and rehabilitation (Geneva, WHO, No. A29/Inf.Doc/1.28) WHO (1981). Disability prevention and rehabilitation. (Geneva, WHO Technical Series no. 668) WHO (1982). Community based rehabilitation. Report of a WHO interregional consultation Colombo, Sri Lanka, 28 June – 3 July 1982 (Geneva, WHO) Wirz, S. L. & Thomas, M. (2002). Evaluation of community-based rehabilitation programmes: a search for appropriate indicators. International Journal of Rehabilitation Research, 25, 163 – 171 Wolfensberger, W., (Ed.) (1980). A brief overview of the principle of normalization. Normalization, social integration & community services. (Baltimore, MD: University Park Press) Wolfensberger, W. (1985). Social role valorization: a proposed new term for the principle of normalization. Mental Retardation, 21, 234 – 329 Wolffers, I. (2000). Empowerment of sex workers & HIV prevention. Research for sex work, 1 – 3. Retrieved June 4, 2007 from http://www.nswp.org/pdf/R4SW-03.PDF Wolffers, I. & Finkenflügel, H. (1993). PHC and CBR: concepts for empowerment. (In H. Finkenflügel (Ed.) The handicapped community. The relation between primary health care and community based rehabilitation (pp. 5–16) Amsterdam: VU University Press)

Index

A Abuse of (state power), power abuse, 8, 161, 164, 169, 171, 174 Accessibility, accessibility of services, service accessibility, 8, 177, 180, 183–189 Access (to social services), 139–157 Accountability accountability to the people, 120, 155 holding governments accountable, 3, 8 Activities of daily living, 266, 271 Affect-cognition dimension, 201–202, 215 cognitive evaluation, 205 Affect (positive affect, negative affect), 198–206, 208–214 African National Congress, 17, 19, 23 AIDS, See HIV/AIDS Alaska, 27, 29–38 Alcohol abuse, 226–227, 230, 232–234 Algeria 8, 106, 115–137 Algerian population, 115, 120–122 Alienation, 104, 141, 230 Amputation, 59–77, 272 Amputees, 1, 7, 59–77 Analysis themes, 27, 29 ANOVA analysis, 199, 209 Antiretroviral treatment programmes (ART) eligibility for ART (treatment), 233 antiretroviral(s), 17, 150, 224–226, 232 antiretroviral treatment, 150, 224, 232 Asylum seeker(s), 8, 139–141, 143–157 asylum seeker permit, 153 ‘Art of life’, 81–82 ars vitae 81–82, 84, 95 Arctic, 7, 27–40 Attitudes to migrants, 8, 149, 210–211, 214 Australia, 52, 54, 59–67, 69–71, 74–77, 116–117, 119, 124–125, 131, 137 Authoritarianism, 199, 207–208

B Barriers, 88, 143, 146, 148–149, 153–154, 259. See also Hurdles and cultural barriers Basic needs, 6, 102, 151, 268–269 Basic rights, 142 Basic security, 84, 87, 92–93 Beach Centre Family Quality of Life scale (FQOL), 272 ‘Better life for all’, 17 Biodiversity, 3 ‘Black decade’ (Algeria’s ‘black decade’) 119 Black economic empowerment, 13, 18 Black middle class, 13–14 Boredom, 73, 76 Bottom-up models (of well-being), 204–205. See also Top-down models Buffer(s) buffering effect, 167–169, 172–173 buffering of distrust, 161, 173

C Canada, 27, 29–36, 38, 53, 106 Capability/ies capabilities approach, 83, 88 educational capability approach, 88 Carnegie Report (Second Carnegie Inquiry into Poverty & Development in Southern Africa) 19, 21, 23, 25 Chukotka, 27, 29–38 Challenges, 1–9, 24, 88–89, 139–142, 145–146, 151–153, 156, 231–232, 239–241 Chronic health problems, 76, 234 Civil service, 161–164, 166, 168–174, 243–245 Climate change, changes of climate, 3, 5, 7 Closeness to nature, 35, 40 Club of Rome (Club of Rome report), 5

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276 Cold War, 6 Common health problems, 253 Community-based rehabilitation (CBR), 9, 265–272 Community connectedness, 124–125, 133, 135 Community development, 9, 265, 268–273 Community quality of life, 3, 182 Comparability, 45–58, 117, 124 Comparative international surveys, 161. See also Cross-national surveys Compensation policy, 109 Complexity/Complexities, 2, 59, 61, 68, 77, 182–183, 190, 233 Compliance adherence to ART, 232 ART compliance, 235–236 treatment compliance, 232–233 Comprehensibility of questions, 60 Concentration of populations, 177 Confidence, 56, 94, 132, 165–166, 173, 249, 261 Congestion, 8, 185, 190 Context contextual changes, 137 importance of context, 76 sensitivity to contextual changes, 137 Convenience samples, convenience sampling, 115, 117, 122 Coping with adversity, 229 Corruption, 117, 120–121, 148, 151, 155, 165–166 Crime, 13, 17, 24, 120, 154 Crisis of confidence, 173 Crisis of legitimacy, 105 Cross-national studies cross-national analysis, 56, 102, 106, 111–112 cross-national comparisons, 49, 112 cross-national design, 101, 105 cross-cultural study/ies, 124 Cultural barriers, 88, 259. See also Barriers Cultural bias (in measurements), 7 Cultural continuity, 34, 36, 40 Cultural diversity, 3 Cultural identity, 40 Cultural significance, 29

D Daily quality of life, 8 Deconstruction of satisfaction with life as a whole, 124 Democracy, hallmarks of (modern) democracies, 2–3, 7–8, 14, 54, 102–103, 110–112, 116–117, 143. See also Direct democracy

Index Democratisation/Democratization Democratization index, 106–107 of rehabilitation services, 270 Depression, 24, 59–60, 73–74, 76, 85, 226–227, 230, 232, 233 depressive disorder, 226 Derogatory labels, 147 Developing country/ies developing country contexts, 226 developing country in transition, 8, 115–137 Diabetes, 63–65, 239–240, 246–247, 250, 252–254, 258 Dignity, 146, 156–157 Direct democracy, 102. See also Democracy Direct effects, 161, 174 Disability Adjusted Life Years, 250 Discrimination, 144, 226, 229 Discourses on health, health discourse(s), 242–244, 260 Diseases of modernity, 242–244. See also Modernity Disclosure non-disclosure, 232 selective disclosure, 231–232 Domains domains/aspects of daily life, 199, 202 domains of life quality, 2 life domains, 2, 66, 72, 76, 196, 202, 204–214 Drivers of HIV infection, 224–225

E Eastern/Western Europe, 8, 53, 161–174 Economic approach (to quality of life), 194 Economic disparities, 177, 182 Economic growth, 4–5, 13, 17–18, 101–102, 106–108, 111–112, 116, 119, 239–240, 261 Economic migrants, 140–141, 147, 251 Education educated human being, 3, 88–90, 117 educational meaning and content, 88 Ellison’s Spiritual Well-Being Scale, 91. See also Spirituality Emotional well-being, 201, 204–206, 272 Employment equity, 13, 18 Empowerment, empowerment in rehabilitation, 270 Encampment, 140 Environmental risks, 234, 251–252 Envy, 24

Index Epidemiology risks, 9, 234, 236 transition, 239–240, 249–250 Equalization of opportunities, 269 Eudaimonic theory, 5 European Values Study (EVS), 161–162, 165–166, 168, 174 Evaluation of life conditions, 194 Expectations for a better life, 4, 141

F Fear, 24, 73, 112, 209, 234–235, 254, 272 Flanders (Belgium), 8, 49, 116, 176, 193, 197, 206 Flemish, 8–9, 193, 197 Food security, 8–9 Forced migrants, 8, 139–157 Four qualities of life (matrix of), 84–87 Free riders, 3 Freedom, 3, 25, 85, 90, 102, 106–107, 117, 143–144, 179, 181, 198, 254 Frustration, 73, 76, 121, 147, 240 Fuel, 3, 19, 28, 145, 156 Functionings, 177, 179–183, 189 Future security, 124–127, 132–133, 135

G General health, 60, 63–66, 74–76 Global era, 4–5 Global inequality, 3 Global measures (of well being), 202, 205, 215 Global warming, 3, 7. See also Climate change Globalisation, 1–2, 4 Good life, 2–4, 6, 81–85, 90–93, 95 Governance, good governance, 1–3, 8, 19, 25, 102, 106, 117, 120–121, 165 Governance Matters Data, 106 Government intervention, 8, 14–15, 193 Government propaganda, 136 Greenland, 27–35, 37–38 Grief, 60, 76 Growth, Employment and Redistribution (GEAR) strategy/policy/programme, 17, 144 Guilt, 24

H Happiness, 7–9, 45–59, 81–84, 90–95, 101–103, 105–112, 116, 179–180, 201–206, 244 Happiness in nations, 50, 52–54, 56, 116–117 Health

277 Health care for all, 1 Health challenges, 224, 239–240 Health-related quality of life, measures of, 7, 9, 59, 61–62, 65, 242 Health risks, contemporary health risks, 249–252 Health seeking, health-seeking behaviour, 239–241, 246–247, 259 Health transition(s), 66, 76 Health and wellbeing, connection between health and wellbeing, 39, 242, 254–256, 261 Healthcare reforms, 260–261 Hedonic treadmill, 4 High risk society, 5. See also Risk Hinterlands, 185–188 HIV/AIDS epidemic, 9, 223–225 intervention(s), intervention programmes, 9, 236 mental health co-morbidity, 235–236 prevalence, 225 programmes, 235–236 response/strategies, 223–224, 229, 236 success story, 251 HIV infection risk, 233–234 HIV positive, 9, 16, 223, 225–236 HIV positive status, 227–231, 234, 235 HIV+, 24 Hobbes, T., 163, 168 Holistic health, 242–244, 260 Homeostatic effects, 60–61 Homo economicus, 194 Hong Kong, 52–54, 119, 124–125, 131 Hopelessness, 59–60, 230, 232 Household production model, 29, 30 Household resources and needs deprivation indices, 253 Housing, 6, 13, 16, 85, 118–120, 139, 141, 142, 144, 145, 150, 151, 156, 178–179, 251–252 Human being, satisfaction as a .., 202, 204–206 Human concerns, 82 Human development index, 6, 16 Human rights culture, 4, model, 9, 265, 271–272 Hunger-crying, 22 Hurdles, 112, 114. See also Barriers

I Identity markers, 35 Ill-health, 239, 240, 253–254

278 Immigrants, 7, 20, 82, 110, 146, 147, 153 Impoverished living conditions, 120, 224. See also Living conditions Income distribution, 13, 103 Indigenous identity, 35, 36 Indigenous people(s), 27–29, 35–37, 40 Individual well-being, 27–29, 60, 61, 177–178 Individualism, 199, 207, 208, 212 Inequalities, 1, 3, 4, 17–19, 24, 56, 82, 104–105, 182, 224, 239, 261 In-depth interviews, 59, 76 Inflation, 8, 14, 15, 17, 101–104, 106–112, 119 Informal economy, 28, 122 Informal sector(s), 110, 244–245 Information and Communication Technologies (ICT), 190 Infrastructure, 6, 13, 14, 16, 117, 119–121, 151, 179, 224, 241 Innovative (public) policies, 8, 189, 190 Instability. See also Stability approach, 102 variable, 102–103 Institutional history (of Eastern Europe), 168, 171 Instrumentation, need for, 272 International Society for Quality-of-Life Studies (ISQOLS), 1, 4, 6, 7, 20 7th conference of, 1, 6 International Wellbeing Group (IWG), 117, 118, 124 International Wellbeing Index (IWI), 115, 117, 121, 123–125, 131, 132, 136, 137 Italian Multipurpose Survey on Families, 183–184 Italy, 176, 177, 183–190 Inuit, 27–40 Inuit identity, 35, 37 Investment, 13, 15–17, 119–120

J Johannesburg, 8, 24, 139–157 Justice, 5, 7, 17, 25, 83, 142, 162, 164–171, 174, 176, 180. See also Social justice Justice system, 17, 162–170, 174

K Karma, 244 Keiskammahoek Rural Survey, 20 Knowledge society, 2

Index L Large-scale survey(s), 45–46, 115 Latin America, 104, 106–109, 111 Legal/illegal migrants, 147–149, 155 Leprosy, 267 Life-ability, 85, 86, 90 Life as a whole, (satisfaction with), 38–40, 46, 117–118, 121, 123–124, 132–135 Life chances, 3, 8–9, 85, 86, 112 equal life chances, 9 Life choices, 86 Life domains, 2, 66, 76, 196, 201–202, 204–214. See also Domains Life expectancy, 6, 16, 24–25, 225, 239, 240 Life opportunities, 86 Life satisfaction, 8, 28, 45, 47, 53–54, 91, 101–103, 105–112, 115–116, 161–174 Life styles, 2, 4, 8–9, 27, 31, 37, 38, 40, 54, 85, 89–90, 139, 182, 189–190, 260 Linear transformation, 47 Liveability, livability, 85, 86, 101–102, 185, 195 of environment, 85, 86 Living conditions, 27–40, 54, 105, 120, 141, 152, 180, 182–183, 195, 196, 224 in the Arctic, 27–40 Longevity, 3, 8–9 Longitudinal study/ies, 8 Low-income country/ies, 124–125 Lower-limb amputees, 7, 59–77

M Male dominant societies, 135–136 Mass communication, 4–5 Material conditions, 215 Material progress, 101–102 Mbeki and AIDS, 13, 16. See also HIV/AIDS Measurement, 1, 7, 45, 47, 51, 60–61, 115–117, 124, 193, 196, 200–202, 205–206, 210 Mental disorder(s),121, 226–229, 232–236, 268 diagnosable, 226, Mental health, 9, 59–65, 72–77, 82, 85, 104, 141, 223–236 support needs, 226 Mental illness, 141 Meta-analysis, 50–51 Methodology, 61–62, 195, 197–198, 239–241, 272 Mobility, 8–9, 66, 75–76, 110, 177–190, 272 Modern lifestyles, 8–9. See also Life styles Modern technologies, 8 Modernity, 82, 242, 244, 250, 255 contradictions of, 255

Index Monitoring function of quality-of-life studies, 7 Middle income countries 104, 265–267, 272 Millennium, new millennium millennium bug, 5 millennium challenge, 1, 6 Millennium Development Goals (MDG), 2–3, 5–6, 265, 271–273 Minimum standard of living, 180 Mixed cash-and harvest herding based economy, mixed economy, 27–40 Mixed methods, 75–76 triangulation, 61 Mobility, 8, 66, 75, 76, 110, 177–190, 272 Moral personhood, 242 Mother-to-child HIV transmission, 233 Multicephalic process of urbanization, 189 Multilayered disparities, disparities that are multilayered, 183 Multiple discrepancies theory, 196, 211 Multiple drug resistant-tuberculosis (MDR-TB), 232 Mutual causality, 227

N Narratives, 59–77 National Wellbeing (NWB), 117, 119–121, 125, 126, 129, 130, 132, 135 National Wellbeing Index (NWI) 115, 117, 118, 121, 123–127, 129–131, 135–137 Non-communicable diseases, 239, 240, 249–250 Number of response options, See Response options

O Operationalization/operationalisation, 165–166, 198–199 Opportunities for self improvement, 139 Optimal city size theory 177–178. See also Urban size Outcomes-based model of education, 90 Over-the-counter medicine, 260–261 Overall life satisfaction. 45–46. See also Life satisfaction and Global measures

P Pain, in muscles and joints, 249–250, 252–253 Paradigm shift, 9, 265, 268, 271–272 Participation in social life, 215 Pax Americana, 6

279 People living with HIV/AIDS (PLWHA), 9, 226, 251 People with disabilities, 244–245, 253, 257–258, 265–272 Perceived quality of life, 193–216, 232 Personal safety, 123–124, 135, 137 Personal Well-being, (PWB), 115–137, 178–179, Personal Wellbeing Index (PWI), 115–118, 121, 123–127, 129–132, 134–137 Physical functioning, 59, 63, 64, 66–67, 74–76 Police, 17, 142, 147, 154, 161, 162, 164–174, 176, 184–187 Political culture, 173–174 Political migrants, 140–141 Political propaganda, government propaganda, 136, 179–180 Political regime, 105, 111–112 Political science approach, 195 Political stability, 8, 14, 101, 106–107, 110, 111, 120, 135 Population surveys, 47, 50, 52 Positive environment, 9, 236 Post-material values/Postmaterialism, 177–178, 199 Post-rehabilitation, 59. See also Rehabilitation Poverty enduring, 19, 21, 23 dimensions of, 23 markers of, 23 Poverty research, milestones in poverty research, 7, 19–21, 23–25 reduction, 271, Uprooting Poverty: the South African Challenge, 21–23 Powerlessness, 213, 215 Preferred lifestyle, 38. See also Lifestyle Prejudice, 104–105, 144, 146–148, 156 Price stability, 103–104, 112 Primary goods, 180 Primary health care, 153, 268, 271 Principle component factor analysis, 132 Priorities in life, 133 Private sphere, 215 Pro-poor, 240–241 Project for Statistics on Living Standards and Development (PSLSD), 23, 24 Prospective life satisfaction, future life satisfaction, 161, 163, 171–174. See also Life satisfaction Psychological well-being/psychological wellbeing, 73–74, 198–199 Psychosocial support(s), 223, 227

280 Public goods, 3 Public transport, (efficient), 180

Q Quality of life, 1–9, 13, 15, 19–25, 28, 40, 45, 52, 54, 59–62, 65, 72, 75–77, 81–95, 101, 102, 104, 116, 150, 152, 164, 177–183, 189, 190, 193–195, 204, 232, 234, 239–242, 253, 265–266, 272 Quality of urban life, 178, 183

R Race relations, 13, 15, 17, 20 Racial engineering, 13 Racial restructuring, 13, 18 ‘Rainbow nation’, 143, 153, 157 Rapid change(s), 2, 5, 8, 40, 106, 116 Reach, concept of reach of the individual, 183 Real-time news, 5 Relevance of questions, 60 Refugee(s) Refugee Act, 143–145, 150, 152 refugee status, 140, 141, 143 Regime instability, 101–112. See also Instability Regression modelling, 103, 111, 171, 206, 207 Rehabilitation goals, 77 in institutions, 265–268 in low-and middle income countries, 266, 267 Relative deprivation, 4 Remote concerns, 207 Resilience, 74, 77, 85 Re-scaling, 45 Resource theory, 193, 196, Response options number of response options, 48–51 verbal response options, 45, 47–48, 51, 52, 54 wording of response options, 46, 48, 50, 51 Ridge regression equations, 110 Rising incomes, 13, 102, 116 Risks, escalating risks, 1, 5, 9, 234, 236, 241, 242, 249–251 Role limitation, 64, 65, 67–68, 72–77 Romania, 52–54, 106, 119, 124, 166, 176 Rule of law, 117, 162, 164, 165 commitment to, 162, 164 Rural migrants, 110

Index S Safe sex practices, 233 Sami, 28 Satisfaction with life scale, 201, 203 with life as a whole, 38–40, 124, 133–135 Satisfactory quality of life, 81, 93, 95 Scale interval recorder, 45, 55 Scale maximum (%SM), 47, 124 Scarce resources, 3, 154 Scenarios, 4, 163, 171–174, Search for truth and meaning, 81 Self-esteem, 199, 207, 208, 212–215 Self-care, 66, 242, 244, 246, 257–258 Self-developed questionnaires, 271 Self-reported health, 59, 62 Self respect, 253 Self-stigma, 232 Self-worth, sense of self-worth, 24 Sense of entitlement, 4 Sense of isolation, See Social isolation Sense of local control, 39 Service delivery, 142, 144, 148, 154, 155 SF-36 instrument, 69, 75, 76 scale(s), 63 scores, 7, 64, 68, 70 Single direct questions (to measure happiness), 46 Skills deficit, 13, 334 Skill(s) shortage(s), 13, 14, 16, 18 Social capital, 208–209 Social change, 5, 8 Social conditioning, 89, 117, 124, 125, 127, 132, 133, 179, 225 Social context, 73, 88, 115, 211, 244 Social exclusion, 156 Social functioning, 63–65, 71–72, 75–77 Social grants, 13–15, 156 Social indicator movement, 2 Social indicators (of the good life), 7, 88, 115, 117, 194, 195, 215 Social integration, 199, 211, 213–215, 269 Social isolation, 60, 61, 141 Social justice, Rawlsian theory of, 7, 83, 142, 180 Social networks, 71, 72, 76, 155, 189, 215 Social order, compliance with, 8, 105, 163, 174 Social policy, 101, 106, 107, 110, 111, 195 Social protection, social (protection) policy, 101, 103–105 Socially relevant, 88, 89

Index Social rights, 102, 105 Social services, (access to) social services 137–157, 177–190, 266, 269. See also Accessibility Social spending, 105, 106, 110, 111 Social status, 91, 105 Social stigma, 226 Social support, 72, 77, 164, 199, 211, 213–215, 232 Societal domains 117, 124, 131, 132, 136. See also Domains Sociological approach, 182 Sophisticated services, 178, 185 South Africa, 6–9, 13–25, 49, 52, 53, 108, 116–118, 139–156, 223–227, 229, 231, 233, 235 South African Constitution, 139, 142, 143, 148, 149, 154 South African Survey, 7 Spare time use, 118, 134, 135 Spiritual development spiritual dimension (of quality of life/ well-being), 7, 28, 81–95 spiritual health, 254 spiritual identity, 92 Spirituality, 81–95 matrix, 84, 92–94 Squatter settlements, 110 Stability, 1, 7, 8, 14, 101–112, 115–137, 233. See also Instability Stabilized democracy, 2–3, 7, 8, 14, 54, 102, 103, 110–112, 116–117, 143. See also Democracy Stereotypes, 147 Sub-clinical levels of depression, 24, 59, 73, 74, 76, 85, 226, 227, 230, 232, 233. See also Depression Subjective experience, 91, 194, 215 of daily life, 215 Subjective indicators, 116, 193, 195 Subjective quality of life, 91, 239–241, 253, Subjective well-being, 37–39, 101–112, 116, 117, 137, 193–216 Sub-Saharan Africa, 106–109, 111, 224 Subsistence activities, 28–32, 36–40 Subsistence way of life, 40 Successful ageing, 82 Sustainable development, 3, 7 Survey of Living Conditions in the Arctic (SliCA), 27–40 Synthetic studies (of happiness), 48 research synthesis, 48, 50

281 T Thailand, 9, 239–261 Third World societies, 2, 4, 104, 121, 135 Thurstone transformation, 45, 47 Time poverty, 260 Time studies (time-use studies), 188 Top-down models, 204, 205. See also Bottomup models Traditional food, 30, 32–36, 40 Traditional healers, 242, 244, 246, 256 Traditional health beliefs, 244 Traditional medicine, 239, 241, 248, 255, 257–260 Traditional skills, 33, 34, 39 Translation error/problem, 49, 50 Transport system, 177–180, 189 Travel time index, 178, 179 Trust definition of, 176, in institutions, 8, 161–163, 165 Trustworthiness of state agencies, institutional trust (worthiness), 161–175

U Uncertainties, 1, 2, 5, 24, 84, 163 Unemployment, 8, 13, 15, 17–19, 23, 24, 101–104, 106–109, 111, 112, 119, 121, 144, 150, 209, 227, 269 Uneven development, 241, 251 Unintended (negative) consequences, 9, 173 Universal health care, near-universal health care, 239 Universal health coverage (scheme), 239, 240, 244, 248, 261 Universal health insurance, 240 Urban disparities, 189 Urban influx, 101, 103, 110 Urban migration, 101, 111 Urban mobility, Urban Mobility Report, 177–179 Urban pressure thesis, 104 Urban size, city size, 177, 178, 181–186, 188–190, 195 Urban sustainability perspective, 104 Urbanisation, 6, 8, 24,

V Validity, 55, 60, 90, 115, 124, 132, 180 Verbal response options, 45–56. See also Response options Vicious circle, 227 Village Health Volunteers, 242

282 Vitality, Vitality scale, 63–65, 70–71, 77 Voluntary counselling and testing, voluntary counselling and HIV testing, 1, 9, 13, 16, 19, 24, 25, 223–236, 250, 251. See also HIV/AIDS Vulnerable groups, 147, 156

W Water, access to water, 19, 20, 22, 23, 121, 144, 154, 177–190, 251, 257, 259. See also Accessibility Wealth and happiness, link between, 102 Web-based (variation of this) rating method, 47 Well-being/wellbeing, 3, 5, 7–9, 27–29, 37, 39, 59–77, 82–84, 90, 91, 101–112, 115–137, 196, 199, 204, 209–211, 239–242, 254–256, 260, 261 Wellbeing in Developing Countries ESRC Research Group, 239–241

Index Well-educated to be/being well-educated, 89–91 indicators of being well-educated, 95 well-educated person, 89, 90 Wording of response options, See Response options World Database of Happiness, 45, 46, 50, 54, 56, 83 World Health Organisation Quality of Life Assessment (WHOQOL), 272 World soccer cup, 16 World Values Survey, 52, 56, 101, 105, 162

X Xenophobia, 140, 144, 146–148

Z Zero-order correlations, 107, 110

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