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The Well-Being Index WHO-5: hedonistic foundation and practical limitations
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  1. Amalie Oxholm Kusier,
  2. Anna Paldam Folker
  1. The Research Department for Health and Social Context, National Institute of Public Health, Copenhagen, Denmark
  1. Correspondence to Amalie Oxholm Kusier, National Institute of Public Health, 1455 Copenhagen, Denmark; amok{at}sdu.dk

Abstract

Research and policymaking on positive mental health and well-being have increased within the last decade, partly fueled by decreasing levels of well-being in the general population and among at-risk groups. However, measurement of well-being often takes place in the absence of reflection on the underlying theoretical conceptualisation of well-being. This disguises the fact that different rating scales of well-being often measure very different phenomena because rating scales are based on different philosophical assumptions, which represent radically different foundational views about the nature of well-being. The aim of this paper is to examine the philosophical foundation of the Well-Being Index WHO-5 in order to clarify the underlying normative commitments and the psychometric compromises involved in the translation of philosophical theory into practice. WHO-5 has been introduced as a rating scale that measures the affective and hedonistic dimensions of well-being. It is widely used within public health and mental health research. This paper introduces the philosophical theory of Hedonism and explores how two central assumptions that relate to hedonistic theory are reflected in the construction of WHO-5. The first concerns ‘the hedonic balance’, that is the relation between positive and negative emotions. The second assumption concerns ‘the value of emotions’, that is, how to determine the duration and intensity of emotions. At the end, Hedonism is contrasted with Life Satisfaction Theory, an alternative foundational theory of well-being, in order to clarify that the outlook of WHO-5 is more a rating system of positive affect than a cognitive judgement of overall life satisfaction. We conclude that it is important to examine the philosophical foundation of rating scales of well-being, such as WHO-5, in order to be fully able to assess the magnitude as well as the limits of their results.

  • philosophy

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Introduction

Empirical research on mental health and well-being has increased significantly during the last twenty years alongside a growing conviction that it is possible to measure people’s well-being, and that the results can be used in guiding governmental decisions.1 2 As part of this development, the positive dimensions of mental health and well-being have attracted considerable attention.1 This has mainly been due to efforts to measure and to monitor the well-being of populations, and to develop interventions to ameliorate decreasing levels of mental health and well-being among at-risk groups.3 4

Empirical research on well-being is concerned with individuals’ subjective experiences of their lives. It is based on the assumption that well-being can be defined by people’s conscious experiences in terms of their own emotions or cognitive satisfaction,5 6 and that people are able to evaluate themselves and the degree to which they experience emotions of well-being.7 In this context, well-being is defined by people’s subjective emotions or judgements, rather than by objective circumstances such as income, employment, or living conditions.5 Hence, it is possible to report positive well-being in spite of physical disabilities or dysfunction.8

In a broader perspective, there is a great deal of controversy among philosophers and psychologists about the concept and nature of well-being.5 However, these disputes mainly take place within, rather than across, professional disciplines. There seems to be at least three different approaches to the understanding of well-being. In the philosophical tradition well-being has typically been the centre of a normative discussion about the nature of the good life. A person’s well-being in this sense concerns what is ultimately good for her.9–11 There are several competing theories about what ultimately constitutes a good life; that is to experience pleasure, to have one’s desires and preferences fulfilled, or to live a life that can be recognised as good from a more objective perspective.9 12 Within psychology well-being is mainly studied (and measured) as a psychological state. It is often referred to as ‘subjective well-being’ referring implicitly to specific cognitive–affective subjective states.13 14

What interests us here is the third approach to the understanding of well-being. It is taken by contemporary philosophers, but it relates to the psychological approach because it focuses on the nature of the psychological state of well-being (sometimes also referred to as ‘happiness’).10 11 Several different mental states have been considered as potential candidates for the constitution of well-being.5 11 According to a prevalent view, well-being is to be defined as a cognitive state, namely, a cognitive assessment of one’s life.5 The theory of Life Satisfaction is based on this view. Life Satisfaction Theory equates well-being with a cognitive attitude of being satisfied with one’s life as a whole.11

Another dominant contemporary, philosophical view defines well-being as ‘Hedonism’, that is in terms of pleasant affective states, rather than cognitive states.5 7 The word ‘hedonism’ comes from the ancient Greek word for ‘pleasure’. Within the philosophical tradition, hedonistic theory comes in two different versions. One version is Psychological Hedonism which claims that only pleasure or pain motivates us. The other version is Ethical hedonism which claims that only pleasure has value and only pain (or displeasure) has disvalue.15–18 While the first version is essentially descriptive because it attempts to describe what ultimately motivates human beings, the second version is normative because it evaluates what ultimately has intrinsic value. Reflecting both versions of traditional hedonistic theory the contemporary concept of ‘Hedonism’ is used as a philosophical theory about the nature of the psychological state of well-being.10 In this context, Hedonism defines well-being as a phenomenon that consists in the experience of predominantly pleasant states of mind.11 Hence, it is at the same time a descriptive claim about what constitutes well-being as a psychological phenomenon, and a normative claim about how we should conceptualise well-being.

Reflecting the two different foundational views about the nature of well-being; Life Satisfaction Theory and contemporary Hedonism,i there broadly exist two different kinds of empirical, psychometric approaches to the measurement of well-being: the cognitive approach and the affective approach. The cognitive approach consists of questions like ‘How satisfied are you with your life’,19 or ‘Please imagine a ladder with steps numbered from zero at the bottom to ten at the top. Suppose we say that the top of the ladder represents the best possible life for you and the bottom of the ladder represents the worst possible life for you. If the top step is 10 and the bottom step is 0, on which step of the ladder do you feel you personally stand at the present time?’.20 The affective approach consists in probing people’s emotional responses, for example by asking them to report how they are feeling while they are engaged in a broad variety of activities, or asking people to rate the extent to which they have felt ‘cheerful and in good spirits’ over the last 2 weeks.3

Most often, measurement of well-being and discussion of underlying philosophical theories about the nature of well-being take place independently of each other, with sparse or no mutual dialogue.1 This is unfortunate, as both approaches to well-being can learn from one another. Theoretical approaches can benefit from an understanding of how it is practically possible to measure well-being, including an understanding of the practical compromises this may imply. It may not always be possible or even optimal to cover all aspects of a theory in a measuring instrument due to pragmatic reasons and reasons of psychometric validity. Such knowledge of practical limitations may provide valuable feed-back to theory—not just to enable the understanding that practical application involves compromise but also as relevant supplementary criteria for the evaluation of theoretical development which otherwise may have a tendency to wander off in its own direction.

Conversely, measurement approaches can benefit from a better understanding of the philosophical assumptions as well as the theoretical complexity behind rating scales, which may express underlying and sometimes unarticulated normative choices and commitments.19 The joint labelling of well-being scales as ‘well-being scales’ may disguise the fact that they often measure very different underlying phenomena. For instance, it makes a huge difference for the interpretation of results over time whether a scale measures cognitive states of life-satisfaction, which are relatively stable, or affective states of positive or negative emotions, which are much more sensitive to contextual factors such as sleep, social relations and job-related pressures. A better grasp of underlying theory may provide an important context for understanding empirical results of well-being measurement and their practical limitations.21 This may also provide a key to the understanding of potential variation between the results of different scales, which does not necessarily imply a lack of validity of rating scales but may reflect the fact that they measure very different phenomena.

The aim of this paper is to examine the philosophical foundation, as well as the outlook and limits, of the Well-Being Index WHO-5—a widely used instrument for the measurement of well-being within public health and mental health research—in order to clarify its underlying normative commitments, along with the psychometric compromises involved in the translation of philosophical theory into practice.

The Well-Being index WHO-5

The Well-Being Index WHO-5 was designed by the Danish professor and psychiatrist Per Bech in 1998 in collaboration with the WHO.22 23 WHO-5 was introduced as a rating scale that measures the affective and hedonic dimensions of subjective well-being.22 24 At the time of development, WHO-5 was part of an international project that aimed at measuring the degree of well-being of patients in primary healthcare in a manner that reflected the positive tone of WHO’s definition of health as ‘a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity’.1 8 23

Since its release, WHO-5 has been translated into more than 30 different languages, and has been widely used to assess well-being in various scientific contexts worldwide.23 25 A systematic review has concluded that WHO-5 has high validity, and is especially useful for measuring the effects of treatments on well-being across multiple patient and population groups.23 Moreover, the structure of WHO-5, with its five simple items, has been found to be easy and manageable to answer, and to pose few translation problems.23

WHO-5 is a generic rating scale which can be used to measure well-being in non-clinical populations (ie, the general public) and across specific patient groups. It has been used in a variety of different contexts: in routine care, to measure well-being of adolescents with type 1 diabetes26; as an initial screening tool for the risk of depression among older people27; to measure well-being among children and adolescents28 29; and to identify subjects at the risk of committing suicide.23

WHO-5 contains five positively formulated items covering how the respondent has felt over a 2-week period (see table 1).22 23 25 As other self-report measures it relies on the assumption that respondents not only experience their own emotions, but that they are able to relate them to the rating scale.30 Scoring is done using a Likert scale from 5 (all of time) to 0 (at no time), yielding a raw score that theoretically ranges from 0 (absence of well-being) to 25 (maximal well-being). The result is multiplied by four, which gives a percentage scale from 0 to 100 on which 0 is the worst imaginable well-being (quality of life) and 100 is the best imaginable well-being (quality of life).22 23

Table 1

The Well-Being Index WHO-5

Hedonism and WHO-5

In this section, we will introduce the philosophical theory of Hedonism, which forms the theoretical foundation of WHO-5, and explore how two central assumptions that relate to hedonistic theory are reflected in the construction of WHO-5. Hedonism is based on the simple idea that pleasure is intrinsically good and pain is intrinsically bad, and that nothing else than pleasure is intrinsically good or bad.31 In the opening sentences of the 18th-century philosopher Jeremy Bentham’s groundbreaking book An Introduction to the Principles of Morals and Legislation, he asserts both Psychological Hedonism and Ethical Hedonism: ‘Nature has placed mankind under the governance of two sovereign masters, pain, and pleasure. It is for them alone to point out what we ought to do, as well as to determine what we shall do’.17 This implies that pleasure (and the absence of pain) is the only thing that ultimately matters for our well-being. It is important to highlight that it is the pleasure we get from pleasant things that is intrinsically good—not the pleasant things themselves.16 32 Drinking coffee can be considered a pleasant thing; however, drinking coffee is not intrinsically good. According to Hedonism, it is the experience of pleasure (derived from drinking coffee) that contributes to our well-being, and which is considered intrinsically good.

Within hedonistic theory pleasure is generally understood broadly including all kinds of pleasant feeling or experience such as delight, elation, enjoyment, exhilaration, gladness and so on. Pain or displeasure is also understood broadly including all unpleasant experience or feeling such as agitation, anguish, annoyance, anxiety, boredom, dejection, depression, despair, discomfort, disgust, fear, grief, horror, irritation and so on.15

Presumably, most people will agree that pleasure has an impact on our well-being, and that the experience of pleasure is good, and the experience of pain is bad. At first sight, therefore, Hedonism may appear as a simple and appealing theoretical conceptualisation of well-being. However, the hedonist believes that all pleasure and only pleasure has intrinsic value which ultimately may have rather radical implications.31 In philosopher Robert Nozick’s famous thought experiment: ’The Experience Machine', he illustrates the radicality of Hedonism as follows: 

Suppose there was an experience machine that would give you any experience you desired. Superduper neuropsychologists could stimulate your brain so that you would think and feel you were writing a great novel, or making a friend, or reading an interesting book. All the time you would be floating in a tank, with electrodes attached to your brain. Should you plug into this machine for life, preprogramming your life experiences?33

The Experience Machine is often used to question Hedonism because the theory seems to imply that we should agree to plug into the machine for life to achieve an endless supply of pleasure. While few apparently would agree to plug into the machine this is taken as an indication that there is more to well-being than the experience of pleasure and the absence of pain.16

In order to understand the implications of the hedonistic foundation of WHO-5 more fully, it is important to consider two central, theoretical assumptions that relates to hedonistic theory. Both assumptions stem from Utilitarian theory which is an ethical theory about morally right action. According to the classical version of Utilitarianism the morally right action is the action that produces the most good.34 Classical Utilitarians, such as Jeremy Bentham and John Stuart Mill, identified the good with pleasure that is they were hedonists about value.17 35 36 The classical Utilitarians espoused impartiality and agent-neutrality. They held that we ought to maximise the good, that is bring about ‘the greatest amount of good for the greatest number’. When one maximises the good, it is the good impartially considered. My good counts for no more than anyone else’s good. The reason I have to promote the overall good is agent-neutral, that is, it is the same reason anyone else has to so promote the good. It does not only apply to me (agent-relative). In what follows, two assumptions of the Utilitarian tradition will be unfolded and discussed in relation to WHO-5. They both relate to the attempt by Utilitarians to operationalise the hedonistic value of pleasure, that is to translate Hedonism into a universal, impartial, agent-neutral ethical theory about morally right action. The first assumption concerns the hedonic balance, that is the relation between positive and negative emotions or between pleasure and pain. The second assumption concerns the value of emotions, that is how to determine the duration and intensity of emotions.

The hedonic balance

A very straightforward formulation of Hedonism defines well-being as ‘the experience of pleasure and the absence of pain’.37 However, this seems too simple, as we can have good well-being even when we are experiencing some level of pain.10 Consider the following case.

Cathrine is sitting on the grass a sunny day, eating ice cream and chatting with her friends. She just got off from work and she is enjoying the warmth from the sun, the sweet taste from the ice-cream and the conversation with her friends. However, she is not sitting very well. Her legs are getting more and more rigid, and her back starts to hurt. Cathrine is experiencing her sitting position as somewhat painful, but she still enjoys the moment.

According to the simple conceptualisation of Hedonism, in this particular moment Cathrine will not have high well-being, because of the unpleasant experience she is having by sitting on the ground. However, this seems intuitively wrong. To define well-being in a way that is conditioned on the complete absence of pain would exclude a wide range of people from the experience of well-being. It would, for example, exclude all those who suffer from chronic pain.

A more nuanced definition of Hedonism avoids the idea of an ‘absence of pain’ by introducing the hedonic balance.10 11 What is essential, according to this form of Hedonism, is to have a positive balance of pleasure over pain.11 The hedonic balance is calculated by subtracting the amount of pain/unpleasant experience that a person feels during a period of time from the amount of pleasure that the person feels during the same period of time.32 If the person has a net balance of pleasure over pain, then she has a high well-being. If Cathrine’s experience of eating ice cream in the sun while talking to her friends produces enough pleasure to outweigh her pains, the higher her well-being at that time. Hence high well-being requires a favourable balance of pleasure versus pain, and low well-being requires an unfavourable balance of pleasure versus pain.11

Measuring the hedonic balance

The items in WHO-5 cover the positive aspects of emotions. This means that the rating scale cannot be used to measure people’s unpleasant (or painful) experiences. Hence it may seem that WHO-5 misses an important element of hedonistic/utilitarian theory. Namely, it can be argued that WHO-5 should have contained items measuring both pleasure and pain, making it possible to register and counterbalance the amount of pleasant experiences with the amount of unpleasant experiences during the last 2 weeks. This seems correct in theory. However, in practice this may clash with objections relating to how a valid rating scale for well-being may be constructed that is also practically feasible.

In a theoretical perspective, the hedonic balance is based on the important assumption that one unit of pleasure is equal in size to one unit of pain, and that the units have opposite values in the sense that the positive value of a unit of pleasure corresponds to the negative value of a unit of pain.32 Against this assumption, it has been argued that it fails to do justice to complex emotional experiences, when pleasure and pain do not form a simple polarity and cannot be understood as ‘opposites’.3 38 39 Rather, emotions should be understood as context-dependent experiences, where positive emotions (eg, love) are not always pleasant, and negative emotions (eg, anger) are not always unpleasant.3 39 Ultimately, this objection questions the basic idea that it is possible to quantify and generalise emotions across various situations. This is a very serious, although also a very controversial, objection. If true, it questions the validity of psychometrics which is premised on the possibility of measuring and quantifying emotions both intrapersonally and interpersonally. It also questions the relevance and validity of hedonistic theory. It is a serious challenge for a theory if its practical application is futile—not only because of lack of practical relevance but also because of reduction in our reasons to accept the theory. In an abstract sense it may be possible for hedonistic theory to be true ‘in principle’ but if the practical application of hedonism is utterly futile this seriously questions what it means for the theory to be ‘true’. We are not able to settle this matter here. So far, the onus lies on emotion research to provide more substantial empirical evidence for the complexity and context-dependency of emotions to the extent that it renders the aggregation of positive and negative emotions impossible or even meaningless.

Another objection, one more sympathetic to the field of psychometrics, concerns the relation between positive emotions (pleasure) and negative emotions (pain). Emotion research has questioned the hedonistic distinction between positive and negative affect as two opposites that (in principle) can be measured on a one-dimensional scale.3 30 According to this research, the relevant psychometric distinction is not between positive and negative affect, but between pleasantness and arousal as two different dimensions that should be measured separately. Hence, there are two dimensions rather than one, and positive and negative affect are relevant for both dimensions. While the pleasantness dimension goes from pleasant (happy, pleased) to unpleasant (miserable, sad, unhappy), the arousal dimension goes from aroused (active, energetic) to unaroused (quiet, still).40

Emotion research thus introduces complexity into the measurement of positive and negative affect. How does this relate to WHO-5? WHO-5 attempts to measure the pleasantness dimension of emotions (eg, feeling cheerful, in good spirits, fresh) as well as the arousal dimension of emotions (eg, feeling calm, relaxes, vigorous)—although in the same rating scale. However, as noted above, WHO-5 only directly measures positive affect, that is the positive aspects of emotions. In this sense, WHO-5 departs from emotion research and hedonistic theory. In terms of practical feasibility, however, this may turn out to be a wise compromise.

Recent psychometric research has found that positive emotions such as happiness, optimism and vitality have a higher correlation, and show less variance, than negative emotions such as sadness, anxiety, sorrow etc.41 This indicates that it is more complicated to measure negative affect than positive affect, and that more items are needed for the measurement of negative affect. Hence, there may ultimately need to be a compromise between psychometric comprehensiveness and simplicity. Although measuring both positive and negative affect seems desirable from a theoretical point of view, this would also entail more complicated and time-consuming rating scales, which are known to decrease compliance and result in lower response rates.22

The value of emotions

The second important theoretical assumption that relates to hedonistic theory concerns the determination of the value of emotions. In the hedonistic/utilitarian tradition, it is assumed that when a person experiences pleasure, it happens within an ‘episode’. The episode of the experienced pleasure will have a certain duration and a certain intensity.32 Some pleasant (or unpleasant) experiences are more important for our well-being because of their duration. The pleasure of getting a puppy, for instance, can be an experience with a considerably longer duration than the pleasure of eating a piece of chocolate. Likewise, the intensity of a pleasant or unpleasant emotion will be significant for its impact on our well-being. For example, the experience of getting married to the love of your life is likely to be more intense, and thus more important for our well-being, than receiving an e-mail from a distant acquaintance. Consequently, the extent to which a pleasant or an unpleasant experience contributes to our well-being is a function of its intensity and duration.9

Measuring the duration and intensity of emotions

To what extent does WHO-5 measure the duration and intensity of emotions? In the construction of the rating scale, neither duration nor intensity figure explicitly. However, it can be argued that the duration of pleasant emotions does impact WHO-5 scores, because WHO-5 measures the frequency of pleasant emotions within the last 2 weeks. Consider the following case.

Two individuals, Peter and Paula, are about to rate their well-being using WHO-5. Peter got a puppy 2 weeks ago, which has provided an array of pleasant emotions and experiences. He therefore scores high on the WHO-5 scale. Instead of getting a puppy, Paula got a nice piece of chocolate 2 weeks ago, which produced a pleasant experience that particular day. The remaining days have not provided pleasant experiences, and Paula therefore does not score very high on the WHO-5 scale.

As the case illustrates, the duration of a pleasant experience will impact the associated WHO-5 score, even though WHO-5 does not directly measure duration. If we change the case and prolong Paula’s pleasant experience, for instance, by providing her with nice chocolate every day during the last 2 weeks, then her WHO-5 score presumably would be higher.

Furthermore, it can be argued that measuring the frequency of pleasant emotions within the last 2 weeks makes it possible to capture pleasure derived from recollection. Maybe it was the best piece of chocolate Paula has ever had such that the mere thought about it overwhelms her with pleasurable emotions. If so, we would expect this to be reflected in her WHO-5 score.

Regarding the intensity of emotions, it is more difficult to see how this important aspect of hedonistic theory is incorporated within WHO-5. Although respondents are asked to rate their replies on a Likert scale from 5 (all of time) to 0 (at no time), we do not know how intense the relevant emotions were, and therefore we cannot assess them on the basis of their intensity. Consider the case of Julia and Jasper.

Julia and Jasper want to know their level of well-being and decide to use WHO-5. Julia is about to answer the first question in WHO-5: ‘Over the last 2 weeks I have felt cheerful and in good spirits’. She thinks about it and feels that she has actually felt pretty good all the time during the last 2 weeks. She thus chooses response category 5, meaning ‘all the time’. It is now Jasper’s turn to answer the first question in WHO-5. During the last two weeks, Jasper has been on a very nice holiday. Throughout the last two weeks, Jasper has had a very intense feeling of happiness and enjoyment. Obviously, he also chooses response category 5. Suppose that Jasper and Julia also choose the response category 5 in the rest of the questions, and therefore achieve the same WHO-5 score. They have both had pleasant experiences all the time during the last two weeks, but it is undoubtedly Jasper’s experiences that have been the most intense.

In principle, it would be possible to modify WHO-5 to take account of intensity such that respondents should not only rate the frequency of pleasant experiences but also their intensity. If Jasper and Julia had done so, they probably would not have ended up with the same level of well-being.

However, such a modification of WHO-5 might give rise to psychometric problems. It has been argued that affective self-report measures of well-being should be based on frequency and not intensity, because frequency is more amenable to accurate measurement.42 Evidence has shown that people are better able to estimate the frequency of emotions accurately, and are less recall-biased, when compared with their assessments of the intensity of their emotions.42 43 It seems that information on the frequency of emotions can be coded in memory and can therefore be recalled from memory more accurately. In contrast, there seems to be no natural system to code emotional intensity, and therefore it is much more difficult to recall the intensity of emotions accurately.42 Based on these findings, it has been argued that comparisons of well-being across individuals will have a higher validity if they are derived from rating scales that solely measure the frequency of emotions.42

The match between hedonism and WHO-5

To sum up, we have now discussed WHO-5 in relation to two central assumptions that relate to hedonistic theory, namely, the balance between positive and negative emotions, and the determination of the duration and intensity of emotions. We have illustrated some of the main difficulties in translating these theoretical assumptions into the construction of WHO-5. We have shown that WHO-5 departs in some respects from hedonistic/utilitarian theory—mainly due to psychometric compromises and concerns of validity. In general, however, WHO-5 stays close at heart to its hedonistic foundation.

Hedonism and life satisfaction theory

In this final section, we will contrast Hedonism with Life Satisfaction Theory, an alternative foundational theory of well-being, to illustrate that the outlook of WHO-5 is primarily a rating system of positive affect. As mentioned in the introduction, there is a great deal of controversy about the nature of well-being.5 11 According to Life Satisfaction Theory, well-being is to be defined as a cognitive state, namely, as a cognitive attitude of being satisfied with one’s life as a whole.11 44

Rating scales based on Life Satisfaction Theory are popular among psychologists and economists.19 They are widely used in national and international surveys of well-being, where people are asked to judge ‘how satisfied they are with their lives’.19 45 In contrast to hedonistic rating scales of well-being, such as WHO-5, which are typically restricted to a certain period of time (eg, the frequency of pleasant experiences during the last 2 weeks), life satisfaction measures invite a more general or overall perspective on our lives, as they require respondents to judge how satisfied they are with all aspects of their lives, that is their overall life satisfaction.11 According to the World Happiness Report life satisfaction measures provide the most informative measures for international comparisons of well-being, because they capture overall well-being in a more comprehensive and stable way than affective measures based on emotional experience.45

It has been argued that, analytically speaking, judgements of life satisfaction should be distinguished sharply from feelings or emotional states.10 11 This is because life satisfaction is a global judgement about the whole of one’s life, or the totality of one’s life, which may be unrelated to the current experience of specific emotions.11 46 It may be possible, for instance, to be satisfied with life overall even while experiencing emotional distress. This will depend on where the bar is set for what counts as a satisfactory life, which in turn may be highly influenced by contextual factors such as social position relative to others and the general standard of living in a particular setting.47 Satisfaction with life is a judgement that may be relative to what a person expects from life and considers possible to achieve.10 It may also be relative to individuals’ cognitive ability to balance emotional distress related to particular life domains within an overall judgement of life satisfaction across the totality of life domains.

In these various ways, therefore, rating scales derived from Life Satisfaction Theory are based on a radically different theory about the nature of well-being than rating scales derived from Hedonism. One of the strongest objections against the Life Satisfaction Theory, and measures grounded in that view, is that they imply that it is possible to have high well-being in the absence of positive emotions.11 46 Hence, it is possible to have high well-being despite a poor emotional life. Although measures of emotional affect and reported life satisfaction often correlate, substantial divergences have been found.11 Studies have shown, for instance, that 42%–49% of people who rated themselves as ‘completely satisfied’ also reported significant symptoms of anxiety and related forms of distress.11 48

Hence it is important to be selective in the choice of rating scales of well-being and specific in the interpretation of their results. Ratings of well-being based on Life Satisfaction Theory represent overall judgements of life satisfaction that may be unrelated to respondents’ emotional status. In contrast, ratings of well-being based on Hedonism, such as WHO-5, represent time-bound reports about the frequency of emotional states that may vary over time in response to changes in health status or socio-economic conditions.

Conclusion

In this paper, we have examined the philosophical foundation, as well as the outlook and limits, of the Well-Being Index WHO-5. We have clarified the underlying normative commitments of WHO-5 in terms of the relationship between positive and negative emotions, and the determination of the value of emotions based on their duration and intensity. We have shown that WHO-5 departs from emotion research and hedonistic/utilitarian theory because it only measures positive aspects of emotions, and therefore does not cover all emotional states that affect our well-being. Furthermore, WHO-5 departs from hedonistic/utilitarian theory, as it only measures the frequency of emotions, and not their duration or intensity. We have also explored the various psychometric compromises in the translation of philosophical theory into practice. We have shown that it is not always optimal or possible to cover all aspects of a theory in a measuring instrument due to various pragmatic reasons and psychometric validity.

We believe that exposition and discussion of the philosophical foundation of rating scales, and of the compromises involved in their translation from theory to practice, contribute to a greater understanding of what we actually measure when we measure well-being. The latter translation may involve certain assumptions and limitations that will often affect what is being measured. As we have discussed in the article it is an important qualification of WHO-5 that it is restricted to positive emotions. Although WHO-5 is often introduced as a hedonistic, affective rating scale it has a blind spot when it comes to negative emotions and thus cannot reflect the full spectrum of affective states. Nor does it results reflect a counterbalance of negative versus positive emotions. Another important qualification of WHO-5 is that the rating scale is restricted to the measurement of the frequency of emotions and thus fails to capture important emotional qualities such as their capacity for overwhelming, momentary impact (intensity) as well as impact over time (duration). Knowledge of such qualifications is crucial to assess when it is necessary to supplement WHO-5 with other kinds of rating scales, for example rating scales that measure negative emotions or to supplement numerical ratings of well-being with more qualitative approaches like user stories or patient narratives that more adequately expose the richness and intensity of subjective experience.

More generally, knowledge of the limits of affective rating scales encourages a more selective and discriminate interpretation of their results which may provide a key to the understanding of potential variation between the results of different affective scales.19 Such variation does not necessarily imply a lack of validity of rating scales but may reflect the fact that they measure very different phenomena.

Variation between scales also apply across affective and cognitive rating scales—not necessarily due to problems of validity but a reflection of differences in the underlying phenomena. A hedonistic rating scale such as WHO-5 is apt to capture the here-and-now frequency of positive affect within a short period of time. Thus, the sensitivity of WHO-5 makes it relevant for the measurement of positive well-being during treatment, or as a result of a public health intervention. A rating scale with a theoretical foundation in Life Satisfaction theory, on the other hand, is not likely to have the same capacity to capture changes that take place over a short period of time. This is because judgements of life satisfaction are based on global judgments about the totality of one’s life, which are less sensitive to momentary change. However, the assumptions and limitations of rating scales founded in Life Satisfaction Theory have yet to be explored.

References

Footnotes

  • i Haybron has proposed a composite foundational theory; Emotional State Theory, according to which well-being equals a favourable emotional condition. Haybron presents three broad dimensions of this condition, which each corresponds to a specific function of emotional states: (i) the endorsement dimension (joy versus sadness), (ii) the engagement dimension (vitality/flow versus listless/withdrawn), and (iii) the attunement dimension (tranquillity/emotional expansiveness versus compression/confidence).11 However, the discussion in this paper is restricted to Hedonism and Life-Satisfaction Theory since these theories are the most prevalent and mostly cited theoretical foundations of practical rating scales.

  • Contributors The authors have contributed equally to the article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.