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Assessing quality of life: Current approaches

• I. Ilic , I. Milić , M. Aranđelović
• Published 2010
• Medicine, Economics
• Acta Medica Medianae

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• Published: 16 November 2012

Systematic review of health-related quality of life models

• Tamilyn Bakas 1 ,
• Susan M McLennon 1 ,
• Janet S Carpenter 1 ,
• Janice M Buelow 1 ,
• Julie L Otte 1 ,
• Kathleen M Hanna 1 ,
• Marsha L Ellett 1 ,
• Kimberly A Hadler 1 &
• Janet L Welch 1  

Health and Quality of Life Outcomes volume  10 , Article number:  134 ( 2012 ) Cite this article

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A systematic literature review was conducted to (a) identify the most frequently used health-related quality of life (HRQOL) models and (b) critique those models.

Online search engines were queried using pre-determined inclusion and exclusion criteria. We reviewed titles, abstracts, and then full-text articles for their relevance to this review. Then the most commonly used models were identified, reviewed in tables, and critiqued using published criteria.

Of 1,602 titles identified, 100 articles from 21 countries met the inclusion criteria. The most frequently used HRQOL models were: Wilson and Cleary (16%), Ferrans and colleagues (4%), or World Health Organization (WHO) (5%). Ferrans and colleagues’ model was a revision of Wilson and Cleary’s model and appeared to have the greatest potential to guide future HRQOL research and practice.

Conclusions

Recommendations are for researchers to use one of the three common HRQOL models unless there are compelling and clearly delineated reasons for creating new models. Disease-specific models can be derived from one of the three commonly used HRQOL models. We recommend Ferrans and colleagues’ model because they added individual and environmental characteristics to the popular Wilson and Cleary model to better explain HRQOL. Using a common HRQOL model across studies will promote a coherent body of evidence that will more quickly advance the science in the area of HRQOL.

Introduction

Health-related quality of life (HRQOL) has been identified as a goal for all people across all life stages by leading health organizations [ 1 – 3 ]. HRQOL, that is, quality of life relative to one’s health or disease status, is a concern of policymakers, researchers, and health care practitioners [ 4 ]. Especially important is the need to align HRQOL research priorities with the needs and values of patients and their families. Because of the multidimensional aspects of HRQOL, and the varied use of this term across many different health and disease conditions, researchers have used a variety of HRQOL models to guide their research. A conceptual model is a schematic representation of a theory that acts as a heuristic device to provide a better understanding of a phenomenon (e.g., HRQOL) by depicting interrelationships among concepts [ 5 ]. The term conceptual model has been used interchangeably as “conceptual framework, theoretical model, or theoretically based conceptual model [ 6 ].”

There are many HRQOL models applied across different health and illness conditions, across the lifespan, and among individuals, their families, and communities. HRQOL is commonly conceived as dynamic, subjective, and multidimensional, and the dimensions often include physical, social, psychological, and spiritual factors [ 7 ]. However, the specific dimensions are labeled differently by different authors [ 7 ]. For example, these broad dimensions subsume more specific dimensions such as emotions, cognitive function, economic status, and intelligence [ 8 ], and they may incorporate friends and family [ 9 ]. While the theoretical underpinnings of HRQOL may be consistent across models, variations in terminology for analogous concepts make comparison across studies very difficult. Differing conceptualizations of HRQOL limit the ability to have a coherent body of evidence to guide further HRQOL research and practice. Common HRQOL models provide essential structure to the conceptualization of HRQOL using common language that can be shared across studies. Identification and evaluation of common HRQOL models can help guide research and practice toward promoting or attaining optimum HRQOL for populations of interest. Thus, the purposes of this paper were to (a) identify the most frequently used HRQOL models found in the literature over the past ten years and (b) review and critique the most commonly used models using established criteria by Bredow [ 10 ]. Although Bredow’s [ 10 ] criteria were developed to critique middle-range theories in nursing research, they represent a comprehensive approach to theory analysis for review and critique of HRQOL models [ 10 ]. The overall goal was to determine the relevance of HRQOL models to research and practice aimed at improving HRQOL.

Several search engines were used to locate relevant articles. Initially, PubMed, MEDLINE, CINAHL, and PsychINFO were searched using the keywords quality of life, health-related quality of life, conceptual framework, conceptual model, and theory. Both quality of life and health-related quality of life were searched because these terms have been used interchangeably in the literature.

We limited our search to English language articles published between January 1, 1999 and August 31, 2010. The inclusion criteria were published articles pertaining to HRQOL models that had been used to guide (a) literature reviews, (b) instrument development studies, (c) descriptive or correlational studies, (d) intervention studies, or (e) practice. Articles in which research findings were used to derive HRQOL models were also included. We did not limit our search to specific populations (e.g., children, adolescents, adults, older adults) because we wanted a broad representation of the use of HRQOL models. Exclusion criteria were articles that did not pertain to humans, were non-English, or involved studies and information published only as dissertations, abstracts, editorials, or clinical opinion. Relevant articles were identified from the literature search using a three-step process. In the first step, authors working in pairs reviewed the article titles based on inclusion/exclusion criteria. In cases in which there was a lack of consensus between the two reviewers, a third reviewer was sought, consistent with methods outlined by the Joanna Briggs Institute [ 11 ]. In the second step, titles that met the criteria were further evaluated. Authors, again working in pairs, reviewed abstracts and reached agreement about whether the abstracts met inclusion/exclusion criteria. In the third step, the identified articles were obtained and evaluated by the same pairs of authors. Full text articles were reviewed and again were included only if the pairs agreed the article met the criteria.

The paired authors then extracted and consolidated pertinent information from the articles into a review table. Column variables in the table were: author and date, country of origin, purpose, methods, design, and model. Each row represented a unique article. All authors engaged in group discussion to reach consensus on articles to be included in the review and to determine the format in which to present review findings. After reviewing articles, the most commonly used HRQOL models were identified, fulfilling the first purpose of this review. For purpose two, each of the most commonly used HRQOL models was critiqued by the author pairs using established criteria by Bredow [ 10 ]. After considering several alternatives, we chose Bredow because he incorporated the most comprehensive criteria for evaluating theories, frameworks, and models [ 10 ]. Although these criteria are used to evaluate middle range theories in nursing research, they are also useful in evaluating quality of life theories [ 10 ]. A description of Bredow’s [ 10 ] criteria appears in the first column of Table 1 , and is summarized below.

Bredow’s [ 10 ] criteria for evaluating theories were organized around two major areas: internal and external criticism. Internal criticism involves a judgment about the internal components of the theory, whereas external criticism involves a judgment about the match between the theory and context of its use. When evaluating internal criticism, the evaluator assesses the adequacy (thoroughness in addressing topic), clarity (clearness of statements), consistency (congruency in semantics, etc.), logical development (support from evidence), and level of theory development. To make judgments about external criticism, the evaluator assesses the complexity (number of concepts/variables, from parsimonious to complex), discrimination (uniqueness), reality convergence (relevant assumptions), pragmatism (ability to use in the real world), scope (narrow to broad use for practice), significance (impact of theory), and utility (ability to produce hypotheses). Critique information for each of the commonly used models was summarized in a table after consensus had been reached by two (or sometimes three) authors.

The disposition of the search results is shown in Figure 1 as a PRISMA flow diagram [ 14 ]. Searching the three databases with the selected keywords yielded a total of 1,602 records. Author review excluded 50 records because they were duplicates, books, dissertations, presentations, or could not be located. This left 1,552 titles to screen. Author pairs excluded 1,334 titles because they did not meet inclusion criteria. This left 218 abstracts to be screened, of which 70 did not meet inclusion criteria; 148 progressed to the full text assessment for eligibility. Of the 148 full text articles assessed, 48 were eliminated because a HRQOL model had not been derived from or used to guide the research, review, and/or findings. This process resulted in a total of 100 articles being included in this review (see Figure 1 ).

Literature search flow diagram.

Of the 100 articles, 46 were quantitative. Of the remaining 54, 16 were qualitative research, 1 was mixed methods research, 15 involved instrument development, 20 were literature reviews, 1 described a model revision, and 1 was a consensus paper. The 46 quantitative studies were mainly descriptive studies ( n = 31), with a few being correlational ( n = 13), or randomized controlled trials ( n = 2). Sample sizes ranged from 10 [ 15 ] to 69,031 participants [ 16 ]. The 100 articles came from 21 different countries including Australia ( n = 4), Austria ( n = 1), Brazil ( n = 3), Canada ( n = 12), China ( n = 3), Finland ( n = 1), Germany ( n = 4), India ( n = 1), Ireland ( n = 1), Israel ( n = 1), Italy ( n = 2), Japan ( n = 1), Netherlands ( n = 7), Norway ( n = 2), Spain ( n = 3), Sweden ( n = 2), Taiwan ( n = 1), Thailand ( n = 4), Ukraine ( n = 1), United Kingdom ( n = 10), and the United States ( n = 49). Of these 100 articles, 9 involved more than one country.

Most frequently used HRQOL models

Of the 100 articles, 57 used an existing HRQOL model as a guide and 25 derived a HRQOL model. Interestingly, 18 articles used an existing HRQOL model as an initial guide and then also derived a revised model based on the findings. Figure 1 shows that of the 100 full-text articles included in the review, 77 either derived a HRQOL model (n = 25) or were guided by a HRQOL model that was used only once or twice (n = 52). There was little consensus among the models used, with each article essentially citing a different model. These 77 articles are summarized in Additional file 1 : Tables SA and SB included as an appendix for this paper. Of the 25 articles that derived a HRQOL model, 24 were disease-specific, and 1 was a consensus paper on HRQOL (Additional file 1 : Table SA). The disease-specific models were classified as using a uniquely derived HRQOL model based on the findings. For example, Barr and Schumacher [ 17 ] identified six categories of HRQOL specific to individuals receiving medical nutrition therapy. Similarly, Klassen, Pusic, Scott, Klok, &; Cano [ 18 ] examined the impact of breast conditions and surgery to develop a quality of life framework specific to breast surgery patients. Because there was such a wide variation in disease states, HRQOL domains, and particular characteristics, findings could not be adequately synthesized. Of the 52 articles that were guided by a HRQOL model that was used only once (n = 46) or twice (n = 6), only three HRQOL models were cited twice (Additional file 1 : Table SB). Those used twice were Maslow’s hierarchy of needs (n = 2), Mishel’s Uncertainty in Illness Theory (n = 2), and Stewart’s conceptual model of factors affecting dying patients and families (n = 2) (See Additional file 1 : Table SB for details).

As depicted at the bottom of Figure 1 , there remained a total of 23 articles that cited the same model 4 or more times. As shown in Table 2 (and in Figure 1 ), the most common existing HRQOL models found in the literature were those by Wilson and Cleary [ 12 ] ( n = 14), Ferrans and colleagues [ 13 , 19 ] ( n = 3), and the World Health Organization (WHO) [ 20 , 21 ] ( n = 4). Two additional articles used a combination of two of these models. Ferrans et al. [ 13 ] used the Wilson and Cleary [ 12 ] model as a guide to derive a revised model of HRQOL [ 13 ]. Valderas and Alonso [ 22 ] used both Wilson and Cleary [ 12 ] and the WHO [ 20 ] models. Schematic diagrams for each of the three most common HRQOL models have been published in Wilson and Cleary [ 12 ], Ferrans and colleagues [ 13 ], and the World Health Organization [ 20 , 21 ], and are described in more detail in the results section. The largest group ( n = 10) of the 23 articles in Table 2 reported observational studies (descriptive or correlational) and focused on patients with chronic illness, with sample sizes ranging from 61 [ 23 ] to 917 [ 24 ]. Literature reviews ( n = 6) and instrument development studies ( n = 3) were also found. Only one randomized controlled trial was found [ 25 ], along with one mixed-methods study [ 26 ], one qualitative study [ 27 ], and one article that described a model revision [ 13 ].

Critical analysis of predominant HRQOL models

Table 1 details the critique of the three most commonly used HRQOL models found in the literature over the past 10 years using criteria by Bredow [ 10 ]. Wilson and Cleary’s [ 12 ] model of HRQOL combines two paradigms, biomedical and social science. Their model is a taxonomy that includes five major well-defined domains: biological, symptoms, function, general health perception, and overall HRQOL. However, the definitions for two other domains, individual and environmental characteristics, were not made explicit. Each domain is related to the others, and reciprocal relationships may exist. The authors suggest that environmental and individual factors are associated with outcomes, thus affecting total HRQOL.

Ferrans, Zerwic, Wilbur, and Larson [ 13 ] published a revision of Wilson and Cleary’s [ 12 ] HRQOL model. The five major domains of the original model were retained. Ferrans and colleagues [ 13 ] made explicit the definitions for individual and environmental characteristics, and they simplified the depiction of the model by removing non-medical factors and labels on the arrows portraying the relationships in the figure. In addition, they contributed further theoretical background about the main concepts in the model [ 19 ] and provided examples of instruments to enhance measurement. According to Ferrans et al. [ 13 ], the model depicts dominant causal associations; however, reciprocal relationships are implied. An explicit assumption is that understanding relationships among these components will lead to the design of optimally effective clinical interventions. The revised conceptual model could be applied to any health care discipline.

The World Health Organization International Classification of Functioning, Disability, and Health (WHO ICF) is a model designed to provide a description of health and health states, while providing a unified and standard language that can be used across disciplines and cultures [ 3 , 20 , 21 ]. The WHO ICF has evolved over time from a focus on “consequences of disease” in 1980 to “components of health” in 2001 [ 20 , 21 ]. The more recently developed WHO ICF-CY covers infants, children, and adolescents [ 3 ]. The WHO has conceptualized HRQOL as an individual’s perception of his or her health and health-related domains of well-being [ 3 , 21 , 43 ]. Health and health-related domains have been further conceptualized in terms of functioning within the WHO ICF model. The WHO ICF model includes components within two main parts. Part 1 focuses on functioning and disability (body functioning and structures, activities, and participation), whereas Part 2 addresses contextual factors (environmental and personal). The main concepts are well-defined overall, with explicit propositions and assumptions. However, unlike the models by Wilson and Cleary [ 12 ] and Ferrans and colleagues [ 13 ], the WHO ICF is not specific to HRQOL. Cieza and Stuki [ 43 ] assert that the WHO ICF categories under functioning can serve as the basis for the operationalization of HRQOL but are not the only potential application of the WHO ICF. For example, Miller and colleagues [ 44 ] used the WHO ICF as a framework to organize a comprehensive overview of nursing and interdisciplinary care of the stroke patient. The WHO ICF serves more as a mapping and classification framework than as a guide for hypothesis generation in the area of HRQOL.

Critique of the internal components of the HRQOL models using the Bredow criteria [ 10 ] indicated many similarities and some differences. All were fairly complete in the descriptions and definitions of HRQOL, with some gaps in the influence of management of therapeutic regimens and self-management on quality of life. Most existing models focus on the influence of symptoms rather than on management related to the condition. For example, for those with diabetes, both symptoms (such as hypoglycemia) and management (such as frequent checking of glucose levels) are important influential factors for HRQOL. Within the WHO ICF model [ 3 ], there was some definitional overlap between activities and participation. The Ferrans et al. [ 13 ] model was more complete and clear than that of Wilson and Cleary [ 12 ] because of the revisions and because of better definitions for individual and environmental factors. The relationships among the concepts were less clear in the Wilson and Cleary model [ 12 ], whereas the Ferrans et al. model [ 13 ] added clarity. Both the Wilson and Cleary [ 12 ] and Ferrans et al. [ 13 ] models implied potential reciprocity. In contrast, the WHO ICF [ 3 ] was explicit with the depiction of causal and reciprocal relationships.

There were greater variations among the three models when critiquing model fit with operational application. The models were similarly parsimonious, yet the complexities of multiple relationships were described. They made sense for use in real-world settings and have been used to guide research and practice. A major difference is that the Wilson and Cleary [ 12 ] and Ferrans et al. [ 13 ] models specifically explain HRQOL, whereas the WHO ICF model [ 3 ] describes health related to functioning and disability. In addition, though the Wilson and Cleary [ 12 ] and Ferrans et al. [ 13 ] models were primarily intended for application to individuals, the WHO ICF model [ 3 ] could be used to explain the health of individuals, families, communities, populations, and cultures. With the former, adaptations may be needed for use with families, communities, and individuals unable to report their own HRQOL, such as infants and young children and those with cognitive impairment. Empirical evidence for use of the models for intervention research is limited. However, the Ferrans et al. [ 13 ] model and the WHO ICF model [ 3 ] have robust potential for guiding the design of interventions that could be tested and applied in practice settings. The WHO ICF may be more applicable to practice situations for needs assessments, matching treatments with conditions, and evaluating outcomes because it is primarily a classification and mapping system. All three models were at a similar level of development emerging from the two paradigms of biomedical and social sciences.

Discussion and recommendations

There are two important findings from this review. First, there has been little consistency in HRQOL models within the literature of the past 10 years. Approximately three-fourths of the articles reviewed used an existing HRQOL model as a guide; however, most of these applied a variety of different models, rather than using a common model found in the literature such as the Wilson and Cleary model [ 12 ]. Thus, there were wide variations in terminology for analogous HRQOL concepts, making cross-study comparisons virtually impossible. This seriously limits the ability to have a coherent body of evidence to guide further HRQOL research and practice. Second, the most commonly used models were based on work by Wilson and Cleary [ 12 ], the revised model by Ferrans and colleagues [ 13 , 19 ], and the WHO [ 3 , 20 , 21 ]. A majority of the researchers using these models could be doing so because of an absence of better alternatives. However, based on our findings, we recommend that authors consider the advantages of using one of the three commonly used global models in research to more quickly advance the science in the area of HRQOL. Our findings show that Wilson and Cleary [ 12 ], as well as the revisions of Wilson and Cleary’s model proposed by Ferrans et al. [ 13 ], together are the most frequently referenced in the HRQOL literature, representing nearly a quarter of all of the articles reviewed. Ferrans and colleagues’ [ 13 ] model provides clear conceptual and operational definitions, and it also clarifies relationships among concepts to guide research and practice. The WHO ICF model [ 3 ] may be useful in specific HRQOL studies; however, it has more potential for application to studies of an epidemiological, sociological, or educational nature.

There are a great many models in the HRQOL literature that have not been adequately tested or refined. Cross-comparisons across diseases could be done if authors had at least used a global HRQOL model as a starting point. In fact, many single-use models included the same concepts as the three global HRQOL models but labeled them differently. In the future, when a common global HRQOL model is not used, authors should clearly delineate why a context- or disease-specific model is preferred. Increasing the consistency in models used across studies would help increase our understanding of this important concept.

Of the 23 articles citing the three most common HRQOL models, most articles were descriptive, correlational, or literature reviews. Importantly, future HRQOL research should involve comparisons of intervention outcomes. Only one randomized controlled trial was found that used the most commonly cited Wilson and Cleary [ 12 ] model [ 25 ]. Although disease-specific or situation-specific models may be better for testing interventions, the global models should still be useful as a template and a jumping-off point for adaptations to specific contexts. In addition, using an existing model can advance the state of the science of HRQOL by contributing new information about the applicability of the selected model to research and practice, thus leading to model refinement such as the revised model proposed by Ferrans and colleagues [ 13 ]. This underscores the need to start with the best available HRQOL models and build upon them, rather than creating new models.

Limitations

Our search strategies were limited to selected databases (PubMed, MEDLINE, CINAHL, and PsychINFO) and keywords (e.g., quality of life, health-related quality of life, conceptual framework, conceptual model, and theory). Given that standard keywords were used within each search engine, any article indexed by that search engine would have been captured; however, follow up manual searches and review of reference lists might have revealed additional citations. The search strategies were specifically designed to capture articles that were guided by or derived HRQOL models that were further analyzed in detail by the reviewers. All reviewers were doctorally-prepared and a research librarian assisted with the searches. Because the aim of our paper was to identify the most frequently-used HRQOL models found in the literature over the past 10 years, a complete synthesis of disease-specific models was not undertaken. Future work to analyze uniquely derived disease-specific HRQOL models may provide unique HRQOL domains that might further inform the three more commonly used HRQOL models. For example, Klassen et al. [ 18 ] qualitatively derived a HRQOL model for women who had undergone breast surgery. Their model consisted of six themes (satisfaction with breasts, satisfaction with process of care, satisfaction with overall outcome, psychosocial well-being, sexual well-being, and physical well-being). The satisfaction with process of care theme further informs both Ferrans and colleagues’ model [ 13 ] and the WHO ICF [ 3 , 20 , 21 ] as an important characteristic of the environment. Sexual well-being could further inform the functional status domains in all three models. Identifying domains that are unique to disease-specific models, or particular characteristics such as feedback or recursive patterns to address dynamic changes in HRQOL with time, may further inform or strengthen the rationale for using the three existing HRQOL models.

In summary, based on this systematic review of the literature, Ferrans et al., [ 13 ] revision of Wilson and Cleary’s [ 12 ] model appears to have the greatest potential to guide HRQOL research and practice. We recommend Ferrans and colleagues’ [ 13 ] model because they added individual and environmental characteristics to the popular Wilson and Cleary [ 12 ] model to better explain HRQOL. Although the WHO ICF model has been considered a model of HRQOL, it is more of a mapping and classification framework than a guide for hypothesis generation in the area of HRQOL. Use of one model, such as Ferrans et al. [ 13 ] revised HRQOL model, will provide more opportunities for testing and refinement of the model and more evidence about which relationships among HRQOL concepts are common to different populations. Finally, and maybe most importantly, using one model will help in comparing HRQOL across studies and populations, contribute to the development of more intervention studies, and more quickly advance the science in the area of HRQOL.

Abbreviations

Health-related Quality of Life

Quality of Life

World Health Organization

World Health Organization International Classification of Functioning, Disability, and Health.

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Acknowledgements

Funding for this study was provided by Indiana University School of Nursing Research Investment Funds and the Center for Enhancing Quality of Life in Chronic Illness. The authors thank Phyllis Dexter, RN, PhD, Assistant Scientist and Editor, Indiana University School of Nursing Center for Nursing Research, for her editorial assistance. The authors also wish to thank Randi L. Stocker, Research Librarian at Indiana University Purdue University at Indianapolis, for her assistance with literature searches.

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TB provided overall leadership and contributed to the conception and design, participated in the review and critique process, drafted sections of the manuscript, and revised it critically for intellectual content. SMM, JSC, JMB, JLO, KMH, MLE, &; JLW contributed to the conception and design, participated in the review and critique process, drafted sections of the manuscript, and revised it critically for intellectual content. KAH acquired articles for review, abstracted findings to tables, contributed to analysis and interpretation, provided reference management, and drafted sections of the manuscript. All authors read and approved the final manuscript.

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Bakas, T., McLennon, S.M., Carpenter, J.S. et al. Systematic review of health-related quality of life models. Health Qual Life Outcomes 10 , 134 (2012). https://doi.org/10.1186/1477-7525-10-134

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A Complete World Literature Review of Quality of Life (QOL) in Patients with Kidney Stone Disease (KSD)

Francesca new.

Department of Urology, University Hospital Southampton NHS Trust, Southampton, SO16 6YD UK

Bhaskar K. Somani

Purpose of review.

The purpose of this study was to review the current evidence for quality of life (QOL) in patients with kidney stone disease (KSD).

Recent Findings

A review of literature from inception to May 2016 for all prospective English language articles on QOL in patients with KSD was done. QOL studies post urological procedures or ureteric stents were excluded. Nine studies (1570 patients) were included of which most ( n  = 6) used the SF-36 QOL tool. Overall, seven of the nine studies demonstrated a lower QOL in patients with KSD. Bodily pain and general health were significantly lower in patients with KSD compared to their control groups.

Patients with KSD have an overall lower QOL with most impact on bodily pain and general health domains. Compared to the scale of patients suffering from KSD, more work needs to be done in measuring QOL both in terms of ‘Stone specific’ QOL measuring tools and the quality/number of studies in this field.

Introduction

Kidney stone disease (KSD) is a common problem, affecting approximately 10–15 % of people in Europe and North America [ 1 •]. In the USA, the lifetime prevalence for men is 12 %, and for women, it is 6 % [ 2 ]. Stone formers are 50 % more likely to have a further stone in the following 5 years [ 3 ]. Although some patients are asymptomatic with their KSD, many will have pain, urinary tract infection (UTI) or haematuria and may require multiple hospital admissions or multiple surgical procedures for this. This may also affect their renal function with an impact on their quality of life (QOL).

There are numerous ways to treat renal tract calculi, depending on their size, location, volume, anatomical factors and patient comorbidities. Historically, it was open surgical techniques; shock wave lithotripsy (SWL) was introduced in 1980, followed by percutaneous nephrolithotomy (PCNL) and subsequently endourological techniques with the popularisation of ureteroscopy (URS). After any one of these procedures, especially ureteroscopy, a ureteric stent may need to be placed. The presence of KSD, interventions for it and/or ureteric stents can all influence the QOL to varying degrees [ 4 – 10 ].

Patients with KSD can have increased levels of bodily pain, depression, loss of days at work and increased anxiety and financial distress, leading to overall lower QOL scores [ 11 – 15 , 16 ••]. How KSD and its treatments affect QOL may affect patient or surgeon decisions regarding the management of their KSD [ 15 ]. The impact of KSD on patients’ QOL is becoming increasingly important to consider, as the focus of treatment has shifted not just only from considering morbidity and mortality but also considering the impact on their QOL [ 17 – 22 , 23 •].

Quality of life is a subjective experience and hence makes the effective measurement difficult. It is important to consider patients’ QOL, as it can help us understand how the disease affects their day to day living, and the personal burden of illness. This is not always related to the severity of their disease, by laboratory values or imaging, but by how the disease and possibly its treatment are perceived by the patient [ 18 ]. There are many psychosocial factors that need to be taken into consideration as well as symptom-related aspects of QOL. Examples of these are financial difficulties, stresses from job, family and associated pain [ 5 ]. There are a multitude of designed and validated tools used to measure this [ 5 – 8 ]. It is important for patients to assess their own QOL, not for health professionals to try and assume what it might be. Measuring QOL is important as one of the aims of any treatment is for the patient to feel and function normally. Using the information gathered from QOL studies, patients can be better informed on their treatment options and how they may fair after different treatments. Over the last 30 years, improving patients QOL has become an increasingly important part of treatment, and therefore, many tools have been produced to measure this [ 5 – 8 ]. However, there are currently no validated KSD-specific QOL tools available [ 15 ].

We conducted a systematic review of literature to look at the tools used for measuring QOL and the aspects of patients QOL most affected by KSD.

Materials and Methods

Evidence acquisition, criteria for studies to be included in this review, inclusion criteria.

• Prospective studies written in the English language from inception to May 2016
• Studies reporting on QOL in patients with KSD

Exclusion criteria

• QOL studies of patients with ureteric stents
• QOL studies immediately after any urological procedure

Our aim was to look at the impact of KSD on patients’ QOL, which domains were affected, and to see which QOL tools were commonly used in urolithiasis patients.

Search Strategy

The systematic review was performed according to the Cochrane reviews guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 9 ]. We searched Pubmed, MEDLINE, EMBASE, Scopus, CINAHL, Cochrane library, Clinicaltrials.gov, Google Scholar and individual urological journals from inception to May 2016, and all English language articles were included in the original search. The search terms included: ‘Quality of life’, ‘kidney stone disease’, ‘urolithiasis’, ‘calculi’, ‘stones’ and ‘nephrolithiasis’. Boolean operators (AND, OR) were used with the above search terms to refine the search. Studies reporting on QOL in patients with KSD were included but studies on QOL in patients with ureteric stents or immediately after any surgical intervention were excluded. Data was extracted for the type of study, country of origin, review period, patient demographics, QOL tools used, domains measured and their effect on QOL.

Literature Search and Included Studies

After an initial search of 145 articles, 9 (1570 patients) met the inclusion criteria for the final review (Fig.  1 ). These were published from 2007 onwards, with six studies being from the USA. A full breakdown can be seen in Table ​ Table1 1 .

Inclusion criteria for final review of patients

All studies reporting on KSD (included in our review)

Patient Characteristics and QOL tools used

In total, there were 1570 patients, with a mean age of 50 years (range 18–88 years). There was an even male to female distribution of 1:1. Most studies used the SF-36 QOL tool [ 11 – 14 , 18 , 23 •] while two studies developed, and used a tool named the ‘Winsicon stone QOL tool’ [ 5 , 15 ]. The final study used the Emory stone questionnaire (an aid to collect patient demographics, information about stones and procedures) and the CES-D depression questionnaire [ 16 ••, 24 ]. Eight of the studies were prospective in nature, all being level 2a/b in their evidence quality.

Primary Outcomes

Qol questionnaires used.

The main QOL tool used was the SF-36 questionnaire [ 11 – 14 , 18 , 23 •]. It consists of 36 questions, which asses eight QOL domains; physical function (PF), role physical (RP), bodily pain (BP), general health (GH), Virility (V), social factors (SF), role-emotional (RE) and mental health (MH). It asks how these factors affected their life in the month preceding the questionnaire [ 5 ]. The three other studies used the Winsicon stone QOL tool [ 5 , 16 ••] and the Centre for Epidemiologic Studies Depression Scale (CES-D) [ 15 , 24 ]. The Winsicon stone QOL tool has 28 questions, which covered similar QOL aspects but also specifically asked about urinary frequency, dysuria and nocturia. The CES-D depression questionnaire is a 20-question survey used to illicit if patients have depressive symptoms.

Domains of QOL Measured

Six of the nine studies [ 11 – 14 , 18 , 23 •] used the SF-36 questionnaire, a generic QOL tool, which divides patients QOL into eight domains. Five of these studies [ 12 – 14 , 18 , 23 •] compared different QOL domains of patients with KSD to a case control group, or to the average QOL of the matched population. Four of these studies [ 13 , 14 , 18 , 23 •] reported the QOL scores for each domain (Table ​ (Table2). 2 ). Of these four, all demonstrated a lower QOL in patients with KSD, with Denise et al. demonstrating a statistically significant difference in all eight domains [ 14 ]. Byrant et al. showed a lower QOL in six of the eight domains (Physical Health, Bodily pain, General Health, Virility, Sexual Function) [ 18 ], while Kristina et al. showed lower QOL in general health and bodily pain [ 13 ]. Modersitzki et al. demonstrated a statistical significance in all eight domains within 1 month of a stone episode, with scores rising (QOL improving) over time from this episode [ 23 •]. Bensalah et al. demonstrated significantly lower scores in five domains, including role physical, bodily pain, general health, social function and physical function [ 12 ].

Studies using SF-36 matched with a case control

The other three studies used alternative QOL tools. Angell et al. demonstrated clinically significant depression in 30.4 % of their patients with urolithiasis, where clinical depression was characterised as a CES-D score of 16 or more [ 16 ••]. The last two studies developed and used a specific QOL tool for patients with urinary tract stones. It contained 28 questions, looking at areas including irritability, fatigue, social impact, virility, urinary frequency and urgency, general health, physical pain and difficulty sleeping [ 16 ••]. Kristina et al. demonstrated that patients with active stones scored lower for the sum total of the questionnaire, than those who where asymptomatic [ 16 ••]. In the asymptomatic stone group, those with stones still scored lower in urinary frequency, urgency, general anxiety or nervousness about the future ( p  < 0.027) [ 5 ].

Association Between Stone Episode and Time to Questionnaire Completion

Three out of the six studies documented average time from previous stone episode to questionnaire completion [ 12 , 15 , 16 ••]. The average time from these studies was 13 months (range 1–37 months). One study showed stability of SF-36 in KSD patients over a median follow-up of 18 months; however, a small cohort ( n  = 18) who had an acute stone episode within a month of completing their first questionnaire showed no significant differences in scores compared to other patients ( n  = 75) [ 11 ].

Byrant et al. demonstrated a significantly lower QOL for bodily pain and physical health domains in patients who had stone episode <1 month from completing the questionnaire [ 18 ]. A study on cysteine stone patients suggested that QOL gets better over a period of time and the timing of SF-36 needs to be accounted for when interpreting the domain scores and treatment, especially in patients with previous stone episodes [ 23 •].

Association Between Previous Stone-Related Procedure and QOL

Of the nine studies, two did not document any previous surgery for KSD [ 14 , 15 ]. Seven studies documented previous surgical procedures for KSD, with an average of 64 % (43–80 %) of patients having prior stone surgery [ 5 , 11 – 15 , 23 •]. Most suggest improvement of QOL over time especially in patients who suffered a recent or previous stone episode. Bensalah et al. analysed 155 patients from their clinic and found that the number of previous surgical interventions and body mass index had most affect on QOL especially their physical and mental components [ 12 ]. Similarly, another study using the SF-36 questionnaires on 115 patients suggested that the number of surgeries and surgical complications, time to stone episodes and the number of emergency room visits correlated most with the SF-36 physical and mental domains [ 18 ].

Findings of Our Study

Overall, seven of the nine studies demonstrated a lower QOL in patients with KSD. Bodily pain and general health was significantly lower in patients with KSD compared to their control groups. There seems to be a correlation between stone episodes and QOL, and this seems to improve with the passage of time. Similarly, previous surgical intervention seems to have a negative impact on their QOL, as compared to the control group.

Importance of Measuring QOL in KSD Patients

Patients with KSD tend to have a lower QOL even in the absence of stone episodes or interventions. It might reflect their previous experience of stone disease or an apprehension of the need for further treatment. Measurement of QOL is important to understand the impact of psychosocial and physical aspects of the disease. It can aid us in advising which management option may be more suitable for the individual. Only a longer-term follow-up over a few years would help us determine the time taken for the QOL domains to get back to baseline. QOL measurements also help us to evaluate and see ways in which we can improve our surgical choices or technique to improve patients’ QOL [ 21 ].

Comparison and Outcomes of Different QOL Studies

There are a multitude of generic QOL tools; selecting a measure can be difficult, as there are so many to choose from [ 4 ]. Examples of generic available measures are Short Form 36 (SF36) [ 5 ], Hospital and Anxiety Depression Scale (HADS) [ 6 ] and Profile of Mood States (POMS) [ 7 ]. There is also a QOL tool for patients with a ureteric stent in situ, the ureteric stent specific questionnaire (USSQ) [ 8 ]. The four different tools that where used in the literature in this review all have their own advantages and disadvantages that are summarised in Table ​ Table3. 3 . None of the tools used so far are perfect for assessing the QOL of patients with KSD. Large numbers of patients suffer with KSD [ 1 •, 2 , 3 ], and it has a huge impact on a person’s QOL [ 11 – 15 , 16 ••, 18 ]. A disease-specific QOL tool that is universally used would be useful to measure and compare QOL in these patients.

Advantages and disadvantages of current questionnaire used

The most common QOL tool used in our literature review for patients with KSD was the SF-36. As the SF-36 is a generic questionnaire, it does not target symptoms specific to stone formers and may not be sensitive enough to measure their QOL accurately [ 11 ]. However. when analysing the studies using the SF-36 questionnaire, we found a statistically significant difference in the bodily pain and general health sub domains (Table ​ (Table2 2 ).

There are many disease-specific QOL tools [ 25 ], although we could find none specifically designed for patients with KSD that had been widely validated. One study [ 15 ] aimed to fill this gap and produce a tool (the Winsicon Stone Quality of life questionnaire), specifically for patients with KSD. They also looked at asymptomatic stone formers in a paper published in 2016, and they found that even if the person was not aware of having KSD, but did have stones, they still had a lower QOL in specific domains, particularly urinary frequency, urgency, anxiety or nervousness ( p  = <0.027) [ 22 ]. In the limitations of these two studies, the authors identified that further research into this area needs to include understanding the role of comorbidities and social economic status in patients with both symptomatic and asymptomatic stones, as well as identifying the need for multi-institutional testing of the WiSQoL questionnaire to validate it.

Limitations of the Study

The studies using the same QOL questionnaires did not assess the data in a similar fashion, or compared the patients QOL to the same ‘norm’. None of the studies made it clear if the patient was having an active stone at the time of questionnaire administration, or in the month prior (the SF-36 only measure QOL in the 31 days prior to completing the questionnaire). It is well recognised that recent procedures and ureteric stents lower patients’ QOL and to avoid bias, we did not include these studies in our review [ 17 ].

Some of the other limitations are the lack of stone characteristics in the data provided, such as size, position and composition of stones. There were no randomised controlled trials and all studies were of level 2a/b evidence.

A number of confounding factors associated with KSD can also affect QOL of these patients. For example, obesity has been shown to lower QOL [ 19 ] and is also known to be associated with stone formers. One of the studies demonstrated that QOL in stone formers was worse in women and in patients with high BMIs [ 13 ]. Chronic diseases such as gout, diabetes, inflammatory bowel disease and bowel procedures are all associated with stone formation, but may themselves lower patients QOL [ 20 , 26 , 27 ]. Other patient-related confounding factors that may impact on measurement of QOL includes difficulty completing the questionnaire, procedural and judgement issues. Even with these limitations, seven [ 5 , 12 – 15 , 16 ••, 23 •] out of the nine studies demonstrated lower QOL in patients with KSD.

Areas of Future Research

Areas of future research could include evaluating the WisQOL questionnaire over a larger and multi-institutional patient cohort. It would also be of benefit to look not just at health-related QOL, including the physical, mental and emotional burden of KSD to health, but also the financial impact, including the loss of earnings to the individual as well as the financial cost on the health service. Donnally et al. in their longitudinal evaluation of QOL using SF-36 found no significant changes in domains suggesting that a validated disease-specific questionnaire might be better in these patients [ 11 ].

An important aspect of KSD is the affect to patients’ family and wider concept of management of other associated medical conditions either related to or contributing to KSD. Any QOL study is perhaps incomplete without addressing some of these factors. It is perhaps time that research and resource is allocated to generating patient-reported QOL outcome measures specific to KSD.

KSD affects QoL in most patients with most impact on bodily pain and general health domains. Compared to the scale of patients suffering from KSD, more work needs to be done in measuring QOL both in terms of ‘Stone specific’ QOL measuring tools and the quality/number of studies in this field.

Compliance with Ethical Standards

Conflict of interest.

Francesca New reports personal fees from Coloplast and other from Storz.

Bhaskar K. Somani declares no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

This article is part of the Topical Collection on Kidney Diseases

Contributor Information

Francesca New, Email: moc.liamg@wenjeiknarf .

Bhaskar K. Somani, Phone: 00442380795273, Email: moc.oohay@inamosraksahb .

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A Methodological Review of Quality of Life Scales Used in Schizophrenia

Affiliations.

• 1 University of Alberta, Edmonton, Alberta, Canada [email protected].
• 2 The Aga Khan University, Karachi, Pakistan.
• PMID: 33334848
• DOI: 10.1891/JNM-D-18-00053

Background and purpose: Evidence is lacking with regard to the most suitable instrument for measuring quality of life (QOL) in patients with schizophrenia. The researchers carried out a methodological review of literature pertaining to scales used to measure QOL in this population.

Methods: Twenty-eight studies, assessing nine different QOL scales, were reviewed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.

Results: While the content of most scales proved valid, the Lancashire Quality of Life Profile (LQOLP), Self-Report Quality of Life Scale (SQOL), and Quality of Life in Schizophrenia (QLiS) outscored the other scales in almost every other domain measured by COSMIN.

Conclusion: LQOLP and SQOL stand out among QOL scales for patients with schizophrenia, but further evidence is required to verify this finding, and no one scale appears ideal for all patients with schizophrenia.

Keywords: measurement quality; quality of life; reliability; schizophrenia; validity.

© Copyright 2021 Springer Publishing Company, LLC.

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• Discriminant and convergent validity of a subjective quality-of-life instrument aimed at high content validity for schizophrenic persons. Franz M, Fritz M, Meyer T. Franz M, et al. Qual Life Res. 2013 Jun;22(5):1113-22. doi: 10.1007/s11136-012-0221-8. Epub 2012 Jun 22. Qual Life Res. 2013. PMID: 22723151
• Quality of life in schizophrenia measured by the MOS SF-36 and the Lancashire Quality of Life Profile: a comparison. Meijer CJ, Schene AH, Koeter MW. Meijer CJ, et al. Acta Psychiatr Scand. 2002 Apr;105(4):293-300. doi: 10.1034/j.1600-0447.2002.1198.x. Acta Psychiatr Scand. 2002. PMID: 11942934
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Applied Research in Quality of Life: A Computational Literature Review

• Published: 09 August 2021
• Volume 17 , pages 1433–1458, ( 2022 )

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• Christian WEISMAYER   ORCID: orcid.org/0000-0003-1143-5651 1  

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As quality of life (QoL) is a highly interdisciplinary topic with a multitude of related research areas, it is beneficial to avail researchers of an overview of the different streams explored in the field. Furthermore, knowledge of prominent sub-domains helps researchers identify links and overlaps between QoL and their fields of interest. To meet these needs, a text-mining-based computational literature review (CLR) of the journal of Applied Research in Quality of Life (ARQOL) was conducted using a machine learning process, latent Dirichlet allocation (LDA), in combination with selection criteria for the decision on the number of topics. The outcome provides the reader with a list of the twelve most heavily discussed topics: 1) consumption & materialism, 2) character strength, 3) spirituality, religiousness & personal beliefs, 4) inequality, 5) leisure & tourism, 6) health related QoL (HRQoL) I, 7) quality of working life (QWL), 8) childhood & adolescence, 9) disparity & development, 10) disorder, 11) community issues, and 12) health related QoL (HRQoL) II. In addition, authors, titles, and publication dates are listed for the top-5-ranked papers that most typify these topics. Subsequent content summaries of these papers reveal more detailed information, such as measurement constructs and theories.

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Introduction

One way to stress a heavily discussed subtopic within a pre-defined research field is through Systematic Literature Reviews (SLRs) (Petticrew & Roberts, 2006 ). Authors of such papers first frame the thematic scope and subsequently provide a structure for this pre-defined scope. Hence, SLRs represent an important source of insight into a delimited research area. Such review papers have also been elaborated on QoL subtopics: for an SLR on QoL research in medicine and health sciences, see Haraldstad et al. ( 2019 ), on multimorbidity, see Makovski et al. ( 2019 ). Several more review papers analyzing subtopics within the broad thematic field of QoL (Bak-Klimek et al., 2015 ; Bhatt et al., 2012 ; Charlemagne-Badal et al., 2015 ; Galloway, 2006 ; Lavy, 2020 ; McIntyre et al., 2014 ; Merianos et al., 2015 , 2016 ; Mogos et al., 2013 ; Paloma et al., 2020 ; Qi et al., 2020 ; Roepke et al., 2014 ; Sirgy & Lee, 2018 ) have been published in ARQOL, the official journal of the ISQOLS (International Society for Quality-of-Life Studies 2020 ), but no reviews are available at its meta-level. Since at least the publication of the European Commission on the Measurement of Economic Performance and Social Progress (Stiglitz et al., 2009 ) confronting traditional approaches of economists with human wellbeing, efficient communication of a structured list of the most prominent drivers of QoL discussed in academic literature to a broader audience is a must. To address this omission, the research goal of the paper at hand lies in the categorization of ARQOL topics.

The ‘science of science’ (Fortunato et al., 2018 ), called ‘scientometrics’ (Leydesdorff & Milojevic, 2015 ), helps to summarize scientific outcomes and is therefore appropriate for this task. Scientometrics partly overlaps with bibliometrics and informetrics (Hood & Wilson, 2001 ) and brings its strengths into play when it comes to cross-sectional and longitudinal information extraction (IE) applied to big data. Scientometric ideas combined with probabilistic topic detection algorithms (Blei et al., 2003 ) offer several advantages compared with SLRs based on manual content analysis. First, the massive workload necessary to screen a single journal (e.g. ARQOL), a thematic field with an intra-disciplinary perspective (e.g. QoL), or an inter-disciplinary perspective (e.g. social sciences), is handed over to a computer-assisted process (Jennex, 2015 ). Second, text-mining-based algorithms reveal topics in an objective way compared with manual approaches lacking reproducibility due to reasons of subjectivity. Consequently, ARQOL topics are herein categorized by means of a computational literature review (CLR; CLR examples: Mortenson & Vidgen, 2016 ; Knuc et al., 2018 ; Hindle et al., 2020 ).

The remainder of this paper is divided into the following sections: The theoretical framework outlines challenges in the creation of a thematic structure for QoL subtopics and screens SLRs published in ARQOL. The methodology section discusses an alternative solution to the more common SLRs by outlining the steps involved in performing CLRs, including data preparation, weighting, and topic modeling. The results section presents descriptive statistics on ARQOL and its inherent topical foci based on the term clusters revealed by the machine learning algorithm, LDA. The five papers that best typify each identified topic are listed. The discussion section compares the term clusters with the content of these papers for validity purposes. The paper closes with limitations and further research directions.

Theoretical Framework

Up to January 14 th 2021, 893 papers had been published in ARQOL since the first edition opened with a personal note by Michalos ( 2006 ). The journal’s aims and scope are communicated as follows:

“The aim of this journal is to publish conceptual, methodological and empirical papers dealing with quality-of-life studies in the applied areas of the natural and social sciences […] crafted from interdisciplinary, inter-professional and international perspectives […] guide decision making in a variety of professions, industries, nonprofit, and government sectors, including healthcare, travel and tourism, marketing, corporate management, community planning, social work, public administration, and human resource management […] help decision makers apply performance measures and outcome assessment techniques based on concepts such as well-being, human satisfaction, human development, happiness, wellness and quality-of-life. The editorial review board is divided into specific sections indicating the broad scope of practice covered by the journal. […]” (Applied Research in Quality of Life 2020).

The whole statement and especially the very last comment show that the aims and scope of ARQOL are broadly defined as QoL overlaps with a wide range of research fields. Even though some narrower subtopics are mentioned, a list of topics following the mutually-exclusive-and-collectively-exhaustive (MECE) principle (Lee & Chen, 2018 ) is hardly possible. A mutually exclusive list of topics enabling each paper to be assigned to a single topic is not possible as papers are frequently built upon a bundle of different topics. A collectively exhaustive list is similarly infeasible, as the range of topics is continuously broadening with the emergence of new research fields influencing QoL research. Examples for such new streams are studies tackling genetic influences on happiness (Nes & Røysamb, 2017 ), discussions taking an evolutionary perspective (Wilson, 2016 ), or analyses following a neurobiological perspective (Kringelbach & Berridge, 2017 ). In sum, not all topics covered by ARQOL can be explicitly stated in the aims and scope, yet researchers could nevertheless benefit from a quick and accessible overview of the most heavily discussed topics.

One type of paper summarizing widely debated topics from a broader perspective are SLRs (Petticrew & Roberts, 2006 ; Snyder, 2019 ). To promote high quality SLRs, best practice guidelines have been proposed for wellbeing research (Hennessy & Johnson, 2019 ; White & Schmidt, 2005 ). The approach common to all SLRs involves initially collecting papers connected with a delimited topic, before summarizing those publications across the topic of interest. Most ARQOL papers classified as SLRs on the journal’s website or identified as such by crawling ARQOL’s titles for the search term “review” conducted a systematic bibliographic computerized online search using pre-defined keywords handed over to various databases (chronologically ordered in Table 1 ).

Galloway ( 2006 ) conducted a systematic mixed literature search (electronically and manually) of English language publications from 1995 to 2006 to study the effect of cultural participation on individual QoL. Bhatt et al. ( 2012 ) systematically collected questionnaires for the measurement of diabetes mellitus health outcomes and compared psychometric properties of these instruments. Mogos et al. ( 2013 ) studied QoL measurement scales in pregnant and postpartum mothers. McIntyre et al. ( 2014 ) compared different neurogenic bladder management techniques after spinal cord injuries (SCI) among extracted articles and came to the conclusion that not only physiological, safety, and practical considerations but also urologic-specific QoL outcome measures must be included in determining the “gold standard”. Roepke et al. ( 2014 ) used a SLR to investigate the term ‘meaning’ and to examine its relationship with physical health. Bak-Klimek et al. ( 2015 ) systematically reviewed the determinants of well-being among international immigrants. Charlemagne-Badal et al. ( 2015 ) identified the absence of instruments suitable for the measurement of wellbeing and life satisfaction (LS) which would be highly beneficial for health research as well as professionals dealing with clinical applications. Their measurement instrument revealed the most often included domains across the following concepts: cognitive, economic, emotional, physical and social health, environmental, health behavior, health care, intellectual pursuits, leisure, life satisfaction, non-leisure activities, sleep, spirituality/meaning, and vitality. Merianos et al. ( 2015 ) collected different studies to examine hospital-based, school-based, and community-based strategies health professionals use to improve the QoL of youth with chronic illnesses. Another comprehensive review conducted by Merianos et al. ( 2016 ) identified mentoring/coaching and peer-led interventions in community-based programs to improve the QoL outcomes for adolescents. Sirgy and Lee ( 2018 ) portrayed an integrative concept of work-life balance. Lavy ( 2020 ) analyzed the mechanisms and practices necessary to foster strength of character in twenty-first-century schools and developed an integrative model of an optimal school system. Paloma et al. ( 2020 ) studied migrants from developing countries settling in countries with very high human development levels to identify main determinants of LS. Qi et al. ( 2020 ) studied the development of publications discussing positive youth development (PYD) between 1995 and 2020 focusing predominantly on bibliometric information.

Each of these papers provides a thorough exploration of research on a delimited topic, as is its respective purpose. The time effort invested through SLRs in the identification of the most valuable research by manually screening the collected papers over the preceding decades is of great use to other researchers – particularly those connected only tangentially to the topic – as it economizes their own literature search and encourages empirical studies instead. However, manual content analysis cannot be conducted continuously due to time constraints, meaning that SLRs may quickly become outdated in fast-changing research fields, and results might differ between different authors because of the innate subjectivity of the process (Mortenson & Vidgen, 2016 ): the latter also raises validity questions of longitudinal comparisons between SLRs on the same topic (i.e. updates).

Considered together, these reviews begin to charter the broad field of QoL research, yet the result is just a piecemeal and overlapping collage of topics that fails to systematically map the broad scope covered by ARQOL at the meta-level. On this account, computerized topic modeling solutions have been developed to produce objective reproducible results that supplement and/or replace manual content analysis to a certain extent (Suominen & Toivanen, 2015 ). As the purpose of this study is to provide a holistic overview of the thematic scope of ARQOL, accompanied by their most representative papers, the methodology section outlines how to embed computer-assisted techniques for the creation of CLRs.

Methodology

Data preparation and term selection.

All 893 papers published in ARQOL between May 2006 and January 14 th 2021 were converted from.pdf to.txt and imported into R (release 4.0.3), an open source software environment for statistical computing and graphics (R Core Team, 2021 ). Subsequently, the following data preparation steps were conducted:

Lemmatization was used to determine the root form of inflected terms (e.g. organs → organ; organizations → organization) (Rinker, 2018 ). Lemmatization was preferred to the more frequently used stemming procedure: Porter’s stemming algorithm (Porter, 1980 ). Stemming cuts prefixes and suffixes from the inflected terms, but this raises the problem of terms with different meanings being reduced to the same root (e.g. organization → organ; organs → organ). Consequently, lemmatization was preferred (Gupta & Jivani, 2018 ). AE and BE distinctions were ignored.

A list of stopwords (e.g., ‘and’, ‘or’, ‘if’) (Benoit et al., 2019 ), white spaces, terms ≤ 2 characters, as well as numerical and other non-alphanumeric characters were removed (Feinerer & Hornik, 2020 ; Feinerer et al., 2008 ).

Furthermore, punctuation was removed, as part-of-speech tagging (POS) (Kumawat & Jain, 2015 ) used to label full sentence terms by their word class categories (e.g., noun, verb) will not wash out the word-sense disambiguation for those parts of a text that do not consist of full sentences (e.g., the term ‘park’ has several meanings: ‘park a car’, or ‘go for a walk in a park’). Hence, tokenization was used to transform the sentence structure to a bag-of-words (BoW) model (Sebastiani, 2001 ) and the difference between upper- and lower-case letters was ignored by changing all capital letters to lower-case letters. This guarantees that terms starting with a capital letter, e.g. at the beginning of a sentence, are treated as having identical meanings as the same terms starting with a small letter within a sentence.

Subsequently, terms were deleted upon their ‘term frequency – inverse document frequency’ ( \(tf\_idf\) ) weight (Spärck, 1972 ). It is the most widely used global term-weighting procedure for text-based analysis (Breitinger et al., 2015 ).

\({f}_{ji}\) is the frequency of a specific term in a document. \(\sum_{i=1}^{n}{f}_{ji}\) is the total number of terms in a document. \(\left|D\right|\) is the number of documents, here 893 ARQOL papers, and \(\left|\left\{{d}_{j}|{t}_{i}\in {d}_{j},{d}_{j}\in D\right\}\right|\) is the number of documents containing the specific term. \(tf\_idf\) puts more weight on terms contained in relatively few documents and stresses their discriminative power. Deletion of terms with \(tf\_idf\) -weights below the median of the \(tf\_idf\) -distribution of all terms has been recommended (Grün & Hornik, 2011 ) and was applied to the whole corpus to sort out irrelevant terms.

Topic Modeling

After data preparation and term selection, one of the most often used generative machine learning techniques for topic modeling was used to retrieve the strongest ARQOL topics as well as their best matching papers, namely LDA (Blei et al., 2003 ). In contrast to correlated topic models (CTM) (Blei & Lafferty, 2007 ), topics are assumed to be uncorrelated in LDA. It determines topics under the following probabilistic logic: First, each document (here ARQOL papers) is a multinomial mixture of several different topics – the topic per document model. The terms of each document should be allocated to as few topics as possible. Second, each topic is a multinomial mixture of several different terms – the term per topic model. As few terms as possible should be allocated to each topic with the highest possible probabilities. Both are modeled by Dirichlet distributions (Blei et al., 2003 ). Assuming that it is possible to sketch a paper with just a small number of topics and to sketch a topic with just a small number of terms, the most discriminative topics from the ARQOL corpus are determined and the most typical ARQOL papers that fit a certain topic are discovered.

The model was estimated using Gibbs sampling as variational expectation–maximization (VEM) is computationally more demanding in terms of memory, as well as the fact that Gibbs sampling allows for application to large corpora (Grün & Hornik, 2011 ). In addition, LDA is preferred against widely used techniques like latent semantic indexing (LSI) or non-negative matrix factorization (NMF) (Rahman et al., 2020 ).

Based on the assumption that single papers may cover multiple topics at the same time, overlapping term clusters are requested. Compared with hierarchical cluster analysis (HCA) that produces disjoint term clusters (topics) and does not allow for overlaps between topics, LDA is not bound by this restriction. Thus, each term can be allocated with different probabilities to multiple topics and not just one single topic, as with HCA. Summarized, joint term clusters derived from LDA are preferred against disjoint ones so that each paper can capture more than one single topic.

Finally, the number of topics is not known a priori. If a small number of topics is chosen, LDA reveals broader topics at higher latent levels. In contrast, the selection of a large number of topics results in narrower topics at lower latent levels. The specification of the number of topics can be statistically explored (Murzintcev, 2020 ). Two minimization heuristics (Arun et al., 2010 ; Cao et al., 2009 ) and two maximization heuristics (Deveaud et al., 2014 ; Griffiths & Steyvers, 2004 ) were estimated to ease the decision on the number of topics (Fig.  1 ).

Number of topics

No outstanding value nor striking inflection point (i.e. remarkable differences between neighboring solutions) were detectable for Griffiths and Steyvers’s ( 2004 ) criterion, except from a constant improvement of fit towards higher-dimensional solutions – underlining the broad variety of QoL topics – and a state of indifference at around 40 topics. Hence this criterion did not reveal any further insights, but the other three did. The highest value for Deveaud et al.’s ( 2014 ) criterion maximizing divergence between all LDA topic pairs was found for 12 topics. An in-depth evaluation of its path along the number of topics indicated increasing fit up to 6 topics, almost indifference between 6 and 10 topics, another increase in fit up to 12 topics, but much worse fit for 13 topics with varying dissimilarity values for higher-dimensional solutions. The same noticeable differentiation between 12 and 13 topics was observed by Cao et al.’s ( 2009 ) minimization criterion, minimizing the average cosine distance between all topic pairs (small values signalize independent topics). Likewise, Arun et al.’s ( 2010 ) minimization criterion shows a monotonic decrease in similarity up to 12 topics but worse fit for 13 topics. Therefore, the 12 topic solution is presented in the results section.

Descriptive Statistics

ARQOL was founded in 2006. Between May 2006 (first issue) and January 14 th 2021, 893 articles were published in 15 volumes (61 issues) and as online first publications. These include original research and review papers, book reviews, reports, editorial notes, brief communications, corrections, and errata. The latter do not distort the topic formation as it is solely based on Dirichlet-distributed topic-term distributions ignoring the type of paper. The average number of terms per document after removal of stopwords, punctuation, numbers, non-alphanumeric characters, and terms ≤ 2 characters was 3,970 terms (median: 4,208). After deletion of the least discriminative terms according to their \(tf\_idf\) weight, on average 846.6 terms (median: 854) per document were handed over to the LDA machine learning algorithm.

Exploratory Statistics – Term Clusters

Figure  2 illustrates the twelve most fundamental topics discussed in ARQOL revealed by LDA. The content-wise summation of terms within each cluster is as follows: 1) Consumption & materialism, 2) Character strength, 3) Spirituality, religiousness & personal beliefs, 4) Inequality, 5) Leisure & tourism, 6) Health-related QoL (HRQoL) I, 7) Quality of working life (QWL), 8) Childhood & adolescence, 9) Disparity & development, 10) Disorder, 11) Community issues, and 12) Health-related QoL (HRQoL) II.

ARQOL topics

Exploratory Statistics – Paper Clusters

Table 2 lists the five papers most representative of each topic. They were determined by calculating the estimated proportion of terms within a specific paper that are built upon the terms of just one specific topic, the so called per-topic per-document probabilities or gamma values, γ, listed in column three. For each topic, the top-5-ranked papers were selected based on the highest proportion of explained terms. A manual assessment of these papers found all to be thematically consistent with the topic to which they were computationally assigned.

SLRs are valuable sources of information as they give detailed overview on a specific research topic in a condense way. However, as review papers providing a holistic picture of the overall thematic field of QoL were not available, a CLR using a generative machine learning process was implemented to identify topics discussed in the 893 papers published in ARQOL between May 2006 and January 14 th 2021. Following several data preparation steps, the resulting corpus was handed over to a probabilistic LDA algorithm – a Bayesian Gibbs sampler – for topic detection. The five papers computationally determined as best matching the resulting twelve topics were qualitatively screened for validation purposes and to explore them in more detail. Theoretical overlaps, similar methods, measurement constructs containing the same QoL impacting factors and identical catchwords listed below depict the content-related closeness between papers that led to the formation of the twelve topics. The following enumeration confirms the consistency of the topic names derived from the term clusters with the content presented in the top-5-ranked papers:

Consumption and Materialism: Quality of College Life (QCL) and Quality of Academic Life (QAL) focusing on services offered; hero attachment due to brands and products to enhance ones A-R–C (Autonomy, Relatedness, and Competence) need; Consumer Well-Being (CWB); shopping well-being and ill-being;

Character Strengths: European Social Survey (ESS) on personal and social wellbeing capturing evaluative/emotional/community wellbeing, functioning, vitality, and supportive relationships; Values In Action(-Inventory of Strength) (VIA-IS) classifying character strengths into six virtues (wisdom and knowledge, courage, humanity, justice, strengths that protect against excess, transcendence); Character Strengths Rating Form (CSRF); Positive emotion, Engagement, Relationships, Meaning and Accomplishment (PERMA) to measure hedonic and eudaemonic well-being; Big Five; Humor Mindfulness Relationship Model (HMRM);

Spirituality, Religiousness & Personal Beliefs: Islamic coping strategies and spiritual support mechanisms of Muslim employees; ill-being of militant Jihadist terrorism groups in the MENA (Middle East North Africa) region; interplay between positive affect, loss of faith, religious practices, compassion, emotional support provided to others, and meaning in life; a diasporic Russian Jewish community sharing linguistic and cultural heritage for mutual support, engagement, socialization, independence and resilience; altruism and Existential Well-Being (EWB);

Inequality: Gender gaps driven by import penetration, employment, marital status, housework, or income; Health Care Expenditure (HCE) and economic growth in South Asian Association for Regional Cooperation (SAARC) countries;

Leisure & Tourism: Sport event legacy (UEFA EURO 2016, World Games Taiwan 2009, Summer Deaflympics 2009, Summer Universiade Taipei 2009); Player Experience of Need Satisfaction (PENS) and creative travel experience; disabilities restricting Activities of Daily Living (ADL) measured with the leisure domain of the Life Satisfaction Questionnaire (LISAT-11); elderly tourists’ travel motivation & constraints;

Health Related QoL (HRQoL) I: Effects of Percutaneous Coronary Revascularization (PCR) after Coronary Artery Disease/Bypass Grafts (CAD/CABG) analyzed with the Nottingham Health Profile (NHP), the Seattle Angina Questionnaire (SAQ), or the Short-Form 36 (SF-36) for medical outcomes; validating EuroQol 5D (EQ-5D) on acute cough/Lower Respiratory Tract Infections (LRTI); Short Form 6D (SF-6D); Health Utilities Index (HUI); chronic musculoskeletal disorders (MSD) evaluated by the Short-Form 12 (SF-12) Physical and Mental Component Summary (PCS & MCS), the Life Orientation Test-Revised (LOT-R), or the Visual Analogue Scale (VAS) for pain measurement; outcome after spinal surgery by the Oswestry Disability Index (ODI); Patient Reported Outcomes Measurement Information System (PROMIS) Global Short Form (GSF), Edinburgh Postpartum Depression Scale (EPDS), or Modified Kendler Social Support Index (MKSSI) during pregnancy;

Quality of Working Life (QWL): Effect of Work-Family/Family-Work Conflict (WFC/FWC) on job satisfaction/work engagement and job autonomy and schedule flexibility as moderators in the Job Demands-Resources (JD-R) model; Work-To-Family/Family-To-Work Enrichment (WTFE/FTWE); Work Interference with Family/Family Interference with Work (WIF/FIW); Utrecht Work Engagement Scale (UWES); intention to quit predictors; Work Facilitation with Family/Family Facilitation with Work (WFF/FFW);

Childhood & Adolescence: Maternal/Paternal Sacrifice Scale (MSA/PSA) on developmental outcomes (self-identity, self-determination, self-efficacy) using Walsh’s family resilience framework; Authoritarian/Reciprocal Filial Piety (AFP/RFP) scale; the influence of Paternal/Maternal Expectations of Children’s Future scale (PECF/MECF) and Paternal/Maternal Control Scale (APCS/AMCS) on Cognitive Competence (CC) and the Clear and Positive Identity subscale (CPI) of the Chinese Positive Youth Development Scale (CPYDS); parent–child relationship, sibling and friend bullying; mother’s and father’s parenting style (authoritarian, authoritative and permissive) on Rosenberg Self-Esteem Scale (RSES)/Student’s Life Satisfaction Scale (SLSS), Subjective Happiness Scale (SHS)/Perceived Parenting Style Survey (PPSS)/Friendship Quality Scale (FQS);

Disparity & Development: Linking income-driven governance (voice & accountability and political stability/no violence for political governance, regulation quality and government effectiveness for economic governance, rule of law and corruption-control for institutional governance) and inclusive human development in Sub-Saharan Africa; fulfillment of MDG1 (Millennium Development Goal) (eradicate extreme poverty and hunger) in Southern Africa/Horn of Africa, MDG2 (achieve universal primary education), MDG3 (gender equality and women’s empowerment), and MDG4 (reduce child mortality) in Least Developed Countries (LDC) of Asia, or all MDGs in African countries;

Disorder: Morbidly obese subjects’ pre-operative expectations and after gastric banding evaluations; benefits/costs of cell/mobile phone use domains (social/leisure/family/education/health and safety/love, work, financial life); non-normative eating behavior [Binge Eating Disorder (BED), Night Eating Syndrome (NES), sweet/fat food cravings, continuous nibbling] of women to bariatric surgery with Obesity Related Well-being (ORWELL-97); women’s race (black/white) moderating the relationship between the Impact of Weight on Quality of Life (IWQOL-Lite) and Body Mass Index (BMI); elderly’s alcohol consumption in São José dos Campos-Brazil using the Alcohol Use Disorders Identification Test (AUDIT)/Oral Health Impact Profile (OHIP-14);

Community Issues: Urban–rural comparison in China; waste recycling behavior in Hong Kong’s high-rise buildings to improve public living environment by Use of Public Recycling Facilities (UPRF)/Use of Private Recycling Sectors (UPRS) models; Local Economic Development (LED) in large Chinese cities (basic life, housing conditions, education & culture, health and medicine, social security, urban transportation, physical environment, recreation); linking walking patterns among employed urban Canadians and commuting modes/time of day/days of week/purposes; social, infrastructural and economic conditions in rural communities in Enugu State/Nigeria;

Health Related QoL (HRQoL) II: (Abbreviated) World Health Organization QoL (WHOQOL-100/WHOQOL-BREF) questionnaire: negative affect [Quality of Life, Enjoyment, and Satisfaction Questionnaire (Q-LES-Q)], functioning [Work and Social Adjustment Scale (WSAS)], and depressive symptom severity [Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR)] from comorbid Social Phobia (SP), Major Depressive Disorder (MDD), and remission measured with the Psychiatric Diagnostic Screening Questionnaire (PDSQ); patients with Vasovagal (VVS)/unexplained syncope (US) using the Illness Perceptions Questionnaire-Revised (IPQ-R), the Quality of Life Systemic Inventory (QLSI), Tilt-Table Testing (TTT), Head-Up Tilt Testing (HUTT), the Pain Self-Efficacy Questionnaire (PSEQ), the Primary Care Evaluation of Mental Disorders (PRIME-MD), the Diagnostic and Statistical Manual-Revision 4 (DSM-IV), the Psychatric Symptom Index (PSI), and the Lifetime Number of Syncope (LNS); Post-Traumatic Stress Symptoms/Disorders (PTSS/PTSD) of adults treated for primary benign Meningioma (MGM); anxiety/depression of patients under chemotherapy due to Soft Tissue Sarcomas (STS) assessed by the Functional Assessment of Cancer Therapy-General (FACT-G) and the Hospital Anxiety and Depression Scale (HADS); WHOQoL-BREF as Patient Reported Outcome (PRO) domains (physical, psychological, social relations, environment).

All twelve topics are hot topics. Most of them already attract transnational attention for a considerable time, e.g., disparity and development (9) focus on specific Sustainable Development Goals (SDGs) (United Nations 2021 ). Others do not explicitly name them but are devoted to one or several of the 17 SDGs, e.g., inequality (4) tackles gender disparities that will be stressed even more in the future and concern not only specific countries. Likewise, disorder (10) and resulting obesity problems, burn-out in relation with quality of working life (QWL) (7) is already included in the 11 th Revision of the International Classification of Diseases (ICD-11) and classified as a “factor influencing health status” (World Health Organization 2019 ), or health related QoL (6) issues due to musculoskeletal disorders of desk work are problems rising special attention of highly developed countries nowadays. Especially, depression as a subtopic of health related QoL (12) has been identified as a worldwide problem by the World Health Organization’s (WHO) Department of Mental Health and Substance Abuse (Marcus et al., 2012 ). Changes driven by information technology (IT) advancements are mobile working and home office that will impact community issues (11) in the future as well. Finally, topics like consumption & materialism (1), spirituality, religiousness & personal beliefs (3), and leisure & tourism (5) are pull factors elicited by shifts in the way of living, generational changes and mobility, degrowth or ethical motivations, or improvements in character strength (2) or childhood and adolescence (8).

Overall, the proposed CLR methodology has demonstrated itself capable of detecting heavily discussed topics partly captured by SLRs published in ARQOL in the past. CLR can quickly grasp the content of a journal in a highly efficient and objective way. Hence, QoL topics can be determined at fine-grained or coarse levels depending on the granularity requested of the LDA. Special issue or conference topic suggestions can be identified in this way. From a more inter-disciplinary perspective, overlaps between different scientific fields can also be uncovered.

Limitations and Further Research

Some concerns related to the data preparation steps must be mentioned. First, seldomly used terms and untypical modifications with neglectable influences on the outcome cannot be lemmatized. Second, the lemmatization step cannot process acronyms and initialisms and match them with their fully expounded counterparts. Therefore, it cannot transform 100% of the terms to their lemmas. However, the significance of abbreviated terms is enhanced by the term-frequency inverse document frequency weight to account for their discriminating power in a paper due to the resulting low number of occurrences of the unabbreviated term. Third, polysemy and ambiguity describe the problem that many meanings may exist for the same term. But this is partly solved as LDA addresses this problematic by simultaneously connecting terms with different meanings to multiple topics.

With regards to further research, one of the most interesting extensions lies in the inclusion of more QoL-related journals, e.g., surveying all ISQOLS affiliated journals (Social Indicators Research, Journal of Happiness Studies, Quality of Life Research, Psychology of Well-Being, Health and Well-Being, International Journal of Community Well-being, and the International Journal of Wellbeing) to study well-being from a more comprehensive point of view. Analyses based on such broader list of journals should reveal a list of topics at an overarching framework, e.g., the life quality and well-being (LQW) model (Skevington & Böhnke, 2018 ). However, as the focus of the current study was to determine QoL domains, selection of a single journal, here ARQOL, has been preferred.

Alternatively, running the same algorithm in a cross-sectional approach focusing solely on online first articles would reveal upcoming research streams in the field of QoL, such as the COVID-19 pandemic (Shek 2021 ). Next to cross-sectional analyses, longitudinal attempts could provide insights into the development of the field by revealing topics that have gained or lost prominence over the years. A critical look at emerging topics should provide insights about their actual importance, both now and into the future, while the recognition of important topics that have drifted from popularity may prompt reinforcement strategies including a relaunch in the form of a special issue to shine a spotlight and generate academic interest.

In addition to CLRs, qualitative analysis of QoL related papers would uncover emerging topics which might claim for themselves a topic of their own in the future that cannot be detected by CLRs, e.g., the rise of living alone (Klinenberg, 2016 ), climate change related QoL (Estoque et al., 2018 ), or quality of virtual life (Novak, 2012 ).

Data Availability

ISQOLS members have free access to the journal of ARQOL.

Code Availability

Custom code could be provided and published as supplemental material upon request.

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WEISMAYER, C. Applied Research in Quality of Life: A Computational Literature Review. Applied Research Quality Life 17 , 1433–1458 (2022). https://doi.org/10.1007/s11482-021-09969-9

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DOI : https://doi.org/10.1007/s11482-021-09969-9

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• http://orcid.org/0009-0005-9691-4599 Jacob Stevenson 1 ,
• Alexandra Clinch 2 , 3 ,
• Maria Ftanou 2 , 4 and
• Clare Delany 2 , 5
• 1 The University of Melbourne Faculty of Medicine Dentistry and Health Sciences , Melbourne , Victoria , Australia
• 2 Peter MacCallum Cancer Centre , Melbourne , Victoria , Australia
• 3 The University of Melbourne , Melbourne , Victoria , Australia
• 4 The University of Melbourne School of Population and Global Health , Melbourne , Victoria , Australia
• 5 The University of Melbourne Department of Medical Education , Melbourne , Victoria , Australia
• Correspondence to Dr Jacob Stevenson, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, VIC 3010, Australia; Jacobdeanstevenson{at}gmail.com

The use of clinical ethics services (CES) has been increasing over time, but little is known about the role of CES in cancer care. Cancer diagnosis and treatment are emotionally charged and life-changing experiences, raising existential and ethical questions about the quality and meaning of, living and dying. This narrative review seeks to consolidate the available information regarding how CES are accessed and used in cancer care. The review attempts to answer the question, ‘What is known about the role of CES in cancer care?’ Papers included in this review were identified through searching PubMed and MEDLINE Ovid; a variety of keywords were used to ensure the capture of all relevant literature. 387 papers were identified using the search strategy, 13 papers were included in the final synthesis following the application of the inclusion and exclusion criteria. Citation searching was conducted. 11 of 13 papers were conducted in the USA, 1 in Germany and 1 in South Korea. A variety of study designs were incorporated into this review. Five key roles of CES in cancer care were identified; conflict resolution/mediation, delivery of ethics education to clinical staff, advising on specific aspects of care, guideline development/resource allocation and emotional support of clinicians. This narrative review outlines how CES can assist clinicians to reflect on, better understand and address, the complex ethical dimensions of their practice. The identified literature demonstrates that early involvement of CES may reduce conflict. More research is needed gathering information from CES directly.

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https://doi.org/10.1136/spcare-2023-004300

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Contributors CD was responsible for study conception and is the study guarantor. JS was responsible for study design, literature search, collection of results and manuscript drafting. JS, AC, MF and CD reviewed manuscripts for inclusion in the study. AC, MF and CD reviewed and made critical revisions to the paper. CD supervised the study.

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.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Ecology and sustainable conservation of the nase, chondrostoma nasus : a literature review.

1. Introduction—Generality

2. methodology and worldwide publication trend on nase, 3. european repartition, 4. morphology and identification, 5. reproduction and life cycle, 7. movement dynamics of adult and young stages, 7.2. young stages, 8. characteristics of spawning areas and habitats of juvenile and adult, 8.1. spawning area, 8.2. juvenile habitats, 8.3. adult habitats, 9. impact of anthropogenic pressures, environmental disruptions, and restoration measures, 9.1. water pollution, 9.2. loss of habitat and hydromorphological perturbations, 9.3. disruption of hydrological regimes—hydropeaking, 9.4. obstruction of movements, 9.5. mean threats, guidelines for conservation, and key research questions for the future, 10. conclusions and perspectives, author contributions, data availability statement, acknowledgments, conflicts of interest.

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Ovidio, M.; Nzau Matondo, B. Ecology and Sustainable Conservation of the Nase, Chondrostoma nasus : A Literature Review. Sustainability 2024 , 16 , 6007. https://doi.org/10.3390/su16146007

Ovidio M, Nzau Matondo B. Ecology and Sustainable Conservation of the Nase, Chondrostoma nasus : A Literature Review. Sustainability . 2024; 16(14):6007. https://doi.org/10.3390/su16146007

Ovidio, Michaël, and Billy Nzau Matondo. 2024. "Ecology and Sustainable Conservation of the Nase, Chondrostoma nasus : A Literature Review" Sustainability 16, no. 14: 6007. https://doi.org/10.3390/su16146007

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