Vous êtes sur la page 1sur 164


Baby Hunger and Australian Women illness. The scale was originally developed to
measure life changes in family caregivers of
Childbearing Desires Among Australian stroke survivors, but has also been used in family
Women caregivers of those with heart failure and
a variety of other chronic conditions.

Bad Jobs Description

Dead-End Jobs Family caregivers are known to experience many

negative outcomes as a result of providing care for a
stroke survivor after discharge to the home setting
(Bakas, 2009; Miller et al., 2010). The Bakas Care-
Bakas Caregiving Outcomes Scale giving Outcomes Scale (BCOS) was originally
developed in 1994 to measure life changes in family
Tamilyn Bakas caregivers of stroke survivors. Details regarding the
Indiana University School of Nursing, development and psychometric testing of the first
Indianapolis, IN, USA two versions of the BCOS are provided by Bakas
and Champion (1999). The BCOS has since been
revised to a 15-item version with psychometric
Synonyms evidence being published in Bakas, Champion,
Perkins, Farran, and Williams (2006).
Caregiver burden; Caregiving outcomes; Development and psychometric testing of the
Caregiving outcomes measurement; Caregiving BCOS was based upon a conceptual model derived
questionnaire; Caregiving scale; Life changes from Lazarus transaction-based approach to stress
and caregiving outcomess; Measurement of care- (Bakas & Champion, 1999; Bakas, Champion,
giving outcomes; Quality of life of caregivers; et al., 2006; Lazarus, 1991; Lazarus & Folkman,
1984). Within this model, antecedent personality
factors (e.g., self-esteem or optimism) and care-
Definition giver tasks (e.g., providing personal care) are medi-
ated by cognitive appraisal to produce caregiver
The Bakas Caregiving Outcomes Scale (BCOS) emotional distress and adaptational outcomes.
is an instrument designed to measure life changes The BCOS items were developed based upon Laz-
in family caregivers of persons with chronic arus (1991) definition of adaptational outcomes,

A.C. Michalos (ed.), Encyclopedia of Quality of Life and Well-Being Research,

DOI 10.1007/978-94-007-0753-5, # Springer Science+Business Media Dordrecht 2014
B 320 Bakas Caregiving Outcomes Scale

defined as changes in social functioning, subjective Correlations between the 15-item BCOS and the
well-being, and health specifically as a result of SF-36 Health Survey subscales improved, provid-
a stressful situation, such as providing care. ing stronger support for criterion-related validity
Of the 48 BCOS items that were initially devel- (Bakas, Champion, et al., 2006).
oped, 27 exhibited 100 % agreement by a panel of Although the 15-item BCOS is recommended
experts as having evidence of content validity. The for use with family caregivers of stroke survivors
27 BCOS items were then tested in a sample of 92 (Bakas, 2009; Bakas & Champion, 1999; Bakas,
family caregivers of stroke survivors, where the Champion, et al., 2006; Miller et al., 2010), it
scale was further reduced to 12 items using item has also been used in a variety of other caregiving
analysis (Bakas & Champion, 1999). Further test- populations, such as with family caregivers of
ing of the BCOS in another sample of 104 family persons with heart failure (Bakas, Pressler,
caregivers of stroke survivors further shortened the et al., 2006; Nauser, Bakas, & Welch, 2011;
scale to 10 items (Bakas & Champion, 1999). Both Pressler et al., 2009), coronary artery bypass sur-
12-item and 10-item versions had good evidence gery (Halm & Bakas, 2007), and bone marrow
of internal consistency reliability (Cronbach transplant (Fife, Monahan, Abonour, Wood, &
alphas .90 and .77), and unidimensionality was Stump, 2009). The 15-item BCOS has also been
supported by factor analysis. Using hierarchical used as an outcome measure in stroke caregiver
multiple regression, concepts in the conceptual intervention studies (Bakas et al., 2009; King,
model explained 63 % of the variance in the Hartke, & Denby, 2007) and was used to describe
12-item BCOS scores in the first sample and the impact of stroke caregiving in a population-
45 % of the variance in the 10-item BCOS scores based study in Auckland, New Zealand (Parag
in the second sample. Criterion-related validity et al., 2008). Two comprehensive reviews of
was supported in both samples with significant caregiving burden measures have cited the
BCOS correlations with the SF-36 Health BCOS as having the most psychometric testing
Survey, a life satisfaction instrument (LIFE-3), of all of the tools reviewed (Deeken, Taylor,
and a single item asking caregivers how their Mangan, Yabroff, & Ingham, 2003) and of hav-
lives had changed overall as a result of providing ing the highest rate of agreement among authors
care (Bakas & Champion, 1999). Although both for representing key caregiver concepts (Visser-
12-item and 10-item versions of the BCOS Meily, Post, Riphagen, & Lindeman, 2004).
exhibited promising psychometric properties, low The current 15-item BCOS consists of items
correlations with some of the SF-36 Health Survey that address changes in social functioning, sub-
subscales and the deletion of two poorly worded jective well-being, and health specifically as
financial items led to the addition of five new items a result of providing care for a family member.
to the 10-item BCOS (Bakas, Champion, et al., Items are rated on a 7-point scale ranging from
2006). These new items included changes in finan- 3 (changed for the worst) to +3 (changed for the
cial well-being, physical functioning, general best), with 0 meaning did not change. The 3 to
health, roles in life, and level of energy. This +3 ratings are recoded to 17 so that positive
revised 15-item BCOS was then tested in a third numbers can be used for analyses. The advantage
sample of 147 family caregivers of stroke survi- of the BCOS over most caregiving scales is
vors (Bakas, Champion, et al., 2006). Satisfactory the ability for caregivers to express positive
evidence was provided for internal consistency changes in their lives as a result of providing
reliability (Cronbach alpha .90) and 2-week care. For example, on average, caregivers rate
test-retest reliability (intraclass coefficient .66). their self-esteem and relationship with the stroke
Confirmatory factor analysis provided further sup- survivor as changing for the best as a result of
port for unidimensionality of the 15-item BCOS, providing care (Bakas & Champion, 1999;
and hierarchical multiple regression showed that Bakas, Champion, et al., 2006). The most nega-
the constructs in the conceptual model explained tive life changes include time for family and
36 % of the variance in the 15-item BCOS scores. social activities, relationship with friends,
Balance in Life 321 B
financial well-being, emotional well-being, level A review of self-report instruments developed to mea-
of energy, and physical health (Bakas & Cham- sure the burden, needs, and quality of life of informal
caregivers. Journal of Pain and Symptom Manage-
pion, 1999; Bakas, Champion, et al., 2006). Not ment, 26, 922953.
only can the BCOS be used as a research instru- Fife, B. L., Monahan, P. O., Abonour, R., Wood, L. L., &
ment, but it could also be used as an assessment Stump, T. E. (2009). Adaptation of family caregivers B
tool at the item level to identify problem areas for during the acute phase of adult BMT. Bone Marrow
Transplantation, 43, 959966.
family caregivers in clinical practice (Bakas, Halm, M. A., & Bakas, T. (2007). Factors associated with
2009; Miller et al., 2010). Other advantages of caregiver depressive symptoms, outcomes, and per-
the BCOS include the fact that it is brief and ceived physical health following coronary artery
easily administered by mail, telephone, or by bypass surgery. Journal of Cardiovascular Nursing,
22(6), 508515.
face-to-face interviews (Bakas & Champion, King, R. B., Hartke, R. J., & Denby, F. (2007). Problem-
1999; Bakas, Champion, et al., 2006). For more solving early intervention: A pilot study of stroke
information or permission to use the BCOS in caregivers. Rehabilitation Nursing, 32(2), 6876, 84.
research or practice, please contact Dr. Tamilyn Lazarus, R. S. (1991). Emotion and adaptation.
New York: Oxford University Press.
Bakas, Professor, Indiana University School of Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal,
Nursing, 1111 Middle Drive, Indianapolis, IN, and coping. New York: Springer.
(317) 2744695, tbakas@iupui.edu. Miller, E. T., Murray, L., Richards, L., Zorowitz, R. D.,
Bakas, T., Clark, P. (2010). Comprehensive overview
of nursing and interdisciplinary rehabilitation care of
the stroke patient. A scientific statement from the
American Heart Association. Stroke, 41, 24022448.
Cross-References Nauser, J. A., Bakas, T., & Welch, J. L. (2011). A new
instrument to measure quality of life of heart failure
Caregiver Burden family caregivers. Journal of Cardiovascular Nursing,
Caregiver Quality of Life 26(1), 5364.
Parag, V., Hackett, M. L., Yapa, C. M., Kerse, N.,
Caregiving McNaughton, H., Feigin, V. L., Anderson, C. S., on
Family Caregiving behalf of the Auckland Regional Community Stroke
Quality of Life (ARCOS) Study Group. (2008). The impact of stroke
on unpaid caregivers: Results from the Auckland
Regional Community Stroke Study, 20022003.
Cardiovascular Disease, 25, 548554.
Pressler, S. J., Gradus-Pizlo, I., Chubinski, S. D., Wheeler,
References S., Wu, J., & Sloan, R. (2009). Family caregiver out-
comes in heart failure. American Journal of Critical
Bakas, T. (2009). Chapter 42: Stroke and the family. In Care, 18(2), 149159.
J. Stein, R. Harvey, R. Macko, C. Winstein, & Visser-Meily, J. M. A., Post, M. W. M., Riphagen, I. I., &
R. Zorowitz (Eds.), Stroke recovery and rehabilita- Lindeman, E. (2004). Measures used to assess burden
tion. Woodbridge, CT: Demos Publishing. among caregivers of stroke patients: A review. Clini-
Bakas, T., & Champion, V. (1999). Development and cal Rehabilitation, 18, 601623.
psychometric testing of the Bakas Caregiving
Outcomes Scale. Nursing Research, 48(5), 250259.
Bakas, T., Champion, V., Perkins, S. M., Farran, C. J., &
Williams, L. S. (2006). Psychometric testing of the
Revised 15-item Bakas Caregiving Outcomes Scale.
Nursing Research, 55(5), 346355.
Balance and Happiness
Bakas, T., Farran, C. J., Austin, J. K., Given, B. A.,
Johnson, E. A., & Williams, L. S. (2009). Stroke care- Balanced Life
giver outcomes from the Telephone Assessment and
Skill-Building Kit (TASK). Topics in Stroke Rehabil-
itation, 16(2), 105121.
Bakas, T., Pressler, S. J., Johnson, E. A., Nauser, J. A., &
Shaneyfelt, T. (2006). Family caregiving in heart
failure. Nursing Research, 55(3), 180188.
Balance in Life
Deeken, J. F., Taylor, K. L., Mangan, P., Yabroff, K. R., &
Ingham, J. M. (2003). Care for the caregivers: Balanced Life
B 322 Balanced Life

involved in multiple domains to satisfy the full

Balanced Life spectrum of human development needs (biologi-
cal, safety, social, esteem, self-actualization,
M. Joseph Sirgy knowledge, and aesthetics needs). Different life
Department of Marketing, Virginia Polytechnic domains tend to focus on different human devel-
Institute & State University, Blacksburg, opment needs. More specifically, balance
VA, USA contributes to subjective well-being because sub-
jective well-being can only be attained when both
survival (basic) and growth needs are met.
Synonyms In other words, high levels of subjective well-
being cannot be attained with satisfaction of
Balance and happiness; Balance in life; Role basic needs or growth needs alone. Both sets of
balance; Work-family conflict; Work-life needs have to be met to contribute significantly to
balance; Work-nonwork balance subjective well-being in the long run.
Research on imbalance between work and
family roles has shown that work-family role
Definition conflict is associated with life dissatisfaction as
well as low marital and family satisfaction and
Balance in life is an important dimension of sub- symptoms of low mental and physical well-
jective well-being. It is defined as a state being (Edwards & Rothbard, 2000; Sturges &
reflecting satisfaction or fulfillment in several Guest, 2004). Family-work conflict occurs
important domains with little or no negative when one domain consumes resources needed
affect in other domains. Achieving balance in for another domain. With respect to balance,
life allows people to satisfy the full spectrum of there is some evidence suggesting that people
human development needs, both basic and are more satisfied with life when the source of
growth needs, which in turn contributes to the satisfaction derives from multiple life
long-term happiness. domains than a single domain. For example,
Marks and McDermid (1996) described
a theory of role balance that suggests that peo-
Description ple who have well-balanced role systems,
which they conceptualize as full engagement
Martin Seligman, in his very popular book in and enjoyment of all roles, have higher levels
Authentic Happiness (Seligman, 2002), argued of well-being. Using a sample of employed
that authentic happiness is derived from three mothers, they showed that those who were
major sets of experiences in life, namely, more role-balanced and enjoyed every part
experiencing pleasantness regularly (the pleasant of their life equally well reported less role
life), experiencing a high level of engagement in overload, had higher self-esteem, and lower
satisfying activities (the engaged life), and depression levels.
experiencing a sense of connectedness to Bhargava (1995) conducted a study in which
a greater whole (the meaningful life). Sirgy and subjects were asked to discuss life satisfaction
Wu (2009) built on Seligmans three dimensions of others. Most subjects inferred life satisfac-
of happiness by adding a fourth dimension: the tion of others as a direct function of their satis-
balanced life. They argued that balance in life faction in multiple domains. They calculated
contributes significantly to subjective well- happiness by summing satisfaction across sev-
being. This may be due to the fact that only eral important domains the more positive
a limited amount of satisfaction can be derived affect in multiple domains, the higher the sub-
from a single life domain. People have to be jective well-being. Additional evidence comes
Balanced Life 323 B
from a study conducted by Chen (1996) who developmental needs. Furthermore, balance
found that those who believe they will achieve contributes to subjective well-being because
some of their goals (and receive satisfaction subjective well-being can only be attained
from multiple domains) report higher levels of when both survival and growth needs are met.
life satisfaction than those who do not believe High levels of subjective well-being cannot be B
that they will achieve these goals. attained with satisfaction of basic needs or
Balance theory of subjective well-being has growth needs alone. Both needs have to be met
three main postulates. These are: to induce subjective well-being.
Postulate 1: People who have balance in their This balance phenomenon has an important
lives (life satisfaction stemming from multiple clinical implication. Balance implies that put-
life domains) are likely to experience higher ting all your eggs in one basket may not be
levels of subjective well-being than those who effective in enhancing subjective well-being.
have imbalance (life satisfaction stemming That is, one should not allow one life domain to
from a single life domain). overwhelm ones satisfaction or dissatisfaction
Postulate 2: Balance contributes to subjective with life. It is best to be invested emotionally in
well-being because of the satisfaction limit several domains. Doing so allows one to compen-
that people can derive from a single life sate for the dissatisfaction of some domains with
domain. People have to be involved in multi- satisfaction of other domains.
ple domains to satisfy the full spectrum of
human development needs. Different life
domains tend to focus on different human
development needs. Cross-References
Postulate 3: Balance contributes to subjective
well-being because subjective well-being can Happiness
only be attained when both survival and Life Satisfaction, Concept of
growth needs are met. High levels of subjec- Meaningfulness of Work
tive well-being cannot be attained with satis- Role Theory
faction of basic needs or growth needs alone. Work-Family Enrichment
Both needs have to be met to induce subjective Work-Family Facilitation
well-being. Work-Family Fit
Work-Life Balance
Work-Life Harmony

Balance theory of subjective well-being posits

that people who have balance in their lives
(life satisfaction stemming from multiple life
Bhargava, S. (1995). An integration-theoretical analysis
domains) are likely to experience higher levels of life satisfaction. Psychological Studies, 40,
of subjective well-being than those who have 170180.
imbalance (life satisfaction stemming from Chen, N. (1996). Individual differences in answering the
four questions of happiness. Ph.D. dissertation,
a single life domain). That balance contributes
University of Georgia, Athens, GA.
to subjective well-being because of the satisfac- Edwards, J. R., & Rothbard, N. C. (2000). Mechanisms
tion limit that people can derive from a single linking work and family: Clarifying the relationship
life domain. People have to be involved in mul- between work and family constructs. Academy of
Management Review, 25, 178199.
tiple domains to satisfy the full spectrum of Marks, S. R., & MacDermid, S. M. (1996). Multiple roles
human development needs. Different life and the self: A theory of role balance. Journal of
domains tend to focus on different human Marriage and the Family, 58, 417432.
B 324 Ballet

Seligman, M. E. P. (2002). Authentic happiness: Using the dismiss all employees. Overall, it implies finan-
new positive psychology to realize your potential for cial failure. Lehman Brothers is a good case the
lasting fulfillment. New York: The Free Press.
Sirgy, M. J., & Wu, J. (2009). The pleasant life, the consequence of bankruptcy (see Thomas, 2008).
engaged life, and the meaningful life: What about the However, bankruptcy may allow for a financial
balanced life? Journal of Happiness Studies, 10(2), recovery of individual or business finances
183196. (Daily & Dalton, 1994).
Sturges, J., & Guest, D. (2004). Working to live or living
to work? Work/life balance early in the career. Human The treatment of bankruptcy differs across
Resource Management Journal, 14(4), 515. countries, depending on distinctive legal defini-
tions of bankruptcy (Darydenko & Franks,
2008). For example, in India, the legal mean-
ing of the terms bankruptcy, insolvency, liqui-
dation, and dissolution is contested in the Indian
Ballet legal system: there is no regulation or statute
legislated upon bankruptcy which denotes
Arts and Quality of Life a condition to meet a demand of a creditor, as
is common in many other jurisdictions (Kang &
Nayar, 2003). In the United Kingdom, bank-
ruptcy relates only to individuals and partner-
ships: companies and other corporations enter
Bankruptcy into differently named legal insolvency proce-
dures. The USA defines six types of bankruptcy
Benedicto Lukanima under the Bankruptcy Code, Title 11 of the
Business School, Universidad del Norte, United States Code. In Switzerland, bankruptcy
Barranquilla, Colombia can be a consequence of insolvency, whereby all
assets of the debtor are liquidated under the
administration of the creditors. In Canada, bank-
Definition ruptcy is filed when a person or an organization
becomes insolvent and cannot pay their debts as
Bankruptcy refers to inability of a person or orga- they become due. However, a person can file
nization to meet debt repayment obligations. a consumer proposal (a negotiated settlement
Therefore, bankruptcy means endeavors to settle between a debtor and their creditors) as an alter-
debt problems, which is generally associated with native to bankruptcy.
a legal insolvency status. Usually, this legal status As a result of difference bankruptcy codes,
is a result of either a petition made by the debtor there is evidence of different implications
and imposed by a court order or by own applica- across countries, such as creditors rights also
tion to be declared bankrupt. vary across countries, thereby influencing the
way banks adjust their lending and reorganiza-
tion practices (Darydenko & Franks, 2008); the
Description way firms in different countries respond to mac-
roeconomic instability is associated with differ-
Although it can help to clear debts, bankruptcy ences in bankruptcy codes (Battacherjee,
tends to have negative implications too; hence, it Higson, Chris, Kattuman, & Paul, 2004); for-
is often considered a last resort after exhausting eign ownership and domestic ownership in
other measures. For example, bankruptcy may the United States reflect differences in the
entail giving up any possessions of value and frequency of financial failure, in which foreign-
any interest in your home or business. For controlled firms fail less frequently (Li &
a business, it will become necessary to close or Guisinger, 1991).
Barthel Index 325 B
Cross-References Definition

Economic and Financial Literacy The Barthel index measures the likelihood
Federal Debt to GDP, Ratio of of being able to live at home with a degree of
Personal Household Debt to GDP, Ratio of independence following discharge from hospital. B
Public Debt Ten basic activities of daily living (ADL) are
captured: bowels, bladder, grooming, toilet use,
feeding, transfers, walking, dressing, climbing
stairs, and bathing.
Battacherjee, A., Higson, C., Holly, S., & Kattuman, P.
(2004). Business failure in UK and US quoted firms:
Impact of macroeconomic instability and the role of Description
legal institutions, Cambridge Working Papers in
Economics, CWPE 0420, accessed at: http://www.
dspace.cam.ac.uk/handle/1810/399. The Barthel index was introduced in 1965 and
Daily, C. M., & Dalton, D. R. (1994). Bankruptcy and was measured in a 020 scale (Mahoney &
corporate governance: The impact of board composi- Barthel, 1965). Although this original version
tion and structure. The Academy of Management is still widely used, it was modified by Granger,
Journal, 37(6), 16031617.
Darydenko, S. A., & Franks, J. R. (2008). Do bankruptcy Dewis, Peters, Sherwood, and Barrett (1979)
codes matter? A study of defaults in France, Germany when it came to include 010 points for every
and the UK. Journal of Finance, 63(2), 565608. item (total possible score of 0100). Further
Kang, N., & Nayar, N. (2003), The evolution of corporate refinements were introduced by Shah, Vanclay,
bankruptcy law in India, ICRA Bulletin, Money and
Finance, October 2003 March 2004, 3758. and Cooper (1989).
Li, J., & Guisinger, S. (1991). Comparative business failure The ten performance items of the Barthel
of foreign-controlled firms in the united states. Journal index (with original scales and scores as
of International Business Studies, 22(2), 209224. introduced in 1965) are shown in Table 1.
Thomas, L. (2008). Examining the ripple effect of
the Lehman bankruptcy, New York Times. Accessed
at http://www.nytimes.com/2008/09/15/business/
worldbusiness/15iht-lehman.4.16176487.html Discussion
The Barthel index is one of the first contribu-
tions to the functional status literature and it
represents physical therapists lengthy period
Barthel ADL Index
of inclusion of functional mobility and ADL
measurement within their scope of practice
Barthel Index
(OSullivan & Schmitz, 2007). The scale is
regarded as reliable, although its use in clinical
trials in stroke medicine is inconsistent (Sulter,
Barthel Index Steen, & De Keyser, 1999). It has, however,
been used extensively to monitor functional
Michaela Saisana changes in individuals receiving in-patient
Econometrics and Applied Statistics, Joint rehabilitation, mainly in predicting the func-
Research Centre, European Commission, tional outcomes related to stroke. The Barthel
Ispra, Italy index has demonstrated high interrator reliabil-
ity (0.95) and test-retest reliability (0.89)
as well as high correlations (0.740.8)
Synonyms with other measures of physical disability
(Collin, Wade, Davies, & Horne, 1988; Wade
Barthel ADL index; Barthel scale & Collin, 1988).
B 326 Barthel Scale

Barthel Index, Table 1 Barthel index items

Bowels (i.e., fecal incontinence) Transfer
0 incontinent (or needs to be given enemata) 0 unable no sitting balance
1 occasional accident (once/week) 1 major help (one or two people, physical), can sit
2 continent 2 minor help (verbal or physical)
Bladder (i.e., urinary incontinence) 3 independent
0 incontinent, or catheterized, and unable to manage Mobility
1 occasional accident (max. once per 24 h) 0 immobile
2 continent (for over 7 days) 1 wheelchair independent, including corners
Grooming 2 walks with help of one person (verbal or physical)
0 needs help with personal care 3 independent (but may use any aid, e.g., stick)
1 independent face/hair/teeth/shaving (implements provided) Dressing
Toilet use 0 dependent
0 dependent 1 needs help, but can do about half unaided
1 needs help, but can do something alone 2 independent (including buttons, zips, laces)
2 independent (on and off, dressing, wiping) Stairs
Feeding 0 unable
0 unable 1 needs help (verbal, physical, carrying aid)
1 needs help cutting, spreading butter, etc. 2 independent up and down
2 independent (food provided within reach) Bathing
0 dependent
1 independent (or in shower)

Barthel Scale
Hospital Anxiety and Depression
Scale (HADS) Barthel Index
Katz Activities of Daily Living Scale

References Basic Capabilities Index (BCI)

Collin, C., Wade, D. T., Davies, S., & Horne, V. (1988). Ian Percy
The Barthel ADL Index: A reliability study. Interna- Instituto del Tercer Mundo (ITeM), Montevideo,
tional Disability Studies, 10, 6163. Uruguay
Granger, C. V., Dewis, L. S., Peters, N. C., Sherwood,
C. C., & Barrett, J. E. (1979). Stroke rehabilitation:
Analysis of repeated Barthel index measures. Archives
of Physical Medicine and Rehabilitation, 60, 1417. Synonyms
Mahoney, F. I., & Barthel, D. W. (1965). Functional
evaluation: The Barthel Index. Meryland State
Medical Journal, 14, 6165.
BCI; QLI; Quality of Life Index
OSullivan, S. B., & Schmitz, T. J. (2007). Physical
rehabilitation (5th ed.). Philadelphia: F.A. Davis
Company. Definition
Shah, S., Vanclay, F., & Cooper, B. (1989). Improving the
sensitivity of the Barthel Index for stroke rehabilita-
tion. Journal of Clinical Epidemiology, 42, 703709. The Basic Capabilities Index (BCI) was designed
Sulter, G., Steen, C., & De Keyser, J. (1999). Use of the by Social Watch as an alternative way to monitor
Barthel index and modified Rankin scale in acute the situation of poverty in the world. Most of the
stroke trials. Stroke, 30, 15381541.
Wade, D. T., & Collin, C. (1988). The Barthel ADL Index:
available poverty-measurement indicators are
A standard measure of physical disability? based on the premise that poverty is a monetary
International Disability Studies, 10, 6467. phenomenon. The BCI, like other alternative
Basic Capabilities Index (BCI) 327 B
(nonmonetary) ways of measuring poverty, is average of all the scores obtained by a country in
based instead on a persons capability of accessing each of the thematic areas related to develop-
a series of services that are indispensable for sur- ment. Given the practical difficulties involved in
vival and human dignity. The indicators that make taking so many different dimensions into
up the BCI are among the most basic of those used account, SW had been working on designing an B
to measure the Millennium Development Goals. index that would provide a functional summary
of the overall situation of a given country using
available information. Until 2004, the Social
Description Watch methodology had produced an index rank-
ing countries in relation to each other, based on
In the 2001 Philippines Social Watch Report, the average values of their current situations by
Rene R. Raya wrote an article outlining the meth- area. In contrast, the BCI/QLI aimed not only to
odology for the Quality of Life Index. This provide a criterion for ranking the countries in
index was derived from the Capability Poverty relation to each other but also to allow the situa-
Index proposed by Professor Amartya Sen and tion in a given country to be monitored over time,
popularized as the UNDP Human Development by tracking changes in its summary value.
Index. The Quality of Life Index was an approach There are several possible strategies for
for measuring poverty and welfare based purely constructing such an index. One is to take into
on capabilities. The index was based on indica- account the different thematic areas and their
tors directly linked to development goals and component indicators, in order to obtain (through
excluded variables relating to income. In 2004, factorial analysis) a statistical index that, by
Social Watch (SW), an international watchdog reducing the number of dimensions, comes closer
citizens network on poverty eradication and gen- in empirical terms to explaining variance
der equality, published the first (and last) interna- between countries. This option, however, is sig-
tional Quality of Life Index (QLI). In 2005, SW nificantly hampered by the heterogeneity of the
created the Basic Capabilities Index (BCI) using set of available indicators, both in terms of the
the same methodology as the QLI. number of countries for which information is
The BCI compares and classifies countries available and the degree of comparability
according to their progress in social develop- between countries. A second approach, which
ment. Most of the available poverty- has been adopted in several summary indexes in
measurement indicators are based on the premise use by various international organizations, is to
that poverty is a monetary phenomenon, and they select certain indicators for which the above-
measure, for example, how many persons live mentioned difficulties can be minimized since
with an income of less than two dollars a day. there is sufficient and comparable data available
Social progress does not automatically follow for them and which in empirical terms show an
economic growth, and better indicators are evolution that reflects a series of basic indicators
needed to more accurately monitor the evolution of economic and social development. In princi-
of nonmonetary poverty in the world. The indi- ple, opting for summary measurements means
cators that make up the BCI are among the most consciously leaving out certain dimensions that
basic of those used to measure the Millennium on a conceptual level may be considered essen-
Development Goals. tial. However, by reducing the analytic dimen-
Beginning in 1996, the Social Watch Annual sions and selecting a set of variables that has
Report included a listing of the countries of the a strong correlation with the range of original
world ranked by their situation in a series of variables allows us to explain the same levels of
dimensions considered important for evaluating variance between countries while using fewer
social development, the Social Watch Score- variables.
card. The method used before the introduction The BCI/QLI is an approach for measuring
of the BCI/QLI was to calculate the unweighted poverty and welfare based purely on capabilities.
B 328 Basic Capabilities Index (BCI)

The index is based on indicators directly linked rate (expressed as a percentage) or the probability
to development goals and excludes variables of death in the first five years of life per 100 live
relating to income. The dimensions included births. Education is represented as I2, where I2 is
in the BCI/QLI are infant health, reproductive the rate of school retention or the percentage of
health, and education. The indicators of the BCI/ children enrolled in the first grade who reach the
QLI are mortality in under-fives, percentage of fifth grade. Reproductive health is shown as I3,
births attended by skilled health personnel, and where I3 is the percentage of births assisted by
the proportion of children enrolled in first grade skilled health personnel (doctors, nurses, or mid-
who reach fifth grade. These indicators are wives). The BCI/QLI value for a particular coun-
approximate measures of human capabilities try is obtained by taking a simple average of the
and have been shown to be sensitive enough to three components: BCI/QLI (I1 + I2 + I3)/3.
summarize a populations overall situation with Using this methodology, the BCI/QLI proved
respect to health, educational performance, and to be a good tool for measuring aspects relating to
literacy. the quality of life and presented a strong correla-
On a conceptual level, the choice of the vari- tion with other indicators and indexes that are
able relating to staying in primary school until 5th generally used to measure development or to
grade is justified on the grounds that if just the classify countries according to their levels of
rate of coverage were taken into consideration, well-being: the Human Development Index, the
the phenomenon of high primary school drop-out Human Poverty Index, the international poverty
rates present in less developed countries would be line, and per capita gross domestic product
ignored. The variable infant mortality is an indi- (GDP).
cator that shows a high correlation with food Poverty, quality of life, and welfare are com-
security and child malnutrition and is more plex concepts. It is almost impossible to reflect
widely available in national statistical records the complexity and dynamic nature of a particular
than direct malnutrition or food security indica- situation by using a simple numerical value.
tors. The percentage of births attended by skilled However, a well-designed index can be an effi-
health personnel is in practical terms an accurate cient tool for identifying the incidence of poverty,
measure of levels of health care, which enjoys defining objectives, and monitoring and evaluat-
a degree of independence from geographical or ing strategies. Indicators cannot replace a more
climatic factors that could distort analyses of the comprehensive social analysis of the situation,
health situation. Indicators based on the preva- but they can provide a good starting point for
lence of diseases would be biased in this way. The the development and design of programs since
selection of these three indicators was also deter- they provide tools for measuring and comparing
mined by the criterion of seeking to obtain the situations.
highest possible number of units of analysis with Income-based measurements of poverty have
information available at national and local levels, functional limitations that make precise monitor-
in order to ensure consistency with international ing of their evolution difficult. These indices
standards of measurement, and thus allow com- depend on household-level surveys of spending
parisons to be made and links identified with and consumption which, because of the high
existing indicators of welfare. cost that they entail, are not always carried out in
The BCI/QLI was calculated using the non- a systematic manner in all countries. The BCI/QLI
weighted average of the original values of the has comparative advantages in that it is relatively
three indicators in question (in the case of infant simple to calculate and inexpensive because it
mortality, a lineal transformation was previously does not depend on household surveys to estimate
applied to the indicator). To simplify the calcula- levels of income. It is compatible with the various
tions, all three indicators were given the national and international statistical systems, and
same weight. Child health is represented as it can be calculated easily from indicator data that
I1 (100  M), where M is the under-5 mortality are regularly issued by governments and agencies.
Basic Needs 329 B
In addition to being an instrument for classifying Social Watch. (2003). Social Watch Report 2003 The
the relative situation of countries or of particular poor and the market. Accessed April 21 2011, http://
sectors within a country (e.g., population groups or Social Watch. (2004). General classification of countries:
geographical areas), it can also be used to generate situation by thematic area and Quality of Life Index
time series for monitoring situations related to (QLI). The Social Watch 2004 Scorecard. Accessed B
poverty. April 21 2011, http://www.socialwatch.org/node/11944
Social Watch. (2005). Methodology. The Social Watch
The BCI/QLI makes it possible to distinguish 2005 Scorecard. Accessed April 21 2011, http://www.
between countries which have not yet reached the socialwatch.org/node/11939
minimum conditions represented by the three Social Watch. (2006). The Social Watch 2006 Scorecard.
indices, but it is less sensitive when detecting Accessed April 21 2011, http://www.socialwatch.org/
differences between countries that have reached Social Watch. (2007). The Basic Capabilities Index
a relatively high level of development. Thus, it is 2007 Far from where we should be. Accessed April
more suitable for identifying critical situations 21 2011, http://www.socialwatch.org/sites/default/
than for detecting slight differences between files/ICB_2007_eng/BasicCapabilitiesIndex2007.pdf
Social Watch. (2008). The Basic Capabilities Index
more developed countries. 2008 Way too slow. Accessed April 19 2011,
Without doubt there is a great need to improve http://www.socialwatch.org/node/9239
the series and the accuracy and consistency of the Social Watch. (2009). Basic Capabilities Index: A starting
data used in the generation of the key indicators point. Basic Capabilities Index 2009. Accessed April
19 2011, http://www.socialwatch.org/node/11389
of social development. The gaps in the informa- Social Watch. (2010). The current picture as shown by the
tion available are a constant problem plaguing the BCI. Basic Capabilities Index 2010. Accessed April 19
definition of objectives and the process of moni- 2011, http://www.socialwatch.org/node/12259
toring. The BCI/QLI was designed precisely to
fill these gaps and so to contribute toward ana-
lyses of poverty and policy design and planning
for development. Basic Child Care and Well-Being

Parental Time and Child Well-Being


Basic Emotions Recognition
Measuring Emotion Recognition Ability
Gender Equity Index
Quality of Life Research
Basic Needs

Enrica Chiappero-Martinetti
Department of Political and Social Sciences,
References University of Pavia, Pavia, Italy
HDCPIRC, Institute for Advanced Study,
Raya, R. R. (2001). An alternative measure of poverty and
human capability: Introducing the Quality of Life Pavia, Italy
Index. Social Watch Philippines 2001 Report.
Accessed April 21 2011, http://www.socialwatch.org/
Social Watch. (1997). Methodological Appendix. Social
Watch Annual Report 1997. Accessed April 21 2011,
http://www.socialwatch.org/node/11326 Core needs; Human needs; Minimal needs
B 330 Basic Needs

Definition (as can be seen in the works of Max-Neef, 1991;

Streeten et al., 1981; Stewart, 1985).
Basic needs (BN) are generally defined in In this extract, we will restrict the attention
terms of a minimal list of elements that to the contributions offered to this debate by
human beings necessitate, in order to fulfill economists and development experts.
basic requirements and achieve a decent life. From the common notion of basic needs,
Typically, the list includes basic commodities, a variety of conceptions have been formulated
such as food, clothing, and shelter, as well as on the basis of different interpretations of
essential services, as access to drinking water, what is to be essential to human life. There are
to sanitation, to education, to healthcare facil- two main definitions, both formed by
ities, and to public transportation. Broader a dichotomy, which are particularly worth men-
definitions of basic needs further extend the tioning: First, basic needs can either be defined
attention to other psychological and social in absolute or in relative terms and, secondly,
needs such as participation, self-reliance, basic needs can be intended as ends or as means.
autonomy, and self-expression. With regard to the prior definition and
A basic needs approach (BNA) to dichotomy, basic needs can be defined either in
development is a strategy according to which absolute or relative terms similarly to abso-
development is defined by the fulfillment of every- lute and relative approaches to poverty. In the
ones basic necessities, together with the participa- case of absolute basic needs, the attention is
tory involvement of people in the decision-making restricted to a minimal list of aspects that are
process of policies that shall affect them. considered to be necessary for mere survival of
individuals and without which human life would
be seriously impaired. In this case, the attention
is usually focused on things such as food,
Description shelter, clothing, access to basic healthcare and
educational services, and availability of clean
Concepts water and transportation. For each of these
The concept of basic needs dates back to the first basic necessities, a minimum threshold might
half of the nineteenth century, and it originally be defined by technical experts such as nutri-
stemmed from a variety of disciplinary perspec- tionists, medical doctors, teachers, and engi-
tives. In fact, this notion can be traced back to the neers or by policy-makers, or even by the
field of psychology (see, for example, Maslows people themselves. The resulting lists and
Hierarchy of Needs (Maslow, 1943) and Douglas thresholds need not be the same across different
McGregors Managerial and Human Motivation basic needs. Moreover, this absolute view does
Theories (McGregor, 1960)). Afterwards, it not limit the essential elements to material needs
benefitted from the contribution of anthropology but allows for taking into account also other
(Malinowskis Basic Human Needs (Langness, dimensions such as human rights, freedom,
1987)), to social and political theory (Bradshaws participation, and self-reliance. However, the
Taxonomy of Social Need (Bradshaw, 1972) and absolute view strictly assumes that the same
The Theory of Human Need, formulated by basic necessities are to be equally relevant for
Doyal and Gough (1991), to philosophy (for everybody in every country thus being basic
example, Wiggins definition of absolute and needs in absolute or universal terms.
entrenched needs (Reader, 2005; Wiggins, On the other hand, a relative perspective to
1987)), to economics (starting from Marxs con- the concept of basic needs acknowledges that
cepts of primary and secondary needs and the social construction process of selecting and
Keynes juxtaposition between basic but limited defining basic necessities can significantly
needs and relative but limitless needs), and also to differ across countries and cultures. Thus,
development economics and development policy according to this second approach, the lists of
Basic Needs 331 B
basic needs would have to be identified and A second dichotomy is related to the interpre-
structured depending on what is in fact consid- tation of basic needs as either means or ends.
ered as essential in a particular society they This differentiation reflects the investment and
should not be defined in absolute terms. For consumption roles that basic needs might have
example, from the relative point of view, what in human life. For example, education can be B
could be considered to be a basic necessity for considered as a consumption good that has an
a person living in a rural community in intrinsic value for those who enjoy it; however,
Africa may differ significantly from that of it may also have an instrumental role as a human
a person living in a European capital or from capital investment that will pay off for both
an inhabitant of the same region but in the individual and for society as a whole.
a different period of time. Also in this case, there is not a strict dichotomy
However, the absolute and relative perspectives whereby the means vs. ends views are necessarily
may not actually conflict as much as it might opposing and conflicting. On the other hand, these
appear at first sight. Indeed, these two views views are often integrated, because in most cases
can at least in principle be combined. The the fulfillment of a basic necessity is not only an
general concept of basic needs can be, end that is valuable in itself but it is also
and frequently is, considered of universal applica- a means, which contributes to the attainment of
bility as it refers to all people in all countries. other goals. For instance, health, education, and
Nevertheless, the particular specification of the employment are good examples of the twofold
list of basic needs and the corresponding thresh- instrumental and intrinsic roles that these basic
olds of commodities and resources required to needs have: A better nourished, healthy, educated,
fulfill them can be country-specific and reflect and skilled labor force allows to increase produc-
prevailing customs and cultural trends. Moreover, tivity and reduce reproductivity, which in turn are
basic needs need not necessarily be fixed in time: both central goals for economic and human devel-
In fact, from a dynamic perspective, they can opment. Nevertheless, as pointed out by Streeten
change across years and incorporate new emerging (1984), conflicts may arise between a means-/pro-
needs in addition to the existing ones, or following ductivity-based approach and an instrumental/
their fulfillment. human development view of basic needs, in
Ultimately, the distinction between an terms of which groups are to be targeted as not
absolute and relative view of basic needs opens all human beings are members of the labor force
the way to other related and controversial issues as well as regarding the content of human capital
that need to be taken into account (Streeten, investment; for instance, should education be only
1984), as to the following: Who is to determine productivity-oriented? Thus, the two visions can
and define basic needs? To what extent can the only partially overlap.
definition of a basic necessity be arbitrary or An official definition of basic needs first arose
objective? How can a consensus be reached on from the works of the World Employment Con-
what is to be considered as essential for human ference, organized by the International Labour
beings? And, would the fulfillment of a basket of Organization (ILO) in 1976. In this occasion,
basic necessities be the ultimate goal of a nearly unanimous adoption of the Declaration
a given society, or do human needs expand and of Principle and Programme of Action was taken
build upon their satisfaction, giving rise to by the member states, in which basic needs were
other needs? (See also Ghai and Alfthan (1977)) defined in terms of a minimum standard of liv-
While consensus on these queries is not reached, ing which a society should set for the poorest
what seems to generally prevail, especially from groups of its people (ILO, 1976, p. 7).
a development perspective, is that it is both The established bundle of basic needs
urgent and legitimate that the basic needs of included two elements: first, a minimum require-
the poorest people are to be met (International ment of private consumption in terms of food,
Labour Organization [ILO], 1976). shelter, and clothing, and, secondly, access to
B 332 Basic Needs

essential services, such as safe drinking water, methodology for identifying and measuring basic
sanitation, transport, health, and education needs targets (Ghai & Alfthan, 1977).
provided by and for a community at large Measuring basic needs is not an easy task. First
(ILO, 1976, p. 6). Moreover, a specific goal was of all, it requires the identification of the material
also agreed: increasing the rate of employment of and nonmaterial aspects that are to be considered
the labor force and its productivity indeed, basic necessities. This could imply a rather exten-
[the basic needs approach] implies that each sive list or a restricted core set of basic needs. In
person available for and willing to work should any case, as previously outlined, it is not at all
have an adequately remunerated job. Special obvious who should be in charge of compiling
attention was placed on employment, as in this this list and how it should be done. Once a list of
occasion it had been conformed as the main basic necessities is identified, the subsequent step
instrument for achieving the ultimate goal of is to define the corresponding level at which the
a minimum standard of living for all people. basic needs might be fulfilled this may, for
In the same report, it was also specified that example, be in terms of a threshold of calorie
these minimum standards should be universally intake, or educational contents, or housing charac-
regarded as essential to a decent life: Whereas teristics. These minimum requirements could be
basic needs targets can in principle vary from interpreted as basic needs targets to be reached
country to country, a minimum level of basic within a given time period: as in the case of
needs [were to be] targets to be achieved by the the 1976 ILOs document, where the objective
world community (ILO, 1976, pp. 67). was to meet basic necessities within one genera-
Finally, the importance of participation and in tion thus, by the year 2000 or as in the more
particular, the participation of the poorest people, recent case of the Millennium Development Goals
whose basic needs had to be met was strongly that are to be reached by 2015.
emphasized. It was affirmed that ideally, the people At the individual or household level, the
themselves should directly, or indirectly through fulfillment of basic needs can be directly observed
a representative institution, decide the scope, con- in terms of the thresholds defined: for instance,
tent, and priority of their own basic necessities. checking that the minimum amount of calorie
However, it was neither clear nor obvious how intake per day per person is met or calculating
this could concretely be done: People, and disad- the number of people per room in the household
vantaged groups in particular, can be severely ham- or the level of education completed. These are
pered in expressing their views and interests, even known as direct methods of measurement.
more so if they live in the most destitute contexts. Alternatively, an indirect measure of basic
Yet, even in more promising conditions and in needs can be employed, by calculating the cost of
general, it is not easy to understand what form of the basic needs (BNI basic needs income level
participation should be taken or what kind of sup- method: cfr. Khan, 1977). This indirect method,
port is needed in order to give actual effect to the first used by Rowntree (1901) in his seminal stud-
participatory opinions. In other words, while there ies of poverty in York, is still commonly used by
seems to be a broad consensus on the necessity to the World Bank and other agencies for estimating,
engage people in the decision-making process, as for example: the amount of money required to buy
Streeten (1984, p. 975) remarks, the call for par- enough food for an adequate level of nutrition
ticipation is (still) too vague. (usually considered to be 2,100 cal per person per
day), or of clothing and shelter, as well as for other
Indicators elements considered to be essential to human life
A year after the above-mentioned document, (Haughton & Khandker, 2009).
an ILOs volume was published (Ghai, Khan, Lee, At the level of the country, aggregate or aver-
& Alfthan, 1977) in order to discuss the main con- age indicators such as child nutritional status, life
ceptual and empirical issues connected with a expectancy at birth, morbidity schooling, enroll-
basic needs strategy and to develop a general ment ratio, or percentage of household with access
Basic Needs 333 B
to clean water are used as a proxy for measuring a basic needs strategy in their development
the basic needs that were met or unmet. Streeten agenda.
et al. (1981) suggested a list of core indicators for The focus on basic needs in the development
five basic needs health, education, food, water debate arose as a reaction to the predominant
supply, and sanitation by focusing mainly on the macroeconomic development policies which B
results (direct measures), more than the inputs paid very little attention to the poor ultimately,
(indirect measures). Streetens list included the it aimed at putting the living condition of the poor
following: life expectancy at birth, literacy and in the international agenda. Moreover, it was also
primary school enrollment at ages 5 and 14, calo- a consequence of the failure of economic growth
rie supply per head or as a percentage of require- to guarantee the attainment of basic needs for all
ments, infant mortality, percentage of population people (Streeten et al., 1981; Stewart, 1985,
with access to potable water, and percentage of the 1989; see also Jolly, Emmerij, & Weiss, 2009;
population with access to sanitation facilities. Jolly, 2010 for an overview of the contribution of
Overall, significant progress towards reaching BNA in the development debate).
a common definition of basic needs and appropri- However, the BNA was not against growth
ate methodologies has been made; however, per se which, on the contrary, was considered
unsettled issues (Streeten et al., 1981; Streeten, an essential instrument in order to allow basic
1984) in the basic needs literature remain when needs to be met but a coherent and consistent
one moves towards their empirical analysis. First, macroeconomic strategy at national and interna-
it is unclear whether input or output indicators tional level was set out in order to combine eco-
should be used: that is, should we focus on the nomic growth with redistributive policies (see ILO,
availability and provision of a specific bundle of 1976). Compared to more standard development
goods, or should we look at the capacity and strategies based on redistribution with growth or
autonomy of individuals and households to inclusive growth, the BNA had a greater concern
achieve a minimal level of living conditions? of the living conditions of the poorest people and
Second, most social indicators are average mea- called for restructuring the production process in
sures, which reflect the living conditions of the order to provide income-earning opportunities
overall population and not those of the poorest: to the poorest and give them access to the goods
Ad hoc indicators that focus on the most disad- and services that they needed.
vantaged groups and on the distributive dimen- As outlined by Jolly (2010), the BNA has had
sion between and within subgroups of the a rather short, even if remarkable, story. The
population can provide a better understanding of world economic recession and the rising debt
peoples effective living conditions. crisis of the early 1980s determined the decline
of the concerns for BNs and a shift towards sta-
Development Policies bilization and structural adjustment policies
The notion of basic needs had a pivotal role in the within the major international organizations.
international debate on development strategies, Today, the BNA has lost its identity as an auton-
which took place throughout the end of the omous theoretical paradigm, although the impor-
1970s and the beginning of the 1980s. tance of basic necessities for human lives remain
The origin of a basic needs approach (BNA) an important source of inspiration and are some-
to development dates back to the aforemen- how encompassed by other theoretical frame-
tioned World Employment Conference promoted works included by the human development
by the International Labour Office (1976). Since and capability approach.
then, for several years, the World Bank and
a variety of UN agencies (UNEP, UNICEF, Links with the Human Development and
USAID) strongly supported this view and many Capability Approach
countries (including China, Taiwan, Mexico, The human development approach, first presented
Cuba, Sri Lanka, and Tanzania) incorporated by the UNDP in 1990, shows some noticeable
B 334 Basic Needs

commonalities with the BNA. They are both Cross-References

people-centered development theories, as they
equally claim that improving human well-being Capabilities
should be the ultimate goal of development. Sim- Human Development
ilarly, they both emphasize that economic growth Human Needs
is an essential means for improving human well- Human Rights
being, but that it is not the end to development. Relative Poverty Rate
Moreover, in both cases, attention is placed on Social Indicators
dimensions of human life such as material living
conditions, education, and health that should be
universally regarded as essential for human beings. References
Nevertheless, there are also some remarkable
differences between the two theoretical frame- Alkire, S. (2002). Valuing freedom. Sens capability
approach and poverty reduction. Oxford: Oxford Uni-
works. These are more clearly understandable if
versity Press.
we refer to the capability approach as pioneered Bradshaw, J. (1972). A taxonomy of social need. In G.
by Amartya Sen (1981) which deeply inspired McLachlan (Ed.), Problems and progress in medical
the human development approach and can indeed care. Seventh series NPHT (pp. 7082). London: Open
University Press.
be seen as its main theoretical foundation.
Crocker, D. (1992). Functioning and capability: The foun-
Amartya Sen recognizes the centrality of the dations of Sens and Nussbaums development
BNA for development strategies in fact, he ethic. Political Theory, 20(4), 584612.
claims: the strategic relevance of basic needs is Doyal, L., & Gough, I. (1991). A theory of human needs.
New York: Palgrave Macmillan.
not a controversial matter (Sen, 1987, p. 2). How-
Ghai, D. P., & Alfthan, T. (1977). On the principles of
ever, he also addresses several fundamental cri- quantifying and satisfying basic needs. In D. P. Ghai,
tiques to the BNA (Sen, 1984): (1) It is largely et al. (Ed.), (pp. 1959). The basic needs approach to
focused on commodity possession, rather than development: Some issues regarding concepts and
methodology. Geneva: International Labour Office.
functioning achievements; (2) it lacks an adequate
Ghai, D. P., Khan, A. R., Lee, E. L. H., & Alfthan, T.
philosophical foundation and leaves open some (1977). The basic needs approach to development:
unsettled questions; (3) it neglects that individ- Some issues regarding concepts and methodology.
ual commodity requirements are connected to the Geneva: International Labour Office.
Haughton, J., & Khandker, S. R. (2009). Handbook on
actions or judgments of other people and, there-
poverty and inequality. Washington, DC: World Bank.
fore, social interdependence should also be taken International Labour Office. (1976). Employment, growth
into account; (4) it confines attention to quantita- and basic needs: A one-world problem. Report of the
tively minimal thresholds of basic needs and Director-General of the International Labour Office.
Jolly, R. (2010). Employment, basic needs and human
thereby restricts its application to poor countries;
development: Elements for a new international
and (5) the concept of need is more passive than paradigm in response to crisis. Journal of Human
the concept of capability, and thus, the emphasis Development and Capabilities, 11(1), 1136.
is on what can be done for the person more than on Jolly, R., Emmerij, L., & Weiss, T. (2009). UN ideas that
changed the world. Bloomington: Indiana University Press.
what can the person do (see Crocker, 1992).
Khan, A. R. (1977). Basic need targets: An illustrative
The human development and capability exercise in identification and quantification with
approach tries to overcome these limits and gives reference to Bangladesh. In D. P. Ghai, et al. (Ed.),
a more substantial importance to human freedom. It (pp. 7295). The basic needs approach to develop-
ment: Some issues regarding concepts and methodol-
also makes explicit some implicit assumptions in
ogy. Geneva: International Labour Office.
the basic needs approach about the value of choice Langness, L. L. (1987). The study of culture. Novato, CA:
and participation (Alkire, 2002, p. 170). Finally, Chandler and Sharp.
the human development approach powerfully Maslow, A. H. (1943). A theory of human motivation.
Psychological Review, 50(4), 370396.
reintroduced some of the essential ideas that also
Max-Neef, M. A. (1991). Human scale development.
laid behind the BNA, into the international devel- Conception, application and further reflections.
opment debate. New York: The Apex Press.
Beauty 335 B
McGregor, D. (1960). The human side of enterprise.
New York: MacGraw Hill. BD I
Reader, S. (2005). The philosophy of need. Royal Institute
of Philosophy Supplement 57. Cambridge, UK:
Cambridge University Press. Bipolar Disorder (BD)
Rowntree, B. S. (1901). Poverty: A study of town life. B
London: Macmillan.
Sen, A. K. (1981). Poverty and famines. An essay on
entitlement and deprivation. Oxford: Clarendon Press.
Sen, A. K. (1984). Goods and people. In A. K. Sen (Ed.), BD II
Resources, values and development. Oxford:
Blackwell. Bipolar Disorder (BD)
Sen, A. K. (1987). The standard of living. Cambridge, UK:
Cambridge University Press.
Stewart, F. (1985). Planning to meet basic needs. London:
Stewart, F. (1989). Basic needs strategies, human rights, BDI-II
and the right to development. Human Rights
Quarterly, 11(3), 347374.
Streeten, P. (1984). Basic needs: Some unsettled Beck Depression Inventory
questions. World Development, 12(9), 973978.
Streeten, P., Burki, S.J., ul Haq, M., Hicks, N., & Stewart, F.
(1981). First things first. Meeting basic human needs in
developing countries. Oxford: Oxford University Press.
Wiggins, D. (1987). Claims of need in his needs, values, Beauty
truth: Essays in the philosophy of value. Oxford:
Blackwell. Samantha Kwan
Department of Sociology, University of Houston,
Houston, TX, USA

Basic Values and Well-Being in

Europe Synonyms
Well-Being and Personal Values in Europe Attractiveness

Basic Values and Well-Being in
Migrants to Spain Beauty is a characteristic of a person that elicits
a subjective experience of pleasure or satisfaction
Well-Being and Values of Immigrants to Spain for an observer. It can be derived from a persons
physical features that conform to cultural expec-
tations of aesthetic body norms.

Basic Capabilities Index (BCI)
Societies typically have a set of norms dictat-
ing which physical traits are regarded as beauti-
ful. These cultural norms convey messages about
BD how bodies should appear aesthetically (e.g., in
shape or size) and vary by gender. For example,
Bipolar Disorder (BD) Western cultural norms celebrate a slender and
B 336 Beauty

taut body type for women and a muscular and can involve practices that compromise both
toned body type for men (Bordo, 2003; Pope, mental and physical health. Such is the case of
Phillips, & Olivardia, 2000). There is also some eating disorders, like anorexia nervosa, which
evidence that many societies idealize youth, have been documented in young women striving
unblemished fair skin, and symmetry, along to achieve cultural ideals (Bordo, 2003). Beauty
with a low waist-hip ratio and full breasts can also impact social outcomes. As a diffuse
for women and height and a V-shaped torso status characteristic, beauty is an accessible fea-
for men (Etcoff, 1999; Rhode, 2010). Scholars ture of an individual that people use in social
have noted, however, the existence of subcultural encounters to inform expectations about the abil-
aesthetic norms that celebrate alternate body ities of others (Webster & Driskell, 1983).
aesthetics. For instance, there is some evidence Research indicates that observers often assume
that, compared to other ethnic groups, African- that physically attractive individuals are more
Americans are less invested in the thin ideal sociable, talented, happier, and successful in life
(Collins, 2000). compared to their less physically attractive coun-
While some scholars argue that cultural terparts (see Eagly, Ashmore, Makhijani, &
beauty norms are socially constructed by capital- Longo, 1991). The association of physically
ist and patriarchal interests and disseminated via attractive individuals with positive traits that con-
mass media (Bartky, 1990; Bordo, 2003; Wolf, fer status and favorably shapes expectations has
1991), others argue that they are associated with been labeled a halo effect.
fertility, health, and reproduction and have Beauty not only shapes perceptions but results
their roots in human nature and evolution (Buss, in quality of life advantages for those who
2003; Etcoff, 1999). Social constructivists tend to embody cultural standards and, conversely, dis-
point out the changing nature of beauty ideals and advantages to those who do not. Compliance or
how they vary both historically and cross-cultur- deviation from aesthetic norms impacts an array
ally; in contrast, evolutionary psychologists of social outcomes in various arenas including
underscore the stable and universal element of education, employment, and marriage.
these ideals. In education, studies report a relationship
Research shows that hegemonic beauty between teachers perceptions of intelligence
norms disparately impact social groups. For and students physical attractiveness (Clifford &
example, women experience greater pressure to Walster, 1973). Moreover, teachers are less likely
conform to aesthetic norms and are penalized to label the transgressions of a physically attrac-
more severely when they do not (Fikkan & tive child as reflecting an enduring negative per-
Rothblum, 2012). Western beauty ideals also sonality trait in comparison to a more physically
appear to be racially biased, favoring physical attractive child (Dion, 1972). Perceptions may
characteristics (such as skin color, facial fea- even impact actually educational achievement.
tures, and hair texture) that exclude some For example, researchers have documented
racial/ethnic minorities from conforming to a positive relationship between physical attrac-
these ideals (Collins, 2000). Moreover, body tiveness level and levels of educational attain-
modification aimed at achieving aesthetic ideals ment (Umberson & Hughes, 1987). One
often requires time and financial investments longitudinal study underscores the gendered
that are more accessible to the economically nature of beauty nonconformity; statistical anal-
privileged, and there is some evidence that ysis of a large national dataset found that obese
members of the upper socioeconomic girls were less likely to enter college after high
status (SES) classes are more concerned with school compared to their nonobese peers, even
body weight compliance than their lower SES though obese boys did not fair any worse than
counterparts (Wardle & Griffith, 2001). their nonobese peers (Crosnoe, 2007).
Beauty is a key factor impacting quality of The impact of physical attractiveness on qual-
life. Attempts to conform to cultural beauty ideals ity of life is also evident in the workplace.
Beauty 337 B
A meta-analysis of experimental studies found Bordo, S. (2003). Unbearable weight: Feminism, western
that physical attractiveness elicits benefits in culture, and the body (2nd ed.). Berkeley: University
of California Press.
many stages of the employment process for both Buss, D. M. (2003). The evolution of desire (Revised ed.).
men and women. These include advantages in New York: Basic Books.
hiring outcomes, performance evaluation, and Clifford, M. M., & Walster, E. (1973). The effect of B
promotion decisions (Hosoda, Stone-Romero, & physical attractiveness on teacher expectations.
Sociology of Education, 46, 248258.
Coats, 2003). Moreover, experimental studies
Collins, P. H. (2000). Black feminist thought: Knowledge,
examining workplace weight bias shows consciousness, and the politics of empowerment
a marked disadvantage for those who do not (2nd ed.). New York: Routledge.
conform to beauty ideals (Cort, Well, Weller, & Conley, D., & Glauber, R. (2005). Gender, body mass
and economic status. Cambridge: National Bureau of
Baltes, 2009). Labor market participation rates,
Economic Research Working Paper Series.
as well as earnings, including both family and Cort, W. R., Well, C. L., Weller, M. D., & Baltes, B. B.
personal income, are also stratified by physical (2009). A meta-analysis of empirical studies of
appearance (Conley & Glauber, 2005; Umberson weight-based bias in the workplace. Journal of
& Hughes, 1987). Vocational Behavior, 74, 110.
Crosnoe, R. (2007). Gender, obesity, and education.
Research also shows that beauty influences the Sociology of Education, 80, 241260.
probability of marriage, particularly for women; Dion, K. (1972). Physical attractiveness and evaluation of
for example, higher body mass for women nega- childrens transgressions. Journal of Personality and
tively impacts the probability of marriage Social Psychology, 24, 207213.
Eagly, A. H., Ashmore, R. D., Makhijani, M. G., & Longo,
(Conley & Glauber, 2005). Physically attractive L. C. (1991). What is beautiful is good, but . . .:
females are also more likely to marry highly A meta-analytic review of research on the physical
educated husbands with higher income (Udry & attractiveness stereotype. Psychological Bulletin,
Eckland, 1984). 110, 109128.
Etcoff, N. L. (1999). Survival of the prettiest: The science
In sum, cultural and social structures privilege
of beauty. New York: Doubleday.
the beautiful. Individuals who conform to cul- Fikkan, J. L., & Rothblum, E. (2012). Is fat a feminist
tural beauty ideals, whether because they are so issue? Exploring the gendered nature of weight bias.
fortunately genetically endowed or because they Sex Roles, 66, 575592.
engage in body modification practices to achieve Hosoda, M., Stone-Romero, E. F., & Coats, G. (2003). The
effects of physical attractiveness on job-related
such ideals, may encounter an array of social outcomes: A meta-analysis of experimental studies.
benefits that ultimately influence overall quality Personnel Psychology, 56, 431462.
of life. Pope, H. G., Phillips, K. A., & Olivardia, R. (2000). The
Adonis complex: The secret crisis of male body obses-
sion. New York: The Free Press.
Rhode, D. L. (2010). The beauty bias: The injustice of
appearance in life and law. New York: Oxford
Cross-References University Press.
Udry, J. R., & Eckland, B. K. (1984). The benefits of being
Aesthetic Value attractive: Differential payoffs for men and women.
Psychological Reports, 54, 4756.
Body Image
Umberson, D., & Hughes, M. (1987). The impact of
Educational Inequality physical attractiveness on achievement and psycho-
Employment Discrimination logical well-being. Social Psychology Quarterly, 50,
Gender Discrimination 227236.
Wardle, J., & Griffith, J. (2001). Socioeconomic status
and weight control practices in British adults. Journal
of Epidemiology and Community Health, 55, 185190.
Webster, M., & Driskell, J. E. (1983). Beauty as
References status. The American Journal of Sociology, 89,
Bartky, S. L. (1990). Femininity and domination: Studies Wolf, N. (1991). The beauty myth: How images of
in the phenomenology of oppression. New York: beauty are used against women. New York:
Routledge. W. Morrow.
B 338 Beck Depression Inventory

Mendelson, Mock, & Erbaugh, 1961) and

Beck Depression Inventory a slightly revised later version (BDI-IA; Beck,
Rush, Shaw, & Emery, 1979). The 21 items in
Anita M. Hubley the original BDI reflected symptoms frequently
Measurement, Evaluation, & Research reported by depressed patient samples and
Methodology (MERM), Adult Development and infrequently reported by nondepressed psychiat-
Psychometrics Lab, The University of British ric patients (Beck et al., 1961) and did not reflect
Columbia, Vancouver, BC, Canada any particular theory of depression (Beck et al.).
According to the BDI-II manual, items covered
affective, cognitive, somatic, and vegetative
Synonyms symptoms of depression. Each item contained
four to six self-evaluative statements organized
BDI-II; Beck inventory in order of increasing severity. The original BDI
was administered orally by trained interviewers.
Beginning in 1971, Beck and colleagues began to
Definition use a modified version that included revised
wording for 15 items, avoided double negatives,
The Beck Depression Inventory Second Edition eliminated alternative phrasing for the same
(BDI-II) is a 21-item self-report measure symptoms, and limited the number of response
designed to measure severity of depression options to four for all items. The final amended
consistent with symptoms of depression as version resulted in the BDI-IA, which was
presented in the Diagnostic and Statistical copyrighted in 1978 and published in 1979;
Manual of Mental Disorders Fourth Edition a technical manual was published later (Beck &
(DSM-IV; American Psychiatric Association, Steer, 1987). Beck, Steer, and Garbin (1988), in
1994) in both adolescents aged 13 years and their review of the literature on the BDI, noted
older and adults (Beck, Steer, & Brown, 1996). that most researchers seemed unaware that there
were two versions, as some cited the 1961 refer-
ence, but used the 1978 revision. Because of this,
it is difficult to tell not only which version is used
Description more often, but it is often impossible to tell which
version is being used in any given study.
Overview Criticisms that the BDI/BDI-IA did not
The BDI-II is a well-recognized self-report measure adequately address Diagnostic and Statistical
designed to measure severity of depression consis- Manual of Mental Disorders Third Edition
tent with symptoms of depression as presented in (DSM-III; American Psychiatric Association,
the DSM-IV (American Psychiatric Association, 1980) symptoms of depression (e.g., Moran &
1994). There are 21 items on the BDI-II; each Lambert, 1983; Vredenburg, Krames, & Flett,
item references a symptom (e.g., sadness) and 1985), the subsequent releases of the Diagnostic
typically contains four statements from which and Statistical Manual of Mental Disorders
respondents choose the statement that best reflects Third Edition, Revised (DSM-III-R; American
the severity of the symptom for them over the past 2 Psychiatric Association, 1987) and the DSM-IV,
weeks. The BDI-II can be used with both adoles- and changes related to the definition, assessment,
cents aged 13 years and older and adults and expression of depression resulted in the
(Beck et al., 1996). development of the BDI-II beginning in 1994
(Beck et al., 1996). Item and factor analyses
Development were conducted on a 27-item pilot version of
The BDI-II replaced both the original Beck the test given to 193 psychiatric outpatients. In
Depression Inventory (BDI; Beck, Ward, developing the final 21-item BDI-II, four BDI-IA
Beck Depression Inventory 339 B
items (i.e., Body Image Change, Work Difficulty, depression requires further assessment, (b) to
Weight Loss, and Somatic Preoccupation) were be aware of response biases (including both
dropped and four new items (i.e., Agitation, under- and over-reporting of symptoms), and
Worthlessness, Loss of Energy, and Concentra- (c) to pay particular attention to suicide ideation as
tion Difficulty) were added, several symptoms well as the overall pattern of depressive symptoms. B
were renamed, and the majority of the response For researchers or practitioners wanting to
option statements were reworded (Beck et al.). compare scores, equivalent BDI-II and BDI-IA
scores, based on an equipercentile equating
Administration and Scoring method, are provided in the BDI-II manual
Respondents are instructed to circle the number (Beck et al., 1996).
for the one statement for each symptom that best
describes how they have felt during the past 2 Factor Structure
weeks, including today (Beck et al., 1996). In the manual, Beck et al. (1996) report
The BDI-II takes about 510 min to two principal components analyses (PCAs)
complete; patients with severe depression or conducted with 500 psychiatric outpatients and
with obsessional disorders may take longer to 120 introductory psychology students. Both
complete the measure. Although the BDI-II is analyses found two factors on the BDI-II;
typically self-administered, it can also be admin- a factor-matching procedure suggested that
istered orally. there were two highly correlated cognitive-
As noted in the BDI-II manual (Beck et al., affective and somatic factors with a couple of
1996), responses to each of the 21 items on affective symptoms (i.e., sadness, crying) that
the BDI-II range from 0 to 3. Two items may shift between cognitive and somatic factors
(#16 Changes in Sleeping Pattern and depending on the sample. Vanheule, Desmet,
#18 Changes in Appetite) each have seven Groenvynck, Rosseel and Fontaine (2008) noted
response options that allow for increases or that five two-factor structures (e.g., somatic-
decreases in behavior, but they are still scored affective 12 items and cognitive 9 items,
using a range of 03. If a respondent has selected Beck et al., 1996; cognitive-affective 10 items
multiple responses for any BDI-II item, the and somatic-vegetative 8 items, Dozois, Dob-
response with the highest score value is used. son, & Ahnberg, 1998) and four three-factor
A total score is obtained by summing the structures (e.g., cognitive 9 items, somatic
responses to each of the items; thus, total scores 8 items, and affective 4 items, Buckley, Parker,
range from 0 to 63. Higher scores suggest greater & Heggie, 2001; general factor plus cognitive
severity of depression. 8 items and somatic 5 items that are all orthog-
Cut-scores provided in the manual for the BDI-II onal, Ward, 2006) have been supported in the
(Beck et al., 1996) were derived using receiver literature. Most involve some combination of
operating characteristic (ROC) curves based on cognitive, somatic, affective, and general factors.
101 patients who were classified as nondepressed, Still other models have been identified that vary
mildly depressed, moderately depressed, or based on which items load and on what factors. In
severely depressed according to the outpatient ver- many cases, it is the loading of affective items such
sion of the Structured Clinical Interview (SCID) for as crying and sadness that tend to vary (Palmer &
DSM-III. As a screening measure, sensitivity was Binks, 2008; Steer, Ball, Ranieri, & Beck, 1999;
favored over specificity and the following cut- Ward, 2006; Whisman, Perez, & Ramel, 2000).
scores were suggested for patients diagnosed with There are several items that have been found not
major depression: 013 minimal, 1419 mild, to load on either cognitive or somatic factors (e.g.,
2028 moderate, and 2963 severe. When loss of interest in sex, pessimism Wiebe & Penley,
interpreting performance on the BDI-II, the authors 2005; appetite Viljoen, Iverson, Griffiths, &
cautioned the test user (a) that the test is only Woodward, 2003) or items that have been found
a screening measure and that diagnosis of to cross-load on factors (e.g., loss of interest in sex,
B 340 Beck Depression Inventory

concentration difficulty, self-dislike, indecisive- equally high in samples of medical outpatients

ness Viljoen et al.; self-criticalness Arnau, (0.900.94; Arnau et al., 2001; Beck et al., 1996;
Meagher, Norris, & Bramson, 2001; sadness Dutton et al., 2004; Grothe et al., 2005), neuro-
Steer et al., 1999). It is also worth noting that rehabilitative inpatients (0.89; Siegert et al., 2009),
a variety of analyses (e.g., principal components depressed adult outpatients (0.90; Steer et al.,
analysis, principal axis factoring, confirmatory fac- 1999), substance abusers (0.910.95; Buckley
tor analysis), dimension criteria (e.g., scree plot, et al., 2001; Dum, Pickren, Sobell, & Sobell, 2008;
eigenvalues > 1, parallel analysis), rotation Hepner, Hunter, Edelen, Zhou, & Watkins, 2009),
approaches (e.g., varimax, Promax), and samples adolescents (0.92; Osman, Barrios, Gutierrez, Wil-
(e.g., depressed outpatients, college students, male liams, & Bailey, 2008); adolescent psychiatric
substance abusers, low income African-American inpatients (0.900.92; Krefetz, Steer, Gulab, &
adults, nonclinical adolescents, incarcerated adults, Beck, 2002; Osman et al., 2008), adolescent psy-
various medical patient groups, youth offenders) chiatric outpatients (0.89; Krefetz, Steer, &
have been used; all of these factors can impact the Kumar, 2003), young male offenders (0.90;
results of factor analytic studies. Palmer & Binks, 2008), troubled adolescents
A key issue that arises is that the scoring of the (0.90; VanVorrhis & Blumentritt, 2007), older
BDI-II in studies often does not match adults (0.86; Segal et al., 2008), depressed older
the obtained internal structure of the measure. psychiatric inpatients (0.89; Steer, Rismiller, &
Specifically, the presence of two or three factors Beck, 2000), adults with intellectual disabilities
does not support the use of a total score. This raises (0.91; Ailey, 2009), depressed and nondepressed
concerns about findings (e.g., reliability and valid- adults with insomnia (0.89 and 0.82, respectively;
ity evidence, group differences) based on a total Carney, Ulmer, Edinger, Krystal, & Knauss,
score when a unidimensional factor structure or 2009), suicide attempters (0.94; Joe et al., 2008),
a second order factor of depression has not been women who are pregnant or recently pregnant
found or supported. A few studies have found (0.880.89; Bos et al., 2009), and low income
evidence for a unidimensional structure (Hooper, African-American women with chronic health
Qu, Crusto, & Huffman, 2012; Segal, Coolidge, problems (0.94; Kneipp, Kairalla, Staccianni, &
Cahill, & ORiley, 2008) and a number of studies Pereira, 2009).
have examined and found evidence for a second Studies that examine internal consistency
order factor of depression (e.g., Arnau et al., 2001; estimates for subscale scores based on various
Chilcot et al., 2011; Grothe et al., 2005; Joe, two- or three-factor structures for the BDI-II
Woolley, Brown, Ghahramanlou-Holloway, & tend to report Cronbachs alphas that are satisfac-
Beck, 2008; Siegert, Walkey, & Turner-Stokes, tory (>0.80) for cognitive-affective, cognitive,
2009; Steer et al., 1999; Ward, 2006). It is critical and somatic-affective subscales (e.g., Bos et al.,
that researchers find appropriate support for the 2009; Joe et al., 2008; Kneipp et al., 2009; Osman
use of a total score before using such a score in et al., 2008; Siegert et al., 2009; Steer et al., 1999;
subsequent analyses. Ward, 2006). Cronbachs alphas for somatic sub-
scales tend to be more variable, ranging from
Reliability 0.65 to 0.89 (e.g., Bos et al., 2009; Joe et al.,
Internal consistency estimates of reliability for the 2008; Kneipp et al., 2009; Siegert et al., 2009;
BDI-II have been obtained in a wide range of Ward, 2006).
samples. All of these studies use Cronbachs Very little research has been conducted
alpha and most treat the items as though they examining test-retest reliability estimates for
form a unidimensional scale. In college student the BDI-II. Beck et al. (1996) report a 1-week
samples, alphas range from 0.89 to 0.93 (Beck test-retest reliability estimate of 0.93 in a small
et al., 1996; Carmody, 2005; Dozois et al., 1998; sample of US outpatients. Wiebe and Penley
Hooper et al., 2012; Segal et al., 2008; Whisman (2005) reported an ICC for agreement of 0.73
et al., 2000; Wiebe & Penley, 2005). Alphas are over a 1-week interval in a large sample of
Beck Depression Inventory 341 B
Hispanic college students that completed the Arnau et al. (2001) reported that BDI-II total
BDI-II in English. scores and factor scores correlated more
highly with SF-20 mental health scores
Validity (r 0.590.65) than with physical health
Content Validation (i.e., health perceptions, physical pain, physical B
No content validation evidence is provided in the functioning, and role functioning) scores
BDI-II manual (Beck et al., 1996). The only (r 0.180.43) in an adult primary care sam-
content validation evidence appears to be offered ple. Dum et al. (2008) reported that the BDI-II
by Osman, Kopper, Barrios, Gutierrez, and correlated more strongly with a depression inven-
Bagge (2004), who had seven doctoral-level tory (PHQ-9, r 0.84) than with measures of
clinical psychologists with expertise with chil- alcohol (AUDIT, r 0.33) and substance
dren and adolescents and at least 5 years of expe- (DAST, r 0.26) abuse in a sample of outpatient
rience in research or clinical assessment rate each substance abusers. Similarly, Hepner et al. (2009)
BDI-II item for: (a) how relevant it is as reported that the BDI-II correlated more
a symptom of a major depressive disorder strongly with a measure of depression (PHQ-9,
(MDD) and (b) how specific it is as a symptom r 0.76) than with a measure of alcohol abuse
of MDD. In addition, Osman et al. asked 13 (AUDIT-Consumption, r 0.17) in a sample of
adolescent boys and girls in a long-term care residential substance abuse treatment clients.
unit of a psychiatric hospital to rate: (a) the extent Kneipp, Kairalla, Stacciarini, Pereira, and Miller
to which each item was easy to read and under- (2010) found that the BDI-II was more
stand and (b) how useful the item statements highly correlated with a depression measure
would be when talking to a mental health profes- (PHQ-9, r 0.80) than with measures of stress
sional about how they feel. Overall, the findings (Perceived Stress Scale, r 0.69) or anxiety
supported the inclusion of most items of the (Beck Anxiety Inventory, r 0.60) in a sample
BDI-II when used with an adolescent sample. of low income Black women with chronic health
The most problematic item based on feedback conditions.
by both groups was loss of interest in sex. The VanVorrhis and Blumentritt (2007) showed
authors suggested that items focusing on loss promising construct validation evidence in that
of interest in sex, past failure, and punishment the BDI-II was more highly correlated with
feelings may not correspond well to DSM-IV Adolescent Psychopathology Scale scales of
depressive symptoms and that items related to Major Depression (r 0.61), Dysthymic
agitation, concentration difficulty, and loss of Disorder (r 0.62), Generalized Anxiety
interest in sex are the least specific to MDD. They Disorder (r 0.64), Social Phobia (r 0.54),
also questioned the unequal number of items and an Internalizing Disorder factor score
representing each of the DSM-IV depressive (r 0.61) than an Externalizing Disorder factor
symptoms. score (r 0.34), Conduct Disorder (r 0.17),
Oppositional Defiant Disorder (0.30), Substance
Convergent and Discriminant Validation Abuse (r 0.18), or Attention Deficit Hyperac-
In the BDI-II manual, Beck et al. (1996) reported tivity Disorder (r 0.41) in a sample of Mexican
that the BDI-II correlated more strongly with American youth from three facilities; however,
measures of depression (Revised Hamilton the equally high correlations with both depres-
Psychiatric Rating Scale for Depression, sion and anxiety scales are troubling. Similarly,
r 0.71) and hopelessness (Beck Hopelessness Segal et al. (2008) reported that the BDI-II
Scale, r 0.68) than measures of anxiety (Beck correlated significantly with measures of depres-
Anxiety Inventory, r 0.60; Revised Hamilton sion (CES-D, r 0.680.69; Coolidge Axis II
Psychiatric Rating Scale for Anxiety, r 0.47) Inventory (CATI) Depression, r 0.530.66;
and suicidal ideation (Scale for Suicide Ideation, CATI Depressive Personality, r 0.560.59),
r 0.37) in samples of psychiatric outpatients. anxiety (CATI Anxiety, r 0.480.60),
B 342 Beck Depression Inventory

well-being (Short Psychological Well-Being psychiatric outpatients scored significantly

Scale total scores, r 0.600.69), and stress higher on the BDI-II than undergraduate psychol-
(Perceived Stress Scale, r 0.640.71), and ogy students.
less so with overall perceived health Krefetz et al. (2002) reported significantly
(r 0.130.27) for younger and older adult higher scores on the BDI-II for adolescent
samples; the equally high correlations with both psychiatric inpatients with MDD than those who
depression and anxiety suggest poor discrimina- were not depressed. Osman et al. (2008) found
tion between these constructs. In a sample of that (a) an adolescent inpatient group from a state
adolescents, Osman et al. (2008) reported that psychiatric hospital with MDD, dysthymia,
the BDI-II correlated slightly higher with the conduct disorder, or oppositional defiant disorder
Beck Hopelessness Scale (r 0.63), but similarly diagnoses scored significantly higher (with
with the Brief Reasons for Living Inventory for a large effect size) on the BDI-II than
Adolescents (r 0.55), State-Trait Anxiety a nonclinical group of adolescents, and (b) an
Inventory-State (r 0.53), and Suicide adolescent outpatient group scored significantly
Behaviors Questionnaire Revised (r 0.57). higher (with a moderate effect size) on the BDI-II
In a few studies, the BDI-II has shown good than a nonclinical group of adolescents.
convergent validity with other measures of Within clinical samples, there is also satisfac-
depression (e.g., r 0.66 with the Hamilton tory known-groups validation evidence for the
Rating Scale for Depression in adult suicide BDI-II. Beck et al. (1996) reported that outpa-
attempters, Joe et al., 2008; r 0.84 with the tients with mood disorders scored significantly
Reynolds Adolescent Depression Scale in adoles- higher than groups with anxiety, adjustment,
cent psychiatric inpatients, Krefetz et al., 2002) and other psychiatric disorders. Steer et al.
but no discriminant measures were examined to (2000) found that geriatric inpatients with MDD
provide appropriate comparisons. scored approximately 2.7 times higher on the
Overall, there is some good convergent and BDI-II than those with adjustment disorders
discriminant validation evidence available for the with depressed mood. In a group of adult psychi-
BDI-II. It would be useful to see some more atric outpatients with MDD, significant differ-
comparisons made with other depression mea- ences were found on the BDI-II among those
sures when the focus is on examining the BDI-II with severe, moderate, and mild specifiers, such
and far more attention needs to be paid to rela- that greater severity of specifiers was associated
tionships between the BDI-II and measures of with increasingly higher BDI-II scores (Steer,
anxiety versus depression. Brown, Beck, & Sanderson, 2001). More mixed
results were found in Beck et al. (1996) whereby
Known-Groups Validation no significant differences on BDI-II scores
There has been strong known-groups validation were reported among five mood disorder groups
evidence for the BDI-II in both adult and adoles- (i.e., MDD single episode, MDD recurrent epi-
cent groups. Significantly higher scores on the sode, dysthymia, bipolar, depression NOS),
BDI-II have been reported for adults with MDD except between the MDD recurrent episode and
than those without MDD in primary care clinic bipolar groups. Finally, Palmer and Binks (2008)
samples (Arnau et al., 2001; Dutton et al., 2004) found that young male adult prisoners with
and in adults with insomnia (Carney et al., 2009). previous suicidal behavior scored significantly
In a study of cardiac patients, Low and Hubley higher on the BDI-II than those without
(2007) reported significantly lower mean BDI-II a history of such behavior.
scores (and large effect sizes) for nondepressed
than depressed participants across each of three Criterion-Related Validation
SCID-I/NP diagnostic categories: (a) MDD, A number of studies have examined the useful-
(b) MDD + double depression, and (c) mixed ness of the BDI-II as a screening measure by
depression group. Beck et al. (1996) found that reporting the area under the curve (AUC) and
Beck Depression Inventory 343 B
Beck Depression Inventory, Table 1 Selected sample reflects low prevalence of depression in the sam-
of criterion-related validation studies ples (Wassertheil-Smoller, 1990).
Study Sample Score Results
Ailey 75 adults with 11 Sensitivity 89 % Discussion B
(2009) intellectual Specificity 82 %
disabilities PPV 61.5 %
The BDI-II is a widely used self-report measure
NPV 95.8 %
designed to measure severity of depression in
Arnau 333 adults in 18 Sensitivity 94 %
both adolescents aged 13 years and older and
et al. a primary care Specificity 92 %
(2001) setting adults. Its 21 items were selected to be consistent
PPV 54 %
NPV 99 %
with symptoms of depression as presented in the
Carney 140 adults with >17 Sensitivity 81 %
DSM-IV. Administration of the BDI-II is straight-
et al. insomnia Specificity 79 % forward and takes about 510 min for most
(2009) individuals. Scoring of the BDI-II is also straight-
Dutton 220 African- 14 Sensitivity 88.2 % forward. Cut-scores for identifying severity of
et al. American Specificity 92.1 % depression in patients diagnosed with MDD are
(2004) patients PPV 69.5 %
recruited from provided in the manual. It is noteworthy,
NPV 94.2 % however, that the standardization sample is rela-
primary care
clinics tively small and does not appear to be diverse in
Huffman 131 post- 16 Sensitivity 87.7 % terms of race, culture, or socioeconomic status, or
et al. myocardial Specificity 83.9 % widely representative of the US population.
(2010) infarction
patients There is little agreement on the internal struc-
Krefetz 56 adolescent 24 Sensitivity 74 % ture of the BDI-II. Numerous two- and three-factor
et al. psychiatric Specificity 70 % structures have been identified for the BDI-II; in
(2002) inpatients PPV 76 % addition, some researchers have identified
NPV 67 % a general or second order factor of depression. It
Low & 119 cardiac 10 Sensitivity 100 % is troubling that the scoring of the BDI-II in studies
Hubley patients Specificity 75 % often does not match the identified internal struc-
(2007) PPV 18 % ture of the measure. This raises questions about
NPV 100 % reliability and validity evidence and other study
findings (e.g., group differences) based on use of
a total score when a unidimensional factor struc-
ture or a second order factor of depression has not
providing sensitivity, specificity, positive predic- been found or supported. Nonetheless, internal
tive value (PPV), and negative predictive value consistency alpha estimates of reliability for total
(NPV) information for various cut-scores on the or subscale scores on the BDI-II generally range
BDI-II. Most studies have found the BDI-II to be from satisfactory (>0.80) to excellent. Very few
an excellent case-finding screen for depression test-retest reliability estimates for the BDI-II are
with AUC values typically greater than 0.90 in available, but these report good to excellent
a variety of adult samples (e.g., Ailey, 2009; 1-week test-retest reliability.
Arnau et al., 2001; Dutton et al., 2004; Huffman Very little research has addressed the content
et al., 2010; Low & Hubley, 2007). Widely vary- validation of the BDI-II. Only one study has
ing cut-scores have been recommended for use in examined content validity and it focused on the
screening for depression in different samples as use of the BDI-II with adolescent inpatients.
seen in Table 1. Sensitivity and specificity values The findings supported the inclusion of most
tend to be satisfactory, at least with adult sam- items of the BDI-II with this group, with the
ples. In most general settings, NPVs are high; exception of loss of interest in sex. Overall,
PPVs tend to be relatively low and this often there is good convergent and discriminant
B 344 Beck Depression Inventory

validation evidence available for the BDI-II with American Psychiatric Association. (1987). Diagnostic
a variety of samples. It would be useful to see and statistical manual of mental disorders (3rd ed,
rev.). Washington, DC: Author.
more comparisons made with other depression American Psychiatric Association. (1994). Diagnostic
measures and far more attention needs to be and statistical manual of mental disorders (4th ed.).
paid to relationships between the BDI-II and Washington, DC: Author.
measures of anxiety versus depression as the Arnau, R. C., Meagher, M. W., Norris, M. P., &
Bramson, R. (2001). Psychometric evaluation of the
BDI-II has been found to be equally correlated Beck Depression Inventory-II with primary care med-
with both types of measures. Known-groups val- ical patients. Health Psychology, 20(2), 112119.
idation evidence for the BDI-II in both adult and Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979).
adolescent groups tends to be strong; expected Cognitive therapy of depression. New York: Guilford
differences have been found between depressed Beck, A. T., & Steer, R. A. (1987). Manual for the
and nondepressed groups, clinical and Beck Depression Inventory. San Antonio, TX: The
nonclinical groups, inpatients and outpatients, Psychological Corporation.
depressed and other psychiatric conditions, and Beck, A. T., Steer, R. A., & Brown, G. K. (1996). BDI-II
manual. San Antonio, TX: The Psychological
among severity levels of depression. Finally, Corporation.
criterion-related validation studies have found Beck, A. T., Steer, R. A., & Garbin, M. G. (1988).
the BDI-II to be an excellent case-finding screen Psychometric properties of the Beck Depression
for depression in a variety of adult samples. Inventory: Twenty-five years of evaluation. Clinical
Psychology Review, 8, 77100.
Sensitivity, specificity, and NPV values tend to Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., &
be satisfactory; however, recommended cut- Erbaugh, J. (1961). An inventory for measuring
scores for screening for depression vary widely depression. Archives of General Psychiatry, 4,
depending on the sample. 561571.
Bos, S. C., Pereira, A. T., Marques, M., Maia, B., Soares,
M. J., Valente, J., et al. (2009). The BDI-II factor
structure in pregnancy and postpartum: Two or three
factors? European Psychiatry, 24(5), 334340.
Cross-References Buckley, T. C., Parker, J. D., & Heggie, J. (2001).
A psychometric evaluation of the BDI-II in treatment-
Confirmatory Factor Analysis (CFA) seeking substance abusers. Journal of Substance
Abuse Treatment, 20, 197204.
Convergent Validity
Carmody, D. P. (2005). Psychometric characteristics of
Criterion Validity the Beck Depression Inventory-II with college
Cronbachs Alpha students of diverse ethnicity. International Journal of
Discriminant Validity Psychiatry in Clinical Practice, 9(1), 2228.
Carney, C. E., Ulmer, C., Edinger, J. D., Krystal, A. D., &
Factor Analysis
Knauss, F. (2009). Assessing depression symptoms in
Geriatric Depression Scale those with insomnia: An examination of the Beck
Internal Consistency Reliability Depression Inventory Second Edition (BDI-II).
Principal Component Analysis Journal of Psychiatric Research, 43(5), 576582.
Chilcot, J., Norton, S., Wellsted, D., Almond, M.,
Davenport, A., & Farrington, K. (2011). A confirmatory
Test-Retest Reliability factor analysis of the Beck Depression Inventory-II in
end-stage renal disease patients. Journal of Psychoso-
matic Research, 71(3), 148153.
Dozois, D. J. A., Dobson, K. S., & Ahnberg, J. L. (1998).
References A psychometric evaluation of the Beck Depression
Inventory-II. Psychological Assessment, 10(2), 8389.
Ailey, S. H. (2009). The sensitivity and specificity of Dum, M., Pickren, J., Sobell, L. C., & Sobell, M. B.
depression screening tools among adults with intellec- (2008). Comparing the BDI-II and the PHQ-9 with
tual disabilities. Journal of Mental Health Research in outpatient substance abusers. Addictive Behaviors,
Intellectual Disabilities, 2(1), 4564. 33(2), 381387.
American Psychiatric Association. (1980). Diagnostic Dutton, G. R., Grothe, K. B., Jones, G. N., Whitehead, D.,
and statistical manual of mental disorders (3rd ed.). Kendra, K., & Brantley, P. J. (2004). Use of the Beck
Washington, DC: Author. Depression Inventory-II with African American
Beck Depression Inventory 345 B
primary care patients. General Hospital Psychiatry, Osman, A., Kopper, B. A., Barrios, F., Gutierrez, P. M., &
26(6), 437442. Bagge, C. L. (2004). Reliability and validity of the Beck
Grothe, K. B., Dutton, G. R., Jones, G. N., Bodenlos, J., Depression Inventory II with adolescent psychiatric
Ancona, M., & Brantley, P. J. (2005). Validation of the inpatients. Psychological Assessment, 16(2), 120132.
Beck Depression Inventory-II in a low-income African Palmer, E. J., & Binks, C. (2008). Psychometric properties
American sample of medical outpatients. Psychologi- of the Beck Depression Inventory-II with incarcerated B
cal Assessment, 17(1), 110114. male offenders aged 1821 years. Criminal Behaviour
Hepner, K. A., Hunter, S. B., Edelen, M. O., Zhou, A. J., & and Mental Health, 18(4), 232242.
Watkins, K. (2009). A comparison of two depressive Segal, D. L., Coolidge, F. L., Cahill, B. S., & ORiley, A. A.
symptomatology measures in residential substance (2008). Psychometric properties of the Beck Depression
abuse treatment clients. Journal of Substance Abuse Inventory-II (BDI-II) among community-dwelling
Treatment, 37, 318325. older adults. Behavior Modification, 32(1), 320.
Hooper, L. M., Qu, L., Crusto, C. A., & Huffman, L. E. Siegert, R. J., Walkey, F. H., & Turner-Stokes, L. (2009).
(2012). Scalar equivalence in self-rated depressive An examination of the factor structure of the Beck
symptomatology as measured by the Beck Depression Depression Inventory-II in a neurorehabilitation inpa-
Inventory-II: Do racial and gender differences in tient sample. Journal of the International Neuropsy-
college students exist? Psychology, 3, 762774. chological Society, 15(1), 142147.
Huffman, J. C., Doughty, C. T., Januzzi, J. L., Pirl, W. F., Steer, R. A., Ball, R., Ranieri, W. F., & Beck, A. T. (1999).
Smith, F. A., & Fricchione, G. L. (2010). Screening for Dimensions of the Beck Depression Inventory-II in
major depression in post-myocardial infarction clinically depressed outpatients. Journal of Clinical
patients: Operating characteristics of the Beck Depres- Psychology, 55(1), 117128.
sion Inventory-II. International Journal of Psychiatry Steer, R. A., Brown, G. K., Beck, A. T., & Sanderson,
in Medicine, 40(2), 187197. W. C. (2001). Mean Beck Depression Inventory-II
Joe, S., Woolley, M. E., Brown, G. K., Ghahramanlou- scores by severity of major depressive episode.
Holloway, M., & Beck, A. T. (2008). Psychometric Psychological Reports, 88, 10751076.
properties of the Beck Depression Inventory-II in low- Steer, R. A., Rismiller, D. J., & Beck, A. T. (2000). Use of
income, African American suicide attempters. Journal Beck Depression Inventory-II with depressed geriatric
of Personality Assessment, 90(5), 521523. inpatients. Behaviour Research and Therapy, 38(3),
Kneipp, S. M., Kairalla, J. A., Staccianni, J., & Pereira, D. 311318.
(2009). The Beck Depression Inventory II factor struc- Vanheule, S., Desmet, M., Groenvynck, H., Rosseel, Y., &
ture among low-income women. Nursing Research, Fontaine, J. (2008). The factor structure of the Beck
58(6), 400409. Depression Inventory-II: An evaluation. Assessment,
Kneipp, S. M., Kairalla, J. A., Stacciarini, J. M. R., 15, 177187.
Pereira, D., & Miller, M. D. (2010). Comparison of VanVorrhis, C. R. W., & Blumentritt, T. L. (2007). Psy-
depressive symptom severity scores in low-income chometric properties of the Beck Depression
women. Nursing Research, 59(6), 380388. Inventory-II in a clinically-identified sample of
Krefetz, D. G., Steer, R. A., Gulab, N. A., & Beck, A. T. Mexican American adolescents. Journal of Child and
(2002). Convergent validity of the Beck Depression Family Studies, 16(6), 789798.
Inventory-II with the Reynolds Adolescent Depression Viljoen, J. L., Iverson, G. L., Griffiths, S., & Woodward, T. S.
Scale in psychiatric inpatients. Journal of Personality (2003). Factor structure of the Beck Depression
Assessment, 78(3), 451460. Inventory-II in a medical outpatient sample. Journal of
Krefetz, D. G., Steer, R. A., & Kumar, G. (2003). Lack of Clinical Psychology in Medical Settings, 10(4), 289291.
age differences in the Beck Depression Inventory-II Vredenburg, K., Krames, L., & Flett, G. L. (1985).
scores of clinically depressed adolescent outpatients. Reexamining the Beck Depression Inventory: The long
Psychological Reports, 92, 489497. and short of it. Psychological Reports, 57, 767778.
Low, G. D., & Hubley, A. M. (2007). Screening for Ward, L. C. (2006). Comparison of factor structure
depression after cardiac events using the Beck Depres- models for the Beck Depression Inventory-II. Psycho-
sion Inventory-II and the Geriatric Depression Scale. logical Assessment, 18(1), 8188.
Social Indicators Research, 82, 527543. Wassertheil-Smoller, S. (1990). Biostatistics and epide-
Moran, P. W., & Lambert, M. J. (1983). A review of miology: A primer for health professionals. New York:
current assessment tools for monitoring changes in Springer.
depression. In M. S. Lambert, E. R. Christensen, & Whisman, M. A., Perez, J. E., & Ramel, W. (2000). Factor
S. DeJulio (Eds.), The assessment of psychotherapy structure of the Beck Depression Inventory-Second
outcome (pp. 263303). New York: Wiley. Edition (BDI-II) in a student sample. Journal of Clin-
Osman, A., Barrios, F. X., Gutierrez, P. M., Williams, ical Psychology, 56(4), 545551.
J. E., & Bailey, J. (2008). Psychometric properties Wiebe, J. S., & Penley, J. A. (2005). A psychometric
of the Beck Depression Inventory-II in nonclinical comparison of the Beck Depression Inventory-II in
adolescent samples. Journal of Clinical Psychology, English and Spanish. Psychological Assessment,
64(1), 83102. 17(4), 481485.
B 346 Beck Inventory

improve exercise tolerance and quality of life

Beck Inventory (QoL) in healthy subjects and in patient
groups (Wasserman, Hansen, Sue, Stringer, &
Beck Depression Inventory Whipp, 2005).

Behavior Therapy with Children
Historical Antecedents
Cognitive Behavior Therapy with Children Since 1960, exercise has been promoted as
a method of preventing diseases and extending
life (Durstine, Moore, Painter, & Roberts,
2009). However, it was restricted to healthy
Behavior, Social individuals, and in the presence of chronic
diseases, it was recommended to avoid exer-
Prosocial Behavior cises. However, in the 1980s, many studies
demonstrated that exercise had lots of benefits
for persons with chronic diseases and disabil-
ities. For this population, exercise became
Behavior, Sustainable a way to preserve their functional capacity and
independence with positive effects on QoL
Proenvironmental Behavior (Durstine et al.). Some studies reported
increases in survival rates in chronic patients
who participated in exercise programs, but the
effects on their QoL, rather than the quantity of
Behavioral Addictions life, are frequently reported.
Better control of chronic and infectious
Addiction, An Overview diseases is needed for the aging of the worlds
population. Exercise is an important tool to main-
tain the functional capacity and QoL in elderly
people (Spirduso, Francis, & MacRae, 2005) who
frequently enter into a spiral toward exercise
Behavioral Conditioning intolerance, because of the reduction in their
functional capacities and depressed status
Raquel Britto (Spirduso et al.). Exercise intervention programs
Physical Therapy, Universidade Federal de should contribute to enhance exercise tolerance
Minas Gerais, Belo Horizonte, Brazil and to discontinue the process of depressed
conditions. It could also increase the participation
in social activities and contribute to improve the
Synonyms QoL. There is also considerable and growing
evidence that physical activity and/or exercise
Aerobic training; Endurance exercise training behaviors play important roles in a persons
perception of QoL (Gillison, Skevington, Sato,
Standage, & Evangelidou, 2009; Wolin, Glynn,
Definition Colditz, Lee, & Kawachi, 2007). A recent
systematic review shows the effects of exercise
Conditioning is the process of improving global interventions on QoL in clinical and healthy
exercise capacity. It is commonly used to populations (Gillison et al., 2009).
Behavioral Conditioning 347 B
Multidisciplinary Health-Care Team (Padeletti, Jelic, & LeJemtel, 2008; Spirduso et al.,
It is very important that exercise management is 2005). The ACSM recommendation for older
provided by a wide variety of health care and adults (Nelson et al., 2007) is similar to the updated
exercise professionals, including nurses, physi- ACSM/AHA recommendations for adults (Haskell
cians, nutritionists, exercise physiologists, physical et al., 2007) but has several important differences. B
and occupational therapists, psychologists, social For the elderly with risks of falls, the recommended
workers, and other health and education specialists intensity of aerobic activity should take into
and, most importantly, the individuals and the indi- account their levels of aerobic fitness and include
viduals families (Wolin et al., 2007). activities which maintain or increase flexibility and
balance. In addition, older adults should have an
Healthy People activity plan for achieving the recommended
Largely because of the success of conditioning physical activity which integrates preventive and
which modifies the risk factors for chronic dis- therapeutic recommendations (Nelson et al., 2007).
eases and maintains their functional capacities
and independence, the number of healthy people People with Chronic Diseases
in conditioning programs has increased. For people with chronic diseases, the program
Depression, in particular, has been associated should include several facets designed to provide
with less energy, more fatigue, lower exercise interventions for restoring functional capacity,
capacity, and reduced QoL and sense of reducing the impact of the disease, and promoting
well-being. Subjects who do physical exercise positive psychosocial behavioral changes that lead
regularly have reduced risks of developing to the maintenance of health and social indepen-
chronic diseases (Perraton, Kumar, & Machotka, dence and consequently to enhance their QoL
2010). The benefits of conditioning to reduce (Durstine et al., 2009). Exercise prescription
cardiac risks and depression and to improve needs to consider the effects of the disease or
QoL have been described (Durstine et al., 2009; disability on both acute and chronic responses to
Perraton et al., 2010). exercise (adaptations), on the interactions between
According to Perraton et al., 2010, the majority exercise and medications, and mental health
of trials that evaluate the impact of exercise on (Durstine et al.). It is also important to identify
depression used supervised aerobic exercise inter- the expectations of the patients and their families.
ventions and the most common exercise parame- Problem-oriented exercise management was
ters were set at 6080 % of the maximum heart developed in the late 1960s to provide helpful
rate for 30 min, three times per week for an overall ways to approach patient with chronic diseases
duration of 8 weeks. According to the American (Durstine et al., 2009). The SOAP technique
College of Sports Medicine (ACSM) (Haskell is defined as getting (1) subjective data, (2) objective
et al., 2007), to promote and maintain health, all data, (3) assessment, (4) the formulation of a plan
healthy adults aged 1865 year need moderate- based upon the list of problems, and (5) continuous
intensity aerobic (endurance) for a minimum of reassessments. The subjective data help identify the
30 min for 5 days per week or vigorous-intensity persons history of physical activity, medical prob-
aerobic physical activity for a minimum of 20 min lems, and the reasons they are participating in exer-
for 3 days a week (evidence level IA). cise. The objective data include appropriate tests to
provide measurements that confirm or refute possi-
Elderly People ble causes of the symptoms during exercise. The
Conditioning rapidly reverses the progression of assessment lists the problems and defines priorities
skeletal muscular metabolic changes, such as atro- for interventions to make a plan. In the past, much
phies, and promotes independence and QoL in the emphasis was on aerobic exercise testing. However,
elderly. It is clearly an essential component of the nowadays, measures of strength, flexibility, neuro-
management for elderly patients with chronic dis- muscular skills, and functional performance are
eases, mainly the respiratory and cardiac disorders recommended (Durstine et al.). More than that,
B 348 Behavioral Conditioning

the approach of the World Health Organization survivors: A randomized controlled trial. Archives of
(WHO) with the International Classification of Physical Medicine and Rehabilitation, 92(2),
Functioning, Disability and Health (ICF) empha- Durstine, J. L., Moore, G., Painter, P,. & Roberts, S.
sizes that functioning and impairments are deter- (2009). ACSs exercise management for persons with
mined by the environmental context where the chronic diseases and disabilities. (3rd Ed.). Human
people live (World Health Organization [WHO], Kinetics.
Fallucca, F., & Pozzilli, P. (2009). Physical exercise,
2001). Thus, it is also necessary to evaluate the public health and quality of life in diabetes. Diabetes/
impact of exercise training on capacities, consider- Metabolism Research and Reviews, 25(Suppl. 1),
ing the activities which a person with impairments S1S3.
in bodily functions and/or structures can perform, Gillison, F. B., Skevington, S. M., Sato, A., Standage, M.,
& Evangelidou, S. (2009). The effects of exercise
and also on their social participation. In this way, interventions on quality of life in clinical and healthy
the use of questionnaires is very important to iden- populations; a meta-analysis. Social Science &
tify the levels of QoL during the progression of the Medicine, 68, 17001710.
Haskell, W. L., Lee, I. M., Pate, R. R., Powell, K. E.,
conditioning program.
Blair, S. N., Franklin, B. A., Macera, C. A.,
Heath, G. W., Thompson, P. D., & Bauman, A. (2007).
Discussion Physical activity and public health: Updated recommen-
There is sufficient evidence showing the positive dation for adults from the American college of sports
medicine and the American heart association. Medicine
effects of conditioning on QoL (Britto et al., 2011; and Science in Sports and Exercise, 39(8), 14231434.
(Fallucca & Pozzilli, 2009); Gillison et al., 2009; Lima, M. O., Rocha, M. O. C., Nunes, M. C. P., Sousa, L.,
Lima et al., 2010; Perraton et al., 2010; Weening- Costa, H. S., Alencar, M. C., Britto, R. R., & Ribeiro,
Dijksterhuis, de Greef, Scherder, Slaets, & van der A. L. P. (2010). A randomized trial of the effects of
exercise training in chagas cardiomyopathy. European
Schans, 2011). Exercise training resulted in signif- Journal of Heart Failure, 12, 866873.
icant improvements in self-reported health status. Nelson, M. E., Rejeski, W. J., Blair, S. N., Duncan, P. W.,
Considering that these positive effects are related Judge, J. O., King, A. C., Macera, C. A., &
to adherence, new studies have to consider strate- Castanedasceppa, C. (2007). Physical activity and
public health in older adults: Recommendation from
gies to promote exercise adherence. According to the American college of sports medicine and the
Gillison et al., 2009, it is also important to identify American heart association. Medicine and Science in
which types of interventions are associated with Sports and Exercise, 39(8), 14351445.
Padeletti, M., Jelic, S., & LeJemtel, T. H. (2008). Coexis-
better gains in QoL. These authors also concluded
tent chronic obstructive pulmonary disease and heart
that there may be reciprocal relationships failure in the elderly. International Journal of
between QoL and exercise behavior, such that, Cardiology, 125(2), 209215.
rather than exercise behavior determining QoL Perraton, L. G., Kumar, S., & Machotka, Z. (2010).
Exercise parameters in the treatment of clinical
outcomes, having better QoL may increase ones
depression: A systematic review of randomized
ability to engage in exercise behavior. It is the controlled trials. Journal of Evaluation in Clinical
positive spiral results of conditioning. Practice, 16(3), 597604.
Spirduso, W. W., Francis, K. L, & MacRae, P. G. (2005).
Physical dimensions of aging. (2nd Ed.). Human
Cross-References Wasserman, K., Hansen, J. E., Sue, D. Y., Stringer, W. W.,
& Whipp, B. J. (2005). Principles of exercise testing
Elderly People and interpretation (4th ed.). Philadelphia: Lippincott
Exercise Williams & Wilkins.
Weening-Dijksterhuis, E., de Greef, M. H., Scherder, E. J.,
QoL Slaets, J. P., & van der Schans, C. P. (2011). Frail
institutionalized older persons: A comprehensive
review on physical exercise, physical fitness, activities
References of daily living, and quality-of-life. American Journal of
Physical Medicine & Rehabilitation, 90(2), 156168.
Britto, R. R., Rezende, N. R., Marinho, K. C., Torres, J. L., Wolin, K. Y., Glynn, R. J., Colditz, G. A., Lee, I. M., &
Parreira, V. F., & Teixeira-Salmela, L. F. (2011). Kawachi, I. (2007). Long-term physical activity pat-
Inspiratory muscular training in chronic stroke terns and health-related quality of life in U.S. Women.
Behavioral Dysfunction 349 B
American Journal of Preventive Medicine, 32(6), regulating clients (Claes, Morisse, Reynaert,
490499. Andries, & Vandevelde, 2009).
World Health Organization, WHO. (2001). International
classification of functioning, disability and health: Within this context, the question arises with
ICF. Geneva: World Health Organization. regard to the significance of inpatient treatment
of problems related to mental health and people B
with intellectual disability.
Over the years, there has been labored strongly
Behavioral Dysfunction for the normalization, integration, and inclusion
as part of quality of life in favor of the general
Filip Morisse1 and Eddy Weyts2 group of people with intellectual disability. Here,
1 all the more striking is the mechanism of exclu-
Psychiatric Centre Dr. Guislain, Gent, Belgium
2 sion, which time and again leads to excluding
Academic Psychiatric Centre, UPC Sint
Kamillus, Bierbeek, Belgium those persons within the group that do not come
up to the standards (Verstraete, 2009), in specific
those who suffer from problems of mental health.
Would it not be interesting to reflect upon the
community-based support that includes the
inpatient treatment, instead of one that avoids
Challenging behavior; Dual diagnosis
hospitalization? To put it differently, can inpa-
tient treatment play a part in the movement of
community-based support and moreover when is
Definition this possible?
We commence with a description of a few type
Quality of life in adults with an intellectual dis- stories of people who ended up in admission
ability and challenging behavior and/or mental departments in a psychiatric hospital, in order to
health problems. question afterward why inpatient treatment was
necessary for each of them (Gardner, Dosen,
Griffiths, & King, 2006). Moreover, neither in
the type of pathology nor in the type of treatment,
Description we can discover criteria for residential care.
What then can be considered the relevance of
The field of intellectual disability (ID) is strongly inpatient treatment?
influenced by the quality of life (QOL) paradigm. P. has not been feeling well in the community
This framework supports the equality of persons, for some time now. Everyone that is worried about
which is reflected by concepts such as self-deter- her sees that she is suffering. Indeed, P. herself
mination, emancipation, inclusion, and empow- affirms that she is not feeling well. In the past she
erment. In the daily practice, however, in which has already been admitted into a psychiatric clinic
concepts should be translated into actions, profes- because of her problems. She herself and her family
sionals are often confronted with the borders of do not want to return to that clinic. The psychiatrist
these leading principles. This seems especially associated with the facility where P. is accommo-
true when working with specific populations, dated has already tried to increase her antipsy-
including persons with ID and challenging chotics, however, without success given that she
behavior and/or mental health problems. The had suffered an epileptic attack. He insists upon an
application of QOL principles, which should in admission to adapt her medication in a medical
ideal conditions lead to a better mental health, context. Eventually everybody is convinced that
seems to be at risk, as accounts from professionals this is necessary. After been admitted, P. and her
who indicate that emancipation is sometimes family do not show any further signs of resistance.
replaced by actions aimed at controlling or P. gains some peace of mind in admission; and her
B 350 Behavioral Dysfunction

medication is adjusted, both antipsychotics and behavior of a person is of that kind that it
antiepileptics. The community stays involved and threatens the safety of the social situation.
starts looking for ways that would improve their This is possible with different types of pathol-
method of identifying the first signals of illness of ogies, such as psychosis, mood disorders,
P. After a few months, P. returns to her community. dementia, and behavioral disorder. This situa-
Facility X asks if J. can be admitted urgently tion is characterized by a constant threat
because of his seriously aggressive outbursts in toward the person himself and the others
the community. They feel they have tried every- (Dosen, 2005).
thing within their reach; however, J. breaks every 3. Non-corresponding support as multi-defining
rule and engagement. J. does not notice any prob- factor.
lem. At least, he believes that he himself does not The emancipatory thinking and the model
have any problems. Everything is fine with him. of citizenship have brought about plenty of
He believes that the others actually have prob- good things for people with intellectual dis-
lems. We need to admit them instead of him and ability. However, sometimes it can go wrong
leave him alone. when one overestimates the capacity of people
T.s dream has always been to go and live with intellectual disability. The capacity is of
independently. After many years in the commu- course different than the capability. Over the
nity, he can finally move to a studio. Everything years, we have seen several admissions that
seems okay; however, after some time the super- deal with the psychological incapability of
visors report more and more complaints. T. wan- something that one is actually capable of.
ders around in the city, frequently goes to cafes A lot of people who have chosen to live inde-
where he drinks large amounts of coffee, and pendently or with as little support as possible
neglects his daily activities. When they find him following their dream of independence will
in the city, introverted and talking to himself, eventually be admitted because of their
they decide to hospitalize him. He found this psychological problems, connected with the
extremely hard; however, very soon we psychological incapability (leading to loneli-
rediscover the happy T. who always offered him- ness) that is characteristic of independent
self spontaneously for tasks or who was always living.
interested in all sorts of things during the daily 4. Environmental factors as multi-defining factor
activities. (Vandeweerdt, Travers, & Bauwens, 2007).
From these stories we can derive some specific Over the last decades the care for people
situations in which inpatient treatment can be with intellectual disability has been occupied
useful: with the matter of small-scaled living. In itself
1. The medical and psychiatric treatment in this is an effective evolution, however, it also
a safe hospital environment. has a downside. We cannot forget that, as
Following the example of P., it is clear that small as the group counts, the persons living
one needs a specific setting in order to receive in it did not choose to live together. The
the necessary pharmacological treatment in smaller the group, the more intense the inter-
proper circumstances. In this case, the doctor actions. This can be very positive and warm;
has to rely more strongly on his own observa- however, if the field of relations between the
tion and that of the supervisors in the daily residents substantially goes wrong, hell can be
practice who are familiar with the side effects broken loose.
of the medication. 5. The relapse position or key stone function of
2. The gravity of the problematic behavior is a network.
dangerous for the patient himself or others. In the case of severe problem behavior, it
A second situation in which an appeal is often occurs that people only get new opportu-
often made to residential observation and nities when a facility makes a permanent appeal
inpatient treatment unit is one where the to the observation and inpatient treatment unit.
Belief in a Just World (BJW) 351 B
Besides, most units have already had some part- References
time treatments to make it possible; however,
there is still more to be done in this field. This Claes, C., Morisse, F., Reynaert, D., Andries, J., &
Vandevelde, S. 2009. Do opposites really attract?
way it is logical that a facility is more willing to
Exploring the borders of emancipation and control.
resume the care of the client when they can fall 7th European congress of mental health in intellectual B
back on the treatment unit when necessary, disability. Amsterdam, September 35, 2009.
without being confronted with waiting lists. Dosen, A. (2005). Psychische stoornissen,
gedragsproblemen en verstandelijke handicap.
6. The hospital functions as first aid for
Assen: Koninklijke Van Gorcum.
unforeseen circumstances. Gardner, W. I., Dosen, A., Griffiths, D., & King, R.
From a social perspective, there have (2006). Practice guidelines for diagnostic, treatment
always been situations where the social sup- and related support services for people with develop-
mental disabilities and serious behavioral problems.
port system as such does not have any answers.
New York: NADD.
A residential observation and treatment unit Vandeweerdt, M., Travers, E., & Bauwens, A. (2007).
can, from within her hospital function, carry Kom Binnen. therapeutische ontmoetingen met
out a first investigation and report the problem. mensen met een verstandelijke handicap. SEN-
publicaties (2). Antwerpen/apeldoorn: Garant.
In conclusion, inpatient mental health care of
Verstraete, P. (2009). Toen ook de Duivelskinderen naar
people with intellectual disability is useful in school mochten. APPeL. Magazine voor
certain circumstances. However, in our opinion, Afgestudeerde Psychologen en Pedagogen K.U.Leu-
it is only possible if it is the intention to improve ven, 4(3), 2.
Williams, V., & Heslop, P. (2005). Mental health support
the quality of life of people with intellectual
needs of people with learning difficulty: A medical or
disability in their social situation (Williams & social model? Disability & Society, 20(3), 231245.
Heslop, 2005). Automatically this implies that
one strives toward an admission period as short
as possible and that the goals of treatment aim at
the functioning in a regular social situation. Behavioral Systems
When the inpatient treatment units function in
this way, they contribute toward the idea of com- Faceted Action System Theory (FAST)
munity-based support in their own way. They
can, however, only accept and fulfill this role
when they are part of the networks that in their
entirety aim at maximizing care in society, with Belief in a Just World (BJW)
respect for everyones capacity. Of vital impor-
tance is the presence of a well-differentiated Adrian Furnham
vision on support in society, taking into account University College London, London, UK
not only the capacity as much as possible and the
functioning as normal as possible but also the
psychological welfare of these persons. Com-
bined with every other possibility of treatment
in the social situation, this seems to be the best
The belief in a just world pattern refers to the
guarantee in order that no person with an intel-
tendency of people to blame victims of misfor-
lectual disability is excluded from this commu-
tunes for their own fate.
nity-based support.

The belief in a just world pattern was identified
Intellectual Disability over 30 years ago and concentrates on the
B 352 Belief in a Just World (BJW)

tendency of people to blame victims of misfor- are just as likely to get hurt in traffic accidents as
tunes for their own fate (Lerner, 1980). The careless ones).
essence of this hypothesis or theory was suc- Many studies have used this scale to examine
cinctly summarized by Lerner & Miller (1978, further the relationship between just world and
pp. 10301031): other beliefs and behaviors (Furnham & Procter,
Individuals have a need to believe that they 1989). The measure is not without its difficulties,
live in a world where people generally get what and numerous other self-report measures are
they deserve. The belief that the world is just available, some measuring related issues about
enables the individual to confront his physical a personal sense of justice. Others have distin-
and social environment as though they were sta- guished between immanent and ultimate justice.
ble and orderly. Without such a belief it would be Nevertheless, the belief in a just world
difficult for the individual to commit himself to (BJW) measure has been shown to correlate sig-
the pursuit of long range goals or even to the nificantly with demographic variables such as
socially regulated behaviour of day-to-day life. age, income, and religion but also such personal-
Since the belief that the world is just serves such ity factors as attitudes to authority, conservatism,
an important adaptive function for the individual, and locus of control. People with strong needs to
people are very reluctant to give up this belief, believe in a just world find it difficult to deal with
and they can be greatly troubled if they encounter others misfortune, such as illness. Hence, they
evidence that suggests that the world is not really may be particularly unsympathetic to colleagues
just or orderly after all. going absent with serious illnesses, because they
The idea is that essentially many people from find it difficult to accept the idea that some ill-
all cultures and creeds have a fundamental need nesses and diseases seem to strike people ran-
to believe that the (social) world is a just place domly. Beliefs about justice are no doubt related
and that this belief is functionally necessary for to such factors as pay and reward satisfaction at
them to develop principles of deservingness. work, as well as feelings about equity. All issues
Many are confronted with difficult issues like concerning distribution and procedural justice at
why some people get cancer, are sexually abused, work are, no doubt, related to just world
and descend into poverty, while others do not. beliefs, as well as sensitivity to all issues to do
They also have to make sense of their own mis- with fairness in the workplace.
fortunes. The idea of the belief in a just world is The literature in this area has grown so much
that it helps answer some of these very difficult that two big reviews have appeared in the past
questions. decade. Furnham (2003) noted that two distinct
Considerable laboratory evidence has been research interests have emerged over the past
accumulated in support of the concept, most of decade. The first has been concerned with devis-
which has attempted to spell out exactly how and ing better and sensitive measures of the BJW. All
when victims are blamed for their fate, how these four self-report measures devised prior to 1991
beliefs arise, and their consequences for those attempted to provide an overall BJW score. Since
who believe them. then, all measures have attempted to measure
Rubin and Peplau (1975) devised a self-report particular facets of BJW beliefs. This has meant
inventory to measure the attitudinal continuity making various distinctions between, for
between the two opposite poles of total accep- instance, imminent versus ultimate justice and
tance and rejection of the notion that the world is hope for, versus ability to promote, a just world.
a just place. About half the items suggest that the What most of these latter studies have been able
world is a just place where good deeds are to show is that these different, but related, beliefs
rewarded (i.e., 11: By and large people deserve are systematically associated with different
what they get), and half refer to an unjust world dependent variables.
where good deeds are no more likely to be The second major development has been to
rewarded than bad deeds (i.e., 4: Careful drivers view the BJW as a healthy coping mechanism
Beliefs About Poverty 353 B
rather than being the manifestation of antisocial References
beliefs and prejudice (Dalbert, 2001). There has
been a subtle movement from focusing on victim Dalbert, C. (2001). The justice motive as a personal
resource. New York: Plenum.
derogation to positive coping. Recent studies
Furnham, A. (2003). Belief in a just world: Research
have portrayed BJW beliefs as a personal progress over the past decade. Personality and Indi- B
resource or coping strategy, which buffers against vidual Differences, 34, 795817.
stress and enhances achievement behavior. For Furnham, A., & Procter, E. (1989). Belief in a just world:
Review and critique of the individual difference liter-
the first time, BJW beliefs have been seen as an
ature. British Journal of Social Psychology, 28,
indicator of mental health and planning. This 365384.
does not contradict the more extensive literature Hafer, C., & Begue, L. (2005). Experimental research on
on BJW and victim derogation. Rather, it helps just-world theory: Problems, developments and future
challenges. Psychological Bulletin, 131, 128167.
explain why people are so eager to maintain their
Lerner, M. (1980). The belief in a just world:
beliefs which may be their major coping strategy. A fundamental delusion. New York: Plenum.
BJW is clearly functional for the individual. One Lerner, M., & Miller, D. (1978). Just world research and
important issue for future research is how BJW the attribution process: Looking back and looking
ahead. Psychological Bulletin, 85, 10301051.
related to other coping strategies and which are
Rubin, Z., & Peplau, L. (1975). Who believes in a just
favored by health individuals who have low BJW world? Journal of Social Issues, 31, 6589.
beliefs. Again, the focus is on how BJW relates to
personal experiences rather than that of others.
In an important and comprehensive review,
Hafer and Begue (2005) described well over 50 Beliefs About Poverty
studies done since 1980. They noted how
unsystematic the research has been and that Ben Law1 and Daniel T. L. Shek2
some researchers have in fact not understood the 1
Department of Social Work and Social
theory upon which the study was based. They Administration, The University of Hong Kong,
also note various important developments in the Hong Kong, Peoples Republic of China
area. The first is to understand the psychological 2
Department of Applied Social Sciences, The
function of believing in a just world to foster Hong Kong Polytechnic University, Hong Kong,
a sense of well-being and a buffer against unfair Peoples Republic of China
life experiences. The second is the strategies that
people use to maintain their belief in a just world
such as distancing themselves from victims and
developing just-world-restoring strategies for
reacting to those who perpetrate injustice. Third,
Causal attributions for poverty; Perceived causes
there is the consideration of injustice to obviously
of poverty; Perception of poverty
innocent others and fourth reactions to ones own
suffering. A final new area of research is consid-
ering reactions to unjust benefits. This area of
research is related to all other social justice Definition
theories and is a thriving area of research.
Beliefs about poverty are defined as personal
views and perceptions about the causes of pov-
erty. Originated from Feagin (1975), there are
Cross-References three main types of reasons for poverty: individ-
ualistic, structuralist, and fatalistic. Individualis-
Locus of Control tic beliefs attribute poverty to the poor people
Personality, an Overview themselves (personal problems) like lack of
Social Justice ability, effort, and morals. Structuralist beliefs
B 354 Beliefs About Poverty

locate the causes in the social and economic individualistic beliefs. The first theory is the
systems (social problems) like lack of opportuni- dominant ideology thesis (Wilson, 1996). It is
ties, discrimination, and exploitation of poor suggested that America or other modern societies
people. Fatalistic beliefs put the causes beyond tend to uphold values of equality, success, and
individual and environmental control (fate) such democracy. In this way, societies are perceived to
as luck, sickness, and chance. be full of equal opportunities. Being poor is an
individual problem rather than a social problem.
Dispositional factors are emphasized over situa-
Description tional factors. Adherence to this self-serving bias
could produce a logical justification of socioeco-
Poverty is defined as the familys total income nomic inequality. The second theory is the cul-
being lower than an income threshold, based on ture-of-poverty model. It is proposed that the
expenditures judged necessary for minimal poor have developed an alternative culture that
acceptable amounts of food, housing, and other they cannot escape poverty (Kane, 1987). For
essentials (Feagin, 1975). However, beliefs instance, the poor may use more slang and vulgar
about poverty are defined as personal subjective language to the extent that they cannot climb up
propositions and views about the causes of the social ladder. The endorsement of a culture of
poverty. poverty prevents them from appreciating higher-
class culture, such as classical music and poetry,
Three Types of Beliefs About Poverty which are more likely to be appreciated by people
Beliefs are concerned with propositions about an without poverty. Besides, when some poor peo-
object or a relation between objects or concepts ple are accustomed to welfare, they lack the
(Jones & Nisbett, 1972). The proposition can be motivation to look for career advancement. The
causal or correlational. The belief is judged low motivation to work forms a vicious cycle
with its subjective true-false and correct- with a manifestation of laziness. Ultimately, this
incorrect status. Beliefs can be classified into forms a distinctive culture of poverty. The
three types based on the functional domains. intergenerational transmission of cultural values
Individual beliefs are concerned with the of the poor further exacerbates the problems. The
characteristics of individuals, social beliefs third theory is actor-observer bias, which also
about social interactions and social groups, and accounts for individualistic beliefs (Jones &
environmental beliefs about the natural and Nisbett, 1972). The nonpoor tend to attribute
supernatural context. their status to their own efforts instead of social
The classification of beliefs about poverty by advantages. Following this line of thinking, they
Feagin (1975) follows the aforementioned con- also apply dispositional reasoning to the causes of
ceptualization. It consists of three categories: poverty. The fourth perspective is stress theory.
individualistic, structuralist, and fatalistic. People in poverty tend to experience more stress
Individualistic beliefs attribute poverty to the (Hayati & Karami, 2005). The stress of a poor
poor people themselves (personal problems) like family results in a negative and pessimistic per-
lack of ability, effort, and morals. Structuralist sonal outlook. This forms a self-fulfilling proph-
beliefs locate the causes in the social and eco- ecy that disables the next generation from
nomic systems (social problems) like lack of breaking through the current predicament. The
opportunities, discrimination, and exploitation stress stops the individuals from combating pov-
of poor people. Fatalistic beliefs put the causes erty. The common feature of individualistic
beyond individual and environmental control belief for all these four theories is that they tend
(fate) such as luck, sickness, and chance. to blame the poor for having immutable personal
Individualistic beliefs emphasize personal pathology for their misfortunes.
problems as the cause of poverty. There are at Structuralist beliefs emphasize poverty as
least four theories in explaining or elaborating social problems. Della-Fave (1974) suggested
Beliefs About Poverty 355 B
that egalitarianism and distributive justice consti- poverty is beyond individuals control. One
tute the foundation of structuralist beliefs. The prominent example is the Chinese culture.
formation of these two ideologies rests on five Cross-cultural studies have shown that Chinese
beliefs: (1) a feeling of deprivation, (2) an attribu- use more passive coping to meet their fates.
tion of blame to the organization of society, Confucianism, Buddhism and Taoism advocate B
(3) a belief that social justice requires equality, fatalistic beliefs in times of life adversity.
(4) a belief that human nature will permit equality According to Confucian doctrines, individuals
in a complex society, and (5) a belief that the should passively accept stress and suffering
transition from the present society to an egalitarian because such experience may be lessons given
one is practically possible and worth the effort. by the Heaven. Such negative experience can
Thus the cultivation of these two ideologies train a persons resilience and will. Thus, there
paves the path toward a more equal and just soci- is a Chinese saying of Thousand dollars cannot
ety. Poverty is a social problem instead of an buy poverty for youth. It is a positive reframing.
individual one. The second theory is public arena On the other hand, Buddhism suggests that
theory (Lee, Jones, & Lewis, 1990). Beliefs about we have to cultivate the good deeds. However,
poverty are influenced by what the citizens know if we receive some mistreatment, it is because we
and perceive. However, many issues in societies have to pay the debt of our previous actions, i.e.,
are competing with each other in order to gain karma. Sometimes we even have to pay the debt
a high problem status. One major institution from our former lives. In reality, we cannot
shaping the public discourse of the poor is the understand and control many things. According
media and pressure groups. The depiction of to Taoism, we have to attain harmony. We should
media and pressure groups for poverty often be contented and accept our fate. A core concept
exposes more eye-catching and flamboyant social of Taoist thinking is wu wei, implying noninter-
problems, exploitation, and inequalities to the vention and following what is given in life.
extent that structural beliefs prevail. For example, Everything is actually relative, and there is no
one recurring theme is hardworking laborers that absolute right or wrong. Besides, anything
fulfilled a need for cheap labor in the capitalist and pushing to the extreme brings evil. Thus, there
exploitative society. The third theory is the reci- are idioms such as poverty would not last more
procity norms theory. The interaction between than three generations; richness would not last
people with the poor facilitates the development more than three generations. We can see that
of structuralist beliefs (Boarini & Le Clainche, a sense of control does not come from mastery
2009). People in advantageous positions can be of the environment but from the acceptance of
more empathetic toward poor people. Instead of fate as the reality. Fatalistic beliefs of poverty
individualistic reasoning, they understand more emphasize that it is beyond an individuals
the social inequality during interaction. The reci- control to be poor or not.
procity norms theory is a reaction against actor- Not many studies focus on fatalistic beliefs.
observer bias. The fourth theory is the underdog Many studies have instead explored the relation-
thesis (Robinson & Bell, 1978). Different groups ship between individualistic and structuralist
of people hold different beliefs. Advantaged beliefs. Apparently they are antagonistic to each
groups take the dominant ideologies, whereas dis- other. However, this dichotomy is not always jus-
advantaged groups are less likely to adopt domi- tified as inconsistent or contradictory beliefs can be
nant ideologies and are more supportive of combined into compromise explanations. Then
ideological challenges (i.e., structuralist beliefs). they are not alternative or polar opposites. They can
The underdog thesis is the foundation of social coexist in each person. This phenomenon is called
action and postmodernism. the dual consciousness hypothesis, which is espe-
Fatalistic beliefs locate the causes of poverty cially common among socially and economically
in nonstructural, but supra-individual forces such marginalized groups (Hunt, 2004). It means a per-
as luck, chance, and sickness. It emphasizes that son understands that society favors the nonpoor
B 356 Beliefs About Poverty

(structuralist belief). However, he or she will strive respondents for validation. All other scales suffer
to get a better position so as to get rid of poor status from the problems of too few subjects and explor-
(individualistic belief). There are two explanations atory factors.
for this dual consciousness hypothesis. The first is
the omnipotence of individualistic explanation. Individual Correlates of Different Beliefs
Although poor people experience injustice and About Poverty
understand structuralist beliefs, individualistic People who believe in a meritocratic ethos tend to
beliefs are so pervasive that they influence people attribute the causes of poverty to the lack of
at all social positions (Lee et al., 1990). Structuralist individual effort and talent (Stephenson, 2000).
belief is like a layer onto the existing individualistic The dominant ideology thesis suggests that
beliefs. The individualistic belief is too deep-rooted people who have the greatest stake in the social
to be replaced. This positioning of structuralist stratification system, greater authoritarianism, and
belief avoids acute group-based conflicts because social dominance will endorse dominant ideolog-
of the inconsistency of belief systems (Hunt, 2004). ical explanations for poverty. Empirical research
The second reason is the denial of personal has shown that males or white people tend to
discrimination. Poor people understand that they adopt individualistic beliefs; being young tends
are marginalized but they tend to underestimate to be intolerant of the poor (Alston & Dean, 1972).
the effect of the discrimination. Otherwise, they Education is a strong predictor of both individ-
think they receive a better treatment than ualistic beliefs and structuralist beliefs. People
other poor people. This denial also results in social with high education tend to be the group of
harmony and apparent social justice. socially privileged, and they tend to adopt the
dominant ideology thesis (individualistic belief).
Assessment of Beliefs About Poverty However, higher education also enlightens people
Despite heated discussions on the categories of to an extent that they understand more structural or
beliefs about poverty, there are not many distant causes of poverty (Hunt, 2004). Low-
validated instruments measuring the perceived income and ethnic minority groups tend to adopt
causes of poverty. Alston and Dean (1972) used structuralist explanations; yet considerable sup-
a single item to measure this belief. Feagins port for individualistic causes was also found,
(1975) classic treatise adopted 11 items to supporting the dual consciousness thesis. Reli-
measure three domains of beliefs. Atherton et al. gions also affect the beliefs about poverty. Protes-
(1993) developed a 37-item scale to measure three tants and Catholics are strongest on individualistic
domains of beliefs. beliefs, Jews and other religions are strongest on
Shek (2004a) developed a Chinese Perceived structuralist beliefs, and Catholics and Jews are
Causes of Poverty Scale. Four factors are strongest on fatalistic beliefs (Hunt, 2004).
established (Shek & Ma, 2009): personal
problems, exploitation, lack of opportunities, and Social Correlates of Different Beliefs
bad fate. As exploitation and lack of opportunities When people think that the society is legitimate
are structuralist beliefs, the factors fit the classic and fair, they tend to attribute poverty to individ-
tripartite classification of beliefs about poverty. ual factors (Stephenson, 2000). The nonpoor tend
For the measurement of beliefs about Third- to see the poor as lazy and undeserving.
World poverty, Hine and Montiel (1999) found In affluent societies, people tend to blame the
five factors based on the Causes of Third-World poor as they do not utilize the resources available
Poverty Scale, namely, blaming the poor, the (Feagin, 1975). In societies with a larger middle-
government, nature, exploration, and conflicts. class population, individualistic beliefs also
Among all scales, the Chinese Perceived Causes outweigh structural factors. When wealth is get-
of Poverty Scale (Shek & Ma, 2009) has some of ting accumulated, individualistic explanations
the most psychometrically sound properties would increase (Stephenson, 2000). In fact,
because of its factorial validity and sizable Feagin (1975) has already predicted the
Beliefs About Poverty 357 B
emergence of individualistic explanations for Shek (2004b) found that the relationship is
better-off countries: bidirectional for Chinese populations. Beliefs
In affluent societies.. members may believe about poverty were concurrently and longitudinal
that there is plenty to go around and that, even related to the psychological well-being of adoles-
though the poor have brought misfortune upon cents and adults (Shek). In general, stronger B
themselves, they should have some part of the beliefs in fate and externality (structuralist fac-
plentiful resources that are available. Ones reac- tors) would predict a decrease in mastery and an
tions to inequalities would therefore depend upon increase in psychological symptoms for adoles-
the sometimes harsh economic and social reali- cents, but not for fathers. However, a stronger
ties of how much is available and whether it can endorsement of fate and externality as the causes
be increased. (Feagin, 1975, p.216) of poverty actually predicted a higher sense of
In a society with a larger poor population, they existential well-being and life satisfaction for
tend to blame the economic system as the cause of Chinese mothers. A sense of exploitation would
poverty. However, for blacks and Latinos, they predict a negative quality of life for parents but
may attribute both individualistic and structuralist not for adolescents. As well, psychological well-
reasons to the causes of poverty (Hunt, 2004). being influences beliefs about causes of poverty.
People from different political orientations Existential well-being and life mastery can affect
have different attributions: those on the left wing the formation of beliefs about poverty, especially
tend to endorse structuralist, whereas those on the structuralist and fatalistic beliefs.
right tend to endorse individualistic beliefs In short, perceived causation of poverty is
(Zucker & Weiner, 1993). In a similar vein, people related to quality of life, the effect of which is
in welfare states, such as Finland (Niemela, 2008), partly influenced by cultures.
tend to have structuralist beliefs about poverty.
In cultures advocating personal efforts such as Implications of Understanding Beliefs
the USA or China, individual beliefs about pov- About Poverty
erty prevail because they think they can achieve Causal attributions are important mediators of
by efforts and perseverance regardless of future behavior. Once a cause is described,
backgrounds. a following consequential action can be taken.
Timing is also critical for the beliefs. Structural- The perceived causes of poverty form a basis for
ist beliefs actually predominate in public opinion the explanation people offer and the policies they
during times of extreme social or economic strain, endorse. Beliefs about poverty also mediate the
such as the Great Depression, economic stagnation, relationship between the political ideology people
and persistent income inequality (Seipel, 2003). hold and the involvement in antipoverty activism
(Hine & Montiel, 1999), which would eventually
Beliefs About Poverty and Quality of Life influence the quality of life of poor people.
There are not many studies related to the relation- Individual explanations predict support for
ship between beliefs about poverty and quality of restrictive policies. Individualistic beliefs are
life. Perception of poverty is related to quality of directly related to feelings of stigma. Holding an
life. In Iran, people with individualistic beliefs individual belief about poverty will engender the
about poverty had a higher quality of life and proposal that those receiving public allowance
upward mobility, whereas people with fatalistic should be forced to find work or engaged
beliefs had the lowest quality of life (Hayati & in mandatory vocational rehabilitation on the
Karami, 2005). African children who did not attri- assumption of their laziness and tendency to
bute poverty to structuralist causes tend to have avoid work. They are also associated with train-
higher academic goals (Murry et al., 2002). More- ing programs with enhanced work orientation and
over, their mothers psychological stress was conscientiousness (Alston & Dean, 1972).
linked with childrens attributions about the causes Beliefs in the structural causes of poverty sup-
of poverty through its association with parenting. port social provision of basic needs. Advocates call
B 358 Beliefs About Poverty

for greater government intervention in distributive Atherton, C. R., Gemmel, R. J., Haadenstad, S., Hold,
justice such as community-based poverty reduction D. J., Jensen, L. A., OHara, D. F., et al. (1993).
Measuring attitudes toward poverty: A new scale.
intervention strategies or progressive policies with Social Work Research & Abstracts, 29(4), 2830.
increased welfare spending. Boarini, R., & Le Clainche, C. (2009). Social preferences
Understanding the beliefs about poverty is criti- for public intervention: An empirical investigation
cal for human service professionals working with based on French data. The Journal of Socio-Econom-
ics, 38(1), 115128.
the poor, such as social workers (Shek, 2004b). Della-Fave, L. R. (1974). On the structure of egalitarian-
Social work education should provide more training ism. Social Problems, 22, 199213.
in this aspect. Weiss-Gal, Benyamini, Ginzburg, Feagin, J. R. (1975). Subordinating the poor: Welfare and
Savaya, and Peled (2009) have argued the inade- American beliefs. Englewood Cliffs, NJ: Prentice-Hall.
Hayati, D., & Karami, E. (2005). Typology of causes of
quacy of social work education of beliefs about poverty: The perception of Iranian farmers. Journal of
poverty. Toporek and Pope-Davis (2005) observed Economic Psychology, 26(6), 884901.
that counselors are ill equipped to provide compe- Hine, D. W., & Montiel, C. J. (1999). Poverty in develop-
tent services to people in oppressive situations ing nations: Cultural attributional analysis. European
Journal of Social Psychology, 29(7), 943959.
including living in poverty. They also observed the
Hunt, M. O. (2004). Race/ethnicity and beliefs about wealth
persuasiveness of the culture of poverty (individu- and poverty. Social Science Quarterly, 85(3), 827853.
alistic beliefs) among professionals. The beliefs Jones, E. E., & Nisbett, R. E. (1972). The actor and the
about poverty among human service professionals observer: Divergent perceptions of the causes of the
behavior. In E. E. Jones, D. E. Kanouse, H. H. Kelley,
directly affect their interest and willingness to help
R. E. Nisbett, S. Valins, & B. Weiner (Eds.), Attribu-
the poor or fight for social justice (Weiss-Gal et al., tion: Perceiving the causes of behavior. Morristown,
2009). Although social workers hold more structur- NJ: General Learning Press.
alist beliefs than other professionals and social work Kane, T. J. (1987). Giving back control: Long-term pov-
students also have more structuralist beliefs than erty and motivation. The Social Science Review, 61,
nonsocial work students, service users still attribute Lee, B., Jones, S. H., & Lewis, D. W. (1990). Public
more importance to individualist beliefs and to fatal- beliefs about the causes of homelessness. Social
istic causes compared with social workers (Weiss- Forces, 69, 253265.
Gal et al.). Human service professionals should Murry, V. M., Brody, G. H., Brown, A., Wisenbaker, J.,
Cutrona, C. E., & Simons, R. L. (2002). Linking
understand the clients beliefs about poverty, as employment status, maternal psychological well-
well as their own beliefs about poverty. The under- being, parenting, and childrens attributions about
standing should include factors shaping beliefs and poverty in families receiving government assistance.
the consequences of adopting the beliefs (Weiss- Family Relations, 51(2), 112120.
Niemela, M. (2008). Perceptions of the causes of poverty
Gal et al.). As such, multicultural training (MCT) in Finland. Acta Sociologica, 51(1), 2340.
has shown that it is effective in facilitating coun- Robinson, R. V., & Bell, W. (1978). Equality, success, and
selors sensitivity to the structural causes of poverty social justice in England and United States. American
(Toporek & Pope-Davis, 2005). Sociological Review, 43, 125143.
Seipel, M. M. O. (2003). Global poverty: No longer an
untouchable problem. International Social Work,
Cross-References 46(2), 191207.
Shek, D. T. L. (2004a). Beliefs about causes of poverty and
psychological well-being of parents and adolescents
Chinese Beliefs About Adversity Scale experiencing economic disadvantage in Hong Kong.
Chinese Culture American Journal of Family Therapy, 32(3), 239254.
Poverty Shek, D. T. L. (2004b). Beliefs about the causes of poverty
in parents and adolescents experiencing economic dis-
advantage in Hong Kong. The Journal of Genetic
References Psychology: Research and Theory on Human Devel-
opment, 165(3), 272291.
Alston, J. P., & Dean, K. I. (1972). Socioeconomic factors Shek, D. T., & Ma, C. M. (2009). Dimensionality of the
associated with attitudes toward welfare recipients and Chinese Perceived Causes of Poverty Scale: Findings
the causes of poverty. The Social Science Review, based on confirmatory factor analyses. Social Indica-
46(1), 1323. tors Research, 90(2), 155164.
Bell, Daniel 359 B
Stephenson, S. (2000). Public beliefs in the causes of wealth He has been described as one of the leading
and poverty and legitimization of inequalities in Russia American intellectuals of the postwar era. His
and Estonia. Social Justice Research, 13(2), 83100.
Toporek, R. L., & Pope-Davis, D. B. (2005). Exploring the three best known works are The End of Ideology,
relationships between multicultural training, racial The Coming of Post-Industrial Society, and The
attitudes, and attributions of poverty among graduate Cultural Contradictions of Capitalism. B
counseling trainees. Cultural Diversity & Ethnic Within the social indicators movement, he
Minority Psychology, 11(3), 259271.
Weiss-Gal, I., Benyamini, Y., Ginzburg, K., Savaya, R., & is best known for his contributions related to
Peled, E. (2009). Social workers and service users causal Toward a Social Report (Bell et al., 1969),
attributions for poverty. Social Work, 54(2), 125133. the first report of its type attempted by a major
Wilson, G. (1996). Toward a revised framework for exam- economic power. The work built on that of
ining beliefs about the causes of poverty. The Socio-
logical Quarterly, 37(3), 413428. Wilbur Cohen, then secretary of the US Depart-
Zucker, G. S., & Weiner, B. (1993). Conservatism and ment of Health, Education, and Welfare. The
perceptions of poverty: An attributional analysis. Jour- goal throughout the two-decade-long planning
nal of Applied Social Psychology, 23(12), 925943. process was to prepare an annual report to the
nation concerning changing social conditions
occurring throughout all sectors of American
life. Many prominent American economists,
Beliefs, Spiritual sociologists, philosophers, and others either pre-
ceded or joined with Bell in bringing the first such
Religious Beliefs and Psychiatric Symptoms report to fruition: William F. Ogburn, Wesley
Clair Mitchell, Otis Dudley Duncan, Louis
Brownlow, Charles Merriam, and Alice Rivlin,
among others. Owing to their perceived politi-
Bell, Daniel cally explosive nature, funding to conduct subse-
quent annual social reports was withdrawn from
Richard J. Estes subsequent efforts by the Nixon administration.
School of Social Policy & Practice (SP2), In Bells obituary that appeared in the January
University of Pennsylvania, Narberth, 25, 2011, edition of the New York Times (2011),
PA, USA the same day as his death, the late journalist
Michael T. Kaufman noted:
. . .two of Bells books, The End of Ideology
Birth, Education, Work History, and (1960) and the Cultural Contradictions of Cap-
Main Contributions italism (1976), were ranked among the 100 most
influential books since World War II by The Times
Born Daniel Bolotsky on New York Citys Lower Literary Supplement in London. In titling The
End of Ideology and another work, The Com-
East Side on May 10, 1919, Daniel Bell was to
ing of Post-Industrial Society (1973), Bell
become one of the worlds most prolific and influ- coined terms that have entered common usage.
ential sociologists, writers, editors, and professor In The End of Ideology he contended - nearly
emeritus of social sciences at Harvard University. three decades before the collapse of communism -
He is best known for his seminal contributions to that ideologies that had once driven global politics
were losing force and thus providing openings for
the study of post-industrialism, i.e., the process newer galvanizing beliefs to gain toeholds. In The
whereby economically advanced countries shift Coming of Post-Industrial Society, he foresaw the
from manufacturing to the service and, now, global spread of service-based economies as gen-
knowledge-based economies. His major lines of erators of capital and employment, supplanting
those dominated by manufacturing or agriculture.
inquiry included the failures of socialism in Amer-
In Bells view, Western capitalism had come to
ica, the exhaustion of modern culture, and the rely on mass consumerism, acquisitiveness and
transformation of capitalism from an industrial- widespread indebtedness, undermining the old
based system to one built on consumerism. Protestant ethic of thrift and modesty that writers
B 360 Bellagio Principles for Assessing Sustainable Development

like Max Weber and R. H. Tawney had long He provided the intellectual leadership, concep-
credited as the reasons for capitalisms success. tual clarity, and a well-honed sense of the future
He also predicted the rising importance of sci-
ence-based industries and of new technical elites. that have contributed to the relevance of these data
Indeed, in 1967, he predicted something like the in both public data gathering and public policy
Internet, writing: We will probably see a national formulation in countries throughout the world.
information-computer-utility system, with tens of He also provided both fields of social inquiry
thousands of terminals in homes and offices
hooked into giant central computers providing with a level of methodological integrity which,
library and information services, retail ordering until the 1940s and 1950s, seemed to be out of
and billing services, and the like. reach for all but a few. Though now at rest, Bells
work will continue to inform the thinking of gen-
Kaufman also reported that Bell became an
erations of social researchers well into the future,
influential editor of periodicals, starting out
especially those that seek to reconcile emerging
with The New Leader, a small social democratic
societal paradigms with existing norms, tradi-
publication that he referred to as his intellectual
tions, values, and modes of collective behavior.
home. He joined Fortune magazine as its labor
editor and in 1965 helped establish and edit The
Public Interest with his old City College References
classmate Irving Kristol, who died in 2009.
Though The Public Interest never attained Bell, D. (1960). The end of ideology: On the exhaustion of
a wide readership, it gained great prestige, begin- political ideas in the fifties. Glencoe: Free Press.
ning as a policy journal that questioned Great Bell, D. et al. (1969). Toward a social report: 1The idea
of a social report. The Public Interest (15): 7284.
Society programs and then broadening into one Retrieved March 12, 2011 from http://www.
of the most intellectually formidable of neocon- nationalaffairs.com/doclib/20080522_196901507
servative publications. It has had more influence theideaofasocialreportdanielbell.pdf
on domestic policy than any other journal in the Bell, D. (1973). The coming of post-industrial society:
A venture in social forecasting. New York: Basic Books.
country by far, the columnist David Brooks Bell, D. (1976). The cultural contradictions of capitalism.
wrote in The New York Times in 2005. New York: Basic Books.
In addition to being such a prolific author, Bell Kaufman, M. T. (2011). Daniel Bell, ardent appraiser
also maintained a distinguished academic career, of politics, economics and culture, dies at 91.
New York Times, January 25. Retrieved March 18,
teaching at the University of Chicago in the 2011 from http://www.nytimes.com/2011/01/26/arts/
1940s, at Columbia University as a professor of 26bell.html?_r1
sociology from 1959 to 1969 the university
awarded him a Ph.D. for his work on The End of
Ideology and then at Harvard University, where
in 1980 he was appointed the Henry Ford II pro- Bellagio Principles for Assessing
fessor of social sciences. As both a public intellec- Sustainable Development
tual and an academic, according to Kaufman, Bell
saw a distinction between those breeds. In one of his Jochen Jesinghaus
typical yeasty digressions in The End of Ideol- JJ, European Commission, Ispra, Italy
ogy, he wrote: The scholar has a bounded field
of knowledge, a tradition, and seeks to find his place
in it, adding to the accumulated, tested knowledge Definition
of the past as to a mosaic. The scholar, qua scholar,
is less involved with his self. On initiative of the International Institute for
Bells contribution in adding momentum to the Sustainable Development (IISD), in November
now worldwide social indicators and social 1996 a group of 24 experts from five continents
reporting movements was second to none. developed at the Rockefeller Foundations Study
BellagioSTAMP 361 B
and Conference Center in Bellagio, Italy, a set of
ten principles for assessing and measuring sus- BellagioSTAMP
tainable development, called (1) guiding vision
and goals, (2) holistic perspective, (3) essential Laszlo Pinter
elements, (4) adequate scope, (5) practical focus, Department of Environmental Sciences and B
(6) openness, (7) effective communication, Policy, Central European University (CEU),
(8) broad participation, (9) ongoing assessment, Budapest, Hungary
and (10) institutional capacity. International Institute for Sustainable
Development (IISD), Winnipeg, MB, Canada

According to IISD, Principle 1 deals with the
starting point of any assessment - establishing Assessing sustainability assessments; Auditing
a vision of sustainable development and clear sustainability assessments; Sustainability
goals that provide a practical definition of that assessment; Sustainability measurement
vision in terms that are meaningful for the deci-
sion-making unit in question. Principles 2
through 5 deal with the content of any assessment Definition
and the need to merge a sense of the overall
system with a practical focus on current priority The Bellagio Sustainability Assessment
issues. Principles 6 through 8 deal with key issues and Measurement Principles (BellagioSTAMP)
of the process of assessment, while Principles 9 provide strategic guidance for the conceptualiza-
and 10 deal with the necessity for establishing tion, development, and practical use of indicator
a continuing capacity for assessment. systems in tracking progress towards sus-
The principles are intended as guidelines for tainability. They also help guide the design of
the whole of the assessment process including the future-oriented integrated assessments and out-
choice and design of indicators, their interpreta- looks from the local level to the global.
tion and communication of the result (Hardi &
Zdan, 1997).
Cross-References Inspired in part by Chap. 40 of Agenda 21, the
decades since the United Nations Conference on
Agenda 21
Environment and Development (UNCED) in
Sustainable Development
1992 witnessed increasing interest in the
establishment of measurement and assessment
systems designed to track and assess progress
References towards a broader range of environment
and development objectives than traditional
BellagioStamp: Sustainability assessment and measure-
ment principles. Retrieved October 30, 2012, indicators (UN-DSD, 1992; Michalos 2011).
from http://www.iisd.org/pdf/2009/brochure_bella- Despite the large number of sustainability
giostamp.pdf measurement and assessment initiatives and
Hardi, P., & Zdan, T. (Eds.). (1997). Assessing sustainable
many harmonization efforts, there has been
development: Principles in practice. Winnipeg: The
International Institute for Sustainable Development. little consensus on common approaches,
ISBN 1-895536-07-3. potentially compromising comparability,
B 362 BellagioSTAMP

consistency, and credibility of these efforts and interested in establishing measurement and
raising the scepter of an indicator zoo assessment systems grounded in specific
(Pinter et al., 2005). This is seen as a result contexts but synergistic with approaches
of various factors, including the ambiguity of elsewhere (Pinter et al., 2012).
sustainable development, the plurality of BellagioSTAMP has been launched at the
purposes related to its characterization and 3rd OECD World Forum on Statistics,
measurement, and confusion in terminologies, Knowledge and Policy in Busan, Republic of
methods, and data (Parris & Kates, 2003). Korea, in October 2009. Following their
Despite the ambiguities in indicator systems, launch, the principles have been used for the
there has been growing political and scientific analysis of international environment outlooks
interest in crosscutting, forward-looking (Bakkes, 2011) and in the design of global
integrated assessments of sustainability at assessments such as UNEPs 5th Global
various scales, resulting in a variety of assess- Environment Outlook (UNEP, 2012). The
ment processes and products. Complementarity possibility of using BellagioSTAMP has also
in the design of measurement and integrated been discussed in guiding the selection of
assessment approaches allowed the emergence ndicators attached to the sustainable
of best practices based on which common development goals (SDGs) mandated through
principles could be identified (Bakkes, 2011). the Rio +20 conferences outcome document
An earlier version of BellagioSTAMP, the (Pinter, 2013; UN, 2012).
Bellagio Principles, was developed in an
expert process, convened by the International
Institute for Sustainable Development (IISD), Cross-References
involving a select group of international measure-
ment and assessment experts in a deliberative Environmental Management
process (IISD, 1997). These earlier principles Environmental Sustainability
were accompanied by the publication of case Environmental Sustainability Index (ESI)
studies (Hardi & Zdan, 1997). Recognizing the Genuine Progress Index
changing social, political, and scientific context Index of Attitudes Favorable Toward
of the sustainability discourse, in 2008 the Orga- Sustainable Development
nization for Economic Cooperation and Develop- Index of Behaviors Favorable Toward
ment and IISD decided to launch a new process to Sustainable Development
review and if necessary revise the principles Index of Knowledge of Sustainable
(IISD & OECD, 2009). BellagioSTAMP was Development
also developed in a deliberative expert process Progress of Societies: OECD Projects
by a diverse group of 19 globally recognized Sustainable Development Indicators
experts in a workshop at the Bellagio Center of Sustainable Governance
the Rockefeller Foundation in Bellagio, Italy. Sustainable Society Index, Tool for Measuring
BellagioSTAMP is based on the notion that Well-Being
sustainability indicator selection and assessment Well-Being and Progress Measurement
are integral part of governance and need to be Well-Being of Nations
approached as elements of the entire policy
cycle, from goal setting to implementation and
assessment of progress (Bakkes, 2011). The References
principles cover conceptual, methodological,
technical, and policy aspects of measurement Bakkes, J. A. (2011). Bellagio SusTainability Assessment
and Measurement Principles (BellagioSTAMP) Sig-
and assessment. Without being prescriptive,
nificance and examples from international environ-
they offer a checklist intended for use by ment outlooks. In F. Rubik & A. von Raggamby
policy-makers, practitioners, and researchers (Eds.), Sustainable development, evaluation and
Benchmarking 363 B
policy-making: Theory, practise and quality insur- Etymologically, it derives from the term bench-
ance. Cheltenham: Edward Elgar Publishing Ltd. mark, a surveyors mark used as a reference point
Hardi, P., & Zdan, T. (1997). Assessing sustainable
development: Principles in Practice. Winnipeg: IISD. in measuring altitudes. Besides land surveying,
http://www.iisd.org/publications/pub.aspx?pno279 the term is used in computing to refer to a process
IISD. (1997). Complete Bellagio Principles. Winnipeg: for assessing the capabilities of software and B
IISD. http://www.iisd.org/measure/principles/pro- hardware systems. In industry, it has become
IISD & OECD. (2009). BellagioSTAMP: Sustainability widespread as a business method consisting in
assessment and measurement principles. Winnipeg: searching for best practices that lead to superior
IISD. http://www.iisd.org/pdf/2009/brochure_bella- performance (Camp, 1989). Both in private and
giostamp.pdf public administration, benchmarking has become
Michalos, A. C. (2011). What did Stiglitz, Sen and
Fitoussi get right and what did they get wrong? Social well known as a key tool in quality management.
Indicators Research, 102, 117129.
Parris, T. M., & Kates, R. W. (2003). Characterizing and
measuring sustainable development. Annual Review of Description
Environment and Resources, 28, 559586.
Pinter, L. (2013). Measuring progress towards
sustainable development goals. Winnipeg: IISD. Genealogy
http://www.iisd.org/publications/pub.aspx?pno1729 First tested in the manufacturing area around
Pinter, L., Hardi, P., & Bartelmus, P. (2005). Sustainable 1980, Xerox executives started talking of com-
development indicators proposals for the
way forward. Winnipeg: IISD. http://www.iisd.org/ petitive benchmarking to refer to the continuous
measure/principles/progress/way_forward.asp process of measuring products, services, and
Pinter, L., Hardi, P., Martinuzzi, A., & Hall, J. (2012). practices against the toughest competitors.
BellagioSTAMP: Principles for sustainability assessment Robert C. Camp, who was responsible for
and measurement. Ecological Indicators, 17, 2028.
UN. (2012). The future we want. Rio + 20 United Nations expanding benchmarking in Logistics and Distri-
Conference on Sustainable Development. Resolution bution units, pioneered a noncompetitor
adopted by the General Assembly, September 11, approach. He identified L.L. Bean, an outdoor
2012. http://daccess-dds-ny.un.org/doc/UNDOC/ sporting goods retailer and mail-order house, as
UN-DSD. (1992). Report of the United Nations the best performer for warehouse operations.
conference on environment and development. Besides direct product competitors like Canon
United Nations Division for Sustainable Development: or Kodak, Xerox selected its benchmarks among
New York. http://sustainabledevelopment.un.org/con- the organizations renowned as the leaders in
UNEP. (2012). Global Environment Outlook-5. a specific function or process, such as Ford for
Environment for the future we want. Nairobi: United assembly automation or the Federal Reserve for
Nations Environment Programme. http://www.unep. bill scanning. In few years, benchmarking was
org/geo/geo5.asp brought into general use and systematized
in a ten-step process (see Fig. 1). A rigorous
methodology was codified to investigate best
Benchmarking practices, collect data, measure performance
gap, quantify targets, develop action plans,
Isabelle Bruno monitor progress, and recalibrate assessment to
Political Science, University of Lille 2 Lille take into account the fact that customer require-
Center for Politics and Administration ments and best-in-class change over time. It
(CERAPS)-CNRS, Lille, France was not meant to be a one-off experience but
a cycle, a never-ending exercise. To a certain
extent, benchmarking was thus devised as a
Definition procedure that would be at the same time the
permanent measure of a gap in relation to an
Benchmarking means evaluating or checking inaccessible norm and the asymptotic movement
something by comparison with a standard. that strives to meet in infinity (Foucault, 1977).
B 364 Benchmarking

Benchmarking, Fig. 1 Benchmarking process steps according to Robert C. Camp (1989)

More than a target-setting method, it exerts an As a consequence, benchmarking has been

indefinite discipline (Bruno, 2009). devised and promoted as a universal method,
This process aims at improving any perfor- applicable everywhere and useful in every kind
mance in any organization by identifying and of organizations. The goal of benchmarking is
applying best demonstrated practices, which can simply to find examples of superior results and to
be found externally or internally, potentially understand the processes driving that performance
everywhere. Unlike traditional competitive anal- in order to tailor and incorporate these best prac-
ysis, benchmarking does not limit the comparison tices into ones own operations Not by imitat-
to direct competitors in a specific industry or ing, but by innovating (Rigby, 2009).
marketplace. In doing so, it opens an unlimited Benchmarking thus consists in steering social cre-
space of commensuration and of competition, ativity through the pressure of examples and num-
integrating all organizations whatever are bers, of peers, and of emulation. It underpins
their activities, their size, or their members, be power relations which are evidence-based,
they factory workers, engineers, researchers, depersonalized, and mediated by hard facts and
teachers, students, doctors, pensioners, volun- so-called unquestionable data. And this kind of
teers, or merely citizens. Everyone is a potential power is all the more efficient since it is neither
competitor, even where there is no economic coercive nor legal. Obedience relies on willing-
competition, strictly speaking, as long as ness and incentives, rather than on constraint and
there is an organization that can be broken up punishments. What is at stake is no longer to do
into processes. things well or to better them, but to be the best,
Benchmarking 365 B
always. The strength of benchmarking lies in this Obviously, there is nothing natural and
competition-oriented rationality, which makes an self-evident about the dissemination of
endless race to the top possible. It is often spoken benchmarking. Its success story cannot be
of a race without a finish line. explained by its great effectiveness and common-
sensical usefulness. A thorough genealogical B
Dissemination investigation would lead us from the U.S. Depart-
For the last 30 years, benchmarking has prolifer- ment of Defense to the postwar Japanese
ated throughout the world and throughout sectors, employers; from the Chief Executive Officer
so much so that it is now deep rooted and wide- (CEO) of Xerox Corporation, David T. Kearns,
spread in all kinds of organizations. Besides who joined the U.S. Department of Education
the United States of America and Japan, it first under Bush Sr., to the European Roundtable of
reached the Commonwealth (New Zealand, Industrialists; and from the Public Management
Australia, the United Kingdom), the Continental service (PUMA) of the OECD, to the European
Europe, and then countries outside the Organisa- Union. To make a long story short, the spreading
tion for Economic Co-operation and Develop- of benchmarking was not supported by the weight
ment (OECD). As regards the sectors of evidence, but by powerful institutions, net-
concerned, taking a glance at the titles of articles works, and leaders who endeavored to promote it
published in Benchmarking: An International as a multipurpose and policy-neutral method. For
Journal (previously Benchmarking for Quality instance, the European Commission and the Euro-
Management & Technology) is quite revealing: pean Roundtable of Industrialists (ERT) co-
Successful implementation of Six Sigma: organized in 1996 a joint seminar on
benchmarking General Electric Company, benchmarking in Brussels to induce policy-makers
Benchmarking the port services: a customer to use benchmarking (ERT, 1996). From then on,
oriented proposal, Airport benchmarking: a benchmarking has been used to compare national
review of the current situation, Association- performances first in the domain of industrial pol-
sponsored benchmarking programs, icies, then in the economic and monetary fields,
Benchmarking in the non-profit sector in and finally in all domains where member states
Australia, Benchmarking: achieving best need to cooperate in order to establish framework
value in public-sector organisations, A system conditions favorable to business and conducive to
dynamics framework for benchmarking policy international competitiveness of both European
analysis for a university system, Benchmarking companies and countries. This political program
the best practices of non-corporate R&D was adopted by the heads of state and government
[research and development] organizations, in March 2000. It is known as the Lisbon strat-
Benchmarking in health services, etc. Here egy, and its ambition was to turn the European
are some examples displaying the wide scope of Union into the most competitive knowledge-
benchmarking, which has been implemented based economy in the world by 2010 (European
both in big firms and in small and medium Council, 2000). Such a shift to a cognitive
enterprises, in manufacturing or services, in non- capitalism (Moulier-Boutang, 2012) was
profit organizations and government sector, espe- supposed to be capable of improving citizens
cially in education and health (Camp, 1998). quality of life and the environment, as well as
Benchmarking is not limited to business quality of employment, quality and sustainabil-
processes. Everything is a potential object of ity of public finances, quality of education, R&D,
performance comparison. For instance, it seems or health services.
possible to benchmark organizational commit-
ment across nonprofit human services organiza- Benchmarking as a Cornerstone of Total
tions in Pennsylvania (Guiler, Rutowski, & Quality Management
Schimmel, 2009), and even to benchmark the From the standpoint of management, quality can
benchmarking models (Anand & Kodali, 2008). be said to be indefinite in both senses of the word:
B 366 Benchmarking

total, its scope is limitless, and it remains ill- against direct competitors and beyond: against
defined despite a long story which dates back to internal operations, functional leaders, and
the end of the nineteenth century (Miranti, 2005). generic processes. The field where to search for
It is commonsense to consider quality two-sided, best practices is presumed boundless. It poten-
both objective and subjective. According to tially embraces all sectors. And as every organi-
Shewhart, it is up to the engineer to satisfy zation is supposed to constantly make progress,
customers subjective wants by translating them the quest is endless. In Japanese, there is a word
into standards expressed in terms of quantita- which means striving to be the best of the best:
tively measurable physical properties, and then dantotsu.
by set[ting] up ways and means of obtaining Drawing on the experience of its joint venture,
a product which will differ from the arbitrarily Fuji Xerox (Kobayashi, 1983), Xerox Corpora-
set standards for these quality characteristics by tion made benchmarking the linchpin of its
no more than may be left to chance (Shewhart, approach to TQM. In 1983, the historical market
1980). After him, quality gurus replaced the leader in copiers embarked on a corporate
engineer by the customer who became the strategy named Leadership Through Quality.
most central to quality: Quality is a customer According to its then CEO Kearns, it was
determination, not an engineers determination, aimed at fundamentally changing the culture of
not a marketing determination or a general man- Xerox over the next several years. At that time,
agement determination. It is based upon the cus- the economic warfare against Japanese firms got
tomers actual experience with the product or coverage in the press, and the battle between
service, measured against his or her require- Canon and Xerox hit the headlines. On March
ments stated or unstated, conscious or merely 1980, the former targeted the latter in a Forbes
sensed, technically operational or entirely article titled as follows: Xerox, Here We Come.
subjective and always representing a moving Five years later, the New York Times announced
target in a competitive market (Feigenbaum that Xerox halts Japanese march. Reported as
quoted in Hoyer & Hoyer, 2001). a success story, it has become a textbook case
From a Total Quality Management (TQM) study. It illustrates the turnaround in the way US
angle, all activities in whatever organization are companies do business, observed all along the
regarded as processes producing goods or ser- 1980s. Xerox alias the quality company
vices intended for a final or intermediary (Xerox, 1993) was set up as a role model.
consumer, held to be the judge in the last resort, In 1986, the Massachusetts Institute of
the ultimate assessor, and the one whose sover- Technology (MIT) convened a multidisciplinary
eign choice falls on the most competitive option. commission to address the decline in US indus-
Insofar as the market is interpreted from trial productivity and identify emerging patterns
a neoclassical economic perspective, satisfying of best practice. The survey, released in 1989,
customers requirements consists not only in took Ford and Xerox as examples of successful
meeting his needs but in doing so better than companies that strive to be best in their class in
competitors. It is not enough to supply a product all the main performance categories.
free from deficiencies or adequate to the demand; They adopted a series of reforms such as
it has to be the best one can get. Consequently, team-based approaches to product and process
aiming at quality calls for knowing as much the development, increased emphasis on customer
market as the competition. The former has been satisfaction, employee involvement in decision
domesticated by marketing (Cochoy, 1998), the making, a commitment to training and continuous
latter through competitive analyses and reverse improvement, and, above all, benchmarking
engineering. Managing total quality goes even which was looked on as the keystone of quality
further. It demands neither to do well nor to do management: A characteristic of all the
better, but to be the best in each practice area. best-practice American firms we observed, large
This entails comparing ones performance or small, is an emphasis on competitive
Benchmarking 367 B
benchmarking: comparing the performance of health care and education providers. The sixth
their products and work processes with those of one has included in 2004 all nonprofits, so
the world leaders in order to achieve improve- that the Baldrige framework now applies to all
ment and to measure progress (MIT Commission types of organizations, from Xerox products or
on Industrial Productivity, 1989). business services (prizewinner in 1989 and 1997) B
A far-reaching vehicle for propagating quality to the City of Coral Springs and the U.S. Army
management, particularly benchmarking, has Armament Research, Development and Engi-
been the Malcolm Baldrige National Quality neering Center (2007), via Baptist Hospital
Award. Instituted in 1987 by President Reagan, Inc. (2003) or University of Wisconsin-Stout,
it was fashioned after the Japanese Deming Prize the first recipient in higher education (2001).
to induce US companies to convert to TQM and, Wherever benchmarking is implemented to
thereby, improve national competitiveness as improve quality and competitiveness, it requires
a whole (Mahoney & Thor, 1994). The Baldrige a sound base of comparable data, a battery of
criteria have provided not only a common reliable indicators, and some indisputable targets,
understanding of TQM principles and compo- which have proven to be attainable somewhere
nents but also a means to achieve their else. This management-by-fact tool thus derives
implementation. The external intervention a great deal of its credibility and legitimacy from
of examiners has proved to help the top manage- the ecumenical language of quantification and
ment to rally the workforce and overcome the the widespread trust in numbers. As Porter
so-called parochial resistance to change or pointed out, a decision made by the numbers
not-invented-here syndrome. The main purpose (or by explicit rules of some other sort) has at
of this performance excellence program is to least the appearance of being fair and impersonal.
get all candidates to assess themselves against Scientific objectivity thus provides an answer to
leading organizations. A requirement of Baldrige a moral demand for impartiality and fairness.
Award recipients is indeed to document Quantification is a way of making decisions with-
their quality journey and open their doors to out seeming to decide (Porter, 1995). Indeed,
interested organizations for 1 full year. Further- benchmarking helps decision-makers be it in
more, benchmarking among contestants is corporations or governments to reach consen-
encouraged as a way of mutual learning. sus by translating problems of collective action
Paradoxically enough, competitors are at the into statistical issues of quantification. Far from
same time partners in a sharing process. This being policy-neutral (ERT, 1996), it is
kind of competitive cooperation is neither an a political technology of power, which fosters
anomaly in a market economy nor a parenthesis quantitative performance rather than quality
in the neoliberal age, but the actual workings of life.
of competition which will get known as
co-opetition (Brandenburger & Nalebuff,
1996; Mann, Samson, & Wolfram, 1997). Cross-References
Such quality models and prizes have prolifer-
ated all over the world. For instance, the Euro- Education
pean Foundation for Quality Management Employee Satisfaction
(EFQM), based in Brussels, established its own Employment Commitment
excellence award in 1992. While expanding Employment Insecurity
throughout space, they also extend their scope Environment and Health
to new categories of applicants. In addition to Health
small businesses and manufacturing companies, Performance Indicators
service firms were entitled to compete from 1990 Quality of Life
onward. In 1998, the United States Congress Service Quality in New Public Management
voted for the creation of two more categories: Sustainability
B 368 Beneficence

References Shewhart, W. (1980). Economic control of quality of

manufactured product. Milwaukee, WI: ASQC.
Anand, G., & Kodali, R. (2008). Benchmarking the Xerox. (1993). A world of quality. The timeless passport.
benchmarking models. Benchmarking: An Interna- Milwaukee, WI/Rochester, NY: ASQC Quality Press/
tional Journal, 15(3), 257291. XQS Press.
Brandenburger, A. M., & Nalebuff, B. J. (1996).
Co-opetition: A revolutionary mindset that combines
competition and co-operation. New York: Currency
Bruno, I. (2009). The Indefinite Discipline of Compet- Beneficence
itiveness. Benchmarking as a Neoliberal Technology
of Government. Minerva, 47(3), 261280. Compassion, Happiness, and Self-Esteem
Camp, R. C. (1989). Benchmarking: The search for indus-
try best practices that lead to superior performance.
Milwaukee: ASQC Quality Press.
Camp, R. C. (Ed.). (1998). Global cases in benchmarking:
Best practices from organizations around the world. Benefit of Doubt Approach to
Milwaukee: ASQ Quality Press. Gender Well-Being Assessment
Cochoy, F. (1998). Another discipline for the market econ-
omy: Marketing as a performative knowledge and
know-how for capitalism. In M. Callon (Ed.), The Gender Well-Being Composite Index
laws of the markets (pp. 194221). Oxford: Blackwell.
ERT. (1996). Benchmarking for policy-makers. The way
to competitiveness, growth and job creation. Brussels:
ERT Publication.
European Council. (2000). Presidency conclusions. Benefit-Cost Analysis
Lisbon summit, 2324 March, Nr: 100/1/00.
Foucault, M. (1977). Discipline and punish: The birth of Cost-Benefit Analysis
the prison. New York: Random House.
Guiler, J. K., Rutowski, K. D., & Schimmel, K. E. (2009).
Benchmarking organizational commitment across non-
profit human services organizations in Pennsylvania.
Benchmarking: An International Journal, 16(1), 135150. Benefits of College
Hoyer, R., & Hoyer, B. (2001). What is quality? Learn
how each of eight well-known gurus answers this
question. Quality Progress, 34(7), 5262. Higher Education: Institutional Effects
Kobayashi, Y. (1983). Fuji xerox the first 20 years
19621982. Tokyo: Fuji-Xerox Co.
Mahoney, F., & Thor, C. (1994). The TQM Trilogy. Using
ISO 9000, the Deming Prize, and the Baldrige Award
to establish a system for total quality management. Benevolent Sexism
New York: American Management Association.
Mann, L., Samson, D., & Wolfram, C. J. R. (1997). Gender Inequality and Subjective Well-Being
Benchmarking as a mixed metaphor: Disentangling
assumptions of competition and collaboration. Journal
of Management Studies, 34(2), 285314.
Miranti, P. J. (2005). Corporate learning and quality
control at the bell system, 18771929. The Business Bereavement
History Review, 79, 3972.
MIT Commission on Industrial Productivity. (1989).
Made in America. Regaining the productivity edge. David Schonfeld
Cambridge, MA: The MIT Press. Department of Pediatrics, St. Christophers
Moulier-Boutang, Y. (2012). Cognitive capitalism. Hospital for Children, Philadelphia, PA, USA
Cambridge, UK: Polity Press.
Porter, T. M. (1995). Trust in numbers: The pursuit of
objectivity in science and public life. Princeton, NJ:
Princeton University Press.
Rigby, D. K. (2009). Management tools 2009: An execu-
tives guide. Boston, MA: Bain. Death; Death and dying; Grief; Loss; Mourning
Bereavement 369 B
Definition or even directed at the individual who died and left
the survivor with the pain of grief and/or by his/her
Bereavement refers to the actual experience of absence has impacted their material well-being
having suffered a loss, whereas grief is the subjec- such as through the loss of a parents income.
tive psychological, social, and somatic reactions This anger is often accentuated after death by B
that result from bereavement (Pearlman, DAngelo suicide but can be seen after any means of death.
Schwalbe, & Cloitre, 2010; Rando, 1984). Children may avoid previously enjoyed activities
because they no longer, for at least a time period,
bring them pleasure. Or the activities may be asso-
Description ciated with the individual who died and serve as
a reminder of the loss and trigger a resurgence of
Bereavement and grief in children. grief. In these ways, grief may impact childrens
sense of happiness, self-satisfaction, and overall
Definition and Prevalence interest in life.
Bereavement refers to the actual experience of Children who are grieving routinely experi-
having suffered a loss, whereas grief is the sub- ence at least a temporary cognitive impact
jective psychological, social, and somatic reac- they may find it difficult to concentrate and recall
tions that result from bereavement (Pearlman or process information, may experience deterio-
et al., 2010; Rando, 1984). Loss (in general) is ration in academic performance which may result
a universal experience even for very young chil- in school failure, and may struggle to make even
dren, and bereavement involving a loss due to relatively simple decisions without assistance
death is highly prevalent among children as (Schonfeld & Quackenbush, 2010). This may
well; this entry will focus on bereavement due negatively impact childrens sense of personal
to loss related to death. Approximately 1 in 20 competence and autonomy.
children experiences the death of a parent by the Guilt is extremely common and can interfere
time they reach 16 years of age, and studies have with successful adjustment. Children will often
estimated that approximately 90 % of children wonder what they did, did not do, could have
will experience the death of a family member or done, or should have done that may have
friend by the time they graduate from high school prevented the death, even if there is no logical
(Ewalt & Perkins, 1979; Harrison & Harrington, reason to believe that they could have done
2001; Hoven et al., 2005). Even though bereave- anything to have prevented the death. Young
ment is a normative experience and is not childrens incomplete conceptual understanding
a disorder per se, the death of a close friend of death may accentuate this phenomenon,
or family member is nonetheless a profound but guilt is extremely common among older
experience that has a dramatic impact on the children and adolescents as well (Schonfeld &
survivors quality of life in the short term and is Quackenbush, 2010). This in turn has implica-
associated with long-term impact as well. tions for childrens sense of self-satisfaction and
can negatively impact their personal growth.
Impact of Bereavement on Intrapersonal Childrens health and physical well-being can
Quality of Life also be impacted by bereavement. Fatigue, loss of
Children may experience a wide range of reactions appetite, difficulty sleeping or waking,
after a significant loss. Sadness and a profound or physical complaints such as abdominal pain
sense of loss are characteristic and may persist or headache are common during the acute phases
for an extended period of time. Children may of grief and may prompt surviving parents to
also experience anger, which may be directed at bring grieving children for medical evaluation.
individuals felt possibly responsible for the death Death also alters ones life view and disrupts
(such as the driver of a vehicle after an accidental a sense that life is predictable, orderly, or fair.
death or the treating physician), attributed to God, Children may become anxious that others close
B 370 Bereavement

to them will die or worry about their personal previously enjoyed activities (and thereby the social
mortality. The death of someone close is a threat interactions with peers related to these activities),
to ones assumptive world (Schonfeld & may withdraw from interactions with others, and/or
Gurwitch, 2011). People generally hold certain may feel distant or unable to relate to peers who do
assumptions that allow them to function on not share a similar life experience. This can
a daily basis without feeling overwhelmed by the negatively impact social integration, social accep-
possibility of disaster and loss at any moment in tance, positive relations with others, and friendship/
many ways, it is through this mechanism that peer satisfaction.
children are able to develop a sense of mastery The death of a family member can place strains
over their environment, even related to those on interpersonal relationships among survivors
aspects over which they in fact have little to no (Emswiler & Emswiler, 2000). Surviving parents
influence. Children assume that the adults they may be emotionally less available to each other and
love will always be there to care for them and their children because of their emotional distress or
about them. But a death forces children to if they are engaging in maladaptive attempts at
confront the reality that those they love actually coping such as increased alcohol or substance use.
can be killed be lightening, murdered in what Many of the reactions and behaviors seen among
appears to be a random attack, die of an illness those that are grieving may place significant strain
even when they appeared healthy and were taking on a marriage and cause marital discord. Often,
reasonable steps to stay well, or be killed in a car members of the family grieve in a different manner
accident even if they are a safe and experienced and along their own timelines one parent may
driver. This loss of the assumptive world leaves seek and provide different types of support than the
children feeling shaken, anxious, and vulnerable. spouse. For example, one adult may become more
It can cause children to question the fairness of the self-absorbed, while the other is seeking physical
world and challenges their emerging sense of mas- intimacy. One may cope through intellectualizing
tery of ones environment. This, in turn, can inter- which may be viewed as emotional detachment or
fere with personal growth. even denial by the other. Childrens family satis-
faction is thereby compromised, and childrens
Impact of Bereavement on Interpersonal inability to predict and manage their family inter-
Quality of Life actions as effectively as they did prior to the death
Children who are grieving may experience devel- may lead them to feel less personal competence
opmental and social regression and thereby become and sense of mastery of their environment. The
irritable, demanding, and self-centered. The devel- importance of active communication and appreci-
opmental regression can impair their sense of per- ation of each others needs and resources becomes
sonal competence; the social regression can result particularly critical as the family works to adjust to
in negative interpersonal interactions. Children who the loss (Schonfeld, 2012).
have experienced the death of a close friend or After the death of a sibling, parents who are
family member may become fearful or resistant to experiencing guilt associated with their perceived
separation from adults and others close to them, role in the death or anxiety related to fears
leading to clinginess in young children and school of additional losses may alter how they parent
avoidance in school-age children. Older children, surviving children, which may result in
adolescents, and adults may initiate or increase use emotional distancing and/or overprotection
of alcohol, tobacco, or drugs (Brent, Melhem, (Krell & Rabkin, 1979). This may disrupt surviv-
Donohoe, & Walker, 2009) and may engage in ing childrens personal and social growth.
other risky behaviors such as reckless driving,
delinquent behavior, and unsafe sexual behavior Impact of Bereavement on Environmental
(Adams & Deveau, 1987). Peers (and adults) may Issues
not know how to interact with or support grieving Death is associated with a number of secondary
children, and grieving children may avoid losses that independently or incrementally impact
Bereavement 371 B
survivors quality of life. The death of a parent growth. Such posttraumatic growth is most likely
who is a wage earner can result in financial to occur when the loss is not overwhelming and
stressors which, in turn, may require that the the individual has sufficient external support and
family move in with relatives or to a less expen- internal resources for coping and adjustment.
sive home or neighborhood which often requires Bereavement generally does not result in mental B
that children change schools. The change in illness or long-term disability, but it almost
schools may result in the loss of a peer network always has a significant and long-lasting impact.
(with related impact on interpersonal quality of The death of a close friend or family member is
life) or pose additional challenges to academic nearly always a life-changing event.
progress (which in turn negatively impacts
childrens sense of personal competence). Loss
of income may jeopardize plans to attend Cross-References
a desired college and alter career aspirations;
surviving spouses may find they can no longer Bereavement Phenomenology Questionnaire
afford vacations or may struggle to provide the Bereavement Response Scale
transportation and supervision required to sustain Mortality
after-school activities for children, especially Widowhood
if they need to increase their working hours to
compensate for lost income or expenses incurred
during a lengthy illness. The death of a parent References
may impact the quality of the meals served,
Adams, D., & Deveau, E. (1987). When a brother or sister
the consistency or quality of parenting and
is dying of cancer: The vulnerability of the adolescent
disciplining, the access to advice of a parent of sibling. Death Studies, 11, 279295.
the same or opposite gender, or the ability to Brent, D., Melhem, N., Donohoe, M. B., & Walker, M.
relive important shared memories. The death of (2009). The incidence and course of depression in
bereaved youth 21 months after the loss of a parent to
a sibling may result in a loss of a confidante,
suicide, accident, or sudden natural death. The Amer-
a preferred (or at least readily available) ican Journal of Psychiatry, 166, 786794.
playmate, or a valued guide to peer relations. In Emswiler, M., & Emswiler, J. (2000). Guiding your child
brief, bereavement involves adjusting not simply through grief. New York: Bantam Books.
Ewalt, P., & Perkins, L. (1979). The real experience of
to the loss of a family member or friend but
death among adolescents: An empirical study. Social
also the loss of everything associated with that Casework: The Journal of Contemporary Social Work,
individual and what they meant to the lives 60, 547551.
of survivors (Schonfeld, 2011, 2012; Swick, Harrison, L., & Harrington, R. (2001). Adolescents
bereavement experiences. Prevalence, association
Dechant, & Jellinek, 2002) resulting in disrup-
with depressive symptoms, and use of services. Jour-
tions to material well-being and interpersonal nal of Adolescence, 24, 159169.
quality of life. Hoven, C., Duarte, C., Lucas, C., et al. (2005). Psychopa-
thology among New York city public school children 6
months after September 11. Archives of General Psy-
Potential Positive Long-Term Impact of
chiatry, 62, 545552.
Bereavement on Quality of Life Krell, R., & Rabkin, L. (1979). The effects of sibling death
Children who are grieving may ultimately learn on the surviving child: A family perspective. Family
skills that help them adjust to future losses and Process, 18(4), 471477.
Pearlman, M., DAngelo Schwalbe, K., & Cloitre, M.
stressors. They may come to appreciate aspects of (2010). Grief in childhood: Fundamentals of treatment
life and its experiences that they were less con- in clinical practice. Washington, DC: American Psy-
scious of prior to the death, thereby ultimately chological Association.
increasing their life satisfaction, sense of social Rando, T. (1984). Grief, dying and death: Clinical inter-
ventions for caregivers. Champaign, IL: Research Press.
contribution, and social growth. They may dedi-
Schonfeld, D. (2011). Ten years after 9/11: What have we
cate their lives and careers to the attainment of (not yet) learned?. Journal of Developmental and
higher goals, thereby enhancing their personal Behavioral Pediatrics, 32(7), 542545.
B 372 Bereavement Phenomenology Questionnaire

Schonfeld, D. (2012). Providing support for families representation of the normal populous. Raphael
experiencing the death of a child. In Kreitler, S., Ben (1983) noted the distinction between bereavement
Arush, M.W., & Martin, A. (Eds.). Pediatric psycho-
oncology: Psychosocial aspects and clinical interventions and grief as follows: bereavement is the reaction to
(2nd ed.,) pp. 223230. Atrium, West Sussex: Wiley. the loss of a close relationship and grief is the
Schonfeld, D., & Gurwitch, R. (2011). Children in disas- emotional response (sadness, anger, helplessness,
ters. In A. Y. Elzouki, F. B. Stapleton, R. J. Whitley, guilt, and despair) to that loss and is therefore part
W. Oh, H. A. Harfi, & H. Nazer (Eds.), Textbook of
clinical pediatrics (2nd ed.). New York: Springer. of the bereavement process. It is agreed that
Schonfeld, D., & Quackenbush, M. (2010). The grieving bereavement is a process that takes place over
student: A teachers guide. Baltimore: Brookes time with initial shock and disbelief progressing
Publishing. to intense distress, yearning, and progressive adap-
Swick, S., Dechant, E., & Jellinek, M. (2002). Children of
victims of September 11th: A perspective on the emo- tation. Time taken for these processes varies.
tional and developmental challenges they face and While some studies suggest specific phases, there
how to help meet them. Journal of Developmental is no clear agreement about these. While grief is
and Behavioral Pediatrics, 23(5), 378384. a normal human reaction to loss, to the breaking
of affectionate bonds, it is also important to
know and be able to measure when it becomes
problematic, disrupting function, or potentially
Bereavement Phenomenology a clinically defined disorder, for which interven-
Questionnaire tion may be required. This differs from the fact
that bereavement, as a stressful life event, may
Beverley Raphael1 and Paul Burnett2 increase risk to health, for instance precipitating
Disaster Response and Resilience Research depression and even physical conditions and
Group, School of Medicine, University of premature death.
Western Sydney, Rydalmere, NSW, Australia This entry describes a body of research under-
Division of Research and Commercialisation, taken by a team of researchers coordinated by
Queensland University of Technology, Kelvin Professor Beverley Raphael. The research team
Grove, QLD, Australia investigated bereavement phenomenology using a
variety of approaches, which culminated in the
Core Bereavement Items (CBI) scale being
Synonyms published in 1997. The journey for measuring
bereavement phenomenology is described below.

Burnett et al. (1994) canvassed the perceptions of
Most people experience the loss of a loved one. 75 significant researchers and writers in the
How they respond to this loss will have an impact field of bereavement using the Perceptions
on their quality of life. In 1944, Lindemann under- of Bereavement Questionnaire (PBQ), which
took the first systematic study of bereavement and consisted of 25 statements designed to measure
noted that uncomplicated bereavement could perceptions of bereavement phenomena using
include somatic distress, preoccupation with the a 4-point Likert format. The respondents
image of the deceased, guilt, hostility, loss of usual rated the perceived frequency of the same 25
patterns of conduct, and imitation of the deceased items for acute bereavement (first 6 weeks
behaviors in some people. However, these descrip- following a loss) and longer-term bereavement
tions were based on the clinical findings of people (beyond the first anniversary). The 25 items were:
who suffered traumatic circumstances of bereave- 1. Intrusive thoughts about the lost person
ment, and they may not have been an accurate 2. Distressing thoughts concerning the loss
Bereavement Phenomenology Questionnaire 373 B
3. Preoccupation with images and thoughts of atypical forms of grief. Seven terms relating to
the lost person grief were identified in the literature (absent,
4. Inability to form clear mental images of the delayed, chronic, distorted, unresolved, inhibited,
lost person and anticipatory), and respondents were asked
5. Hallucinatory experiences of the lost person whether or not they thought that this type of grief B
6. Sense of presence of the lost person occurred and if it did occur to describe its charac-
7. Dreaming of the lost person as if still alive teristics and distinguishing features. Middleton,
8. Yearning or pining for the lost person Moylan, Raphael, Burnett, and Martinek (1993)
9. Looking for the lost person in familiar places reported seven types of grief noting the percentage
10. Distress at reminders of the lost person of respondents who believed that it occurred
11. Attempts to avoid reminders of the lost person and the phenomenons common features and
12. Sadness characteristics:
13. Unreality feelings 1. Delayed grief (77 %) typical grief, just
14. Anger delayed, grief delayed months or years, grief
15. Guilt subsequently triggered by some event
16. Nostalgia 2. Chronic grief (74 %) chronic depression,
17. Anxiety prolonged/unending/unchanging distress,
18. Depression guilt/self-reproach, marked sadness
19. Crying 3. Anticipatory grief (71 %) a normal grief
20. Acting as if the person is still alive reaction which occurs prior to the loss,
21. A need to talk about the lost person thoughts and feelings about a death which
22. Searching for the lost person might occur, sadness/sorrow
23. Somatic symptoms 4. Absent grief (65 %) inhibition or absence of
24. Disorganization typical expressions of grief, continue to act as
25. Special facial features if nothing has happened, denial of loss or
The findings indicated that 23 of the 25 items feelings related to the loss
were rated as common to very common in the acute 5. Unresolved grief (57 %) lack of resolving
phase. The two items deemed uncommon in the major grief symptoms
acute phase were an inability to form clear mental 6. Inhibited grief (53 %) cannot talk about,
images of the lost person (item 4) and attempts to acknowledge or express the loss; inability to
avoid reminders of the lost person (item 11). The cry; social/cultural/learnt restraint of expres-
results for the longer-term phase of normal bereave- sion of grief
ment indicated that 7 phenomena were common to 7. Distorted grief (36 %) excessive anger.
very common. These were intrusive thoughts about
the lost person (item 1), preoccupation with images Measuring Core Bereavement Phenomena
and thoughts of the lost person (item 3), yearning or Burnett, Middleton, Raphael, and Martinek (1997)
pining for the lost person (item 8), distress at described the process followed in developing the
reminders of the lost person (item 10), sadness 17 item Core Bereavement Items (CBI) scale. An
(item 12), nostalgia (item 16), and a need to talk initial pool of 76 items was derived from reviews
about lost person (item 21). Eighteen of the 25 items of the bereavement literature and from the clinical
were rated as uncommon in the longer-term phase experiences of the research team and were grouped
of bereavement. into 5 areas: 22 items related to thoughts, images,
The same group of significant researchers and memories, and dreams of the lost person; seven
writers in the field of bereavement also completed a items tapped attachment behaviors; 21 items mea-
questionnaire relating to different types of grief. sured specific emotions and behaviors invoked by
The objective of this exercise was to gain a perspec- reminders of the lost person; 13 items covered
tive on the degree of acceptance for commonly used ongoing behaviors associated with the lost person;
terminology being applied to the description of and 13 items related to parameters of resolution.
B 374 Bereavement Phenomenology Questionnaire

Factor analysis results indicated seven subscales 15. Do reminders of x such as photos, situations,
as follows: music, places cause you to cry about x?
1. Images and thoughts (7 items) 16. Do reminders of x such as photos, situations,
2. Sense of presence (4 items) music, places cause you to feel sadness?
3. Dreams (3 items) 17. Do reminders of x such as photos, situations,
4. Acute separation (5 items) music, places cause you to feel loss of
5. Grief (5 items) enjoyment?
6. Non-resolution/conflict (6 items) The CBI-17 can be used as a total scale (alpha
7. Personal resolution (5 items) reliability 0.91) or as three separate scales:
Of the seven subscales, sense of presence, images and thoughts (alpha 0.74), acute separa-
dreams, and non-resolution/conflict were not tion (alpha 0.77), and grief (alpha 0.86). The
frequently experienced across 4 time periods CBI-17 has been used in a number of studies since
(4 weeks, 10 weeks, 7 months, and 13 months) being developed. Cluster analysis using the
by 120 bereaved respondents. Additionally it CBI-17 found that approximately 9 % of commu-
was noted that subscale 7 (personal resolution) nity-based bereaved subjects experienced chronic
represented behaviors experienced by someone grief, none experienced absent, or delayed
recovering from the effects of a major life grief and that current estimates of complicated
event. Consequently, the collection of 17 items or pathological bereavement may be inflated
contained in the images and thoughts (7 items), (Middleton, Burnett, Raphael, & Martinek,
acute separation (5 items), and grief (5 items) 1996). Middleton, Raphael, Burnett, and Martinek
subscales offers a reliable distillation of items (1997) reported that scores on the CBI-17 corre-
measuring core bereavement phenomena that lated significantly with depression, state and trait
were common to different groups of bereaved anxiety, and neuroticism. In another study using
subjects. The items are: the CBI-17 Middleton, Raphael, Burnett, and
1. Do you experience images of the events Martinek (1998) found that bereaved parents had
surrounding xs death? higher scores than bereaved spouses who had
2. Do thoughts of x come into your mind higher scores than bereaved adult children.
whether you wish or not? The CBI-17 is available at http://eprints.qut.
3. Do thoughts of x make you feel distressed? edu.au/26824/1/c26824.pdf.
4. Do you think about x?
5. Do images of x make you feel distressed?
6. Do you find yourself preoccupied with Cross-References
images or memories of x?
7. Do you find yourself think of a reunion with x? Anxiety
8. Do you find yourself missing x? Bereavement
9. Are you reminded by familiar objects Bereavement Phenomenology Questionnaire
(photos, possessions, rooms) of x? Bereavement Response Scale
10. Do you find yourself pining or yearning for x? Cluster Analysis
11. Do you find yourself looking for x in familiar Factor Analysis
places? Likert Scale
12. Do you feel distress/pain if for any reason
you are confronted with the reality that x is
not present or not coming back?
13. Do reminders of x such as photos, situations, References
music, places cause you to feel longing
Burnett, P. C., Middleton, W., Raphael, B., Dunne, M.,
for x? Moylan, A., & Martinek, N. (1994). Concepts of nor-
14. Do reminders of x such as photos, situations, mal bereavement. Journal of Traumatic Stress, 7,
music, places cause you to feel loneliness? 123128.
Bereavement Response Scale 375 B
Burnett, P. C., Middleton, W., Raphael, B., & Martinek, N. useful tool for assessing indicators of recovery
(1997). Measuring bereavement phenomena. Psycho- from grief. The Bereavement Response Scale
logical Medicine, 27, 4957.
Lindemann, E. (1944). Symptomatology and management (BR) (Weiss & Richards, 1997) was developed
of acute grief. The American Journal of Psychiatry, as a tool for using narrative accounts taken in
101, 141148. early bereavement to identify indicators of even- B
Middleton, W., Burnett, P. C., Raphael, B., & Martinek, N. tual recovery from loss of a person with whom the
(1996). The bereavement response: A cluster analysis.
The British Journal of Psychiatry, 169, 167171. bereaved had an adult relationship of emotional
Middleton, W., Moylan, A., Raphael, B., Burnett, P. C., & attachment (Weiss, 1988, 1991; Bowlby, 1980;
Martinek, N. (1993). An international perspective on Mikulincer & Shaver, 2007).
bereavement related concepts. The Australian and The findings from the Harvard Bereavement
New Zealand Journal of Psychiatry, 27, 457463.
Middleton, W., Raphael, B., Burnett, P. C., & Martinek, N. Study (Parkes & Weiss, 1983) were used to
(1997). Psychological distress and bereavement. develop the first iteration of the BR, the BR-I.
Journal of Nervous and Mental Diseases, 185, Study findings suggested that indicators of recov-
447453. ery could be observed in interviews conducted
Middleton, W., Raphael, B., Burnett, P. C., & Martinek, N.
(1998). A longitudinal study comparing bereavement 46 weeks following bereavement. Further, in
phenomena in recently bereaved spouses, adult order to regain functioning following bereave-
children and parents. The Australian and New Zealand ment, data indicated that the bereaved person
Journal of Psychiatry, 32, 235241. must (1) achieve cognitive assimilation of the
Raphael, B. (1983). The anatomy of bereavement.
New York: Basic. loss by developing an acceptable account of
how the loss occurred, (2) achieve emotional
assimilation so that memories of the relationship
cease to bring intolerable pain, and (3) develop
Bereavement Response Scale a reorganized emotional life that includes
availability of new relationships of attachment,
T. Anne Richards social life, and adequate ties to community.
Public Health Institute, Oakland, CA, USA The BR-I consists of six categories containing
a total of 21 variables. The categories, with
examples of variables contained within, are
Synonyms the following:
1. Final stage of illness (caregiving behaviors:
BR-I; BR-II physical and emotional care, acceptance of
responsibility, assurance of love)
2. Death of the partner (attitudes, emotions, and
Definition appraisals: anticipated death, partner had an
easy/peaceful death)
The Bereavement Response Scale is an instru- 3. Reactions immediately following the death
ment to identify indicators of eventual recovery (effective functioning)
from bereavement of the loss of a person with 4. Ceremonies (acceptance of service as
whom the bereaved had an adult relationship of satisfactory and appropriate)
emotional attachment. 5. Process of grieving (emotional state: capacity
to control grieving, absence of guilt or
remorse, not overwhelmed by symbolic
Description meanings)
6. Indications of movement toward recovery
Comprehensive narrative accounts may be more (experiencing positive well-being)
easily obtained from bereaved individuals imme- The BR-1 was applied to a subset of qualita-
diately following bereavement than a battery of tive data from the University of California, San
measures, thus making the narrative a potentially Francisco (UCSF) Coping Project which was
B 376 Bereavement Response Scale

a longitudinal study of the effects of caregiving Bereavement Response Scale, Table 1 Significant
and bereavement on male partners of men correlations of BR-II items with Positive States of Mind
Scale scores at 12 months post-bereavement
with AIDS. The subset, called the Rashomon
Project, consisted of narratives from 30 bereaved Pearson r
BR-II item with PSO p
caregiving partners interviewed approximately
5. Emotions and attitudes at time of .34 .03
2 weeks, 4 weeks, and 12 months post- death: ability to anticipate partners
bereavement. death, partner had an easy death,
The 21 variables of the BR-I each had a range perceives self to have been effective
of scores of either 1 to +1 or 2 to +2. Scoring caregiver
was based on the theory that caretaking phenom- 10. Acceptance of ceremonies of .29 .05
leave-taking as appropriate and
ena (Category 1) furthest in temporal sequence satisfactory
from the death would be weaker indicators of 12. Grieving with capacity to control: .37 .02
quality of recovery and that post death indicators absence of guilt and remorse, ability
of movement toward recovery (Category 6) to deal realistically with the fact of
death and its sequelae
would be stronger indicators of recovery.
13. There was an acceptable account .34 .03
Variables could receive positive scores for narra-
of how the death occurred and of
tive data that supported the hypotheses for events associated with the death,
indicators of recovery or negative scores for including belief in an essentially
narrative data that countered the hypothesis benign higher power, and an absence
of ambivalence toward the deceased
for indicators of recovery. Narrative accounts
were coded and scored independently by the 16. Indicator of movement toward .44 .005
two authors. Coding and scoring were compared recovery: ability to accept
and discrepancies resolved collaboratively gratification
through a reexamination of the coded text. 21. Indicator of movement toward .39 .01
Reliability of coding was 71 %. recovery: display of positive well-
The sum of BR-I scores was correlated
Note: Significance tests were one tailed. BR-II Bereave-
with time-of-bereavement (2 & 4 weeks) scores
ment Response Scale-II, PSOM Positive States of Mind
and 12-month post-bereavement outcome scores Scale
of four measures: the CES-D (Radloff, 1977);
Positive Morale Subscale of Bradburns
Affect Balance Scale (Bradburn, 1969); Positive seen in Table 1. These six items were formed into
States of Mind Scale (Horowitz, Adler, & Kegeles, the Bereavement Scale-II (BR-II).
1988); and the Impact of Event Scale (Horowitz, In evaluating the BR-II in comparison with the
Wilner, & Alvarez, 1979). The BR-I sum correlated BR-I, it may be worth noting that the predictive
significantly with all time-of-bereavement value of the BR-I was weakened by its inclusion
measures: CES-D (r = .49, p = .003); Positive of items having to do with quality of caregiving
Morale Subscale of Bradburns Affect Balance and with quality of social support that did not
Scale (r = .51, p = .002); Positive States of Mind prove to be significantly related to outcomes.
Scale (r = .34, p = .03); and the Impact of Event The BR-II, although made up of items chosen
Scale (r = .43, p = .005). However, with outcome empirically, is conceptually more focused.
scores from 12 months post-bereavement, the BR-I It may also be worth noting that the predictive
sum only correlated significantly with the Positive value of the BR-II was weakened by its reliance on
States of Mind Scale (r = .30, p = .05). As a result, interviews which did not systematically collect the
a further investigation was done examining corre- information required. Indeed, when the BR-II was
lations of each item of the BR-I with the Positive used to predict outcomes for the 19 cases in which
States of Mind Scale to identify items that were there was adequate data for scores on at least half
primarily responsible for correlations. Six of the 21 its items, its correlation with the 12-month Positive
items showed correlations significant at p  .05 as States of Mind score was .78.
Bernard, Paul 377 B
From the analyses of these individual items, it Parkes, C. M., & Weiss, R. S. (1983). Recovery from
was concluded that they can be predictive of bereavement. New York: Basic Books.
Radloff, L. S. (1977). The CES-D scale: A self-report
a return to effective functioning within 12 months depression scale for research in the general population.
of bereavement and that further exploration should Journal of Applied Psychological Measurement, 1,
take place. The other aspects of the respondents 385401. B
caregiving and grieving experience which were Weiss, R. S. (1988). Loss and recovery. Journal of Social
Issues, 44, 3752.
measured in the BR-I turned out to be of much Weiss, R. S. (1991). The attachment bond in childhood
less value as predictors of later recovery. It is and adulthood. In C.M. Parkes, J. Stevenson-Hinde
unknown if this occurred because of their lack of & P. Marris (Eds.), Attachment across the life cycle
predictive power or because of study design. (pp. 6676). London: Routledge.
Weiss, R. S., & Richards, T. A. (1997). A scale for
The Harvard Bereavement Study was predicting quality of recovery following the death of
conducted among widows and widowers. The a partner. Journal of Personality and Social
UCSF Coping Project was conducted with male Psychology, 72(4), 885891.
partners of men with AIDS. The findings indicate
that the same bond of emotional attachment
existed in the two kinds of committed partner-
ships and that work done with bereaved widows Bernard, Paul
and widowers was directly applicable to
situations of bereavement of partners in Celine Le Bourdais
a homosexual relationship. Department of Sociology, McGill University,
Montreal, QC, Canada

Birth, Education, Work History, and
Affect Balance Scale Main Contributions
Bereavement A committed researcher and sociologist, Paul
Caregiving Bernard (19452011) dedicated his professional
Center for Epidemiologic Studies Depression life to reducing social inequalities and improving
(CES-D) Scale the quality of life for Canadians. Very early in his
Impact of Event Scale career, he became aware of the need to under-
Reliability stand the complex interactions between the many
Widowhood factors affecting individuals throughout their
lives. To achieve this, he believed that it was
necessary to collect detailed information about
References individual life pathways, to develop theoretical
and statistical tools to analyze and interpret this
Bowlby, J. (1980). Attachment and loss (Loss: Sadness
and depression, Vol. 3). New York: Basic Books.
information, and to ensure that public policy inte-
Bradburn, N. (1969). Psychological well-being. Chicago: grated the research results by presenting them in
Aldine. a comprehensible way.
Horowitz, M., Adler, N., & Kegeles, S. (1988). A scale for An early advocate of the life course
measuring the occurrence of positive state of mind:
A preliminary report. Psychosomatic Medicine, 50,
approach, which aims to analyze the dynamics of
477483. the pathways taken by individuals through time
Horowitz, M., Wilner, N., & Alvarez, W. (1979). Impact and space, Paul Bernard pushed for the creation
of events scale: A measure of subjective stress. of a longitudinal household survey in Canada. In
Psychosomatic Medicine, 41, 208218.
Mikulincer, M., & Shaver, P. R. (2007). Attachment
the mid-1980s, he gathered a multidisciplinary
in adulthood: Structure, dynamics, and change. team of researchers from universities across
New York: The Guilford Press. Canada to work on this ambitious project
B 378 Bernard, Paul

(Bernard et al., 1988, 1992). Their work broadly study of complex social issues was generally
directed the content of the Survey of Labor and recognized. Teaming up with researchers in med-
Income Dynamics (SLID), a prospective survey icine, urban planning, and political science, he
launched by Statistics Canada in 1993. This survey produced important publications on questions of
documented such issues as the growth of income social inequality and health, the revitalization of
inequality in Canada. Ten years later, he brought poor urban neighborhoods, poverty, and social
together a new team of researchers to promote participation. Determined that these research
a similar survey in Quebec (Bernard et al., 2005); findings influence public policy and improve
their efforts inspired the development of the Cana- population well-being, he initiated and animated
dian Household Panel Survey Living in Canada. several multi-sectoral partnerships, including the
Paul Bernard was a member of the steering com- Population Change and Lifecourse Strategic
mittee for this survey, tested on a large sample of Knowledge Cluster, to promote fruitful collabo-
households and individuals in 2008 by Statistics ration between university and government
Canada. This in turn had a direct influence on the milieux. Finally, his involvement in numerous
content of the Longitudinal and International organizations, such as the Canadian Council on
Study of Adults (LISA), the type of long-term Social Development, the Centre detude sur la
household survey Paul Bernard had always pauvrete et lexclusion of Quebecs Ministere de
dreamed of. Statistics Canada carried out the first lEmploi et de la Solidarite sociale or the chari-
data collection in 2011. table organization Centraide of Greater Montreal
Determined that these expensive and valuable to name but a few, demonstrates the values of
data should be of service to society, Paul Bernard equality and social justice which inspired him.
played a crucial role in the creation of a unique Paul Bernard received a masters degree from
social statistics infrastructure in Canada. He Universite de Montreal in 1968 and a doctorate
helped mastermind the Data Liberation Initiative from Harvard University in 1974. He was profes-
(DLI) which aimed to make Statistics Canada sor of sociology at the Universite de Montreal
survey and census data easily accessible to uni- from 1975 to 2010. In 2001, he received the
versities and colleges for research and teaching Canadian Sociological Associations Outstand-
purposes at a minimum cost. He chaired a joint ing Contribution Award for his inestimable con-
working group set up by the Social Sciences and tribution to the advancement of his discipline. His
Humanities Research Council of Canada and Sta- premature death in February 2011 interrupted
tistics Canada to investigate why the national suddenly a career marked by social commitment
longitudinal surveys launched in the mid-1990s for which the Universite de Montreal awarded
were so little used by researchers. Paul Bernard him posthumously the title of professor emeritus.
played a key role in the creation of the Canadian
Research Data Center Network in 2000, one of
wide range of recommendations put forward by Cross-References
the working group, and directed this successful
and ever-expanding network during its first 3 Canadian Research Data Centre Network
years. Over the years, the Network has become Data Liberation Initiative (DLI)
an extraordinary hub of teaching and scientific
activity for a growing number of students and
researchers who carry out cutting-edge research References
on key issues for Canadian and Quebec society. It
has become a model for a growing number of Bernard, P., Beach, C., Curtis, J., Davies, J., Fox, B.,
national statistical offices across the world. Lapierre-Adamcyk, E., et al. (1988). A proposal for
a national panel study of the social and economic
Paul Bernard ventured beyond the bounds of
dynamics of making a living (144 p.). Report submitted
his discipline, sociology, long before the benefits to the Social Science and Humanities Research Coun-
offered by a multidisciplinary approach to the cil (SSHRC) of Canada, December.
BES (Benessere Equo e Sostenibile) Measuring and Assessing Progress of Italian Society 379 B
Bernard, P., Beach, C., Curtis, J., Davies, J., Fox, B., The initiative aims at carrying out a process
Lapierre-Adamcyk, E., et al. (1992). The Canadian which sees the participation of all major repre-
household panel study: Work, income and family life
(144 p.). A Proposal for a Joint Initiative with Statistics sentatives of Italian civil society in order to define
Canada, February. the dimensions of progress as well as the specific
Bernard, P., Bourdon, S., Charbonneau, J., indicators to represent them. B
Contandriopoulos, A.-P., Drouin, C., Drapeau, A., The initiative established a Steering Group
et al. (2005). Connatre, debattre et decider: la contri-
bution dune Enquete socioeconomique et de sante inte coordinated by CNEL and Istat including 20
gree et longitudinale (ESSIL). Institut de la statistique participants representing different stakeholders
du Quebec: Quebec. 468 p. and a Scientific Commission hosted by Istat
and composed by experts and practitioners.
It also foresees the organization of a public
Bernheims ACSA The initiatives objectives are to:
Develop a shared definition of progress for
Anamnestic Comparative Self-Assessment Italian society through the identification of
(ACSA) the most relevant domains
Select a set of high-quality statistical indica-
tors representative of the different domains
Thoroughly communicate the results of the
BES (Benessere Equo e Sostenibile) process. The set of indicators defined is
Measuring and Assessing Progress intended for a broad public audience as well
of Italian Society as for policy use
The process is divided into three phases ful-
Tommaso Rondinella filling the objectives:
Presidents Technical-Scientific Secretariat, 1. During the first phase the Steering Group
Italian National Institute of Statistics Istat, defined the domains to be taken into account.
Rome, Italy Meanwhile Italian citizens have been able to
express their priorities both through an ad hoc
open online consultation and through
Definition a specific question included since 2011 in the
Multipurpose survey; the Steering Group
BES Benessere Equo e Sostenibile. Measuring defined also which tools are the most fit-
and assessing progress of Italian society is for-purpose, evaluating which degree of detail
a national initiative launched by Istat and CNEL the set of indicators has to reach, as well as
for the identification of a set of indicators for their policy relevance
measuring Italian Equitable and Sustainable 2. The second phase has been devoted to the
Well-being. analysis of the available indicators which
could be used to represent the various
domains, stressing their technical features
Description and opportunity of using them: the number of
indicators in the final set should be small
The Italian National Institute of Statistics (Istat) enough to facilitate their understanding by
and the Italian National Council for Economics non-experts. The Scientific Commission is
and Labor (CNEL) launched in December responsible for this part of the work.
2010 an inter-institutional initiative to define 3. The last phase is dedicated to the drafting
a shared set of indicators for measuring progress of a final report and the development of
of Italian society (Giovannini & Rondinella, different tools for dissemination and
2011, 2012). communication
B 380 BES (Benessere Equo e Sostenibile) Measuring and Assessing Progress of Italian Society

BES (Benessere Equo

e Sostenibile)
Measuring and
Assessing Progress of
Italian Society,
Fig. 1 BES initiatives
process framework

Legitimacy: CNEL is a council established 1. Environment

by the Italian Constitution composed by repre- 2. Health
sentatives of all major working categories, 3. Economic well-being
including representatives of entrepreneurs, 4. Education and training
unions and of the third sector, for a total of 64 5. Work and life balance
counselors representing different stakeholders. 6. Social relationships
CNEL working groups and the assembly serve 7. Security
as places for deliberation over controversial 8. Subjective well-being
issues and trade-offs and approve the final 9. Landscape and cultural heritage
version of the BES. 10. Research and innovation
Politics are formally excluded from the pro- 11. Quality of services
cess. Nevertheless after each phase of the initia- 12. Policy and institutions
tive the Parliament is informed about the major On 20th June 2012 CNEL Assembly approved
results emerging from the initiative. with a unanimous vote the list of 134 indicators
Stakeholder discussion within CNEL has been (Fig. 1). For the whole list see: www.misuredel-
aided by a public consultation which happened benessere.it
through three parallel streams. The first one was By March 2013 the first BES report is
an on-line consultation in which experts, practi- expected to be published and presented to the
tioners and anyone interested in the issue was Italian Parliament.
asked to contribute to the monitoring of progress
and well-being in Italy. The second was the inclu-
sion of a specific question in the Multipurpose Cross-References
survey Aspects of daily life, which is submitted
annually to 24 thousand families to assess the International Well-being Group
importance attributed by citizens to different Italy
dimensions of well-being. The third consultation
stream is the organization of a few public meet-
ings to collect broader qualified comments on the References
preliminary results.
Giovannini, E., & Rondinella, T. (2011). Italia. Misurare
On 4th November 2011 the Steering group
il benessere equo e sostenibile: la produzione-
presented a first proposal of 12 domains for mea- dellIstat, Rivista delle Politiche Sociali, n. 1/2011.
suring well-being: Ediesse, Roma.
Better Life Index 381 B
Giovannini, E., & Rondinella, T. (2012). Measuring equi- Description
table and sustainable wellbeing in Italy. In F. Maggino
& G. Nuvolati (Eds.), Quality of life in Italy: Research
and reflections. Dordrecht/New York: Springer. Beta weights are partial coefficients that indicate
Press releases: 27 Dec 2010 (En) (It), 20 Apr 2011 (It). the unique strength of relationship between
www.misuredelbenessere.it a predictor and criterion, controlling for the pres- B
ence of all other predictors. Beta weights are also
the slopes for the linear regression equation,
when standardized scores are used. Beta weights
Best Evidence Synthesis represent values that optimize the relationship
between the predictor and criterion constructs.
Meta-Data-Analysis These values can be determined using a number
of different mathematical procedures, including
least squares and maximum likelihood analyses.
Beta weights usually range in absolute value from
Best-Worst Global Evaluation 0 to 1. Values larger than 1, while possible, are
(Gender) not conceptually meaningful and may indicate
the presence of colinearity among the predictors.
Gender Well-Being Composite Index As a standardized index it has two values. First, it
can serve as a measure of effect size,
documenting predictive value in a universal met-
ric (i.e., standard deviation units). Second, it
allows for a direct comparison of the relative
Beta Coefficient predictiveness of a set of independent variables
against a single criterion (Cohen & Cohen, 1983).
Regression Coefficients


Beta Weights Correlation Coefficient

Multiple Regression
Ralph L. Piedmont
Pastoral Counseling Department,
Loyola University Maryland, Columbia, References
Cohen, J., & Cohen, P. (1983). Applied multiple regression/
correlation analysis for the behavioral sciences
(2nd ed.). Hillsdale, NJ: Lawrecen Erlbaum Associates.

Partial coefficient; Regression coefficient;

Standardized regression coefficient Better Life Index

Niels Lind
Definition University of Waterloo, Victoria, BC, Canada

A coefficient found in multiple regression analy-

sis that represents the unique strength of relation- Synonyms
ship between a predictor and a criterion adjusting
for the effects of all other predictors. BLI; Your Better Life Index
B 382 Bias, Statistical

Definition Cross-References

The Better Life Index is a set of 11 social indi- Calibrated Development Index
cators, of housing, income, jobs, community, Human Development Index
education, environment, governance, health, Legatum Prosperity Index
life satisfaction, safety, work-life balance Life Quality Index
(Organisation for Economic Co-operation and
Development [OECD], 2011). These indicators
in turn are composed of 20 sub-indicators References
through averaging and normalization. By
selecting a set of weights to the sub-indicators, OECD Organisation for Economic Co-operation and
Development. (2011). OECD Better Life Initiative.
a user can rank countries according to their
Your Better Life Index. Retrieved June 16, 2011,
weighted sum. from http://www.oecdbetterlifeindex.org/
Stiglitz, J. E., Sen, A., & Fitoussi, J. -P. (2009). Report by
the commission on the measurement of economic per-
formance and social progress. Retrieved June 16,
Description 2011, from http://www.stiglitz-sen-fitoussi.fr/docu-
In recognition of the limitations of Gross Domes-
tic Product (GDP) as an indicator of social pro-
gress, Stiglitz, Sen, and Fitoussi (2009) called for
better measurement through a richer mix of sta- Bias, Statistical
tistics as basis for decisions about policy. In
response, the Organisation for Economic Co- Ralph L. Piedmont
operation and Development (OECD) identified Pastoral Counseling Department, Loyola
the measurement of well-being and societal pro- University Maryland, Columbia, MD, USA
gress as an area of high priority and produced an
extensive database of the 20 sub-indicators for
34 countries available in spreadsheet format Synonyms
(OECD, 2011).
Recognizing that different peoples ideas Nonresponse bias
of social progress would call for different
weights to be given to these sub-indicators, the
OECD Better Life Initiative declined to Definition
produce a summary index and has not ranked
the countries as so many other indices do Statistical bias is a term that refers to any type of
(e.g., the Human Development Index). In May error or distortion that is found with the use of
2011, it launched instead an interactive online statistical analyses.
tool, Your Better Life Index, designed to let any-
one assign weights and compare the factors that
contribute to well-being in countries for which Description
the requisite statistics are available, such as the
34 OECD countries. The online program shows Bias can arise for a number of reasons including
the countries relative performance according to failure to respect either comparability or consis-
the importance placed on the subindices, all of tency, the price collection and measurement
which in some way reflect a better life. Your procedures followed, and the calculation and
Better Life Index is user friendly, making it aggregation formula employed.
easy to visualize how a country compares on The types of statistical biases will be reviewed
each dimension to other countries. here. The first type of statistical bias is found when
Bidirectional Explanation of Satisfaction 383 B
a statistic systematically under (or over) estimates
a population parameter. This is the case with the Bidirectional Explanation
formula for standard deviation ((S(Xm)2/N)1/2). of Satisfaction
When this formula is applied to samples, it will
consistently underestimate the population param- Willem Egbert Saris B
eter, s. In this instance, the bias can be corrected Research and Expertise Centre for Survey
by substituting (N1) in the denominator. This Methodology, Universitat Pompeu Fabra,
type of bias can be easily corrected mathematically Barcelona, Spain
(Rosenthal & Rosnow, 1984).
The second type of statistical bias occurs when
there is a bias in the subjects selected for analysis. Synonyms
In this case, a nonrepresentative sample will lead
to population estimates that are skewed. This Reciprocal causal relationships
situation arises in studies that do not rely on
random sampling or use only a small sample of
subjects. Definition
Finally, statistical bias can be found in many
statistical analyses. Correlational techniques Bidirectional explanation of satisfaction
(e.g., multiple regression, canonical correlation, means that it is assumed that domain-specific
and factor analysis) operate by maximally fitting (DS) satisfactions influence subjective
a set of predictors to an outcome. The use of well-being (SW) but that SW also affects DS
a least squares approach insures that sample variables.
specific elements will be used in maximizing
the observed relationships. Thus, the resulting
measures of overall model fit will overestimate Description
the true population value. It is therefore essential
that these types of findings be replicated in new One of the main issues in social indicator studies
samples, where indices of model fit will be lower. has been the explanation of subjective
Such distortion can be minimized by employing well-being (SW). In many older studies, SW
samples with large subjects to variables ratios was explained by a linear combination of
(Achen, 1982). domain-specific satisfaction (DS) variables,
such as satisfaction with income, housing, or
social contacts (Andrews & Withey, 1976;
Cross-References Argyle, 1987; Campbell et al., 1976; Headey,
Holmstrom, & Wearing, 1985). Diener (1984)
Estimator was the first to criticize this intuitive approach.
Response Bias(es) He suggested that the effects could just as well
Test Bias be reversed, that is, go from SW to DS. He called
his model the top-down model in contrast with
the intuitive bottom-up model that was used till
that moment. This suggestion was based on the
idea that satisfaction might be determined more
Achen, C. H. (1982). Intepreting and using regression. by personality characteristics than situational cir-
Sage University Paper series on Quantitative cumstances. It seems that some people have
Application in the Social Sciences, 097-029. Beverly a disposition to be satisfied while others do not,
Hills, CA: Sage Publications.
so that satisfaction with life in general (SW) is the
Rosenthal, R., & Rosnow, R. L. (1984). Essentials of
behavioral research: Methods and data analysis. more fundamental variable which spills over onto
New York, NY: McGraw-Hill. domain satisfaction.
B 384 Bidirectional Explanation of Satisfaction

A third possibility, suggested in the literature relationship for satisfaction with marriage.
by Costa and McCrae (1980, 1984, is that there Furthermore, they found no significant effects in
are personality traits which cause the SWB either direction for satisfaction with friendship
and the DS to covary. In that case, the relation- and health. For the last two topics, the relation-
ships between SWB and DS variables would be ships between SW and DS variables turned out to
spurious due to personality characteristics. be spurious due to personality characteristics like
The direction of the effects can also vary with Neuroticism and Extroversion. These studies
the country studied. In countries with a lower make it clear that the direction of the effects
BNP, the effect of income satisfaction might be varies with the domain studied. Moeller and
bottom up from DS to SW while in countries with Saris (2001) found that in one country (South
a higher BNP, the effect might be reversed or not Africa), different directions of effects were
existing. In the latter countries, the effect of found for racial and income groups. For the rich
domain satisfactions of social contacts or mar- blank population, the effect of the DS social
riage on SW might be significant instead because contacts had an effect on SW and SW an effect
with respect to income, the people have already on DS with income while for the poor black
reached a high enough level so that the people are population, the DS of the income had
not too much worried about this domain any- a significant effect on their SW.
more. In that case, they are more concerned In order to be sure that these results are not
about their social relationship as suggested in artifacts, it is important to have a study design
Saris, Veenhoven, Scherpenzeel, and Bunting and an estimation method which provides rather
(1996). Such a difference between countries robust estimates of the reciprocal effects so that
would be in line with the theory of Inglehart one can decide with a lot of confidence in what
(1990 ) that people are nowadays less concerned direction the effects go. Scherpenzeel and Saris
about income matters than by environmental (1996) suggested that in general, this is not the
problems, democratic liberties, etc. Also Maslow case. They studied the two most commonly used
(1970) suggested that there is a hierarchy of procedures. The first approach tries to identify the
values where the higher values become only reciprocal relations at one point in time using
important if the lower level values have been exogenous variables (Lance et al., 1995). The
satisfied. other procedure uses the same DS and SW vari-
The above arguments suggest that effects of ables at different points in time for identification
DS to SW and from SW to DS can be expected. of the reciprocal effects (Headey et al., 1991). It
So in research, it makes sense to start with was found that these different approaches for the
a model with bidirectional or reciprocal effects same population did not provide the same results.
between DS and SW. However, such models Saris (2001) suggests that it would be the best to
create difficulties for the estimation of the effects. use panel data as done by Headey et al. (1991) but
Since the paper of Diener (1984), several stud- with reciprocal, lagged effects and exogenous
ies have been done in order to test the different variables. It would be attractive to have at least
models (Headey, Veenhoven, & Wearing, 1991; three waves of the panel. In that case, the model is
Lance, Mallard, & Michalos, 1995). These rather overidentified, and one can test for possible
studies have not resolved the dispute but rather instantaneous and lagged effects in both direc-
complicated it, as they found different effects for tions. The model suggested will be described
the different domains studied: Lance et al. found below.
a significant top-down effect of SW for the First of all, it is specified that the DS(t) is
domains job satisfaction and satisfaction with largely determined by the DS(t-1) except when
social activities but a bottom-up effect of mar- changes occur in the comparison variables (C).
riage satisfaction on SW. Headey et al. also found The comparison variable presents the difference
a top-down effect for job satisfaction and satis- between the factual situation and the wish they
faction with leisure activities but a reciprocal have for this specific domain (Michalos, 1985).
Bidirectional Explanation of Satisfaction 385 B
To this equation, it is added that also a change in C1 C2 C3
SW might affect the DS variable, as suggested by
Diener (1984), and personality characteristics,
especially neuroticism (N) and extroversion (E)
as suggested by Headey et al. (1991) and Costa B
and McCrae (1980, 1984). This can be formu-
lated as follows: SW1 SW2 SW3

DSt b1 DSt1 b2 CtCt1

b3 SWt SWt1 g1 N
g2 E zt (1) N E

For SW, we specify a similar process with Bidirectional Explanation of Satisfaction, Fig. 1 The
presentation of the model of (1) and (2) in a causal dia-
respect to its value at time t, but now it is expected
gram. In order to avoid confusion, the arrows from N and
that SW at time t is largely determined by SW E to DS(t) have been omitted
at time t-1 while both are affected by personality
characteristics like neuroticism and extroversion
as suggested by Costa and McCrae (1984) and disturbance terms for the variables have been omit-
Headey et al. (1991). Furthermore, as suggested ted in the figure as well as the effects of personality
by many researchers mentioned above, a variables on the DS variables.
bottom-up effect of changes in DS is introduced. This model is very much in line with the
This leads to the following specification: model used by Headey et al. (1991) except for
the fact that a comparison variable is introduced
SWt b4 SWt1 as an exogenous variable for the DS variables.
b5 DSt DSt1 g3 N This model differs considerably of the model of
g4 E u t (2) Scherpenzeel and Saris (1995) who used all DS
variables at the same time. It is rather suggested
In this model, b3 represents the top-down to follow the approach of Headey et al. who tested
effect and b5 the bottom-up effect. The fact that separately the effects of the different DS
the personality characteristics appear in both variables.
equations means that these variables generate A major difference with the model of Headey
spurious relationships between the DS and SW is that effects of lagged variables are specified
variables. next to the effect of variables at the same point in
The disturbance terms u(t) and z(t) can be time. This may lead to a better fit of the model
correlated at the same point in time but not at than they got, specifying these effects to be zero.
different points in time. One can also expect that If data are available for all variables men-
the effects at different points in time are equal to tioned in three waves of a panel, the model can
each other. be estimated with standard Structural
It will be clear that both equations can be rewrit- Equations software, and the model can be
ten by writing out the change term as separate level adjusted by omitting nonsignificant effects from
variables. In that case, the variables at time t and the the model. This approach has been used to test
lagged variables at time t-1 will become separate this model on Russian data (Saris, 2001). It turned
variables, but the effects of these variables will be out that effects for DS marriage and housing were
the same except for the sign. The effect of top down and for the DS income there are
a variable at the same point in time will be positive; reciprocal effects in Russia. This illustrates that
the effect of a lagged variable will be equal but it makes sense to study the direction of these
negative. Using this notation, the model can also be effects because the assumption that all effects of
represented in Fig. 1. For reasons of simplicity, the the DS variables are only bottom up is too simple.
B 386 Bi-factor Analysis

Bi-factor Analysis
Subjective Well-Being
Robert Gibbons
Departments of Health Studies, Medicine, and
Psychiatry, University of Chicago, Chicago,
References IL, USA
Andrews, F. M., & Withey, S. B. (1976). Social indicators
of well-being. New York: Plenum Press.
Argyle, M. (1987). The psychology of happiness. London: Definition
Campbell, A., Converse, P. E., & Rogers, W. R. (1976). The bi-factor model is a confirmatory factor ana-
The quality of American life. New York: Russel Sage
lytic model originally proposed for measurement
Costa, P. T., & McCrae, R. R. (1980). Influence of extra- data by Holzinger and Swineford in 1937
version and neuroticism on subjective well-being. (Holzinger & Swineford, 1937) and then gener-
Journal of Personality and Social Psychology, 338, alized to the case of discrete item-response data
by Gibbons and Hedeker in 1992 (Gibbons &
Costa, P. T., & McCrae, R. R. (1984) Personality as
a lifelong determinant of well being. In C. Malatesta Hedeker, 1992). The bi-factor restriction requires
& C. Izard (Eds.), Affective processes in adult that each item load on a primary dimension of
development and aging. Beverly Hills: Sage. interest and no more than one secondary
Diener, E. (1984). Subjective well-being. Psychological
dimension. The secondary dimensions or
Bulletin, 95, 542575.
Headey, B., Holmstrom, E. L., & Wearing, A. J. (1985). subdomains can be nuisance variables such as
Models of well-being and ill-being. Social Indicators positively and negatively worded questions (i.e.,
Research, 17, 211234. a methodologic factor) or content domains from
Headey, B., Veenhoven, R., & Wearing, A. (1991).
which the items are sampled (e.g., component
Top-down versus bottom-up theories of subjective
well-being. Social Indicators Research, 24, dimensions underlying the overall quality of
81100. ones life). When appropriate the bi-factor
Inglehart, R. (1990). Culture shift in advanced industrial model provides numerous advantages over an
society. Princeton, NJ: Princeton University Press.
unrestricted exploratory item factor analysis
Lance, C. E., Mallard, A. G., & Michalos, A. C. (1995).
Tests of the causal directions of global-life facet satis- model, including rotational invariance and
faction relationships. Social Indicators Research, 34, unlimited dimensionality. For categorical item
6992. responses, the likelihood of the model can be
Maslow, A. (1970). Motivation and personality.
evaluated using two-dimensional integration
New York: Harper & Row.
Michalos, A. C. (1985). Multiple discrepancies theory. regardless of the number of subdomains. The
Social Indicators Research, 16, 347413. model assumes that all of the intercorrelations
Moeller, V., & Saris, W. E. (2001). The relationship among the items are explained by their joint
between subjective well-being and domain satisfac-
association with the primary dimension
tions in South Africa. Social Indicators Research, 55,
97114. and the specific subdomain that they are a part
Saris, W. E. (2001). What influences subjective well- of. The subdomains are assumed to be
being in Russia. Journal of Happiness studies, 3, independent.
Saris, W. E., Veenhoven, R., Scherpenzeel, A. C., &
Bunting, B. (Eds.). (1996). A comparative study of
life satisfaction in Europe. Budapest: Eotvos Univer- Description
sity Press.
Scherpenzeel, A., & Saris, W. E. (1996). Causal
In quality of life measurement, interest in
direction in a model of life satisfaction: the top-
down/bottom-up controversy. Social Indicators bi-factor analysis has increased as the state of
Research, 38, 161180. the art for scale development shifted from
Bi-factor Analysis 387 B
classical test theory to item-response theory and the probability that the individual will
(IRT) approaches. Historically, IRT assumed respond incorrectly, indicated by xij 0, is the
unidimensional data, that is, responses to items complement,
could be accounted for by a single attribute or
random effect parameter for each subject. How- Pxij 0jyi 1  Fyi : B
ever, empirical Bayes and marginal maximum
likelihood methods easily extend the theory to Since the multiple factor model implies
item responses that have more than one dimen- conditional independence (i.e., the items are
sion. Such an extension was sketched by Bock uncorrelated conditional on the underlying
and Aitkin (Bock & Aitkin, 1981) and presented factors y), the conditional probability of the
more formally in Bock, Gibbons, and Muraki item score vector xi is
(Bock, Gibbons, & Muraki, 1988). The basic
ideas follow: Px xi j y; g; a
Following Thurstone (1947) assume that an
individuals response to a test item j is controlled Fi yi xij 1  Fj yi :
by a latent variable j

m For computational purposes it is convenient to
yij ajk yki eij express the argument of the response function in
k terms of an intercept,

where ajk is the loading of item j on factor k, yki is

cj gj =sj
the attribute value, or score, of individual i on
factor k, and eij is an independent residual.
According to the conventions of factor analysis, and factor slopes
assume that all variables are standardized and
that scores for different factors are uncorrelated. ajk ajk =sj
Assuming normality, the distributions of these
parameters are yj  N(0,1), yk NID(0,1) and ej rather than threshold and factor loadings.
  Pm In the context of Bayes estimation, the
NID 0; s2j , where s2j 1  a2jk is the
k equation above is the likelihood of yi , and the
uniqueness (i.e., unique item variance). prior, which is multivariate normal, is completely
Individual i is assumed to respond positively specified. However, because of the nature of this
to item j when yij is greater than the item likelihood function, this is an example of a model
threshold gj . Thus, the probability that an individ- outside the exponential family for which no
ual with factor score vector yi will respond closed form of the posterior mean or covariance
positively to item j, as indicated by the item matrix is available. Note, however, that the
score xij 1, is given by the item-response unconditional probability of score pattern xi can
function, be expressed as
Z 1
Fj yij Pxij 1jyij
hxi Px xi j y; g; agydy
Pyij > gj jyi 1
2 !2 3
Z 1 X
1 1
exp4 yij  ajk yki =s2j 5dyj As such, the integral in the preceding equation
2psj gj 2 k
is numerically approximated by m-fold
gj  m k ajk yki Gauss-Hermite product quadrature (Bock &
sj Aitkin, 1981; Bock et al., 1988).
B 388 Bi-factor Analysis

The Bi-factor IRT Model where the bi-factor pattern might also arise at the
The bi-factor restriction for IRT models (Gibbons item level (Muthen, 1989). It is plausible for
& Hedeker, 1992) was the first example of paragraph comprehension tests, for example,
a confirmatory multidimensional IRT model. where the primary dimension describes the
The bi-factor model is based on the idea that in targeted process skill and additional factors
many cases multidimensionality is produced by describe content area knowledge within para-
the sampling of items from multiple domains of graphs. Similarly, in the context of mental health
an overall psychological construct. For example, measurement, symptom items are often selected
in the measurement of fatigue impact, a measure from measurement domains and can be related to
could include items that assess cognitive, physi- the primary dimension of interest (e.g., depres-
cal, and social impact of fatigue. It is quite natural sion) and one subdomain (e.g., anxiety). In these
for responses to such items to appear to be contexts, items would be conditionally indepen-
multidimensional, when in fact, the items mea- dent between paragraphs or domains but
sure a unidimensional construct, that is, fatigue conditionally dependent within paragraphs or
impact. However, the items within subdomains domains.
are more highly correlated than items between The bi-factor restriction leads to a major sim-
domains. For example, responses to two items plification of likelihood equations that (a) permits
measuring cognitive fatigue will be more highly analysis of models with large numbers of group
correlated than responses to a pair of items, one factors (e.g., domains), (b) permits conditional
measuring cognitive fatigue and the other dependence among identified subsets of items,
measuring physical fatigue. This leads to viola- (c) is rotationally invariant in contrast to the
tion of the conditional independence assumption unrestricted item factor model, (d) always
of a unidimensional IRT model and results in reduces the likelihood to a two-dimensional
dimensionality equal to the number of domains integral that is easily evaluated using traditional
from which the items were sampled. However, numerical methods, and (e) in many cases pro-
a plausible s-factor solution for many types of vides a more parsimonious factor solution than an
psychological and educational tests is one that unrestricted full-information item factor analysis
exhibits a general factor and s-1 group- or (Bock & Aitkin, 1981). Furthermore, in the
method-related factors. The bi-factor solution context of computer adaptive testing (CAT), the
constrains each item j to have a nonzero loading bi-factor model provides a single endpoint (i.e.,
aj1 on the primary dimension and a second load- the core dimension) by which to adaptively select
ing ajk ; k 2; . . . ; s on not more than one of items from a potentially large bank of symptom
the s-1 group factors. For four items, the bi-factor items.
pattern matrix might be Recently, Gibbons and coworkers (2007)
extended the bi-factor model to the case of ordi-
2 3
a11 a12 0 nal symptom items, making the methodology
6 a21 a22 0 7 even more useful in the context of psychological
4 a31
0 a33 5 measurement problems (e.g., quality of life)
a41 0 a43 where Likert-type rating scales are often used.
The bi-factor model can also be used in conjunc-
This structure, which Holzinger and tion with CAT to measure mental health con-
Swineford (1937) termed the bi-factor solution, structs (Gibbons et al., 2008). Cai (2010) has
also appears in the inter-battery factor analysis of further generalized the bi-factor model to the
Tucker (1958) and is one confirmatory factor case in which there are multiple intercorrelated
analysis model considered by Joreskog (1969). primary domains in addition to subdomains that
In these applications, the model is restricted to nested within each of the multiple primary
test scores assumed to be continuously domains. There are numerous interesting
distributed. But it is easy to conceive of situations applications of this even more general model.
Bi-factor Analysis 389 B
The IRTPRO computer program (Cai) can fit discriminating items were global life satisfac-
unidimensional and multidimensional IRT tion, factor loading (FL) 0.694; satisfaction
models in addition to the bi-factor model for with free time, FL 0.611 (subdomain 4);
binary and ordinal response data. and emotional well-being, FL 0.609
Recently, there have been several applications (subdomain 3). The three least discriminating B
of bi-factor models in the area of personality items were satisfaction with people in general,
research (Patrick, 2007; Reininghaus, McCabe, FL 0.385 (subdomain 7); amount you pay for
Burns, Croudace, & Priebe, 2011; Reise, basic needs, FL 0.391 (subdomain 2); and
Moore, & Haviland, 2010; Rijmen, 2010; Yang, pleasure from TV, FL 0.414 (subdomain 4).
Tommet, & Jones, 2009). In the area of life The unique life as a whole item loaded heavily
quality assessment, unidimensional IRT models on the primary dimension, but not at all on the
have been considered (Fryback, Palta, subdomain, indicating that the primary dimension
Cherepanov, Bolt, & Kim, 2010) as well as is a good measure of overall life satisfaction. The
IRT-based CAT (Rebollo et al., 2010). Gibbons item intercepts permit items to be positioned rela-
and coworkers (2007) have presented a bi-factor tive to the global life satisfaction item to determine
analysis of a quality of life scale, as described in at what point on the scale a person would report
the following. global life satisfaction. Table 1 shows that the
Health (subdomain 3), Living (subdomain 5), and
Quality of Life Illustration Social domains (subdomain 7) were typically
As an illustration of the bi-factor model for graded reported at lower levels of satisfaction than the
response data, (Gibbons et al., 2007) Gibbons and global item, whereas Financial (subdomain 2)
colleagues analyzed the Quality of Life Interview and Leisure (subdomain 4) items had, on average,
for the Chronically Mentally Ill (Lehman, 1988). higher intercepts than the global satisfaction item.
Their analysis was based on item responses of 586 The domains of Family (subdomain 1) and Safety
chronically mentally ill patients. Analyses were (subdomain 6) items were located at similar levels
performed using the freely available POLYBIF to the global item.
software (Gibbons & Hedeker, 2007). The scale In terms of subdomains, items within domains
consists of seven subdomains (Family, Finance, had a high degree of residual association, with an
Health, Leisure, Living, Safety, and Social), each average loading of.406.Consistent with this find-
with 46 items for a total of 34 items. In addition, ing was a significant likelihood ratio test for
there is one global life satisfaction item, which was improvement in fit of the bi-factor model over
allowed to load on its own subdomain in the event the unidimensional graded response model
that it had a unique contribution to the residual (w2 2188, df 35, p < .0001). Table 2 displays
variation above and beyond its contribution to the observed and expected (in italics) category
the primary dimension. Each item is rated on proportions for each item. In general, there is
a 7-point scale with the following response cate- close agreement between observed and expected
gories: 1 terrible; 2 unhappy; 3 mostly response proportions. The root mean square error
dissatisfied; 4 mixed, about equally satisfied (RMSE) between observed and expected propor-
and dissatisfied; 5 mostly satisfied; tions (over all items and categories) was 0.026,
6 pleased; and 7 delighted. indicating that the model with common category
Item intercepts, primary factor loadings, and parameters (Muraki, 1990) fit these data
factor loadings on the eight subdomains are extremely well. The six category parameters
displayed in Table 1 based on the polytomous were as follows:
rating scale model (Gibbons et al., 2007). Table 1
shows that all items had substantial loadings on the  1:395  :858  :449 :044 :866 1:793
primary dimension (factor 1), indicating that the
scale was well designed and that all items were A model with unique item category parame-
related to overall life satisfaction. The three most ters (Samejima, 1969) produced a significant
B 390 Bi-factor Analysis

Bi-factor Analysis, Table 1 Nine-dimensional bi-factor solution for the Lehman quality of life rating scale data
(N 586) item intercepts and factor loadings
Scale Item Intept 1 2 3 4 5 6 7 8 9
Global Life as a whole 0.402 0.694 0.001
1 Family 0.768 0.499 0.566
1 Amount of family contact 0.349 0.534 0.443
1 Family with interaction 0.282 0.548 0.518
1 General family stuff 0.350 0.597 0.491
2 Total money you get 0.209 0.435 0.568
2 Amt pay for basic needs 0.136 0.391 0.477
2 Financial well-being 0.319 0.503 0.562
2 Money for fun 0.242 0.491 0.568
3 Health in general 0.482 0.458 0.270
3 Medical care 0.701 0.475 0.419
3 How often see doctor 0.441 0.441 0.397
3 Talk to therapist 0.621 0.478 0.378
3 Physical condition 0.582 0.553 0.299
3 Emotional well-being 0.284 0.609 0.185
4 Way spend free time 0.139 0.611 0.262
4 Amount of free time 0.292 0.509 0.342
4 Chance to enjoy time 0.552 0.578 0.386
4 Amount of fun 0.270 0.597 0.430
4 Amount of relaxation 0.306 0.525 0.393
4 Pleasure from TV 0.776 0.414 0.163
5 Living arrangements 0.435 0.493 0.493
5 Food 0.982 0.449 0.468
5 Privacy 0.709 0.478 0.610
5 Amount of freedom 1.090 0.478 0.649
5 Prospect of staying 0.100 0.469 0.630
6 Neighborhood safety 0.298 0.511 0.445
6 Safe at home 0.666 0.542 0.416
6 Police access 0.062 0.487 0.429
6 Protect robbed/attack 0.214 0.517 0.465
6 Personal safety 0.533 0.531 0.326
7 Do things with others 0.614 0.494 0.326
7 Time with others 0.411 0.519 0.257
7 Social interactions 0.604 0.472 0.346
7 People in general 0.835 0.385 0.220

likelihood ratio test for improvement in fit over the two models, despite the fact that the rating
the rating scale model (w2 1637, df 169, scale model has only one item-specific threshold
p < 0.0001), with a decrease in RMSE between (and six general thresholds) and Samejimas
observed and expected proportions to 0.010. Fac- model has six unique thresholds per item. For
tor loadings were almost identical between the example, estimated item thresholds for the first
two models. Furthermore, there were only minor ten quality of life items for both models are
changes in the estimated item thresholds between presented in Table 3. Table 3 shows that the
Bi-factor Analysis 391 B
Bi-factor Analysis, Table 2 Observed and expected (in italics) proportions from the nine-dimensional graded bi-
factor analysis of Lehman quality of life rating scale data (N 586)
Item 1 2 3 4 5 6 7
Life as a whole .063 .087 .080 .176 .224 .212 .159 B
.098 .084 .088 .128 .232 .211 .158
Family .046 .068 .049 .160 .203 .232 .241
.078 .065 .069 .105 .208 .224 .251
Amount of family contact .061 .097 .114 .133 .244 .210 .140
.104 .088 .090 .131 .232 .206 .149
Family with interaction .067 .125 .094 .167 .200 .217 .131
.135 .092 .089 .123 .211 .190 .160
General family stuff .072 .108 .087 .159 .229 .186 .160
.134 .088 .084 .117 .205 .192 .180
Total money you get .138 .155 .137 .128 .235 .143 .063
.204 .121 .108 .137 .203 .145 .081
AMT pay for basic needs .077 .121 .106 .145 .276 .195 .080
.114 .103 .106 .149 .246 .187 .096
Financial well-being .174 .152 .133 .131 .201 .142 .067
.240 .122 .104 .128 .187 .136 .083
Money for fun .147 .171 .148 .109 .208 .135 .082
.223 .119 .104 .129 .193 .143 .090
Health in general .048 .063 .051 .113 .392 .215 .118
.056 .072 .087 .140 .272 .239 .133
Medical care .043 .039 .055 .135 .258 .311 .160
.052 .061 .073 .119 .245 .250 .199
How often see doctor .049 .061 .099 .125 .309 .242 .114
.070 .078 .089 .138 .259 .228 .138
Talk to therapist .036 .041 .085 .123 .292 .280 .143
.055 .065 .078 .126 .253 .247 .176
Phisical condition .034 .072 .084 .119 .261 .283 .174
.062 .069 .080 .127 .249 .240 .173
Emotional well-being .065 .087 .104 .157 .273 .195 .119
.098 .091 .097 .141 .246 .205 .122
Way spend free time .077 .113 .126 .159 .225 .201 .099
.126 .102 .102 .142 .235 .185 .108
Amount of free time .060 .077 .119 .154 .273 .208 .109
.091 .090 .097 .143 .252 .207 .118
Chance to enjoy time .053 .082 .087 .130 .218 .241 .189
.081 .075 .081 .122 .232 .225 .186
Amount of fun .077 .118 .114 .126 .218 .196 .150
.130 .093 .091 .186 .217 .192 .151
Amount of relaxation .077 .080 .108 .131 .259 .225 .119
.100 .090 .095 .137 .212 .205 .131
Pleasure from tv .020 .034 .055 .143 .275 .282 .188
.026 .016 .065 .120 .276 .287 .181
Living arrangements .073 .070 .085 .131 .271 .210 .189
.095 .082 .086 .127 .232 .214 .163
Food .041 .032 .056 .072 .234 .304 .261
.035 .045 .057 .100 .227 .267 .269
B 392 Bi-factor Analysis

Bi-factor Analysis, Table 2 (continued)

Item 1 2 3 4 5 6 7
Privacy .087 .051 .080 .097 .186 .258 .241
.092 .069 .071 .105 .202 .214 .247
Amount of freedom .065 .051 .049 .067 .195 .230 .343
.071 .054 .057 .087 .179 .214 .339
Prospect of staying .130 .119 .094 .150 .160 .140 .186
.177 .099 .090 .119 .196 .170 .147
Neighborhood safety .077 .080 .082 .143 .294 .218 .106
.106 .091 .094 .135 .236 .202 .136
Safe at home 0.55 .043 .061 .111 .280 .280 .171
.066 .067 .075 .117 .233 .237 .205
Police access .137 .061 .131 .172 .217 .174 .108
.134 .108 .107 .146 .235 .176 .094
Protect robbed/attack .094 .073 .118 .147 .254 .203 .111
.124 .097 .096 .135 .229 .191 .125
Personal safety .048 .048 .070 .130 .309 .276 .119
0.66 .072 .083 .130 .252 .235 .162
Do things with others .031 .032 .067 .142 .341 .254 .133
.053 .065 .078 .127 .257 .249 .171
Times with others .036 .063 .080 .167 .317 .247 .089
.070 .080 .091 .141 .262 .225 .130
Social interactions .036 .039 .067 .159 .285 .278 .137
.053 .065 .079 .128 .259 .248 .168
People in general .019 .027 .032 .128 .302 .321 .171
.023 .042 .060 .114 .272 .294 .195

estimated thresholds are quite similar for the two subdomain. In general, this information is readily
models. Although the fit of the model is signifi- available in life quality research in that the items
cantly improved when estimating category are sampled from unique subdomains as
parameters separately for each item (presumably illustrated in the example. A further benefit of
due to the large number of subjects, items, and the bi-factor model over unrestricted exploratory
categories), the model with common category item factor analysis is that the solution is
parameters may be a useful alternative for appli- rotationally invariant and therefore easily inter-
cations in which the items have the same number pretable. As shown here, the model is easily
of categories. extended to the case of ordinal response
items which characterize many if not most
Summary applications in life quality research. When the
In summary, the bi-factor model provides an focus is on the primary domain of interest (e.g.,
excellent modern psychometric approach to life overall life quality) as in the example, the addi-
quality measurement problems. The general tion of the subdomains resolves problems of con-
model provides unlimited dimensionality under ditional dependence that invalidates
the restriction that the subdomains of interest are unidimensional IRT models and allows one to
known in advance and that each item taps the develop large item banks that can be used for
primary domain and no more than one CAT (Gibbons et al., 2012).
Bi-factor Analysis 393 B
Bi-factor Analysis, Table 3 Estimated category thresholds for Rating Scale Model (RSM) and Samejima Model (SM)
for the first ten quality of life items
Item 12 23 34 45 56 67
Life as a whole RSM 1.452 1.005 0.673 0.278 0.361 1.079 B
SM 1.450 0.994 0.714 0.217 0.374 1.072
Family RSM 1.578 1.171 0.868 0.508 0.074 0.728
SM 1.666 1.184 0.950 0.408 0.110 0.722
Family contact RSM 1.435 0.981 0.642 0.241 0.409 1.140
SM 1.484 0.953 0.575 0.210 0.409 1.115
Family interaction RSM 1.236 0.831 0.530 0.172 0.408 1.059
SM 1.441 0.836 0.536 0.085 0.416 1.156
Family stuff RSM 1.240 0.489 0.558 0.213 0.347 0.976
SM 1.397 0.876 0.588 0.154 0.418 1.023
Total money RSM 0.952 0.521 0.199 0.182 0.799 1.493
SM 1.084 0.528 0.134 0.206 0.870 1.552
Basic needs RSM 1.395 0.895 0.523 0.082 0.634 1.437
SM 1.432 0.840 0.486 0.084 0.643 1.424
Financial well-being RSM 0.819 0.415 0.114 0.243 0.821 1.471
SM 0.913 0.417 0.064 0.281 0.869 1.533
Money for fun RSM 0.873 0.467 0.165 0.194 0.775 1.428
SM 1.032 0.439 0.046 0.236 0.829 1.430
General health RSM 1.876 1.322 0.908 0.418 0.376 1.268
SM 1.659 1.189 0.945 0.555 0.465 1.224

Cross-References quality of life indexes using item response theory

analysis. Medical Decision Making, 30, 515.
Gibbons, R. D., & Hedeker, D. (1992). Full-information
Confirmatory Factor Analysis (CFA) item bi-factor analysis. Psychometrika, 57, 423436.
Exploratory Factor Analysis Gibbons, R. D., Bock, R. D., Hedeker, D., Weiss, D. J.,
Factor Analysis Segawa, E., Bhaumik, D. K., et al. (2007).
Item Response Theory [IRT] Full-information item bifactor analysis of graded
response data. Applied Psychological Measurement,
31, 419.
Gibbons, R. D., & Hedeker, D. (2007). POLYBIF [Com-
References puter software]. Chicago: Center for Health Statistics,
University of Chicago. Available from www.
Bock, R. D., & Aitkin, M. (1981). Marginal maximum healthstats.org
likelihood estimation of item parameters: Application Gibbons, R. D., Weiss, D. J., Kupfer, D. J., Frank, E.,
of an EM algorithm. Psychometrika, 46, 443459. Fagiolini, A., Grochocinski, V. J., et al. (2008).
Bock, R. D., Gibbons, R. D., & Muraki, E. (1988). Full- Using computerized adaptive testing to reduce the
information item factor analysis. Applied Psychologi- burden of mental health assessment. Psychiatric Ser-
cal Measurement, 12, 261280. vices, 59, 361368.
Cai, L. (2010). A two-tier full-information item factor Gibbons, R. D., Weiss, D. J., Pilkonis, P. A., Frank, E.,
analysis model with applications. Psychometrika, 75, Moore, T., et al. (2012). Development of
581612. a computerized adaptive test for depression. Archives
Cai, L., du Toit, S. H. C., & Thissen, D. (forthcoming). of General Psychiatry, 69, 11041112.
IRTPRO: Flexible, multidimensional, multiple cate- Holzinger, K. J., & Swineford, F. (1937). The bi-factor
gorical IRT modeling. Chicago: Scientific Software method. Psychometrika, 2, 4154.
International. Joreskog, K. G. (1969). A general approach to confirmatory
Fryback, D. G., Palta, M., Cherepanov, D., Bolt, D., & maximum likelihood factor analysis. Psychometrika,
Kim, J. S. (2010). Comparison of 5 health-related 34, 183202.
B 394 Big Five Model of Personality

Lehman, A. F. (1988). A quality of life interview for the

chronically mentally ill. Evaluation and Program Big Picture Research
Planning, 11, 5162.
Muraki, E. (1990). Fitting a polytomous item response
model to Likert-type data. Applied Psychological Meta-studies
Measurement, 14, 5971.
Muthen, B. O. (1989). Latent variable modeling in het-
erogeneous populations. Psychometrika, 54,
557585. Bigotry and Religion
Patrick, C. J. (2007). A bifactor approach to modeling the
structure of the psychopathy checklist revised. Journal
of Personality Disorders, 21, 118141. Religion and Sexism
Rebollo, P., Castejon, I., Cuervo, J., Villa, G., Garcia-
Cueto, E., Diaz-Cuervo, H., et al. (2010). Validation
of a computer-adaptive test to evaluate generic
health-related quality of life. Health and Quality of Binary Response
Life Outcomes, 8, 18.
Reininghaus, U., McCabe, R., Burns, T., Croudace, T., &
Priebe, S. (2011). Measuring patients views: Eric K. H. Chan
A bifactor model of distinct patient-reported outcomes Department of ECPS, University of British
in psychosis. Psychological Medicine, 41, 277289. Columbia, Vancouver, BC, Canada
Reise, S. P., Moore, T. M., & Haviland, M. G. (2010).
Bifactor models and rotations: Exploring the extent to
which multidimensional data yield univocal scale
scores. Journal of Personality Assessment, 92, 544559. Synonyms
Rijmen, F. (2010). Formal relations and an empirical
comparison among the bi-factor, the testlet, and Dichotomous response format
a second-order multidimensional IRT model. Journal
of Educational Measurement, 47, 361372.
Samejima, F. (1969). Estimation of latent ability using
a response pattern of graded scores. Psychometrika Definition
Monograph Supplement, 17, 168.
Thurstone, L. L. (1947). Multiple factor analysis.
Chicago: University of Chicago Press. Binary response format is defined as a response
Tucker, L. R. (1958). An inter-battery method of factor format in measurement with only two possible
analysis. Psychometrika, 23, 111136. values (e.g., yes or no, true or false).
Weiss, D. J. (1985). Adaptive testing by computer. Journal
of Consulting and Clinical Psychology, 53, 774789.
Yang, F. M., Tommet, D., & Jones, R. N. (2009). Dispar-
ities in self-reported geriatric depressive symptoms Description
due to sociodemographic differences: An extension
of the bi-factor item response theory model for use in In quality of life measures, a binary or dichoto-
differential item functioning. Journal of Psychiatric
Research, 43, 10251035. mous response format is often used. Many
behavioral, biological, and social variables of
interests have only two possible values, such as
yes or no, true or false. For example, respondents
are asked to answer true or false to a series of
Big Five Model of Personality items on well-being. Multiple choice items on
educational achievement tests can also be viewed
Five Factor Model of Personality as a form of binary response format, as test-takers
answer each of the items either correctly or incor-
rectly. As only two possible values (or outcomes)
are available in a binary variable, logistic
Big Five Personality Traits regression and related dichotomous item
response models are suitable for analyzing these
Five Factor Model of Personality data (see, e.g., Wu & Zumbo, 2007).
Biodiversity Conservation 395 B
The advantage of binary response format is that
it is easy for respondents to answer; thus, the Biodiversity Conservation
burden placed on respondents is low. Compared
to items with many response options, particularly Bill Freedman
items with a midpoint option (e.g., a 9-point Likert Department of Biology, Dalhousie University, B
scale with 5 as the neutral option), binary Halifax, NS, Canada
response formats are cognitively less demanding.
As a result, respondents may be more likely to
complete binary items particularly when the mea-
sure is lengthy. Another advantage of the binary
Biodiversity, species; Biological diversity
response format is that relatively smaller sample
sizes are needed to fit measurement models
because fewer parameters need to be estimated Definition
(e.g., more item parameters would have to be
estimated for Likert scales). The term biodiversity, or biological diversity, is
Perhaps the major drawback of the binary report a hierarchical concept that refers to the richness
format is that it loses information (forcing people to of the living world. At its lowest scale, it includes
choose one of the two options) and that there is less the varied genetic information encoded within
variability in each item. It is important to note that the DNA of a population or species. At an inter-
variance is needed in psychometric analysis. So, mediate level, it may refer to the number of
compared to other response formats (such as Likert species that occurs in a particular ecological
scale), more items may be needed to achieve the community or geographic area. At an even larger
same level of variance if a binary response format scale, biodiversity is the variety of habitat types
is used. To learn about other response formats that is present on a landscape or seascape. For
(i.e., ordinal and continuous), please refer to the most people, however, the aspect of biodiversity
Response Formats entry in this volume. that is most easily understood is the number of
species present. This is known as species rich-
ness, and it includes all of the animals, plants, and
Cross-References microorganisms that may occur. Species richness
may be enumerated in a particular community,
Data Analysis in a politically defined region such as a park or
Logistic Regression a country, and ultimately in the entire biosphere.
Response Format

References Description

Wu, A. D., & Zumbo, B. D. (2007). Thinking about item So far, biologists specialized in the naming of
response theory from a logistic regression perspective:
organisms, or taxonomy, have identified about
A focus on polytomous models. In S. S. Sawilowsky
(Ed.), Real data analysis (AERA, educational statisti- 1.8 million species. Each is given a binomial
cians book series, pp. 241269). Greenwich, CT: name, such as Homo sapiens for humans. The
Information Age. groups that are best known and most comprehen-
sively named are relatively large or abundant
animals. In contrast, there are millions of as yet
undiscovered species of smaller organisms that
Binge Eating Disorder inhabit poorly documented ecosystems, espe-
cially in tropical forests and deep oceans. Some
Eating Disorder(s) and Health-Related Quality estimates of the ultimate species richness of the
of Life biosphere exceed 3050 million.
B 396 Biodiversity Conservation

About one third of the named species live in There are many examples of such bio-
tropical climes and two third in boreal and tem- resources. For instance, trees, which are mostly
perate latitudes. However, at least 90 % of the harvested from wild forests, are used to manufac-
unknown biodiversity is thought to exist in the ture lumber, paper, and various wooden products,
tropics. The species of tropical rainforest are or they are burned as renewable biomass energy.
especially poorly known, particularly the smaller The fruits of many wild plants are collected as
invertebrates and microorganisms. Most of this food and medicinals, and waterfowl, deer, and
hidden biodiversity of unnamed tropical spe- other wild animals are hunted for meat.
cies is comprised of tiny invertebrates, especially A relatively small number of species has been
beetles. domesticated, and they are the basis of most
Conservationists value indigenous biodiversity cultivated agriculture. Collectively, these uses
much more highly than alien elements. Similarly, of biodiversity are responsible for almost all
ecological communities that are naturally occur- foods eaten by people and much of the materials
ring and self-organized are more highly valued and energy that are used.
components of natural heritage than are anthropo- In addition to the known commercial benefits
genic habitats created by agriculture or urbaniza- of certain species, there are others whose uses are
tion. In fact, when alien species occur in wild not yet discovered, including potential medici-
habitats, they are deemed to be a biological pollu- nals and foods of great value. These potential
tion that degrades ecological integrity, and they benefits are an important reason to conserve all
may be assigned a derogatory label such as inva- elements of biodiversity, as is suggested by
sive alien. In North America, this is the reason a famous quotation of the American ecologist,
why the abundant but nonnative dandelion Aldo Leopold: To keep every cog and wheel is
(Taraxacum officinale) is referred to as a weed the first precaution of intelligent tinkering.
and the alien starling (Sturnus vulgaris) as a pest. Biodiversity is also economically important
because many people will pay money to experi-
Biodiversity Is Important ence its pleasures in nonconsumptive ways, such
To many people, the principal reason to cherish as naturalists seeking to observe birds or wild-
biodiversity is its intrinsic value, which applies flowers in a natural setting. These people expend
to anything having unique and irreplaceable qual- considerable leisure time in pursuit of their out-
ities. Any entity with intrinsic value has moral door sport, and a lot of money may be spent on
standing and a right to exist, regardless of travel, accommodations, and field equipment.
whether it is useful to people. The inherent Finally, at larger scales, biodiversity provides
value of art and other forms of cultural expression vital environmental services that sustain both
is acknowledged as a reason to hold these human people and the natural world. For example, for-
artifacts in esteem. The same is true of native ests store enormous quantities of organic carbon
species and natural ecological communities, and in biomass and so keep it out of the atmosphere as
so society has a responsibility to ensure that these carbon dioxide, a key greenhouse gas. Similarly,
elements of biodiversity will survive at viable well-vegetated landscapes supply predictable
levels of abundance. flows of clean water.
However, biodiversity also has utilitarian
value, and that is another important reason to Threats to Biodiversity
conserve it. Elements of biodiversity are valuable The natural world has always had to cope with
as sources of food, medicine, materials, and changes in environmental conditions. Over evo-
energy, and they are harvested and manufactured lutionary time, which extends through the 3.5-
into many products used by people. In aggregate, billion-year history of life, various stressors
these potentially renewable natural resources have caused many species to become extinct and
generate a huge economy when traded in domes- have even resulted in the loss of larger taxonomic
tic and international marketplaces. units, such as families and orders. In fact, natural
Biodiversity Indices 397 B
environmental factors have caused the extinction endangered-species legislation. Many govern-
of most of the species that have ever lived. mental and private organizations are also setting
Today, however, there is an unnaturally rapid aside large tracts as protected areas, whose key
rate of extinction that is driven by stressors associ- purpose is to conserve the natural habitats of
ated with the actions of people. This modern biodi- indigenous biodiversity. B
versity crisis is ruthless. It is mostly caused by However, it is also vital to do what is possible
the destruction of natural ecosystems to develop to conserve habitats on lands that are working
agricultural and urban land uses, particularly in to serve the economy by providing food and other
low-latitude countries where most biodiversity natural resources. Biodiversity can only be
exists. Secondary factors are ecological damages sustained if comprehensive actions are taken to
caused by alien species and the overharvesting of provide habitats in both working landscapes and
species of economic importance. As bad as it is protected areas. The conservation of biodiversity
today, the biodiversity crisis will become much in this manner is an integral component of the
worse if effective actions are not quickly taken to ecologically sustainable development of the
conserve the natural world. Essentially, the fixes to human economy.
this awful problem involve the implementation of
economic practices that have softer ecological
effects, coupled with the designation of protected Cross-References
areas. Those nature reserves are needed to sustain
the critical habitats of biodiversity at risk as well as Ecological Well-being
wilderness-scale tracts of representative ecosystems. Ecosystem Approach to Human Health
Sustainable Development
Conservation of Biodiversity United Nations Commission on Sustainable
The conservation of biodiversity is an important Development
societal goal. Many people are concerned about the
loss of natural values in their local areas, in their
country, and globally. They are demanding that
effective actions be taken to prevent further dam-
Chivian, E., & Bernstein, A. (2008). Sustaining life. How
ages and to repair some of the ones that have human health depends on biodiversity. New York:
already been caused. Governments are increasingly Oxford University Press.
engaged in conservation actions as are private com- Freedman, B. (2010). Environmental Science: A Cana-
dian Perspective. Pearson Education Canada, Toronto,
panies and many citizens. Nongovernmental con-
ON, Canada.
servation organizations have been formed, and they Gaston, K. J., & Spicer, J. I. (2006). Biodiversity. An
are helping to deal with issues related to biodiver- introduction. Malden, MA: Blackwell Science.
sity. Overall, there is broad-based support for the Lovejoy, T. E., & Hannah, L. (2006). Climate change and
biodiversity. New Haven, CT: Yale University Press.
vision of conserving biological diversity, and little
Naeem, S., Bunker, D. E., Hector, A., & Loreau, M.
opposition to that goal. (2009). Biodiversity, ecosystem functioning, and
At the international level, the conservation of human wellbeing: An ecological and economic per-
biodiversity is subject to its own treaty, the Con- spective. New York: Oxford University Press.
Primack, R. B. (2004). A primer on conservation biology
vention on Biological Diversity (1993) of the
(3rd ed.). Sunderland, MA: Sinauer Associates.
United Nations. The objectives of the CBD are Wilson, E. O. (1999). The diversity of life. New York: W.
to ensure that biological diversity is conserved W. Norton.
and its products used sustainably, with equitable
sharing of benefits among countries and peoples
of the world. Countries signatory to the CBD are
obliged to develop and implement a national Biodiversity Indices
action plan to conserve biodiversity and to report
on its implementation. Usually, this includes Indices for Monitoring Biodiversity
B 398 Biodiversity, Species

in 1970 by one of the twentieth centurys most

Biodiversity, Species prominent developmental psychology theoreti-
cian, and Head Start cofounder, Urie
Biodiversity Conservation Bronfenbrenner (19172005). Bronfenbrenner
envisioned that his bioecological theory be rele-
vant for practice, science, and policy, by studying
human development in real or realistic contexts.
Bioecological Model This vision is reflected in two axioms
Bronfenbrenner commonly quoted: There is
Bioecological Theory of Human Development nothing as practical as a good theory an
expression which Bronfenbrenner credits to his
mentor Kurt Lewin and There is nothing like
the practical to build a good theory
Bioecological Theory of Human (Bronfenbrenner, 1977a, p. 48). The relevance
Development of the theoretical model is underpinned by its
utility and practicality in documenting and study-
Matthew Waugh1 and Martin Guhn2 ing the quality of life. of individuals over their
Department of Educational and Counselling life course in various ecological contexts, with
Psychology and Special Education, University of the explicit goal to inform practice and public
British Columbia, Vancouver, BC, Canada policy (Bronfenbrenner, 1970, 1974). In fact, it
Human Early Learning Partnership, School of was from Bronfenbrenners early work that
Population and Public Health, University of pioneered Head Start (http://www.acf.hhs.gov/
British Columbia, Vancouver, BC, Canada programs/ohs/), a federally funded, comprehen-
sive early education program that has served
families of low-income children in the USA
Synonyms since 1964.

Bioecological model

Definition Fundamental concepts to the theory follow a set

of systems or nested structures having various
The bioecological theory of human development degrees of influence on human development
(Bronfenbrenner, 1986b; Bronfenbrenner & (Bronfenbrenner, 1979, p. 3). The first level
Ceci, 1993, 1994; Bronfenbrenner & Morris, and innermost system is the microsystem, the
2006) is a comprehensive theoretical and setting which contains the developing person at
methodological model for the study of human any given point in time. Settings may consist of
development. Extending on earlier ecological the persons home, classroom, or work setting,
models of development (Bronfenbrenner, 1979, each having roles which the developing person
1989, 1986a, 1986b), the bioecological theory fills (e.g., student, teacher, or parent roles).
expounds on the biopsychological features of The interrelations among major settings
the developing person and on the capability containing the developing person at a particular
for proximal processes to differentiate and point in his or her life form the mesosystem
actualize biological potential (Bronfenbrenner (Bronfenbrenner 1977b, p. 515), and it is with
& Ceci, 1993, 1994; Bronfenbrenner & Morris, the proximal processes, or the bidirectional
2006). The bioecological theory of human devel- interactions between organisms or developing
opment has progressed through periodic revi- person and the environment, immediate or
sions since its first comprehensive formulation distal, that drives human development
Bioecological Theory of Human Development 399 B
(Bronfenbrenner & Ceci, 1993, 1994; The form, power, content, and direction of the
Bronfenbrenner & Morris, 2006). Those envi- proximal processes producing development vary
systematically as a joint function of the character-
ronments in which the individual does not istics of the developing person (including genetic
directly come into contact with, but is nonethe- inheritance); of the environment-both immediate
less influenced by, including neighborhood and and remote-in which the processes are taking B
community systems, local health institutions, place; of the nature of the developmental outcomes
under consideration; and of the continuities and
and media, are defined as the exosystem. The changes occurring in the environment over time,
macrosystem is the fourth level, encompassing through the life course, and during the historical
the cultural, political, religious, and other period in which the person has lived.
macroinstitutions that influence the developing (Bronfenbrenner, 2001/2005, pp. 67)
person within all other levels over time
(chronosystem). At the crux of the bioecological theory is its
Bronfenbrenner critiqued his own original for- intent for both the model and subsequent research
mulation of ecological systems theory, due to his designs to be operational (Bronfenbrenner &
belief that developmental knowledge derived Evans, 2000), meaning that the paradigm would
from examinations of environmental influences necessarily shift from verifying research towards
on human development had come at the expense discovery. The juxtaposition between a mode of
of defining the fundamental processes that verification and the discovery mode is the differ-
underlie human development. This led to ence between verification or replication of find-
a reformulation in the 1990s, when ings and the more robust mode (i.e., discovery) of
Bronfenbrenner added two key defining proper- an extended process involving a series of pro-
ties to the ecological model. The first property gressively more differentiated formulations, with
maintains that human development is the product the results at each successive step setting the
of processes of progressively complex recipro- stage for the next round (Bronfenbrenner,
cal interactions between an active, evolving 2001b, p. 187). This includes the systematic
biopsychological human organism and the per- review and need for devising of alternative
sons, objects, and symbols in its immediate exter- hypotheses prior to the scientific process being
nal environment (Bronfenbrenner & Morris, carried out (Bronfenbrenner, 2001a, p. 4), requir-
2006, p. 797). These processes, or proximal ing researchers to develop hypotheses of
processes, whereby interactions between the sufficient explanatory power and precision to
developing person and the immediate environ- warrant being subjected to empirical test
ment are sustained, are seen as the driving force (Bronfenbrenner & Morris, 2006, p. 801). The
behind human development (Bronfenbrenner, process-person-context-time model (or P-P-C-T )
2001b). In developmental research, the effects that has come out of bioecological research meets
of such enduring interactions are best mea- this criteria as an operational research design,
sured when interactions are taking place on holding theory as a critical component and
a regular basis over extensive durations. Fur- allowing for the investigation of the properties
thermore, the expansion of the microsystem previously discussed (effects of proximal pro-
incorporated the semiotic system (e.g., sym- cesses, genetic variability, and environmental
bols and language) as another set of proximal interactions over time):
processes essential for study. Bronfenbrenner Process: Central to the P-P-C-T model is the
and Morris (2006) advise that objects and concept of process, which includes the
symbols be inviting and promote exploration proximal processes or particular forms of
and manipulation which can give insight into interaction between organism and
the actions, goal setting behaviors, and inten- environment. . .that operate over time and are
tions formed by the developing person. The posited as the primary mechanisms producing
second key property of the bioecological human development (Bronfenbrenner &
model states: Morris, 2006, p. 795). The form, power,
B 400 Bioecological Theory of Human Development

content, and direction of these processes, to activity that is of longer durations and
a large degree, are dependent on a joint func- involves engagement from the developing
tion of the characteristics of the developing person, such as reading a book, participating
person (Person), the environmental contexts in a class discussion, or completing
(Context), and time periods (Time) in which a homework assignment. Acts constitute an
processes take place (Bronfenbrenner & Ceci, instant behavior, such as the clapping of the
1993, p. 178). The properties within proximal hands, tapping of the foot, smile, or nod.
processes are believed to affect the develop- A much needed elaboration to the process of
mental trajectories of the developing person. time was provided and represents three levels
Bronfenbrenner cited two categorical path- of ecology: microtime, mesotime, and
ways including dysfunction and competence. macrotime (Bronfenbrenner & Ceci, 1994).
Dysfunction is defined as the inability for an Microtime refers to continuity versus discon-
individual to self-regulate and integrate tinuity in ongoing episodes of proximal
behaviors appropriately across situations, processes (Bronfenbrenner & Morris, 1998,
whereas competence, as demonstrated by the p. 995). Mesotime involves the recurrence of
developing person, shows an acquisition and episodes across time (e.g., days, weeks, and
further development of knowledge and months). Macrotime, unlike the first two
skills whether intellectual, physical, levels, does not directly involve the develop-
socioemotional, or a combination of them ing person, rather it focuses on the larger soci-
(Bronfenbrenner & Morris, 2006, p. 803). ety, across generations, and the events therein
Person: The power of proximal processes are that have the propensity to affect or be
regulated and set in motion by three types of affected by human development over time.
person characteristics (Bronfenbrenner & Similar to the imbedding of the property of
Morris, 1998, 2006). The first are dispositions, time into the three levels of systems, other com-
which set proximal processes in motion. The ponents of the P-P-C-T model can be viewed
second are an individuals bioecological within each of the nested structures. For example,
resources, including ability and skill sets, the three properties of person can be imbedded
knowledge, and experience necessary for within the microsystem; disposition, resource,
effective functioning of proximal processes and demand characteristics of parents, teachers,
at a given stage of development students are within the niche of the microsystem.
(Bronfenbrenner & Morris, 1998, p. 995). The These components of the P-P-C-T model are
final is the demand characteristic that can either essential for designing studies on human devel-
invite or discourage reactions from the social opment that stand a chance to yield new scientific
environment that can foster or disrupt the oper- knowledge that meets the criteria set forth under
ation of proximal processes (Bronfenbrenner bioecological theory.
& Morris, 2006, p. 796). Central to the bioecological theory of human
Context: When the microsystem was development (Bronfenbrenner & Ceci, 1993,
expanded, so too was the context of the prox- 1994; Bronfenbrenner & Morris, 2006) are the
imal processes taking place in those environ- developmental and behavioral mechanisms
ments that contain the developing person. (proximal processes) in a developing persons
Context incorporates all characteristics of the environment that drive human development.
person (e.g., biopsychological), environments The relevance of the bioecological model to
in which the person is situated, and different developmental research is in its capacity to
levels of time. guide exploration and allow investigators
Time: Early concepts of ecological systems a framework for measuring and organizing envi-
theory only briefly discussed the dimension ronmental and biological variables based on its
of time in relation to molar activities and acts proximity to the developing person. Structuring
(Bronfenbrenner, 1979). A molar activity is an such variables within their respective
Biofeedback 401 B
bioecological systems within and around an indi- around? In Author (Ed.), Making human beings
vidual provides a tool for evaluating the extent to human: Bioecological perspectives on human devel-
opment (pp. 185197). Thousand Oaks, CA: Sage
which those variables influence the persons Publications (Reprinted from Parenthood in America,
development over time. Bronfenbrenners vision pp. 197210, by J. C. Westman, Ed., Madison:
was to promote applied developmental science University of Wisconsin Press). B
that is both theoretically sound and practically Bronfenbrenner, U. (2001b). The bioecological theory of
human development. In Author (Ed.), Making human
relevant so as to provide a scientific foothold for beings human: Bioecological perspectives on human
social policy designs and implementation development (pp. 315). Thousand Oaks, CA: Sage
(Bronfenbrenner, 2001a, p. 4) with the means to Publications. Reprinted from International encyclope-
combat the growing chaos in the lives of chil- dia of the social and behavioral sciences,
pp. 69636970, by N. J. Smelser & P. B. Baltes Eds.,
dren, youth, and families (Bronfenbrenner, New York, NY: Elsevier.
2001b, p. 186). Bronfenbrenner, U., & Ceci, S. J. (1993). Heredity, envi-
ronment and the question How?: A first approxima-
tion. In Author (Ed.), Making human beings human:
Bioecological perspectives on human development
(pp. 174184). Thousand Oaks, CA: Sage Publica-
tions. Reprinted from Nature, nurture, and psychol-
Child Development ogy, pp. 313323, by R. Plomin & G. E. McClearn,
Development Eds., 1995, Washington, DC: APA Books.
Bronfenbrenner, U., & Ceci, S. J. (1994). Nature-nurture
Human Development
reconceptualised: A bio-ecological model. Psycholog-
ical Review, 10(4), 568586. doi:10.1037/0033-
References Bronfenbrenner, U., & Evans, G. W. (2000). Develop-
mental science in the 21st century: Emerging ques-
Bronfenbrenner, U. (1970). Children and parents tions, theoretical models, research designs, and
(pp. 241255). Washington, DC: U.S. Government empirical findings. Social Development, 9, 1525.
Printing Office (Report of Forum 15). doi:10.1111/1467-9507.00114.
Bronfenbrenner, U. (1974). Developmental research, pub- Bronfenbrenner, U., & Morris, P. (1998). The ecology of
lic policy, and the ecology of childhood. Child Devel- developmental processes. In W. Damon & R. M. Ler-
opment, 45. Retrieved from http://www.jstor.org. ner (Eds.), Handbook of child psychology: Vol. 1 The-
ezproxy.library.ubc.ca/stable/1127743. oretical models of human development (5th ed.,
Bronfenbrenner, U. (1977a). Lewinian space and ecolog- pp. 9931028). New York: Wiley.
ical substance. In Author (Ed.), Making human beings Bronfenbrenner, U., & Morris, P. (2006). The
human: Biological perspectives on human develop- bioecological model of human development. In W.
ment (pp. 4149). Thousand Oaks, CA: Sage Publica- Damon & R. M. Lerner (Eds.), Handbook of child
tions. Reprinted from Journal of Social Issues, 33, psychology: Vol. 1. Theoretical models of human
199212. development (6th ed., pp. 793828). Hoboken, NJ:
Bronfenbrenner, U. (1977b). Toward an experimental Wiley.
ecology of human development. American Psycholo-
gist, 32, 513531. doi:10.1037/0003-066X.32.7.513.
Bronfenbrenner, U. (1979). The ecology of human devel-
opment: Experiments by nature and design.
Cambridge, MA: Harvard University Press.
Bronfenbrenner, U. (1986a). Recent advances in research
on the ecology of human development. In
R. K. Silbereisen, K. Eyferth, & G. Rudinger (Eds.), Liana Mattulich1 and David M. Paperny2
Development as action in context: Problem behavior 1
Inner Key Center, Jefferson, CO, USA
and normal youth development (pp. 286309). New 2
University of Hawaii School of Medicine,
York: Springer Verlag.
Bronfenbrenner, U. (1986b). Ecology of the family as Honolulu, HI, USA
a context for human development. Developmental
Psychology, 22, 723742.
Bronfenbrenner, U. (1989). Ecological systems theory.
Annals of Child Development, 6, 187249.
Bronfenbrenner, U. (2001a). Growing chaos in the lives of
children, youth, and families: How can we turn it Self-regulation
B 402 Biofeedback

Definition hints for the trainee on how to make internal

self-adjustments to improve performance and
Biofeedback is a scientific process where an indi- enhance personal success. Biofeedback instru-
vidual usually uses instrumentation to learn to mentation is optimally used in conjunction with
change physiological activity for the purpose of psychological procedures specific to the individ-
improving health and well-being. It is monitoring uals needs, and protocols are tailored to individ-
and mirroring of signals from the body to ual goals and states of well-being or disease
improve health, self-concepts, self-regulation, (Gaarder & Montgomery, 1977). Biofeedback
and quality of life. has been proven to be an effective treatment for
migraine and tension-type headaches, urinary
incontinence, high blood pressure, anxiety, and
a number of other conditions. Neurofeedback
Description (brain wave biofeedback) is an effective treat-
ment for attention deficit hyperactivity
Biofeedback uses scientific instrumentation that disorder, brain injury, post-traumatic stress,
measures physiological activity such as skin tem- seizures, and depression. Cost effectiveness,
perature, heart and breathing parameters, muscle long-term effects, and existing personal contrain-
activity, and even brainwaves. This information dications are considerations for any application
is presented to the individual, resulting in of biofeedback for either personal empowerment
changes in thinking, emotions, and behavior or treatment of specific conditions (Schwartz &
which support positive physiological changes Andrasik, 2003).
for a higher quality of life (see BCIA).
Entrainment devices such as those using light Disorders and Treatment Efficacy
stimulation, binaural sounds, or electrical stimu- The disorders listed below are those most com-
lation are not biofeedback. Biofeedback is as monly evaluated by psychophysiological tech-
simple as using a thermometer to measure tem- nology and treated with biofeedback, which has
perature or a scale to measure weight in order to been shown to be efficacious to various degrees
use the information so as to allow one to take based on research studies (see www.aapb.org)
action to make a desired change. Biofeedback is (Hatch et al., 1987).
a noninvasive scientific way to see, hear, and Efficacious and specific (fifth level):
learn the physiology, which enables the training 1. Urinary incontinence in females
of self-regulation. This process also can provide Efficacious (fourth level):
precise psychophysiological measures that allow 1. Anxiety
the release of unwanted emotional baggage in 2. Attention deficit disorder
order to make better choices in a more aware 3. Headache adult
state (Dunn et al., 1986). 4. Hypertension
Two approaches are used in behavioral medi- 5. Temporomandibular disorders
cine: Biofeedback helps people recognize how 6. Urinary incontinence in males
a physiological system is functioning and learn Probably efficacious (third level):
self-control of that system, so that it works opti- 1. Alcoholism/substance abuse
mally (e.g., body self-regulation, the analogy of 2. Arthritis
a tune-up for a car). Self-hypnosis helps people 3. Chronic pain
develop intention and focus on a goal and to think 4. Epilepsy
and act in a more relaxed and deliberate manner. 5. Fecal elimination disorders
(e.g., mind self-regulation, the analogy of using 6. Headache pediatric migraines
a gas additive for a car). 7. Insomnia
The biofeedback therapist acts as a coach, not 8. Traumatic brain injury
only by teaching skills but also by providing 9. Vulvar vestibulitis
Biofeedback 403 B
Possibly efficacious (second level): EDR (electrodermal response) and GSR
1. Asthma (galvanic skin response) variation of electri-
2. Cancer and HIV, effect on immune cal conductivity of the skin as related to
function emotional states
3. Cerebral palsy EMG (electromyography) strength of action B
4. Chronic obstructive pulmonary disease of sphincters and muscle fibers
5. Depressive disorders OF oxygen flow present in the capillaries as
6. Diabetes mellitus measured in the fingers
7. Fibromyalgia PF pulse variability for training
8. Foot ulcers self-regulation of heart rhythm
9. Hand dystonia HEG (hemo-encephalography) measure-
10. Irritable bowel syndrome ment of blood circulation at frontal areas of
11. Mechanical ventilation the brain
12. Motion sickness CO2 (capnometry) measures exhalations for
13. Myocardial infarction training enhanced respiratory functionality and
14. Post-traumatic stress disorder efficiency (see Applied Psychophysiology)
15. Raynauds disease HRR (heart rate resonance, HRV) measures
16. Repetitive strain injury the relationships between the breath and heart
17. Stroke rhythms (see Applied Psychophysiology)
18. Tinnitus
19. Urinary incontinence in children Thermal Feedback (TBF)
Not empirically supported (first level of Stressful situations cause most people to experi-
evidence): ence cold and clammy hands. Such moods and
1. Autism emotions cause capillaries to contract in response
2. Eating disorders to hormonal activity and neurotransmitters circu-
3. Multiple sclerosis lating in the blood. TBF is usually done on one
4. Spinal cord injury finger of each hand to identify and retrain the
Biofeedback training improves symptoms, stress response. It allows the trainee to precisely
often allows medication reduction, increases emo- sense changes as small as 0.01  F, reflecting the
tional balance, reduces stress, and enhances a sense warmth of blood flow to the fingers. Increasing
of self-control and self-efficacy. In the fields of the volume of peripheral circulating blood
education, sports (especially Olympic training), can be accomplished more effectively by
and among business executives, biofeedback train- using adjunct practices and psychological
ing commonly provides stress resistance, resil- methods of deep engagement using sensory
iency, enhanced creativity, positive self-esteem, integration and visualization of positive
physical and emotional well-being, leadership emotional memories.
development, conflict resolution, and a capacity The trainees first goal is usually to equalize
for delay of gratification, as well as receptivity to the temperature of both hands. Bilaterally equal
learning and greater productivity. Corporate exec- responses in both may not occur in the presence
utives, musicians, artists, and many athletes have of vascular illness in the extremities, neck, or
used biofeedback and neurofeedback to reach their shoulders. Their second goal is usually the capac-
peaks in both competition and performance. ity to raise the temperature in both hands to an
Common modalities of standard biofeedback average of 95  F in less than 10 min. Raising the
(excluding neurofeedback) are as follows, and peripheral skin temperature is a powerful tool for
the top three are foremost: reducing the effects of stress in the entire mind-
TBF (thermal feedback) temperature of the body field and helps sustain the skills learned
fingers from warmth produced by increased in training. Certain mindfulness trainings
circulation of blood use 96.8  F as the threshold for optimal
B 404 Biofeedback

transformation of the psychophysiology to as well as temporomandibular joint problems, are

exceptional performance states. some of the medical diagnoses where EMG offers
sustainable, long-term improvements.
Electrodermal Response (EDR) and Galvanic Fecal and urinary incontinence (sphincter
Skin Response (GSR) failure) are often treatable with only a few EMG
Two reciprocal scales are used to measure the sessions (average 610). Such techniques allow
electrochemistry of the skin. The first is resis- regaining self-control, yet are least invasive
tance also known as GSR, the resistance of and very low cost (vs. surgery) for such condi-
the skin to conduct electrical current. It measures tions in the older population. Preceding other
dryness increase when sweat is reduced, and it is biofeedback techniques, EMG and TBF are
measured in mohs. The second measure is useful preliminary approaches to enhanced
EDR, the conductance the opposite of resis- self-regulation in treating many disease states
tance. EDR reflects electrical activity that and particularly in preparation for neurofeedback
increases with sweat gland activity, which usu- training (see www.InnerKeys.info).
ally accompanies sympathetic nervous system
arousal. It is also known as skin conductance/ Self-Regulation Technology
electrodermal response (SC/EDR) and is Precise psychophysiological measures that pro-
measured in ohms. vide useful feedback can effect change in a very
Stressful situations also cause most people to short time. Cognitive processing of information
experience sweaty hands. EDR, as the measure of alone cannot produce the required changes in
skin conductance (since sweat is a salty conduc- psychophysiology, body-mind energies, and
tive electrolyte), detects both transitory behaviors that are required for optimal function-
emotional states and mental events, providing ing. Biofeedback training using todays technol-
objective information about the psychophysio- ogy has reached a pinnacle in the ability to
logical level of arousal. EDR is usually measured accelerate and sustain over time greater personal
on the palm of the dominant hand or on the effectiveness, focus, endurance, and emotional
fingertips. Trainees can learn to lower hand flexibility, which together empower people to
perspiration to 12 of conductance, what is meet the demands of modern living with greater
the threshold of normal. When individuals are capacity and facility.
consciously or unconsciously repressing When these technologies are used in combi-
disturbing thoughts or emotions, feedback will nation with cognitive tools such as introspection,
often show a flat-line dermal response, and the analogies, storylines, metaphors, sounds, sym-
therapist may utilize cognitive techniques or bols, and sensory integration, then a new level
other methods to assist self-regulation by releas- of well-being and quality of living is created
ing an expressive block, reflected by an improved for daily life which has long-term sustainability:
EDR. Introspection is inner silence with
self-observation. (The observer modifies
Electromyography (EMG) outcomes recently validated by quantum
EMG measures the electric activity of muscles physics.)
(including sphincters) by sensors applied to the Analogies enable a literal meaning to be
skin over a defined muscle of the body. conveyed in a different form and engage both
Some research centers may insert fine needles into hemispheres of the brain simultaneously.
muscle fibers to measure actual contractions. Para- Storylines convey the meaning and signifi-
plegics with damage to the spinal medulla are better cance of events, instilling community and
trained when such electrodes are placed directly cultural values and identity.
into muscle tissue to facilitate regaining self-regu- Metaphors represent ideas in another form
lation. Physical rehabilitation, neuromuscular reed- with emotional content that evoke specific
ucation, headache, muscle tension, pain, and spasm, psychobiochemistry.
Biofeedback 405 B
Sounds focus the mind; modify and restore home, could provide humanity many new options
mind-body energetic pathways; and have and choices. Enjoyable methods such as empow-
been used for millennia in music, vocaliza- erment games can build inner joy, self-esteem,
tions, mantras, and sacred sounds. and confidence and create a new generation that
Symbols focus the mind, broadening the requires no drugs and fewer external controls in B
range of perceptions, and induce abstract the face of pressure and stress, since they will
thought, giving more clarity meaningful have learned internalized coping mechanisms to
information. survive and succeed in modern society (Mattulich
Sensory integration systematically and rapidly & Paperny, 2008).
expands human capacity in unconventional The highest human potential could be attained
combinations to significantly develop new, by every trainable person, producing a quality of
effective pathways within the mind-body- life far beyond the narrow horizon so far provided
energy system. by our current approaches to health and educa-
Biofeedback offers future humanity tion. It is the responsibility of science and tech-
self-development and a psychophysiology to nology to improve the conditions and well-being
obtain a freedom and inner peace that is sustain- of humanity. We are psychophysiological beings
able during the challenges of daily life and in with a desire to improve ourselves. This
personal situations. It is intrinsic learning rather millennium is the moment to allow a new
than external control when people train paradigm, to embrace new options, and to make
self-regulation to reach exceptional performance self-regulation, enhanced perception, and higher
levels. The biofeedback-trained condition called human potentials part of a future of peace and
brain plasticity, together with an enhanced prosperity on this planet.
immune response, creates a healthy and efficient
individual, empowered to handle social,
job-related, and daily stresses. It is also possible Cross-References
to go one step beyond, to create new pathways
that bring the highest potentials of the essence of Applied Psychophysiology
that which is human, to enhance creativity Neurotherapy
and invention, and to develop an optimal life
experience. Stress reduction, enhanced produc- References
tivity, and resiliency in a hostile environment
are all possible with enhanced self-regulation of Association of Applied Psychophysiology and Biofeed-
the psychophysiology. back. (www.aapb.org).
Dunn, T. G., Gillig, S. E., & Ponsor, S. E. (1986). The
Applied psychophysiology has opened learning process in biofeedback: Is it feed-forward or
a window for human potential, possibly offering feed-back? Biofeedback and Self-Regulation, 11(2),
new, effective solutions to multiple global prob- 143157.
lems and needs, including conflicts among the Gaarder, K. R., & Montgomery, P. S. (1977). Clinical
biofeedback: A procedural manual. Baltimore:
billions of people living on the planet. The dis-
Williams & Wilkins.
ease-based paradigm of the past is insufficient for Hatch, J. P., Fisher, J. G., & Rugh, J. (1987). Biofeedback:
global well-being, and rational, scientific mea- Studies in clinical efficacy. New York: Plenum Press.
sures that demonstrate positive outcomes and Inner Key International. (www.innerKey.org).
Mattulich, L. M. D., Paperny D. M. D. (2008) Journey to
changes are necessary for the well-being of awareness and beyond with modern technology and
humanity in so diverse a world today. We are so ancient wisdom: Paving your path to empowerment
at the effect of our physiologic hard wiring and and transformation with brainwave biofeedback
our biochemical emotions on a daily basis that and your inner keys. Xlibris Corporation. ISBN13
Softcover: 978-1-4363-4464-7. (www.innerkeys.
both limit our happiness and success. Training to info).
self-regulate our own individual psychophysiol- Schwartz, M., & Andrasik, F. (2003). Biofeedback:
ogy as part of daily education, and also in the A practitioners guide (3rd ed.). New York: Guilford.
B 406 Biological Diversity

a social response to disease. One can have an

Biological Diversity illness without disease, e.g., grief as a response
to loss, and disease without illness, e.g., asymp-
Biodiversity Conservation tomatic hypertension. The biopsychosocial
model extends and elaborates the traditional
biomedical approach by adding the rich human
dimensions of suffering and clinician-patient
Biomedical Model of Qol and Breast relationships both of which can exert powerful
Cancer influences on the course, direction, and outcome
of care, including quality of life.
Psychological Quality of Life Among Breast
Cancer Patients

In 1910, Abraham Flexner, published what is

Biophilia arguably the most influential report on medical
education in the United States (Flexner, 1910).
Nature and Well-Being Flexner argued that medical education should be
based on evidence from the natural sciences and
that all training should come under the umbrella
of universities and other institutions of higher
Biophilia Theory learning. Until that point, medical education
was largely unregulated, medical schools were
Animal Beauty, Cross-Cultural Perceptions owned by one or several individuals and were in
business to make a profit, and there was no stan-
dard program of learning from school to school
nor was there a licensing body that would
Biophilic Cities accredit schools and the individuals they turned
out. Flexners focus on the causes and conse-
Sustainable Communities Movement quences of disease was well warranted. Just
8 years after his report, the flu epidemic of 1918
killed between 20 and 50 million people world-
wide. By contrast the H1N1 flu epidemic of 2009
Biopsychosocial Model killed an estimated 18,000 people, underscoring
advances in biomedicines ability to respond to
Richard M. Frankel outbreaks and rapid spread of diseases. In 1977,
Department of Medicine, Indiana University some six and a half decades after the Flexner
School of Medicine, Indianapolis, IN, USA report exhorted medical schools to focus on the
diagnosis and treatment of disease largely using
evidence from the biological sciences, George
Definition Engel, an internist at the University of Rochester,
with training in psychiatry, published an article in
Based on systems theory, the biopsychosocial the journal Science entitled The Need for a New
model represents the integration of biological, Medical Model: A Challenge for Biomedicine
psychological, and social information gathered (Engel, 1977). In it, Engel argued that the view
by a clinician in caring for patients. In addition espoused by the seventeenth-century philosopher
to disease as a basis for clinical practice, the Rene Descartes that the mind and body are sepa-
biopsychosocial model conceptualizes illness as rate was false and that biomedicine which is
Biopsychosocial Model 407 B
based in this view needed to be replaced. In its Jensen et al., 2011), and a systematic review of
place Engel proposed a biopsychosocial model, the literature on communication interventions in
one that synthesized and integrated information medical interviewing has shown positive results
from the biological, psychological, and social in terms of patient satisfaction, functional,
sciences and clinically added the patients expe- and even biomedical outcomes (Rao, Anderson, B
rience of disease and illness as a central task of Inui, & Frankel, 2007). Interpersonal communi-
doctoring. cation skills are now among six competencies
The biopsychosocial model has been the basis required by the Accreditation Council for
for a good deal of basic and applied research. For Graduate Medical Education that all residents
example, Robert Ader, who was a close colleague must demonstrate as a condition for licensure.
and disciple of Engels at the University of Roch- In 2001, the Institute of Medicine (IOM)
ester, was investigating the effects of classical published a heavily cited monograph entitled
conditioning in laboratory rats. Using Crossing the Quality Chasm: A New Health
a combination of saccharine and Cytoxan which System for the 21st Century (Institute of Medi-
induces nausea and suppresses the immune sys- cine, 2001). In it, the IOM identified patient-
tem, he found that after conditioning just feeding centered care, as one of six domains of quality.
the rats with saccharine-laced water was suffi- The term patient-centered care was coined by
cient to suppress the immune system of the rats, Joseph Levenstein and his colleagues at the Uni-
demonstrating that the nervous system can affect versity of Western Ontario in 1986 (Levenstein,
the immune system (Frankel, Quill, & Mc Daniel, McCracken, & McWhinney, 1986). It is a direct
2003). Aders research has led to the develop- descendant of the biopsychosocial model. Today,
ment of an entire field called psychoneuroimmu- patient-centered care is the basis for a number of
nology. In terms of quality of life, this work is research and clinical initiatives that include the
important because it suggests that conditioning in founding of the Patient-Centered Outcomes
humans could eventually be used to alleviate Research Institute, instituted as part of the Patient
symptoms and improve quality of life in disorders Protection and Affordable Care Act in 2011 with
such as fibromyalgia and irritable bowel syn- yearly funding of 750 million dollars. Models of
drome, both of which are known to have care almost always reflect the social, scientific,
a psychophysiological component to them. and political context in which they emerge.
Engels work has remained a strong influence For Flexner, it was a context in which modern
in medical education where the physicians role medicine was unregulated and in its infancy in
in affecting patients quality of life, not just diag- terms of curing diseases capable of killing mil-
nosis and treatment of disease, has been recog- lions of people in the space of a few years. Today,
nized. For example, lifestyle issues such as the industrialized world enjoys the unprece-
tobacco and alcohol use are the leading causes dented benefits of science and technology.
of preventable deaths. Physicians skills in All of these benefits, notwithstanding human
counseling patients to make lifestyle changes suffering still exists. Engels biopsychosocial
has been shown to be effective. It has been model was an attempt to restore the age-old
shown, for instance, that 1 min of tobacco cessa- promise of the Hippocratic oath to do no harm
tion counseling has a measurable effect on patient and relieve all forms of suffering irrespective of
quit rates. Almost every medical school in North their origin.
America has a course on medical interviewing
that includes skills training in eliciting psychoso-
cial as well as biomedical information. Several Cross-References
randomized controlled studies have been done
looking at the effects of teaching medical Communication and Personal Well-being
residents and practicing physicians the Patient-physician Communication
biopsychosocial model (Smith et al., 1998; Fossli Quality of Life (QOL)
B 408 Biopsychosocial Model of Quality of Life

Bipolar Disorder (BD)
Engel, G. L. (1977). The need for a new medical
model: A challenge for biomedicine. Science, 196,
Heather Armstrong1, Erin Michalak2 and
Flexner, A. (1910). Medical education in the United States Greg Murray3
and Canada. New York: Carnegie Foundation for the University of Ottawa, Ottawa, ON, Canada
Advancement of Teaching. 2
University of British Columbia,
Fossli Jensen, B., Gulbrandsen, P., Dahl, F. A., Krupat, E.,
Vancouver, BC, Canada
Frankel, R. M., & Finset, A. (2011). Effectiveness 3
of a short course in clinical communication Psychological Sciences and Statistics,
skills for hospital doctors: Results of a crossover Swinburne University of Technology,
randomized controlled trial (ISRCTN22153332). Melbourne, VIC, Australia
Patient Education and Counseling, 84(2), 163169.
Frankel, R. M., Quill, T., & Mc Daniel, S. (Eds.) (2003).
The biopsychosoical approach: Past, present,
future. Rochester, New York: University of Rochester Synonyms
Institute of Medicine. (2001). Crossing the quality chasm:
BD; BD I; BD II; Bipolar affective disorder;
A new health system for the 21st century. Washington,
DC: National Academies Press. Bipolar disorder scale (QoL.BD), quality of life;
Levenstein, J. H., McCracken, E. H., & McWhinney, I. R. Manic depression; Manic depressive disorder;
(1986). The patient centered clinical method I. A Manic depressive illness
model for the doctor patient interaction in family med-
icine. Family Practice, 1, 2430.
Rao, J. K., Anderson, L. A., Inui, T. S., & Frankel, R. M.
(2007). Communication interventions make a differ- Definition
ence in conversations between physicians and patients:
a systematic review of the evidence. Medical Care,
The most widely accepted definition of bipolar
45(4), 340349.
Smith, R. C., Lyles, J. S., Mettler, J., Stoffelmayr, B. E., disorder (BD, previously manic depression or
Van Egeren, L. F., Marshall, A. A., Gardiner, J. C., manic depressive illness) derives from current
Maduschke, K. M., Stanley, J. M., Osborn, G. G., psychiatric taxonomies, which characterize BD
Shebroe, V., & Greenbaum, R. B. (1998). The
as a serious and recurrent mood disorder. People
effectiveness of intensive training for residents
in interviewing. A randomized, controlled study warranting the diagnosis of BD experience mania
[see comments]. Annals of Internal Medicine, 128(2): (pathologically elevated, irritable, or expansive
118126. mood) and depression in various combinations
and intensities.

Biopsychosocial Model of Quality Diagnostic and Definitional Issues
of Life For the current Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV-TR; American
Psychological Quality of Life Among Breast
Psychiatric Association [APA], 2000), the bipo-
Cancer Patients
lar disorders are diagnosed on the basis of manic
symptoms of varying severity. Bipolar I disorder
(BD I), defined by at least one episode of mania
(labeled a mixed episode when a depressive
episode is concurrent), receives most research
Bipolar Affective Disorder and clinical attention. There is growing appreci-
ation that bipolar II disorder (BD II, defined by
Bipolar Disorder (BD) hypomanic episodes and depressive episodes)
Bipolar Disorder (BD) 409 B
generates comparable impairment and suicide DSM-IV-TRs categorical diagnoses are rela-
risk to BD I. While BD I and BD II are concep- tively arbitrary cut points on a dimension
tualized as episodic disorders, cyclothymic dis- (or dimensions) of variation in the general popu-
order is a milder, chronic variant. Contemporary lation. There appear to be two important dimen-
critiques suggest that BD is best viewed on sions underpinning the BD syndrome, namely, B
a spectrum of severity and more radically that depression-proneness and mania-proneness.
a fundamental dimensionality (viz., dimensions Consistent with research elsewhere in description
of mania- and depression-proneness) underlies and diagnosis, these two dimensions are com-
the current categorical diagnostic constructs. monly understood as vulnerability traits.
Some features of the current DSM-IV-TR Although this research throws doubt on DSM-
(APA, 2000) diagnosis of BD are worth IV-TRs categorical constructs (bipolar I, bipolar
highlighting. First, the serious variants II, and cyclothymic disorder), the recognized
(BD I and BD II) are conceptualized as episodic binary diagnoses have accrued significant
disorders, while cyclothymia is a chronic form. validating information (below) and remain
Second, consistent with the unclear boundary indispensable tools.
between hypomania (hypo less than) and
normal mood elevation, a hypomanic episode is Characteristics of Bipolar Disorder
not sufficient for any diagnosis: a diagnosis of BD Bipolar disorder is typically a lifelong, relapsing
II requires a major depressive episode (MDE) in condition. Bipolar I disorder affects approxi-
addition to a hypomanic episode. Third, on the mately 1 % of the population, another 2.9 %
grounds that manic, hypomanic, and depressive appear to develop bipolar II disorder, and perhaps
states often include features characteristic of each 4.2 % of the population are affected by cyclothy-
other (e.g., dysphoria in mania, agitation in mia. Patients differ widely in terms of the length,
depression), it is likely that mixed episodes will number and type of episodes, severity of symp-
be removed from the upcoming DSM-5 and toms, the degree of inter-episode recovery expe-
a specifier, with mixed features, applying to rienced, and consequent disability. The
any type of episode will be added. Fourth, unlike average length of each episode is around
the International Statistical Classification of Dis- 36 months, and some type of episode is experi-
eases and Related Health Problems (ICD-10; enced on average every 2 or 3 years.
World Health Organization, 1993) which Comorbidity with other psychiatric disorders
requires both a manic and depressive episode is the norm: some 56 % of patients with BD
for the diagnosis of BD, only the former is warrant a substance abuse diagnosis, and
required in DSM-IV-TR (unipolar mania does 80 % an anxiety disorder diagnosis. The bipolar
occur, but is sufficiently rare for this to be disorders are associated with significant
a reasonable position). Finally, DSM-IV-TR rec- morbidity, disability, and mortality. It has been
ognizes only one form of MDE, which acts as estimated that a woman who manifests BD at the
a building block toward both unipolar and bipolar age of 25 may lose 9 years in life expectancy,
diagnoses. When a patient presents in 14 years of productivity, and 12 years of normal
a depressive episode, therefore, there is the risk health. Besides costs for the individual patient,
that BD is misdiagnosed as the more prevalent BD symptoms of depressive withdrawal and
major depressive disorder. hypo/manic recklessness can also place burden
As argued in two recent critiques of DSM on partners and families. Comorbid medical
(British Psychological Society, 2011; Society problems (especially vascular disease) are very
for Humanistic Psychology, 2011), the majority prevalent. Suicide is a particularly important risk
of psychological syndromes are in fact extreme in BD 2550 % of patients attempt suicide, and
variants of normal states, rather than discrete 15 % of those not in treatment may complete.
disease-like entities. Bipolar disorder is a case Mania often requires hospitalization, and psy-
in point, as available evidence suggests that chotic symptoms (particularly delusions) are
B 410 Bipolar Disorder (BD)

common. From a safety viewpoint, a critical their goals, expectations, standards, and concerns
symptom of mania is impaired judgment, which (The WHOQOL Group, 1995). People with BD
can lead to risky reward-seeking behaviors. often experience lower mental and physical QoL
Impaired judgment is tricky for clinicians compared to the general population, and impair-
because unlike frank psychosis, the poor ment in QoL tends to persist during remission
decisions made by patients can be well rational- (Michalak et al., 2005).
ized and consistent with their mood state and Quality of life may also differ depending on
sense of self at the time. the type of BD experienced and based on the
occurrence of the different mood states. Unsur-
Treatment prisingly, QoL is negatively associated with
Medications are the first-line treatment for the depression in patients with BD (Michalak, Mur-
acute and maintenance phases of BD (see www. ray, Young, & Lam, 2008). In a series of studies
nimh.nih.gov/health/topics/bipolar-disorder), but with 68 euthymic patients (Cooke, Robb,
outcomes are significantly improved with the Young, & Joffe, 1996; Robb, Cooke, Devins,
addition of psychological interventions Young, & Joffe, 1997), those with BD II
(Miklowitz & Scott, 2009). Most of what reported poorer health-related QoL compared
we know about pharmacological and psychoso- to those with BD I. Another study of 64
cial treatments for BD refers to BD I, and euthymic patients with BD I (MacQueen,
evidence-informed practice for BD II and cyclo- Young, Robb, Cooke, & Joffe, 2000) found
thymia must rely on extrapolations from relevant that the number of previous depressive episodes
data and theory. was a stronger predictor of health-related QoL
than the number of previous manic episodes,
Quality of Life (QoL) in Bipolar Disorder such that QoL outcomes decreased significantly
When exploring QoL in any clinical population, with the first few episodes of depression and
social, emotional, and occupational well-being then continued to decrease slightly as number
need to be considered in addition to the physical of episodes increased. This is consistent with
or health-related concerns that may be present. findings that patients experiencing the manic
Indeed, there is growing recognition that out- symptoms of BD report higher QoL outcomes
comes in BD should not be limited to the mea- than those with depressive symptoms (Ritsner,
surement of psychological symptoms, and Kurs, Kostizky, Ponizovsky, & Modai, 2002;
pharmacological treatment studies have begun Russo et al., 1997; Votja, Kinosian, Glick,
using QoL measures as secondary outcome Altshuler, & Bauer, 2001); however, those
measures (IsHak et al., 2012; Michalak, Yatham, experiencing manic symptoms still reported
& Lam, 2005). BD has a significant impact on impaired health-related QoL functioning com-
psychosocial functioning, defined as a persons pared to euthymic patients (Votja et al., 2001). It
ability to perform activities of daily living and appears that QoL is poorer in BD than in other
to engage in meaningful relationships with others mood disorders and anxiety disorders, but that
(Michalak & Murray, 2010a). Moreover, symp- schizophrenia might compromise QoL more
tomatic recovery does not always equate to func- severely than does BD.
tional recovery, with a substantial proportion of
people with BD experiencing difficulties with Measurement of QoL in BD
their psychosocial functioning during states of The optimal definition and measurement of QoL
remission (Tohen et al., 2000). in BD is a work in progress. Reviews of QoL in
Functional outcomes are therefore a crucial BD have identified limitations of assessing QoL
complement to symptom measures (Keck, in this population because of the variability in
2004). Beyond objective functioning, subjec- assessment tools and the lack of a disease specific
tively assessed QoL provides necessary insight measure (IsHak et al., 2012; Michalak et al.,
into the persons perceptions of life in relation to 2005; Namjoshi & Buesching, 2001). To address
Bipolar Disorder (BD) 411 B
this need, the first disorder-specific measure of Keck, P. E., Jr. (2004). Defining and improving response
QoL in BD, the Quality of Life in Bipolar Disor- to treatment in patients with bipolar disorder. The
Journal of Clinical Psychiatry, 65(Suppl 15), 2529.
der Scale (QoL.BD; Michalak & Murray, 2010b), MacQueen, G. M., Young, L. T., Robb, J. C., Cooke,
was published in both a full 56-item version and R. G., & Joffe, R. T. (2000). Effect of number of
a brief 12-item version. Development occurred episodes on wellbeing and functioning of patients B
over the course of 4 years and a series of four, with bipolar disorder. Acta Pschiatrica Scandinavica,
101, 374381.
mixed-method empirical studies. Item generation Michalak, E. E., & Murray, G. (2010a). A clinicians guide
and reduction included input from individuals to psychosocial functioning and quality of life in bipo-
with BD, family members, and field experts in lar disorder. In A. Young, N. Ferrier, & E. E. Michalak
additional to consultation of the relevant litera- (Eds.), Practical management of bipolar disorder.
Cambridge: Cambridge University Press.
ture. Initial testing of the QoL.BD shows high Michalak, E. E., & Murray, G. (2010b). Development of
internal reliability, validity, and consistency, the QoL.BD: A disorder-specific scale to assess quality
and comparison to existing measures suggests of life in bipolar disorder. Bipolar Disorders, 12,
that the QoL.BD demonstrates greater specificity 727740.
Michalak, E. E., Murray, G., Young, A. H., & Lam, R. W.
resulting in more sensitivity to clinical changes in (2008). Burden of bipolar depression: Impact of disor-
patients with BD (Michalak & Murray, 2010b). der and medications on quality of life. CNS Drugs, 22,
The developers of this instrument note that the 389406.
structure of QoL in BD is not understood but is Michalak, E. E., Yatham, L. N., & Lam, R. W. (2005).
Quality of life in bipolar disorder: A review of the
likely that QoL for people with BD is partially literature. Health and Quality of Life Outcomes, 3,
like everyones QoL, partially like the QoL of 7288.
people with other disorders and partially unique Miklowitz, D. J., & Scott, J. (2009). Psychosocial treat-
to BD. ments for bipolar disorder: Cost-effectiveness, medi-
ating mechanisms, and future directions. Bipolar
Disorders, 11, 110122.
Namjoshi, M. A., & Buesching, D. P. (2001). A review of
Cross-References the health-related quality of life literature in bipolar
disorder. Quality of Life Research, 10, 105115.
Ritsner, M., Kurs, R., Kostizky, H., Ponizovsky, A., &
Mixed Method Modai, I. (2002). Subjective quality of life in severely
Morbidity Measures mentally ill patients: A comparison of two instru-
Mortality ments. Quality of Life Research, 11, 553561.
Physical Well-Being Robb, J. C., Cooke, R. G., Devins, G. M., Young, L. T., &
Joffe, R. T. (1997). Quality of life and lifestyle disrup-
Productivity tion in euthymic bipolar disorder. Journal of Psychi-
Psychiatric Disorders atric Research, 31, 509517.
Russo, J., Roy-Byrne, P., Reeder, D., Alexander, M.,
Dwyer-OConner, E., Dagadakis, C., & Patrick, P. D.
(1997). Longitudinal assessment of quality of life in
acute psychiatric inpatients: Reliability and validity.
References The Journal of Nervous and Mental Disease, 185,
APA. (2000). Diagnostic and statistical manual of mental Society for Humanistic Psychology. (2011). Open letter to
disorders: DSM-IV-TR. Washington, DC: Author. the DSM-5 task force and the American Psychiatric
British Psychological Society. (2011). Response to the Association. Washington, DC: Author.
American Psychiatric Association: DSM-5 develop- The WHOQOL Group. (1995). The World Health Orga-
ment. Leicester, UK: Author. nization Quality of Life Assessment (WHOQOL):
Cooke, R. G., Robb, J. C., Young, L. T., & Joffe, R. T. Position paper from the World Health Organization.
(1996). Well-being and functioning in patients with Social Science & Medicine, 41, 14031409.
bipolar disorder assessed using the MOS 20-ITEM Tohen, M., Hennen, J., Zarate, C. M., Jr., Baldessarini,
short form (SF-20). Journal of Affective Disorders, R. J., Stakowski, S. M., Stoll, A. L., & Cohen, B. M.
39, 9397. (2000). Two-year syndromal and functional recovery
IsHak, W. W., Brown, K., Aye, S. S., Kahloon, M., in 219 cases of first-episode major affective disorder
Mobaraki, S., & Hanna, R. (2012). Health-related quality with psychotic features. The American Journal of
of life in bipolar disorder. Bipolar Disorders, 14, 618. Psychiatry, 157, 220228.
B 412 Bipolar Disorder Scale (QoL.BD), Quality of Life

Votja, C., Kinosian, B., Glick, H., Altshuler, L., & Bauer, Moreover, introduction of modern contraceptives
M. S. (2001). Self-reported quality of life across mood has had a profound impact on womens lives
states in bipolar disorder. Comprehensive Psychiatry,
42, 190195. and society as a whole (Gianotten, Whipple, &
World Health Organization. (1993). International statisti- Fuglsang Owens, 2007; Picavet, Van der Leest, &
cal classification of diseases and health related prob- Wijsen, 2011).
lems (10th ed.). Geneva: Author.
Historical Development
Hormonal contraception became available in the
early 1960s. Some birth control methods had
Bipolar Disorder Scale (QoL.BD), been available for a long time before that,
Quality of Life but they did not have the impact of modern
contraceptives. The introduction of reliable
Bipolar Disorder (BD) contraception enabled women to control their
fertility, thereby delaying their motherhood,
reducing the number of children they had, and
increasing the time between giving birth to their
Birth Control children.
This has had more far-reaching consequences
Charles Picavet than on reproductive health alone. It opened up
Rutgers WPF, Utrecht, UT, The Netherlands new horizons for many women. For example, an
increasing number of women were able to have
jobs and maintain them after giving birth. Both
Synonyms motherhood and fatherhood changed, traditional
divisions of labor became a choice instead of
Contraception; Family planning; Planned a necessary fact of life.
Impact on Quality of Life
Not much research has been done on quality of life
Definition related to contraception. Mental health-related
quality of life is better for women who use contra-
Birth control is every method that enables women ception than for women who do not. Women
and men to influence the timing, number, and who use injectables or who have undergone tubal
spacing of having children. sterilization are less likely to report at least average
Usually, birth control is used as a term that health-related quality of life (Williams, Parisi,
refers solely to (often hormonal) contraception. Hess & Schwarz, 2012). Extended use regimens
However, the term can refer to a broader spec- of short-term hormonal contraception are reported
trum of possibilities, including assisted reproduc- to have beneficial effects on quality of life of
tion for people with fertility problems, postcoital users, mainly because of reducing menstrual
contraceptive methods, and abortion. discomforts and disruptions. The same is probably
true for longer acting hormonal methods
(Nelson, 2006).
Options for birth control are primarily intended The focus of this entry is on quality of life
for enabling women and men to enjoy sexual related to contraception. The impact of
intercourse without the need to worry about fertility problems, assisted reproduction, and
having a child. This has considerably increased abortion is discussed elsewhere in this
the quality of life of particularly women. encyclopedia.
Birth Order 413 B
Furthermore, the research that is summarized
for this entry is cross-sectional, which makes Birth Order
causal inferences impossible. Although it is prob-
able that contraceptive use has a positive impact Linda Welling
on womens well-being, there are studies that Economics, University of Victoria, B
suggest it could be the other way around as Victoria, BC, Canada
well. Women, who are happier and who have
more sense of purpose in their lives, tend to use
contraception more often and also more Synonyms
Finally, most studies on contraception are Order, sibling
done among women. Therefore, little is known
about the impact of contraception on mens qual-
ity of life. Although men have their own needs Definition
when it comes to reproduction, and whether or
not to have children impacts their lives as well, Birth order refers to a persons position in the age
contraception is primarily seen as a womens hierarchy of siblings. Later-born children have
issue. This was probably caused by the pharma- higher birth order.
cological turn in contraception during the 1960s.
There are (still) no pharmaceutical contraceptive
methods for men. However, many women rely on Description
the male methods, condoms, or vasectomy.
Most individuals are aware of their birth order
and have an opinion about how early interactions
Cross-References in their family of origin shaped their character.
There are numerous studies, both popular and
Childlessness academic, relating birth order to individual
Family Planning characteristics, such as personality and IQ, and
Fertility Plans/intentions outcomes, such as education, earnings, choice
Human Infertility of profession, and physical and mental health.
In general, the firstborn is seen to be advantaged,
middle borns are disadvantaged, and the results
for later borns are mixed; for a recent summary,
see Sulloway (2007). There are also many studies
Gianotten, W. L., Whipple, B., & Fuglsang Owens, A. showing that birth order effects, if they exist, are
(2007). Sexual activity is a cornerstone of quality of insignificant.
life: An update of The health benefits of sexual Why position in the sibling age hierarchy
expressions. In M. Tepper & A. Fuglsang Owens
should matter, and how, is still unclear. The con-
(Eds.), Sexual health (Psychological foundations,
Vol. 1). Westport, CT: Praeger. fluence theory, first proposed by Zajonc and
Nelson, A. M. (2006). Extended-regimen contraception: Markus (1975), focuses on the home intellectual
Effects on menstrual symptoms and quality of life. environment, based on the cumulative intelli-
Journal of Family Practice, 55, S1S8.
Picavet, C., Van der Leest, L., & Wijsen, C. (2011).
gence of the parents and siblings. The firstborn
Contraceptive decision-making: Background and con- spends their early childhood at home surrounded
sequences of contraceptive methods. Utrecht, The by adults and develops skills to relate to, and
Netherlands: Rutgers WPF. become like, them. The second born enters
Williams, S. L., Parisi, S. M., Hess, R., & Schwarz, E. B.
a home already inhabited by a child, while later
(2012). Associations between recent contraceptive use
and quality of life among women. Contraception, 85, borns come into homes where the ratio of children
282287. to adults is even higher. The changing intellectual
B 414 Birth Order

environment of the household provides less intel- later in life (see Almlund, Duckworth, Heckman,
lectual stimulation to younger children (at least and Kautz (2011) for an extensive survey), it is
when family size is not too large and children are not surprising that the strongest evidence for
24 years apart). Firstborns receive additional birth order effects is found in studies of IQ.
benefit from teaching their younger siblings. Mixed results for the existence of birth order
The principal alternative theory of resource effects on adult outcomes also stem, in part,
dilution (Blake, 1986; Downey, 1995) starts from the lack of data sets sufficiently large, and
with the recognition that household resources over a long-enough time period, to derive signif-
financial, intellectual, and emotional are lim- icant results.
ited. As the number of children increases, these A number of recent papers have addressed this.
resources are spread more and more thinly. Con- Using various data sets, for different countries,
sider financial resources, an important determi- Ejrns and Portner (2004), Black, Devereux, and
nant of educational attainments. If births were Salvanes (2005), Conley and Glauber (2006), and
perfectly planned and capital markets perfect, Kantarevic and Mechoulan (2006) find that first-
then the effects of resource dilution would born children have greater educational attainment
depend solely on family size and income stream, and/or higher earnings than later borns, even con-
with no independent role for birth order. How- trolling for family size. Working with Norwegian
ever, if a familys financial situation improves as data, Black, Devereux, and Salvanes (2011) and
the parents age, then financial resources available Bjerkedal, Kristensen, Skjeret, and Brevik (2007)
to spend on children may differ for early and later find a strong and significant negative relation
borns, thus generating birth order effects over and between birth order and IQ, one large enough
above those due to family size. Parental time is between the first- and second born to account for
another important resource; Price (2008) found about 2 % of annual earnings as adults. In a related
that children of higher birth order receive less paper, Kristensen and Bjerkedal (2007) argued
quality time with parents at any given age than that since in this data set second-born men whose
do children of lower birth order, at the same age. older sibling died in infancy had higher IQs than
Recognizing that income and time with children second borns whose older sibling survived, social
are to some extent choice variables for parents, interaction within the family rather than biology is
Gugl and Welling (2010) show that parents who important for this birth order effect.
care equally about both children will provide These studies control for family income; stud-
different combinations of time and goods to the ies on some developing countries have shown
two children, because the opportunity cost of that this relationship varies with family income:
parents time is not the same across time. The Tenikue and Verheyden (2010) find that in poorer
rate of dilution may vary across resources as well: families later-born children achieve higher edu-
Downey (1995) provides some evidence for this, cation levels than their older siblings, who spend
and Steelman, Powell, Werum, and Carter (2002) more time in child labor. In wealthier families,
provide a broader survey of the interaction of the firstborns do better.
resource dilution theory and other aspects of sib- Of course, educational attainment and earn-
ling configuration. ings are not the sole indicators of well-being. In
The effects of early family interaction are a data set of children born in early-twentieth-
mediated by the influence of peers in adolescence century Sweden, Modin (2002) found that later-
and adult life, so the impact of birth order on adult born siblings demonstrated a higher mortality
outcomes depends on how constrained these risk than firstborns. For girls/women, this rela-
early resources are, and the extent to which tionship was significant at each of the four age
later experiences can substitute for early differ- intervals studied; for boys/men in the oldest age
ences. Given that cognitive skills seem to range (5580 years), birth order had no indepen-
become stable at relatively early ages, whereas dent explanatory power once adult social class,
noncognitive skills are malleable until much income, and education were introduced into the
Bivariate 415 B
analysis. Modin discusses one of the problems of Kristensen, P., & Bjerkedal, T. (2007). Explaining the
generalizing from long-term studies such as this, relation between birth order and Intelligence. Science,
316(5832), 1717.
when she stresses that the general social and Modin, B. (2002). Birth order and mortality: A life-long
economic conditions in Upsala which the later follow-up of 14,200 boys and girls born in early 20th
borns in this group faced when young might be century Sweden. Social Science and Medicine, 54, B
the source of some of these effects. 10511064.
Price, J. (2008). Parent-child quality time: Does birth
In summary, the existence of birth order order matter? Journal of Human Resources, 43(1),
effects, and their causes, is still an open question. 240265.
As larger, more comparable panel data sets Steelman, L. C., Powell, B., Werum, R., & Carter, S.
become available for more countries, answers (2002). Reconsidering the effects of sibling configura-
tions: Recent advances and challenges. Annual Review
may appear. of Sociology, 28, 243269.
Sulloway, F. (2007). Birth order and sibling competition.
In R. Dunbar, & L. Barrett (Eds.), The Oxford hand-
book of evolutionary psychology (pp. 297311).
Oxford: Oxford University Press.
References Tenikue, M., & Verheyden, B. (2010). Birth order and
schooling: Theory and evidence from twelve Sub-
Almlund, M., Duckworth, A., Heckman, J., & Kautz, T. Saharan countries. Journal of African Economics,
(2011). Personality psychology and economics. In 19(4), 459495.
E. A. Hanushek, S. Machin, & L. Womann (Eds.), Zajonc, R. B., & Markus, G. B. (1975). Birth order and
Handbook of the economics of education. Amsterdam: intellectual development. Psychological Review, 82,
Elsevier. 7488.
Bjerkedal, T., Kristensen, P., Skjeret, G. A., & Brevik, J. I.
(2007). Intelligence test scores and birth order
among young Norwegian men (conscripts) analyzed
within and between families. Intelligence, 35(6),
Black, S. E., Devereux, P. J., & Salvanes, K. G. (2005). Birth Rate
The more the merrier? The effect of family size and
birth order on childrens education. Quarterly Journal
of Economics, 120(2), 669700. Fertility Rate
Black, S. E., Devereux, P. J., & Salvanes, K. G. (2011).
Older and wiser? Birth order and IQ of young men.
CESifo Economic Studies, 57(1), 103120.
Blake, J. (1986). Number of siblings, family background,
and the process of educational attainment. Social
Biology, 18, 521. Birthrate and US Hispanics
Conley, D., & Glauber, R. (2006). Parental educational
investment and childrens academic risk Estimates of
the impact of sibship size and birth order from exoge-
Fertility and Religion Among US Hispanics
nous variation in fertility. Journal of Human
Resources, 41(4), 722737.
Downey, D. B. (1995). When bigger is not better: Family
size, parental resources, and childrens educational
performance. American Sociological Review, 60,
746761. Bisexual
Ejrns, M., & Portner, C. C. (2004). Birth order and the
intrahousehold allocation of time and education. Sexual Orientation
Review of Economics and Statistics, 86(4),
Gugl, E., & Welling, L. (2010). The early bird gets the
worm? Birth order effects in a dynamic model of the
family. Economic Inquiry, 48(3), 690703.
Kantarevic, J., & Mechoulan, S. (2006). Birth order, edu-
cational attainment, and earnings: An investigation
using the PSID. Journal of Human Resources, 41(4),
755777. Zero-Order Relationships
B 416 Bivariate Analysis

Field (2005), Gravetter and Wallnau (2004), and

Bivariate Analysis Glass and Stanley (1970) as well as in other
entries in this encyclopedia to which I have pro-
Debra (Dallie) Sandilands vided links.
Measurement, Evaluation and Research Bivariate Correlation: A bivariate correlation
Methodology, Faculty of Education, is a measure of the linear relationship between
University of British Columbia, Vancouver, two variables. Bivariate correlation is contrasted
BC, Canada with partial correlation (a correlation between
two variables after a third variable has been
taken into account) and with multiple correlation
Definition (correlations between more than two variables).
A bivariate correlation analyzes whether and
Bivariate analysis refers to the analysis of two how two variables covary linearly, that is,
variables to determine relationships between whether the variance of one changes in a linear
them. Bivariate analyses are often reported in fashion as the variance of the other changes. (For
quality of life research. For an excellent example an explanation of variance, please refer to the
of research that utilizes bivariate analyses and univariate analysis section of this encyclope-
demonstrates how the results of bivariate ana- dia). Covariance can be difficult to interpret
lyses can be used to inform further more complex across studies because it depends on the scale or
analyses, please see Michalos, Thommasen, level of measurement used. For this reason,
Read, Anderson, and Zumbo (2005). covariance is standardized by dividing by the
Bivariate analysis is contrasted with univar- product of the standard deviations of the two
iate analysis (analysis of only one variable) and variables to produce the Pearson product
multivariate analysis (analysis of two or more moment correlation coefficient (also referred to
variables simultaneously). as the Pearson correlation coefficient or simply
as a correlation coefficient) which is usually
denoted by the letter r. Pearsons correlation
Description coefficient is used when both variables are mea-
sured on an interval or ratio scale. Other correla-
Bivariate analyses are conducted to determine tion coefficients or analyses can be calculated
whether a statistical association exists between when variables are not interval or ratio, or
two variables, the degree of association if one when they are not normally distributed (see
does exist, and whether one variable may be univariate normal distribution). Spearmans
predicted from another. For example, bivariate correlation coefficient (Rho) is used for non-
analyses could be used to answer the question of normal or ordinal data, Kendalls tau can be
whether there is an association between income used for small data sets with many tied ranks,
and quality of life, or whether quality of life can biserial or point-biserial correlations can be used
be predicted from income. In limited circum- when one of the variables is categorical and
stances (discussed below), bivariate analysis can dichotomous, and a chi-square analysis is used
be used to suggest causation of one variable by to examine the relationship between two nominal
the other. variables (Field, 2005). For more detailed infor-
Two frequently used types of bivariate mation about correlation coefficients, please refer
analyses are bivariate correlation and bivariate to the separate entry in this encyclopedia.
regression. Each is described below. Please note It is possible to calculate the amount of vari-
that regression is a complex statistical concept ability in one variable that is explained or
and this entry is intended as an introduction. accounted for by the other, known as the coeffi-
More detailed information regarding regression cient of determination. The coefficient of determi-
can be found in Miles and Shevlin (2005), nation is the square of the correlation coefficient.
Bivariate Analysis 417 B
Bivariate Analysis,
Fig. 1 Sample scatterplot
showing bivariate

The statistical significance of a correlation can predictor variables. Essentially, a bivariate

be tested (assuming the data meets the assump- regression seeks to find the equation for the best
tions for tests of significance such as normal possible straight line that defines the relationship
distribution). A 1-tailed test can be conducted between two variables based on a particular
for a directional hypothesis (such as there will data set. That equation for that line is then used
be a positive correlation between income and to predict results for values of the outcome vari-
quality of life), and a 2-tailed test can be able that were not found in the original data set.
conducted for a nondirectional hypothesis (such Statistical (numeric) bivariate analyses are
as there will be a correlation between income usually preceded by graphical methods of exam-
and quality of life, without specifying whether ining bivariate relationships, such as scatterplots.
the correlation will be positive or negative). A simple scatterplot is a graph of one variable
Three important notes should be highlighted plotted against the other variable. The following
with regard to correlation. First, the presence of scatterplot shows (hypothetical) scores on mea-
outliers can severely bias the correlation sures of happiness and quality of life (Fig. 1).
coefficient. Second, large sample sizes can result From the scatterplot, it can be seen that there is
in statistically significant correlations that may a very high positive correlation (again, hypothet-
have little or no practical significance. Last, it is ical since the scores are for demonstration
not possible to draw conclusions about causality purposes and not based on any real data) between
based on correlation analyses alone. these two variables, and using the equation for
Bivariate Regression: Bivariate regression the line of best fit, one could predict scores on the
is a simple linear regression model which is quality of life measure based on scores from
used to predict one variable (referred to as the the happiness measure, or vice versa.
outcome, criterion, or dependent variable) from Bivariate Analyses and Causation: It is
one other variable (referred to as the predictor or important to note that bivariate relationships can
independent variable). Bivariate regression is but do not necessarily imply causation. As noted
contrasted with multiple regression in which in Miles and Shevlin (2005), three conditions
one outcome variable is predicted from multiple need to be met before causation can be
B 418 Bivariate Regression

established: association, direction of association, Michalos, A. C., Thommasen, H. V., Read, R., Anderson,
and isolation. Causation necessarily implies cor- N., & Zumbo, B. D. (2005). Determinants of health
and the quality of life in the Bella Coola Valley. Social
relation in that if one thing causes another then Indicators Research, 72(1), 150.
a change in it produces a change in the other; Miles, J., & Shevlin, M. (2005). Applying regression and
therefore, a statistical association is a necessary correlation: A guide for students and researchers.
but insufficient condition for causation. The London: Sage.
example of the correlation between happiness
and quality of life shown in the scatterplot
above exemplifies the problems of establishing
direction of causation and isolation. Could we Bivariate Regression
conclude that happiness causes quality of life?
Or that quality of life causes happiness? Or nei- Ron Johnston
ther? Typically the cause must precede the effect School of Geographical Sciences, University of
in order to establish the direction of causation. In Bristol, Bristol, UK
addition, we must ask ourselves whether one
variable is solely responsible for the other, that
is, whether other variables than those we have Definition
measured may account for the apparent relation-
ship. By definition bivariate analyses cannot sta- Regression involves the estimation of the value of
tistically account or control for other variables one variable from that of another, with the rele-
(since only two variables are taken into account vant coefficients derived from either a complete
in the analyses). set of observations on the two variables or
a sample of them from the total population.
Although no causal link may be intended,
Cross-References the two variables are usually identified as the
dependent and the independent, respectively,
Bivariate Regression with the implication that the purpose of the anal-
Correlation Coefficient ysis is to estimate the value of the latter from that
Levels of Measurement of the former. When presented in graphical form,
Linear Regression Model the independent variable (usually denoted as the x
Multivariate Statistical Analysis variable) is normally placed on the horizontal
Outliers axis and the dependent (the y variable) on the
Partial Correlations vertical.
Standard Deviation(s) The graph illustrates such a regression. The
Significance, Statistical dependent variable (y) is the percentage share of
Univariate Analysis the votes received by Plaid Cymru (the Party of
Univariate Normal Distribution Wales) at the 2010 British general election
campaign in each Welsh constituency; the
independent variable is the percentage of the
population in each constituency who are Welsh
speakers (x). There is a clear upward slope in
Field, A. (2005). Discovering statistics using SPSS.
the relationship between the two shown by the
London: Sage. regression line; the larger the number of Welsh
Glass, G. V., & Stanley, J. C. (1970). Statistical methods speakers the more votes for Plaid Cymru.
in education and psychology. Englewood Cliffs, NJ: Each regression line has two coefficients that
Gravetter, F. J., & Wallnau, L. B. (2004). Statistics for the
describe its trajectory the constant and the
behavioral sciences. Belmont, CA: Thomson slope. The constant value (the a value) is
Wadsworth. the value of the dependent variable when the
Bivariate Regression 419 B
Bivariate Regression,
Graph 1 Bivariate 50.00
regression between % who
speak Welsh and % who
voted for Plaid Cymru at 40.00
the 2010 UK general B

% Voted Plaid Cymru





0.0000 20.0000 40.0000 60.0000 80.0000

% Who Speak Welsh

value of the independent variable is set at zero; votes (0.132 % points; the a value). Where
the slope (the b value) indicates the change in the 10 % of the population spoke Welsh, it
value of the dependent variable for a unit change obtained [(10  0.541) + 0.132] 5.542 %,
in the independent. Each has a standard error and where 40 % spoke Welsh, on average
associated with it, from which confidence inter- Plaid Cymru obtained 21.772 % of the votes.
vals can be derived, and in addition, there is The confidence limits (the standard error of
a standard error of the estimate (e) for the entire the estimate) indicate that in 68 % of all
regression for the scatter of observation points constituencies where 40 % speak Welsh, the
around the regression line. A third parameter, the Plaid Cymru share of the votes will fall within
correlation coefficient (the r value), measures the range 16.78326.761 and that in 95 % of
the goodness of fit around the regression line: It all constituencies, it will fall within the range
varies between 1.0 and 1.0; the closer it is to 11.79431.750.
1.0, the nearer all of the points are to that line. The correlation coefficient for that equation is
The full regression equation is thus 0.887. This is usually interpreted by squaring its
value (r2) and expressing the result as
y a bx = e a percentage which in this case is 78.7; this
is taken as showing that nearly 79 % of the
which for the data in the graph (with the standard variation in the dependent variable (Plaid
errors in brackets below) is: Cymru vote percentage) can be linked to the
variation in the independent variable (the per-
y 0:132 0:541x = 4:989 centage of the population who were Welsh
speakers). The correlation coefficient is usually
corrected for degrees of freedom the larger the
1:27 0:046 r 0:887 r 2 0:787 number of observations, the greater the confi-
dence in the observed coefficient. In this case,
Where there were no Welsh speakers, with 40 observations, the corrected r2 value is
therefore, Plaid Cymru got virtually no 0.780 (Graph 1).
B 420 BLI

References perceptual, cognitive, affective, and behavioral

components. The perceptual component relates to
Harris, R. J., & Jarvis, C. (2011). Statistics for the accuracy with which individuals can make
geography and environmental science. Englewood
judgments of their size, weight, and shape relative
Cliffs/London: Prentice-Hall.
Rogerson, P. A. (2010). Statistical methods for to their actual proportions. The cognitive and affec-
geography: A students guide (3rd ed.). London: Sage. tive components relate to the cognitive appraisals
one makes of his/her appearance and the associated
emotions, respectively. Finally, the behavioral
component relates to how one behaves toward,
and in relation to, his/her body. Each of these
BLI aspects of body image can be studied separately
but are more often combined into an overarching
Better Life Index construct reflecting body image attitudes. Body
image attitudes are divided into two core facets:
evaluation and investment (Cash, 2011). Evalua-
tion refers to individuals satisfaction or dissatis-
Blind, Quality of Life faction with their body and their evaluative beliefs
about it, while investment refers to the cognitive,
Visually Impaired Older People, Quality of behavioral, and emotional importance of the body
Life for self-evaluation (Cash, p. 39).

Current Cultural Perceptions of Beauty

Body Image Beauty ideals represent culturally prescribed

standards of attractiveness within a culture.
Shayna Rusticus Although cultural perceptions of beauty are sub-
Evaluation Studies Unit, University of British ject to fluctuations over time, in contemporary
Columbia, Vancouver, BC, Canada Western society, the major focus of body image
has come to be on body shape and weight. For
women, the last several decades have seen
Synonyms a cultural ideal emphasizing increasing thinness
and to a lesser degree large breasts (Murnen,
Self-image 2011). More recently, muscle tone is also being
incorporated into current ideals for women in the
twenty-first century with women desiring a full-
breasted firm-looking, toned body (Bordo, 2003;
Definition Grogan, 2010). For men, the male body has
become increasingly more visible in popular cul-
Body image is a multidimensional construct ture, and men too are facing mounting pressures
relating to the image that one forms of their to attend to their appearance and conform to
body and appearance. cultural standards. The male ideal takes the
form of a muscular mesomorphic build with
well-developed muscles on the chest, arms, and
Description shoulders and a slim waist and hips (Grogan;
Pope, Phillips, & Olivardia, 2000). For the major-
Body image is widely believed to be ity of both men and women, these ideals are
a multidimensional construct encompassing impossible to meet, but are still desired because
Body Image 421 B
they are associated with self-control, elegance, activities with respect to their bodies (Calogero
social attractiveness, and youth (Bordo, 2003). & Thompson, 2010). Women are much more
Furthermore, individuals who deviate from likely to be susceptible to eating disorders such
these ideals (e.g., obese individuals) can be as anorexia and bulimia and focus on weight loss.
highly stigmatized and face multiple forms of Although women and men are equally likely to B
prejudice and discrimination (Puhl & Heuer, suffer from body dysmorphic disorder, for women,
2009). the focus is more often on their hips, weight, and
skin imperfections, whereas for men, the focus is
on muscularity, their genitals, and thinning hair.
Body Image and Gender Finally, for both genders, the rates of surgical and
nonsurgical cosmetic procedures have dramati-
Gender differences in body image satisfaction cally increased and have come to be perceived as
have been widely documented. Women and men normative behavior although women are nine
perceive, think, feel, and behave differently in times more likely than men to engage in these
regard to their bodies and appearance (Calogero procedures (Calogero & Thompson, 2010).
& Thompson, 2010). Perceptually, men tend to
underestimate the size of their bodies and to view
the body as a whole entity with a functional pur- Body Image and Age
pose (what the body can do), whereas women tend
to overestimate the size of their bodies and to Although predominantly studied in adolescent
perceive the body as a distinct set of parts. Cogni- and young adult female populations, the study
tively, men and women also have different beliefs of body image has been applied increasingly
and attitudes regarding ideal bodies, and they pro- across a broad spectrum of populations: children,
cess appearance-related information differently. men, middle-aged adults, and older adults. Most
Men are much more focused on a muscular phy- of the research with children has focused on
sique, while women tend to be more weight con- weight and shape concerns and has found that
scious and desire a thin physique. Although children as young as five show concerns that
women had previously been more likely to report approximate adolescent and adult concerns; up
more negative thoughts and beliefs about their to 50 % of 612-year-old boys and girls express
bodies, it appears this difference is declining. body dissatisfaction (Ricciardelli, McCabe,
Emotionally, men and women differ in regard to Mussap, & Holt, 2009; Smolak, 2011). While
body dissatisfaction, body shame, and appearance girls generally desire a thinner shape, boys are
anxiety, with more women feeling negatively mixed in wanting either a smaller (less body fat)
about their bodies. For body dissatisfaction in par- or a larger (more muscular) body size
ticular, the last several decades have seen increases (Ricciardelli et al., 2009). In adolescence, rates
in body dissatisfaction among both men and of body dissatisfaction among girls rise to 70 %
women, but more so for women. The widespread and remain fairly stable over time (Wertheim &
weight dissatisfaction reported by women has Paxton, 2011). Body image research involving
become so commonplace that it has been referred adolescent boys is limited but does indicate that
to as a normative discontent; that is, feeling they are preoccupied with achieving a lean and
negatively about ones appearance is thought to muscular body shape (Ricciardelli & McCabe,
be the norm rather than the exception (Rodin, 2011). Pubertal development among adolescent
Silberstein, & Striegel-Moore, 1984; Tantleff- boys has also been associated with a positive
Dunn, Barnes, & Larose, 2011). For men, there is body image experience as their bodies change in
a corresponding normative discontent regarding ways that bring them closer to societal ideals for
their dissatisfaction with their muscularity a man (i.e., they gain in height and muscle mass
(Tiggemann, Martins, & Kirkbride, 2007). Behav- (Ricciardelli & McCabe, 2011)), whereas the
iorally, men and women engage in different body changes and weight gain adolescent girls
B 422 Body Image

experience during puberty move them away from appearance- and performance-enhancing drugs,
the thin ideal (Wertheim & Paxton, 2011). and engagement in surgical procedures (Grogan,
Moving into adulthood, large percentages of 2010; Smolak & Cash, 2011; Woertman & van
both men and women continue to experience den Brink, 2012). Furthermore, these negative
their bodies in a negative manner, reflecting the outcomes can be compounded when individuals
normative discontent that has become preva- have internalized societal ideals and are more
lent in our society (Grogan, 2011). A growing, prone to making upward and unrealistic social
but still limited, body of research in middle-aged body comparisons (Grogan, 2010). Because
and older adults has found that, although the even minor body image concerns can result in
physical changes associated with aging (e.g., potentially harmful effects, continued investiga-
wrinkles, increased body weight, reduction in tions of correlates of body image and protective
muscle tone) take individuals away from cultural body image factors continue to be important
ideals, there is not an associated decline in body areas of research.
dissatisfaction among men and women. Women
across adulthood report similar levels of body
dissatisfaction regarding their weight and shape;
however, the importance of appearance seems to
decrease with age, and fewer older women report
appearance concerns compared to younger
women (Grogan, 2010; Tiggemann, 2004). It
Quality of Life
has been postulated that older women may mod-
ify their appearance standards as they age to
Sexual Dysfunction
standards that are more age appropriate and real-
Social Comparison
istic (Grogan, 2011). Age differences among
adult men have produced inconsistent findings
with some studies suggesting older men are less References
satisfied with their body image than younger men
and other studies finding no differences (Grogan). Bordo, S. (2003). Unbearable weight: Feminism, Western
Overall, most studies suggest that women place cultural, and the body. Berkeley, CA: University of
California Press.
more importance on their appearance than men
Calogero, R. M., & Thompson, J. K. (2010). Gender and
across the adult lifespan (Grogan). body image. In J. C. Chrisler & D. R. McCreary (Eds.),
Handbook of gender research in psychology (Gender
research in social and applied psychology, Vol. 2,
pp. 153184). New York: Springer.
Body Image and Quality of Life Cash, T. F. (2011). Cognitive-behavioral perspective
on body image. In T. F. Cash & L. Smolak (Eds.),
A growing body of research in this field has Body image: A handbook of science, practice, and pre-
examined relationships between body image and vention (2nd ed., pp. 3947). New York: Guildford Press.
Grogan, S. (2010). Promoting positive body image in
various facets of quality of life. Broadly, these males and females: Contemporary issues and future
facets can be categorized as psychological factors directions. Sex Roles, 63, 757765.
(e.g., self-esteem, internalization of the thin/ Grogan, S. (2011). Body image development in adulthood.
muscular ideal, social comparison with ideal- In T. F. Cash & L. Smolak (Eds.), Body image:
A handbook of science, practice, and prevention
ized models) and behavioral factors (e.g., eating (2nd ed., pp. 93100). New York: Guildford Press.
pathology, muscle building, risky body change Murnen, S. K. (2011). Gender and body images. In T. F.
behaviors (Grogan, 2010)). Poor body image Cash & L. Smolak (Eds.), Body image: A handbook of
has been linked to multiple negative health out- science, practice, and prevention (2nd ed., pp. 7379).
New York: Guildford Press.
comes, such as depression, anxiety, low self- Pope, H. G., Phillips, K. A., & Olivardia, R. (2000).
esteem, body shame, sexual dysfunctions, eating Adonis complex: The secret crisis of male body obses-
disorders, body dysmorphic disorder, use of sion. New York: Free Press.
Bottom-Up Versus Top-Down Theories of Life Satisfaction 423 B
Puhl, R. M., & Heuer, C. A. (2009). The stigma of obesity:
A review and update. Obesity, 17, 941964. Botanical Gardens
Ricciardelli, L. A., & McCabe, M. P. (2011). Body image
development in adolescent boys. In T. F. Cash & L.
Smolak (Eds.), Body image: A handbook of science, Museums and Galleries: Their Social Worth
practice, and prevention (2nd ed., pp. 8592). New B
York: Guildford Press.
Ricciardelli, L. A., McCabe, M. P., Mussap, A. J., & Holt,
K. E. (2009). Body image in preadolescent boys. In L.
Smolak & K. J. Thompson (Eds.), Body image, eating Bottom-Up Versus Top-Down
disorders, and obesity in youth: Assessment, preven- Theories of Life Satisfaction
tion, and treatment (2nd ed., pp. 7796). Washington,
DC: American Psychological Association.
Rodin, J., Silberstein, L. R., & Striegel-Moore, R. H. Bruce Headey
(1984). Women and weight: A normative discontent. Melbourne Institute of Applied Economic and
In T. B. Sonderegger (Ed.), Nebraska symposium on Social Research, The University of Melbourne,
motivation: Psychology and gender (pp. 267307). Melbourne, VIC, Australia
Lincoln, NE: University of Nebraska Press.
Smolak, L. (2011). Body image development in child-
hood. In T. F. Cash & L. Smolak (Eds.), Body image:
A handbook of science, practice, and prevention Definition
(2nd ed., pp. 6775). New York: Guildford Press.
Smolak, L., & Cash, T. F. (2011). Future challenges for
body image science, practice, and prevention. In T. F. Bottom-up theories of life satisfaction (or subjec-
Cash & L. Smolak (Eds.), Body image: A handbook of tive well-being, SWB) are based on the idea that
science, practice, and prevention (2nd ed., overall life satisfaction is the sum of its parts.
pp. 471478). New York: Guildford Press. That is, self-reports of life satisfaction represent
Tantleff-Dunn, S., Barnes, R. D., & Larose, J. G. (2011).
Its not just a woman thing: The current state of nor- a weighted average of satisfaction with different
mative discontent. Eating Disorders, 19, 392402. aspects (domains) of life. By contrast, top-down
Tiggemann, M. (2004). Body image across the life span: theories rest on the premise that satisfaction with
Stability and change. Body Image, 1, 2441. domains of life is mainly a consequence of
Tiggemann, M., Martins, Y., & Kirkbride, A. (2007). Oh
to be lean and muscular: Body image ideals in gay and overall life satisfaction, which itself primarily
heterosexual men. Psychology of Men & Masculinity, depends on personality traits and other fixed
8(15), 24. genetic effects.
Wertheim, E. H., & Paxton, S. J. (2011). Body image
development in adolescent girls. In T. F. Cash & L.
Smolak (Eds.), Body image: A handbook of science,
practice, and prevention (2nd ed., pp. 7684). New Description
York: Guildford Press.
Woertman, L., & van den Brink, F. (2012). Body image The distinction between bottom-up and top-down
and female sexual functioning and behavior: A review.
Journal of Sex Research, 49, 184211. theories of life satisfaction was originally made
by Diener (1984). He pointed out that, at time of
writing, most researchers tended to assume that
life satisfaction is a weighted average of satisfac-
tion with different domains of life (working life,
Bog family life, etc.). However, the opposite view was
also tenable. That is, satisfaction with different
Wetland(s) domains of life might be a consequence of fixed
(e.g., genetic) or relatively unchanging (e.g.,
personality traits) factors.
Pioneering QOL researchers who adopted
Booty Calls a bottom-up approach included Bradburn (1969)
and the University of Michigan teams of
Casual Sex and the Quality of Life Andrews and Withey (1976) and Campbell,
B 424 Bottom-Up Versus Top-Down Theories of Life Satisfaction

Converse, and Rodgers (1976). Early investiga- effects on SWB which, on average, lasted more
tors whose research could be said to reflect than a year (Clark, Diener, Georgellis, & Lucas,
a top-down approach included those who 2008). In other words, in response to all other
believed that SWB nearly always returned to events reviewed, most people soon reverted to
a baseline after major life events (Brickman & their previous SWB set points.
Campbell, 1971) and also those who viewed Set-point theory may still be the most widely
SWB as mainly a function of stable personality held theory among empirical SWB researchers.
traits (Costa & McCrae, 1980). However, it is increasingly coming under attack
In general terms, it may be said that research in work which claims that SWB is affected by
which shows that objective conditions, or indi- individual preferences and choices. Several
vidual preferences and choices, affect SWB studies show significant linkages between choice
could be regarded as supporting bottom-up the- of life goals and SWB (Kasser & Ryan, 1993;
ory. Research which shows that fixed traits and Diener & Seligman, 2004; Headey, 2008;
genes affect SWB could be regarded as Kahneman, Krueger, Schkade, Schwarz, &
supporting top-down theory. An obvious point, Stone, 2006). Prioritizing family-related and
however, is that if all these types of variables altruistic goals appears to be positively associated
have significant effects on SWB, the debate with SWB, whereas prioritizing money and mate-
loses its point and the key task becomes one rial goals appears negatively related.
of sorting out main, direct, indirect, and Volunteering an altruistic activity is associ-
interaction effects. ated with high SWB (Thoits & Hewitt, 2001).
Early empirical research on SWB found that Having the resources needed to pursue life goals
objective conditions (income, housing, etc.) had also affects SWB (Diener & Fujita, 1995). SWB
surprisingly small effects (Andrews & Withey, appears to be positively affected by religious
1976; Campbell, Converse, & Rodgers, 1976). beliefs and behavior (Myers, 2008; Headey,
However, a fairly recent review concluded that Schupp, Tucci, & Wagner, 2010). It can be
about 15 % of the explained variance in SWB is enhanced or damaged by choice of
due to objective conditions (Argyle, 2001). More marriage partner (Lucas, Clark, Georgellis, &
interestingly, a study of the 50 American states Diener, 2003; Headey, Muffels, & Wagner,
found that objective economic and environmental 2010). One of the oldest, most replicated findings
conditions, which can be viewed as compensated in SWB research is that people who have strong
for by average income differentials between the friendships and active social and community
states, had an aggregate correlation of 0.6 with involvements are happier than average
SWB (Oswald & Wu, 2010). (Bradburn, 1969; Argyle, 2001). In a recent
Support for top-down theory, in the form of set- study, Headey, Muffels, and Wagner (2010)
point theories, reached its apogee in the 1990s showed that the effects of life goals, religion,
when results from the Minnesota twin study were choice of marriage partner, and social involve-
interpreted, probably incorrectly (Diener, Suh, ments remain substantial, and not merely
Lucas, & Smith, 1999), as showing that up to statistically significant, after taking account of
80 % of the variance in long-term life SWB was personality traits and other fixed effects.
genetic (Lykken & Tellegen, 1996). In addition to Empirical investigations intended to provide
twin studies, the strongest support for set-point direct tests of bottom-up versus top-down
theory came from studies which found that most theories face difficult chicken-and-egg issues,
important-seeming life events have only that is, difficult issues in sorting out time
short-lived effects on SWB. For example, a recent sequences. Suppose one is investigating whether,
comprehensive review claimed that, out of a range in a sample of survey respondents, observed
of events (marriage, bereavement, divorce, etc.), changes in marriage satisfaction and job satisfac-
only long-term or repeated unemployment had tion precede (bottom-up theory) or follow
Bottom-Up Versus Top-Down Theories of Life Satisfaction 425 B
(top-down theory) observed changes in life satis- Cross-References
faction. Clearly, prospective longitudinal data are
needed; investigations based on cross-sectional Experience Sampling
evidence or recall data would be futile. But, Set-Point Theory
even with longitudinal data, it would not nor- B
mally be possible to sort out time sequences in
a direct and clear way. In most longitudinal
surveys, respondents are interviewed at annual References
intervals. If, as is very likely, the time lag
Andrews, F. M., & Withey, S. B. (1976). Social indicators
between the effect of change in a domain of well-being. New York: Plenum.
satisfaction on change in life satisfaction, or the Argyle, M. (2001). The psychology of happiness (2nd ed.).
reverse effect, is less than a year, then an annual London: Taylor & Francis.
Bradburn, N. M. (1969). The structure of psychological
longitudinal survey cannot be used to ascertain
well-being. Chicago: Aldine.
directly which change came first. Brickman, P. D., & Campbell, D. T. (1971). Hedonic
Despite the difficulties, some attempts have relativism and planning the good society. In M. H.
been made to assess the relative importance of Appley (Ed.), Adaptation-level theory. New York:
Academic Press.
bottom-up versus top-down explanations of life
Campbell, A., Converse, P. E., & Rodgers, W. R. (1976).
satisfaction. Using multiple waves of data from The quality of American life. New York: Sage.
an Australian longitudinal survey, Headey, Clark, A. E., Diener, E., Georgellis, Y., & Lucas, R. E.
Veenhoven, and Wearing (1991) reported that (2008). Lags and leads in life satisfaction: A test of the
baseline hypothesis. The Economic Journal, 118,
changes in marriage satisfaction significantly
affected changes in life satisfaction, as well as Costa, P. T., & McCrae, R. R. (1980). Influences of
vice versa. In other words, both bottom-up and extraversion and neuroticism on subjective
top-down explanations had some weight. In other well-being. Journal of Personality and Social
Psychology, 38, 668678.
domains, including work life and leisure, the direc-
Diener, E. (1984). Subjective well-being. Psychological
tion of causation appeared to be mainly top-down. Bulletin, 235, 542575.
Headey, Veenhoven, and Wearing used structural Diener, E., & Fujita, F. (1995). Resources, personal
equation models to estimate their equations. Struc- strivings and subjective well-being: A nomothetic
and ideographic approach. Journal of Personality
tural equation modeling remains controversial in
and Social Psychology, 68, 926935.
the social sciences, and the authors conceded that Diener, E., & Seligman, M. E. P. (2004). Beyond money:
their results were quite sensitive to assumptions Toward an economy of well-being. Psychological Sci-
imposed to identify their models. ence in the Public Interest, 5, 131.
Diener, E., Suh, E. M., Lucas, R. E., & Smith, H. L.
It seems possible that that some bottom-up, top-
(1999). Subjective well-being: Three decades of eco-
down issues could be sorted out if data were col- nomic progress. Psychological Bulletin, 125, 276302.
lected in a longitudinal survey conducted at (say) Headey, B. W. (2008). Life goals matter to happiness:
monthly intervals or if a long-running survey was A revision of set-point theory. Social Indicators
Research, 86, 213231.
conducted using experience-sampling methods.
Headey, B. W., Muffels, R. J. A., & Wagner, G. G. (2010).
However, even without improved data, it seems Long-running German panel survey shows that
clear that both variables associated with bottom-up personal and economic choices, not just genes, matter
explanations, and those associated with top-down for happiness. Proceedings of the National Academy of
Sciences, 107(42), 1792217926.
explanations, help to account for differences in
Headey, B. W., Schupp, J., Tucci, I., & Wagner, G. G.
SWB. Top-down variables personality traits (2010). Authentic happiness theory supported by
and genetic effects mainly account for stability impact of religion on life satisfaction: A longitudinal
in SWB. Bottom-up variables objective condi- analysis with data for Germany. The Journal of
Positive Psychology, 5, 7382.
tions, individual preferences, goals, and choices
Headey, B. W., Veenhoven, R., & Wearing, A. J. (1991).
contribute to accounts of short and long changes Top-down vs. bottom-up theories of subjective well-
in SWB. being. Social Indicators Research, 24, 81100.
B 426 Bounded Rationality

Kahneman, D., Krueger, A. B., Schkade, D., Schwarz, N.,

& Stone, A. A. (2006). Would you be happier if you Brazil, Quality of Life
were richer? A focusing illusion. Science, 312,
Kasser, T., & Ryan, R. M. (1993). A dark side of the John H. Salmela
American dream: Correlates of financial success as Human Kinetics, University of Ottawa,
a central aspiration. Journal of Personality and Social Belo Horizonte, Brazil
Psychology, 65, 410421.
Lucas, R. E., Clark, A. E., Georgellis, Y., & Diener, E.
(2003). Reexamining adaptation and the set point
model of happiness: Reactions to change in marital Synonyms
status. Journal of Personality and Social Psychology,
84, 527539.
Lykken, D., & Tellegen, A. (1996). Happiness is a Aged; Poverty; Social class in Brazil; South
stochastic phenomenon. Psychological Science, 7, America; Sports in Brazil
Myers, D. G. (2008). Religion and human flourishing.
In M. Eid & R. J. Larsen (Eds.), The science of sub-
jective well-being (pp. 323346). New York: Guilford Definition
Oswald, A. J., & Wu, S. (2010). Objective confirmation of Brazil is located in South America. Its the
subjective measures of economic well-being: biggest country in this continent. Its in the Atlan-
Evidence from the U.S.A. Science, 327, 576579.
comment, 53435. tic Ocean side of the continent and it borders all
Thoits, P. A., & Hewitt, L. N. (2001). Volunteer work the other countries in South America, except for
and well-being. Journal of Health and Social Ecuador and Chile.
Behavior, 42, 115131.


Brazil has the fifth largest land mass in the world,

Bounded Rationality the largest in South America, and is one of the
fastest growing world economies. After becom-
Economic Rationality Assumption
ing an independent country in 1822, slavery only
ended in 1888, the last of all of the Americas. The
population in Brazil in 1900 was about
17,438.434 and grew in 1991 to 147,053,940
Boy Soldier and in 2010 to about 190,000.000.
The socioeconomic classes in the northeastern
Child Soldiers states are still the lowest, with pockets in the
largest developed cities to the south, who live in
favelas, or shanty towns. The disparity between
the rich and the poor is enormous, although this
has been considerably reduced through govern-
Bradburn Scale
mental and food subsidies (cestas familiares) for
the lower classes. Because of their exports of
Affect Balance Scale
lumber, ethanol, and recently discovered,
offshore oil fields, it now has the ninth highest
gross national product (GNP) in the world.
The perceived quality of life (QOL) has been
Brainwave Biofeedback recently assessed with empirical protocols with
the community-dwelling elderly (Teixeira-
Neurotherapy Salmela et al., 2005), chronic stroke victims
Brazil, Quality of Life 427 B
(Teixeira-Salmela, Olney, Nadeau, & Brouwer, transportation. Thus, these exercise programs
1999; Teixeira-Salmela et al.), and Parkinsonians gave them more social, emotional, and physical
(Rodrigues-de-Paula, Teixeira-Salmela, Faria, confidence, and a better QOL.
Morais, Rocha de Brito, & Cardoso, 2006) using Similar results were obtained with commu-
strength and conditioning programs, including nity-dwelling Brazilian elderly who were B
QOL measures. Also QOL has been observed, assessed and trained with measures of gait
assessed, and described in Brazil for wealthy speed, ascending and descending stairs, and the
athletes, coaches, and parents from volleyball, NHP (Teixeira-Salmela et al., 2005). During
swimming, and gymnastics, compared to the assessments, after 1, 2, and 3 months, their
less fortunate ones, mainly from soccer (Salmela physical capacities declined after 1 month of
& Morais, 2003). This data was compared to detraining, but their perceptions of their QOL
some of the QOL scales reported by Michalos, remained stable. This may have been due to
Hatch, Hemingway, Lavallee, Hogan, and powerful Hawthorne effects, due to special
Christensen (2007). In addition, published and unaccustomed interventions by trained
observations regarding the QOL scales of professionals.
successful soccer players, and the life in Brazilian This was also the case with Brazilian individ-
favelas, as compared to US ghettos are also uals with Parkinsons who after 12 weeks of
reported. muscular strengthening, isometric and isotonic
Quality of life and exercise training and exercises of the trunk and lower limbs,
detraining in Brazil. In Canada, research was maintained high levels of perceptions of
conducted on the effects of muscular strength QOL, especially for emotional reactions, social
and aerobic training, including gait speed, stair interactions, and physical ability (Rodrigues-de-
climbing, and total peak torques with stroke Paula Teixeira-Salmela, de Morais Faria, de
victims, along with perceptions of QOL, using Brito, & Cardoso, 2006).
the Nottingham Health Profile (NHP) scales Quality of life and individuals from different
(Teixeira-Salmela et al., 1999). After a 10-week socioeconomic levels in Brazil. Brazil has the
program of muscular strengthening and aerobic greatest range of socioeconomic classes with the
conditioning, all variables such as gait speed, lowest earnings, about 336 US dollars per month
stair climbing, and total peak torque improved, and the most wealthy earning 12,000 US dollars,
but the NHP increased by 77.8 %, but there were or more, per month. This is especially true for
no follow-ups after detraining. successful soccer players and corrupt politicians!
Using an identical protocol of subjects with Brazil is considered to have the most unequal
stroke in Brazil, Teixeira-Salmela et al., (2005) distribution of wealth, with the exception of
found similar results for subjects with stroke after South Africa. An interesting conundrum is that
a 10-week strength and conditioning program, wealth is not necessarily associated with
three times a week. After detraining, the physical better QOL.
benefits plus the perceived QOL persisted. In An interesting blog showed the apparently
a one-year follow-up assessment, the exercise- poor lives of Brazilians, who live in favelas and
induced, as well as some of the NHP variables, have high levels of QOL in the major developed
such as energy levels, emotional reactions, and cities of Sao Paulo, Rio de Janeiro, and Belo
physical abilities, remained high. Horizonte (Zezinho, 2010). This is refuted by
The subjects reported that they were now able the famous American burlesque queen Mae
to maintain their social relations, were more Wests quotation: I have been rich and poor,
emotionally balanced and confident about doing but rich is better. This is an important and con-
simple, normal practical life activities, such as tradictory statement regarding the QOL of the
crossing the street, sitting on their stoops, and rich and the poor in Brazil and in North America,
talking to neighbors, and were more confident regarding life in ghettos in the USA and the
getting aboard buses, their main means of favelas in Brazil reported by Zezinho (2010):
B 428 Brazil, Quality of Life

When I was living in the USA, people would com- invasions and established social codes inside
plain about everything. It was as if the stress of the favela.
trying to live up to societys expectations were
a burden. I saw many scenes of parents aggres- Today, the same social codes exist, and unlike
sively yelling or even hitting children in in a US ghetto, one can safely walk through the
public. I started to see a country and people who favelas anytime, day or night, without fear of
were angry and on the edge about their lives, as if it having crimes against them.
was impossible to keep up to expectations. In the
US, they have everything, yet they are still not Where else can one feel totally free and walk
happy. I started to question, what is happiness in the streets safely at three in the morning with total
the US? freedom? Where can one walk in a community
Favelas are called slums or shanty towns, where they get greeted 1015 times a day by their
because of the way the people constructed their neighborhood people? All one needs to do is walk
houses. In the beginning, they had no running out their door and find a party, no need to crash
water nor electricity, and no infrastructures. So the party, since there is no such thing. Today, if
the government for the longest time turned their they decided they wanted peace, they would stay
back, while the poor would build their shacks on inside and relax. In Rocinha, one will never be
the hills. Yet, there was little confrontation lonely.
between citizens and the government, because Our street parties include everyone; nobody is
the favelados represented a large work force for excluded. We can have a party for any reason,
the middle and upper classes. Who else is going samba, funk, football, birthday, or just people
to clean your house or sweep the streets? As who want to get together. If you decide to want
favelas grew, the state started having concerns. to come for a visit, I am always available to show
When you live in conditions where there is no people a good time here that you will never
sanitation, electricity, water, nor anything else, forget. I do not know if the American ghettos
problems begin to occur. There were we had have street parties anymore. In our club, we
problems with garbage removal, and because of can have 3,000 people in there dancing and not
the rats, diseases spread. one fight breaks out. Can that be said in any
But how can people pay taxes when they are US ghetto?
living on less than $700 reais (approximately $400 QOL and sport in Brazil. While volleyball,
US) a month? The rich can send their kids to private swimming, and tennis are popular sports in
schools which ensure them opportunities to get into Brazil, soccer, or futebol, is by far the most
universities. This is foreign to the favelados. The popular (Salmela, 1993). Bellos (2002) quotes
public schools fail to give them these opportunities, Gilberto Freyre in the following manner: The
no matter how intelligent you are. Brazilians play football as if they were dancing.
In the favelas, everybody works. There are no This is probably the result of the influence of
public housing projects, welfare, food stamps, those Brazilians who have African blood or are
nor social programs. If you dont work, you predominantly African in their culture, for such
dont live. We care about our community regard- Brazilians tend to reduce everything to dance,
less of its problems. In the favelas, it is work, and play alike. (p.27).
a community effort for survival and nobody is Football was introduced to Brazil in
better than anybody else. We are all equal; we are 1894 when Charles Miller, an Englishman,
all favelados. Favelas were far from perfect, but disembarked in the port of Santos in 1894 with
for us, it works. two footballs in his hands, but has evolved
In Rocinha, the first drug lord Dennis incredibly since then, resulting in five World
changed the ways of negative social behaviors Cup victories, the most in the world. QOL in
in the favela. The traficantes (drug dealers) Brazil exudes, principally, through football. The
not only sold drugs but acted as internal police country is totally electric during the Cup, which
forces for the community. They protected the has won a record of five times, but between these
community from outside police and rival gang events, the bars are completely dominated by
Brazil, Satisfaction with Life Scale Survey Results 429 B
discussions about the rankings of the local teams J. L. Starkes & K. A. Ericcson (Eds.), Expert perfor-
and their multiple championships. The streets are mance in sports: Advances in research on sport exper-
tise (pp. 273293). Champaign, IL: Human Kinetics.
full of young players, although the poor do not Teixeira-Salmela, L. F., Faria, C. D. C. M., Guimaraes, C.,
have spacious fields, which are only reserved for Goulart, F., Parreira, V. F., Inacio, E. P., & Alcantara,
the upper class families who are members of T. O. (2005). Treinamneto fsico e destreinamento em B
these clubs. hemiplegicos cronicos: Impacto na qualidade de Vida.
Revsita Brasileria de Fisioterapia, 9(3), 347353.
Thus, QOL in Brazil is a complex multiface- Teixeira-Salmela, L. F., Olney, S. J., Nadeau, S., &
ted concept based upon factors of salaries, health, Brouwer, B. (1999). Muscle strengthening to reduce
social classes, and sport and is constantly chang- impairment and disability in chronic stroke survivors.
ing. For example, many academics and medical Archives of Medicine and Rehabilitation, 80,
doctors either cannot speak nor write in English, Teixeira-Salmela, L. F., Santiago, L., Lima, R. C., Lana,
although their children can, thanks to early D. M., Camargos, F. F., & Cassiano, J. G. (2005).
schooling in specialized schools. Ten years ago, Functional performance and quality of life related to
approximately 60 % of Brazilian women worked training and detraining of community-dwelling
elderly. Disability and Rehabilitation, 27(17),
as domestic maids, and their children were taught 10071012.
these skills of washing floors and dishes, and now Zezinho, D.J. (2010). Comparing US ghettos to favelas.
are perpetrating this. Finally, I have seen garbage www.favelatour.org. Accessed 03/03/2011.
men, happily running behind a garbage truck in
orange uniforms, apparently happy, with huge
bags of waste, throwing them into an accelerating
truck, while waving to customers in bars, singing Brazil, Satisfaction with Life Scale
and waving. Obviously, wealth and QOL are not Survey Results
directly related in Brazil and require further
study. Taciano L. Milfont1 and Valdiney V. Gouveia2
School of Psychology, Victoria University of
Wellington, Wellington, New Zealand
Cross-References Department of Psychology, Federal University
of Paraba, Joao Pessoa, Brazil
Family Relationships
Perceived Quality of Life
Satisfaction with Life as a Whole Synonyms


Bellos, A. (2002). Futebol: The Brazilian Way of life. Definition

New York/London: Bloomsbury.
Michalos, A. C., Hatch, P. M., Hemingway, D., Lavallee
The Satisfaction with Life Scale (SWLS) is
Hogan, A., & Christensen, B. (2007). Health and qual-
ity of life of older people: A replication after six years. a domain-free measure developed by Diener,
Social Indicators Research, 84, 127158. Emmons, Larsen, and Griffin (1985) to access the
Rodrigues-de-Paula, F., de, Teixeira-Salmela, L. F., de cognitive-judgmental component of subjective
Morais Faria, C. C. D., de Brito, R. P., & Cardoso, F.
(2006). Impact of an exercise program on physical,
well-being (SWB). Its five items are (1) In most
emotional, and social aspects of quality of life of ways my life is close to my ideal, (2) The
individuals with Parkinsons disease. Movement conditions of my life are excellent, (3) I am
Disorders, 21, 10731077. satisfied with my life, (4) So far I have
Salmela, J. H. (1993). The world sport psychology source-
book (2nd ed.). Champaign: Human Kinetics.
gotten the important things I want in life, and
Salmela, J. H., & Morais, L. C. (2003). The role (5) If I could live my life over, I would change
of coaching, families and cultural contexts. In almost nothing. Responses are made on
B 430 Brazil, Satisfaction with Life Scale Survey Results

a 7-point scale, anchored by 1 (strongly disagree) with life compared to the normative data (Pavot
and 7 (strongly agree). By answering the & Diener, 1993).
SWLS items, individuals provide their global A more systematic study examining the
judgment of satisfaction with life as a whole. validity of the SWLS in Brazilian samples was
A score of 20 represents the neutral point on the published by Gouveia, Milfont, Fonseca, and
scale, and according to the normative data Coelho (2009), who examined the construct and
(Pavot & Diener, 1993), scores on the 59 range criterion-related validity of the Portuguese-
represent being extremely dissatisfied with life, Brazilian version of the scale with data from
the 1014 range represent dissatisfied, the 1519 2,180 participants from five independent and
range represent slightly dissatisfied, the 2125 diverse groups (i.e., undergraduate and high
range represent slightly satisfied, the 2630 school students, general population, elementary
range represent satisfied, and scores above 31 school teachers, and physicians).
represent extremely satisfied. They first reported the statistics for the five
SWLS items in each sample, including item
means and standard deviations as well as item
Description factor loadings and corrected item-total correla-
tions. Item 5 (If I could live my life over, I would
Thousands of international studies have used change almost nothing) had the weakest psycho-
the SWLS since its publication, with translations metric properties, as also observed in other
into several languages. The scale has also been studies (Pavot & Diener, 1993). Exploratory
applied in the Brazilian context. A recent search factor analysis confirmed a single-factor solution
of the SciELO shows that this scale has been used for each sample as well as the overall sample. All
or cited in nine studies between 2002 and 2011 items showed higher factor loadings (the lowest
(SciELO stands for Scientific Electronic Library was 0.50 for item 5 in the general population
Online and is a database of electronic scientific sample), and the single factor accounted for
publications in developing countries). A similar 52 % (high school students) to 68 % (physicians)
search on Google, using Satisfaction with Life of the total variance, explaining 57 % of the
Scale AND Diener as keywords and narrowing variance for the overall sample.
the search only to pages published in Brazil, The unidimensional structure was further
yielded 385 pages citing the SWLS. supported by confirmatory factor analyses, with
The first attempt to validate the SWLS in satisfactory model fit for each of the five sam-
the Brazilian context was described in ples as well as for the overall sample. Lower fit
a conference presentation by Giacomoni and indices were observed for the student sample.
Hutz (1997), and Gouveia et al. (2003; see also Configural invariance was also supported by
Gouveia, Barbosa, Andrade, & Carneiro, 2005) a multigroup confirmatory factor analysis, dem-
were the first to publish articles explicitly examin- onstrating that the single-factor solution is the
ing the psychometric properties of the scale. same across all five Brazilian samples. The scale
Drawing from a large sample of 14,405 physicians displayed internal reliability ( Cronbachs
from all five regions in Brazil, Gouveia et al. Alpha) above the conventional threshold of
(2005) confirmed a single-factor solution for the 0.70 in all samples, with values ranging from
SWLS in Brazil with both exploratory and confir- 0.77 (for both high school students and general
matory factor analyses. Internal consistency population) to 0.88 (physicians), with a value of
(Cronbachs alpha) was greater than 0.80 for all 0.80 for the overall sample. All items also had
regional samples and no gender differences were strong corrected item-total correlations (the
observed, but older physicians had higher life sat- lowest was 0.44 for item 5 in the general popu-
isfaction compared to younger physicians. Scale lation sample).
score for the overall sample was 23.5 (SD 6.77), The general population sample had a lower
which means physicians were slightly satisfied scale score (M 23.95), whereas both physicians
Brazil, Satisfaction with Life Scale Survey Results 431 B
and high school students had a higher score to change profession among physicians, nurses,
(M 24.32 for both), but no statistically signif- and psychologists (Oliveira et al., 2009); and
icant differences were observed across samples. negatively associated with lower levels of mental
The SWLS score for the overall sample was disorders (Goncalves & Kapczinski, 2008).
24.08 (SD 6.18), which means that these While some Brazilian studies have found B
Brazilian participants were slightly satisfied women to score higher than men on the SWLS
with their lives in comparison with the normative (e.g., Goncalves & Kapczinski, 2008), others
data (Pavot & Diener, 1993). have found no gender differences (e.g., Ribeiro
Gouveia et al. (2009) then examined the & Ruiz, 2009), but more consistently there seems
criterion-related validity of the SWLS by exam- to be a pattern for older Brazilians to be more
ining associations with positive/negative affect satisfied with their lives (see Table 1). Despite
and psychological distress. Past research has very good overall psychometric properties of the
shown that greater life satisfaction is associ- SWLS, some studies have shown that item 5 has
ated with high positive affect, while also the weakest parameters in Brazilian samples
associated with low negative affect, general psy- (e.g., Albuquerque et al., 2010; Gouveia et al.,
chological distress, anxiety, and depression 2009, 2010), just like in other studies (Pavot &
(e.g., Diener, Emmons, Larsen, & Griffin, Diener, 1993).
1985; Lucas, Diener, & Suh, 1996). A similar Another noteworthy application of the SWLS
trend was observed across the five Brazilian in the Brazilian context is the use of some of its
samples, with the SWLS positively related to items in a subjective well-being measure. In
positive affect (r 0.62) and negatively related developing their 69-item scale, Albuquerque
to both negative affect and psychological dis- and Troccoli (2004) report combining three
tress (r 0.21 and 0.51, respectively). items from the SWLS, plus three items from
Besides the Gouveia et al. (2009) study that Lawrence and Liangs Subjective Well-Being
publicized the use of the SWLS in Brazil to an Scale (SWBS), 15 items from Watson et al.s
international audience, several other studies have Positive and Negative Affect Schedule
used the scale and are published in Portuguese. (PANAS), and newly developed items. While
Table 1 presents a summary of known published researchers prefer to measure the affective,
studies. For example, Gouveia, Freires, Araujo, emotional aspects of subjective well-being
Santos, and Gouveia (2010) employed the (i.e., positive affect and negative affect) inde-
scale to access life satisfaction among a sample pendently from measures of the cognitive-
of 100 prostitutes, who had a scale score below judgmental aspects (i.e., life satisfaction), their
other Brazilian samples, being slightly dissatis- Brazilian measure combines all aspects in
fied with life. Other Brazilian samples for which a single well-being measure.
the SWLS has been used include caregivers with
chronic back pain (Maia, Fialho, Alcantara, &
Morais, 2008), elders living in rural areas
(Albuquerque, Sousa, & Martins, 2010), nurses Discussion
(Alves, Vasconcelos, Miranda, Costa, &
Sobreira, 2011), bank workers (Paiva & Borges, Future research should consider two main issues
2009), and adults with physical disability related to the scale, which refers to the weak
(Resende & Gouveia, 2011). psychometric parameters of item 5 and the
Associations between the SWLS and broader overall high scale score across samples. As
constructs have also been examined. The SWLS discussed by Pavot and Diener (1993) as well
has been shown to be negatively associated with as Gouveia, Millfont, Fonseca, and Coelho
irrational beliefs (Matta, Bizarro, & Reppold, (2009), the poor performance of item 5 may be
2009); positively associated with personal related to the fact that the item is wording in
income and negatively associated with intention a past orientation. But it could also be related to

Brazil, Satisfaction with Life Scale Survey Results, Table 1 Summary of published studies using the Satisfaction with Life Scale (SWLS) in Brazil
Cronbachs Mean Female Gender Age Single-factor variance
Study Sample type N M SD alpha age (%) differences difference solution (%)
Gouveia, Barbosa, Physicians 14,405 23.5 6.77 0.89 40.8 69.8 Yes (greater No Yes 70.5
Andrade, with age)
and Carneiro (2005)
Goncalves and General population 625 24.9 5.57 0.80 39.7 68.8 Yes (greater Yes (greater  
Kapczinski (2008) with age) for women)
Maia, Fialho, Caregivers with 45 18.9 6.64  35.1 95.6    
Alcantara, chronic back pain
and Morais (2008)
Gouveia, Milfont, High school 454 24.32 5.80 0.77 21 65.2    52
Fonseca, and Coelho students
(2009) Undergraduate 797 24.07 6.46 0.83 24 58.8    
Elem school 306 23.65 6.07 0.78 34 92.2    
General population 306 23.95 6.12 0.77 34 50.3    
Physicians 317 24.32 6.19 0.88 43 32.5    68
Overall sample 2,180 24.08 6.18 0.80 29 59.8 Yes (greater No  57
with age)
Brazil, Satisfaction with Life Scale Survey Results
Matta, Bizarro, Undergraduate 157 24.8 4.97  21 76.8    
and Reppold (2009) students
Oliveira et al. (2009) Nurses 67 25.5 6.22       
Physicians 81 26.5 5.41       
Psychologists 98 24.6 6.04       
Overall sample 246    42.8 81.6    
Paiva and Borges Bank workers 200 4.89b 1.20  35.8 41.9    
(2009) (24.45)
Resende and Adults with 25 5.08b 1.10  48 64.0    
Gouveia (2011) physical disability (25.4)
Ribeiro and Ruiz University 30 26.6   3060  No   
(2009) professors range
Albuquerq, Sousa, Elders from rural 342 7.2c 2.19 0.85 (with 6080 48.5   Yes 59
and Martins (2010) areas item 5 range
Brazil, Satisfaction with Life Scale Survey Results

Gouveia et al. (2010) Prostitutes 100 17.9 6.41 0.62 26.2 100   Yes 41.9
Resende and Elders acting in 12 5.95b 0.94  68 91.7    
Gouveia (2011) a theater group (29.75)
Alves, Vasconcelos, Nurses 20 4.03b 1.32  34 90.0    
Miranda, Costa, and (20.15)
Sobreira (2011)
Missing information refers to data not reported in the original studies. Responses to the SWLS are made on a 7-point scale, ranging from 1 (strongly disagree) to
7 (strongly agree), unless stated. (a) Data originally reported in Gouveia et al. (2003). (b) Original article reports mean for the SWLS, and sum score was then derived for the
present article. (c) Mean based on a 10-point scale

B 434 Brazil, Satisfaction with Life Scale Survey Results

the grammatical structure of the statement, [in Portuguese]. Psicologia: Teoria e Pesquisa, 20,
which implies counterfactual thinking that 153164.
Alves, S. G. S., Vasconcelos, T. C., Miranda, F. A. N.,
might hinder its understanding and conse- Costa, T. S., & Sobreira, M. V. S. (2011). Approach on
quently affect performance and relation to the nurses subjectivity with life: Focused on affection and
other SWLS items (cf. Hershberger, Market, & satisfaction [in Portuguese]. Escola Anna Nery, 15,
Levengood, 1999). 511517.
Diener, E., Emmons, R. A., Larsen, R. J., & Griffin, S.
Regarding the second issue, Pavot and Diener (1985). The satisfaction with life scale. Journal of
(1993) discuss response artifacts that may influ- Personality Assessment, 49, 7175.
ence the SWLS scores, such as acquiescence Giacomoni, C. H. & Hutz, C. S. (1997, July). Measuring
bias and social desirability. There may be subjective well-being: The positive and negative
affect scales and the satisfaction with life scale [in
another methodological artifact related to Portuguese]. In Interamerican Society of Psychology
a self-serving bias. It has been observed that (Eds.), Book of abstracts of the xxvi congress of the
the scale scores for nonclinical samples are interamerican society of psychology: (p. 313). Sao
above the neutral point and this is a widely Paulo, SP: Brazil.
Goncalves, D. M., & Kapczinski, F. (2008). Mental dis-
replicated finding (Pavot & Diener, 1993, p. order, demographic variables and life satisfaction [in
165). In terms of the means given in Table 1, Portuguese]. Revista de Saude Publica, 42,
only two samples (prostitutes and caregivers 10601066.
with chronic back pain) had a score below the Gouveia, V. V., Barbosa, G. A., Andrade, E. O., &
Carneiro, M. B. (2005). Measuring life satisfaction
neutral point of 20. Most groups fall in the range among physicians in Brazil [in Portuguese]. Journal
of slightly satisfied to satisfied, or the 2630 Brasileiro de Psiquiatria, 54, 298305.
range, which is in line with the normative data. Gouveia, V. V., Chaves, S. S., Oliveira, I. C., Dias, M. R.,
An optimistic bias underlying the scale, and Gouveia, R. S. V., & Andrade, P. R. (2003). The use of
the GHQ-12 in a general population: A study of its
well-being constructs more generally (cf. construct validity [in Portuguese]. Psicologia: Teoria
Sanjuan, Magallares, & Gordillo, 2011), thus e Pesquisa, 19, 2412488.
seems to be evident because most individuals Gouveia, R. S. V., Freires, L. A., Araujo, R. C. R., Santos,
answering the SWLS tend to be satisfied with L. C. O., & Gouveia, V. V. (2010). If they are prosti-
tutes, why are they happy? Material correlates of life
their life or fell more satisfied with life than the satisfaction [in Portuguese]. Revista Bioetica, 18,
average person. 603621.
Notwithstanding these general issues, the Gouveia, V. V., Milfont, T. L., Fonseca, P. N., &
available findings support the SWLS as a valid Coelho, J. A. P. M. (2009). Life satisfaction in
Brazil: Testing the psychometric properties of
and reliable measure to the Brazilian context. the satisfaction with life scale (SWLS) in five
Researchers can rely on the Brazilian-Portuguese Brazilian samples. Social Indicators Research, 90,
version of the SWLS presented by Gouveia et al. 267277.
(2009) as an index of life satisfaction. Hershberger, P. J., Market, R. J., & Levengood, J. V.
(1999). Nonevents and adult well-being. Journal of
applied Developmental Psychology, 20, 85100.
Lucas, R. E., Diener, E., & Suh, E. (1996). Discriminant
validity of well-being measures. Journal of Personal-
Cross-References ity and Social Psychology, 71, 616628.
Maia, A. C., Fialho, C. B., Alcantara, M. A., & Morais,
Life Satisfaction Judgments R. L. S. (2008). Functional disability associated to
low-back pain in caregivers of children with severe
cerebral palsy [in Portuguese]. Fisioterapia
References e Pesquisa, 15, 349354.
Matta, A., Bizarro, L., & Reppold, C. T. (2009). Irrational
Albuquerque, F. J. B., Sousa, F. M., & Martins, C. R. beliefs, psychological adjustment and life satisfaction
(2010). Validation of the satisfaction with life scale in college students [in Portuguese]. Psico-USF, 14,
and affect scales for elders in the countryside 7181.
[in Portuguese]. Psico, 41, 8592. Oliveira, G. F., Barbosa, G. A., Souza, L. E. C., Costa,
Albuquerque, A. S., & Troccoli, B. T. (2004). C. L. P., Araujo, R. C. R., & Gouveia, V. V. (2009).
Development of a subjective well-being scale Life satisfaction among health professionals:
Breast Cancer 435 B
Demographic and work-related correlates. Revista These cells can form a mass of tissue, called
Bioetica, 17, 319334. a tumor. Through the blood and lymph system
Paiva, C. S. D. L., & Borges, L. O. (2009). The work
environment in banks and well-being [in Portuguese]. cancer cells can spread to other parts of the body
Psicologia em Estudo, 14, 5766. and form metastases. Breast cancer is the most
Pavot, W., & Diener, E. (1993). Review of the satisfaction frequent cancer among women worldwide. About B
with life scale. Psychological Assessment, 5, 164172. 1.15 million women were diagnosed with breast
Resende, M. C., & Gouveia, V. V. (2011). Quality-of-life
in adults with physical disability [in Portuguese]. cancer in 2002, and approximately 410,000
Psicologia: Reflexao e Crtica, 24, 99106. women died of the disease (Boyle & Levin,
Ribeiro, M. C. C., & Ruiz, V. M. (2009). Subjective well- 2008). Due to early detection and modern
being of university professors: A comparative study of treatment, including combinations of surgery,
knowledge areas and gender [in Portuguese].
Pensamento Plural, 3, 2331. radiotherapy, chemotherapy, and endocrine
Sanjuan, P., Magallares, A., & Gordillo, R. (2011). Self- therapy, breast cancer survival has improved.
serving attributional bias and hedonic and eudaimonic Still, survival rates vary greatly worldwide.
aspects of well-being. In I. Brder (Ed.), The human Five-year relative survival ranges from 80 % or
pursuit of well-being: A cultural approach
(pp. 1526). London: Springer. more in, for example, North America, Sweden,
and Japan to around 60 % in Brazil and Slovakia
and below 40 % in Algeria (Coleman et al.,
2008). Diagnosis and treatment can substantially
Breast Cancer affect patients Quality of Life (QoL).
This entry highlights aspects of Health-
Nina Rottmann1, Marianne Ewertz2 and Related Quality of Life (HRQol) which women
Dorte Gilsa Hansen1 treated for breast cancer may encounter. HRQoL
National Research Centre for Cancer is concerned with QoL in relation to health and
Rehabilitation, Research Unit of General impact of the disease. It is a loosely defined term
Practice, University of Southern Denmark, that can include multiple dimensions such as
Odense, Denmark physical symptoms, emotional functioning,
Department of Oncology Odense University social well-being, and existential issues (Fayers
Hospital, University of Southern Denmark, & Machin, 2009).
Odense, Denmark In this essay, we adopt a broad approach to
HRQoL. We present selected research results in
clusters (Fig. 1), tailored to the experience of
Synonyms breast cancer. The clusters encompass symptoms,
functioning and broader issues, and are grouped
Breast cancer and adaptation; Breast cancer and around the following five overarching aspects of
body image; Breast cancer and depression; Breast HRQoL:
cancer and emotional sharing; Breast cancer and Emotional and cognitive issues
fatigue; Breast cancer femininity and sexuality; Femininity and sexuality
Breast cancer and financial stress; Breast cancer Physical symptoms and late effects
and intimate partner support; Breast cancer and Social relationships and roles
sexual functioning; Breast cancer and spiritual- Existential issues
ity; Breast carcinoma; Pain and breast cancer; The five clusters are not exhaustive, but
Social relationships and roles highlight aspects of particular relevance in the
context of breast cancer. The clusters are
described separately in the following. There is,
Definition however, considerable overlap between them,
and they should be seen as highly dynamic and
Breast cancer is a disease in which abnormal cells interrelated. For example, physical late effects
in the breast grow and divide without control. can have social consequences, and changes in
B 436 Breast Cancer

Femininity and sexuality

Body image
Hair Loss
Sexual functioning
Emotional and
Existential issues Menopause
cognitive issues
Existential questions Distress
Meaning making Cognitive Depression
Life review impairment
Spirituality/faith Anxiety
Sleep disturbances
Life priorities Fear of
Aspects of Fatigue recurrence
growth HRQoL

Social relationships Physical symptoms

and roles Intimate partner and late effects
Family Loneliness

Social support Stigmatization Lymphedema

Participation Work Arm and shoulder

Financial stress function

Breast Cancer, Fig. 1 Aspects of HRQoL for women treated for breast cancer

social roles may bring emotional problems. Emotional and Cognitive Issues
This entanglement is illustrated through exam- This cluster describes aspects of the breast
ples in the text. cancer experience that have a strong emotional
We focus on womens subjective perceptions component. Furthermore, we discuss cognitive
and patient-reported outcomes (PROs) but impairments. These issues are all in themselves
also mention some proxies, where research burdensome, and they can further interfere with
including PROs is sparse. For the more specific functioning in everyday life.
effects of surgery and other treatment modalities, A diagnosis of breast cancer may be a shock,
we refer to the essay Breast Cancer Patients, triggering overwhelming feelings of fear,
Surgery, and Quality of Life. uncertainty, and loss of control. Women go
through a process of emotional adaptation to
the changed life situation. Many experience
Description distress (i.e., emotional upset) or depressive
symptoms. Recently, research has pointed to the
Although breast cancer is not necessarily heterogeneity in womens experience of distress
immediately life-threatening, the diagnosis and throughout the breast cancer trajectory.
treatment can be a life-changing experience that Henselmans et al. (2010) identified four different
impacts on a womans QoL. Women may have trajectories over the first year after diagnosis: 36 %
to deal with physical short- or long-term reported no distress, 33 % only experienced dis-
consequences of treatment, emotional distress, tress in the active treatment phase, 15 % started out
and existential concerns, as well as changed mildly distressed but reported increased distress in
roles in intimate relationships and everyday life. the reentry and survivorship phase, and another
Breast Cancer 437 B
15 % experienced chronic distress. Thus, about problem. In the majority of studies, 3060 % of
two thirds of women experience distress at some patients report moderate or severe fatigue symp-
point in the trajectory, and a subgroup of patients toms. Fatigue usually increases among patients
has persistent problems. However, about one third undergoing radiation therapy or chemotherapy,
of women show a resilient pattern with no or only although it is typically more pronounced during B
minimal distress. Women high in mastery, that is, chemotherapy. It usually decreases after treat-
with a strong sense of control over their lives, were ment completion (Bower, 2008) but may remain
more likely to show a resilient pattern. Likewise, a significant problem for a considerable minority
psychosocial factors (such as use of avoidant cop- (2030 %). For 534 % posttreatment fatigue is
ing strategies and poor social functioning) have still a problem up to 5 years after treatment
been identified as probably the strongest predictors completion (Minton & Stone, 2008).
of depressive symptoms in this population. A cancer diagnosis can result in the develop-
Pain, physical disability, and further physical ment of sleep disturbances, and these may
factors also show modest associations (Bower, significantly disrupt the general ability to
2008), and younger women usually report more function. The prevalence of subjective sleep com-
or more severe symptoms (Howard-Anderson, plaints in women treated for breast cancer ranges
Ganz, Bower, & Stanton, 2012), whereas the from 20 % to 70 %. However, longitudinal studies
severity of the disease or treatment regimen is are lacking and controlled studies are required to
less relevant (Bower, 2008). determine the degree to which sleep problems in
Even years after diagnosis, a fear of recurrence these women differ from the problems in women
may linger on, that is, the fear that the disease with no cancer history (Bower, 2008).
could recur or progress in the same organ or Cognitive impairments, such as impaired
a different area of the body. Koch et al. (2013) memory and ability to concentrate, are common
suggest that fear of recurrence is experienced in among breast cancer patients. This phenomenon
modest intensity by most survivors. The fear is popularly known as chemo brain, because
seems to persist over an extensive period of the earliest cross-sectional studies from the
time after the initial diagnosis without significant mid-1990s detected cognitive difficulties during
changes in intensity. However, fear of recurrence or after chemotherapy. However, later prospec-
is usually not experienced constantly but tive studies with proper control groups have
triggered by symptoms or specific situations, for shown cognitive deficits in women with breast
example, follow-up care appointments. cancer already before start of chemotherapy
Although many women experience distress (Janelsins et al., 2011) indicating that cognitive
and symptoms of depression, mood disorders problems may be due to other factors, for
are not as prevalent. In a large meta-analysis of example, emotional distress because of the
patients in oncological and hematological cancer diagnosis. Studying this issue is complex,
settings, the prevalence of depression was 16 %, and the literature is not consistent. Patients
adjustment disorder 19 %, and anxiety subjective ratings of cognitive functions are
disorders 10 % using the criteria of the Diagnostic typically correlated with fatigue and a depressed
and Statistical Manual of Mental Disorders mood, but not with objective cognitive perfor-
(DSM) or the International Classification of mance as measured by neuropsychological tests.
Diseases (ICD) (Mitchell et al., 2011). A number of studies using such tests have
Fatigue, a subjective lack of physical and/or indicated impairments in cognitive function in
mental energy, is a common adverse effect of a subgroup of women that tended to improve
cancer. Several medical, biological, demo- over time. However, the effects seem to be
graphic, and psychosocial factors are thought to modest in statistical terms (Bower, 2008).
contribute to fatigue, and it is strongly correlated Cognitive impairments may have a profound
with depressive symptoms (Bower, 2008). It can effect on patients lives and interfere with daily
interfere with usual activities and be a major activities.
B 438 Breast Cancer

Issues Related to Femininity and Sexuality breast cancer. Likewise women whose partners
The breast has been identified as an integral were happy in their relationship had
component of a womans self-concept (Denieffe a more positive perception of their own appear-
& Gooney, 2011). It is related to the areas of ance (Zimmermann et al., 2010).
femininity and sexuality. Issues related to these The importance of relationship characteristics
aspects are described in the following cluster. has also been pointed out in relation to sexual
The cancer diagnosis and prospect of surgery functioning. One of the most consistent predic-
that may disfigure or remove a breast can tors of sexual functioning following breast cancer
challenge a womans self-perception. Some no is the quality of the womans partnered relation-
longer perceive themselves as complete women. ship (Gilbert, Ussher, & Perz, 2010). Sexuality
Some fear that they will not be able to attract or can be particularly complex after breast cancer.
keep a partner. Changed self-perceptions can be Pain during intercourse, vaginal dryness,
related to treatment side effects such as weight decreased sexual interest or desire, decreased
changes and hair loss (Bertero & Chamberlain sexual arousal, numbness in a previously sensi-
Wilmoth, 2007). For many women, chemother- tive breast, difficulties achieving orgasm, and
apy-induced hair loss ranks among the most lack of sexual pleasure have frequently been
important side effects. It is often considered described. Women undergoing chemotherapy
unavoidable but transient. Yet, it can be are at higher risk of disturbances in sexual func-
distressing and even traumatizing. As a visible tioning than those not receiving this treatment.
reminder of the disease it may also negatively Evidence regarding a possible link between type
affect social interactions (Lemieux, Maunsell, & of surgical treatment and sexual functioning is
Provencher, 2008). inconsistent (Gilbert et al., 2010). To some extent
The prevalence of problems related to body breast cancer survivors may attribute changes
image is difficult to determine, as assessment typical in middle age to their cancer. In a survey
instruments vary and no cutoff values have been including 863 breast cancer survivors, one third
defined. Falk-Dahl et al. studied disease-free of women reported that breast cancer and its
women 26 years following treatment. They treatment had had a negative impact on their sex
defined poor body image as scores above the life. Nevertheless, the breast cancer survivors did
70th percentile on the body image scale and not differ from age-matched, healthy control
found that 31 % had a poor body image. Body women on a standard measure of sexuality
image was relatively stable over the following (Meyerowitz, Desmond, Rowland, Wyatt, &
3 years. Survivors were slightly more dissatisfied Ganz, 1999).
with their body image than an age-matched For younger women chemotherapy-induced
control group from the general population. menopause, menopausal symptoms, and
However, these differences were small and infertility are important issues: 3373 % of
not considered clinically significant (Falk Dahl, women under 50 reported undergoing a meno-
Reinertsen, Nesvold, Fossa, & Dahl, 2010). pausal transition with treatment. This was asso-
It is unclear whether a womans age and type ciated with bothersome consequences, such as
of surgery (breast-conserving surgery versus vasomotor symptoms, sexual problems, and dis-
mastectomy) are associated with body image tress after treatment. Fertility concerns were
(Falk Dahl et al., 2010; Zimmermann, Scott, & prominent for women with a desire to
Heinrichs, 2010). Associations of distress/ have children (Howard-Anderson et al., 2012).
depressive symptoms with poorer body image
are more consistent. Characteristics of
a womans partnered relationship also seem to Physical Symptoms and Late Effects
play a role: In one study women who were This cluster focuses on problems in the breast,
happy in their relationship worried less about arm, and shoulder area experienced by many
their partners reactions to their appearance after women treated for breast cancer. These problems
Breast Cancer 439 B
develop during or after treatment and can persist problematic, and 27 % reported daily activity
for several years. with involvement of shoulder rotation as
Pain following surgery and treatment is troublesome (Gartner et al., 2010). These
common. In different studies prevalence rates restrictions can impact on social aspects, such as
for pain in the arm and shoulder ranged from participation in activities and work ability. B
9 % to 68 %; prevalence rates for pain in the
breast area ranged from 15 % to 72 % (Lee, Social Relationships and Roles
Kilbreath, Refshauge, Herbert, & Beith, 2008). A diagnosis of breast cancer can influence an
The symptoms tend to diminish with time after array of social relations and contexts, involving
surgery. However, a recent Danish survey of both a womans intimate relationship and family
3,253 breast cancer patients showed that persis- roles, but also working life and participation in
tent pain and sensory disturbances remain signif- other activities. These aspects are outlined here.
icant problems 23 years after surgery (Gartner A womans experience of breast cancer may
et al., 2009): 47 % of patients reported pain, 13 % depend heavily on her intimate partner, who often
of whom had severe and 39 % moderate pain. provides support and participates in treatment-
Younger women aged less than 40 were 3.6 times related decisions. In turn, the patients experience
more likely to report pain than women aged of cancer can also have a crucial influence on the
6069 years. Further, axillary lymph node dissec- partners well-being. In a meta-analysis patients
tion and radiotherapy were associated with and partners distress were significantly related
significantly more pain. There was no difference (r 0.29), possibly indicating that a couple reacts
in pain according to the surgical procedure as an emotional system rather than as individuals
(breast-conserving surgery vs. mastectomy) or (Hagedoorn, Sanderman, Bolks, Tuinstra, &
use of chemotherapy. Coyne, 2008). Relationship processes and cou-
Another frequent breast cancer-related ples common coping with the breast cancer expe-
symptom is lymphedema, that is, swelling or rience, such as emotional sharing and joint
heaviness of the arm due to insufficient lymph problem-solving, can be a resource for both part-
drainage. This chronic condition may occur any ners to draw on. In line with this, it has been found
time after treatment and can cause disfigurement, that in 42 % of couples both the patient and the
physical discomfort, and functional impairment partner reported that breast cancer had brought
(Stamatakos, Stefanaki, & Kontzoglou, 2011). them closer to their partner (Dorval et al., 2005).
Gartner et al. (2010) found that the prevalence Further, divorce rates have not been found to be
of self-reported arm lymphedema varied from 13 higher for women with breast cancer than in the
to 65 % depending on the treatment received, general population, despite anecdotal information
with axillary lymph node dissection and about increased marital breakdown (Carlsen, Dal-
radiotherapy being associated with more ton, Frederiksen, Diderichsen, & Johansen, 2007).
problems. Further, young age was associated Similarly, social support from the larger
with increased problems. network is important and can have beneficial
Related to pain and lymphedema, women may effects. Regarding the womans family,
experience restrictions in arm and shoulder func- Bertero and Chamberlain Wilmoth (2007) have
tion. The prevalence ranges from less than 10 % described conflicting issues: The wish to protect
to almost 70 % in different studies and depends ones family from worry can interfere with the
on method of assessment (measured or self- wish to tell them the truth, especially the children.
reported), time since treatment, and type of treat- Women reported the importance of the children
ment: mastectomy leads to greater impairment giving them love and treating them as the
than lumpectomy, and radiotherapy likewise mother they had always known. However, some-
impairs the functioning (Lee et al., 2008). Two times women felt stressed because the family
to three years after surgery, 47 % of women expected them to continue to manage the same
reported light work above shoulder level as tasks (e.g., in the household) as they had done
B 440 Breast Cancer

before diagnosis. Women felt that their family work environment can help the women to adapt
did not necessarily understand what they were to these challenges (Tiedtke et al., 2010). In
going through, especially once they seemingly a registry-based study, women had an increased
were back to normal. risk for unemployment during the first 3 years
The experienced lack of understanding can after their cancer diagnosis, but after 3 years the
also be prominent in other social contexts. risk for unemployment was not elevated com-
Rosedale (2009) describes it as survivor loneli- pared with the non-cancer population (Carlsen,
ness, a unique and ongoing experience of isola- Dalton, Diderichsen, & Johansen, 2008).
tion. Feelings of loneliness may be triggered Occupational changes may be some of the
when the women realize that others misunder- many factors that can cause financial burden
stand how cancer has changed their lives or are when diagnosed with breast cancer. In a large
not aware of ongoing aspects of the breast cancer Irish study of cancer survivors, primarily
experience, such as an approaching mammogram women treated for breast cancer, 49 % reported
or the anniversary of the diagnosis. financial stress, that is, they stated that the cancer
Womens participation in activities of daily diagnosis had made it more difficult for them to
life and social activities may be restricted through make ends meet. A total of 32 % reported finan-
diagnosis and treatment. In the Gartner study cial strain, that is, concerns about the household
(2010) 24 % of women had to give up everyday financial situation since the cancer diagnosis.
activities after treatment for breast cancer. Those reporting cancer-related financial stress
Another restraining factor is worry about the and strain were at increased risk of anxiety and
stigma that may be attached to a diagnosis of depression (Sharp, Carsin, & Timmons, 2012).
breast cancer both regarding the more visible
external signs of cancer such as hair loss and the Existential Issues
very diagnosis (Denieffe & Gooney, 2011; This last section is concerned with the existential
Lemieux et al., 2008). The stigma attached to and spiritual aspects that may be triggered by the
cancer has diminished over the past decades. experience of breast cancer and its potential
Today women with breast cancer generally threat to life.
receive acceptance and support from the larger When confronted with a diagnosis of breast
society. However, former negative attitudes still cancer, women become aware of their own
linger on (Holland, 2002). mortality. The threat to life and fear of death
Work incapacity during treatment and the prompts many women to reconsider their lives.
return to work phases can cause concern. Women They may feel a need to search and find answers
are concerned with disclosing the diagnosis to to existential questions (Bertero & Chamberlain
their employer and to colleagues. Although Wilmoth, 2007; Denieffe & Gooney, 2011).
a majority has been shown to feel that disclosure Bertero and Chamberlain Wilmoth have
had positive effects, it is an uncomfortable expe- described how diagnosis and treatment led many
rience for some women and some even feel women to a life review: The women analyzed
pressured to leave their job. In the weeks before accomplishments in life and reordered life
returning to work, concerns about appearance, priorities. Certain things were no longer taken
productivity, disappointing the employer, and for granted; ordinary events in everyday life
job loss are prominent. Most women wish to grew in importance, and women chose not to
regain their normal life after treatment but waste their energy on minor, irritating matters.
may be hindered by concentration and arm prob- Women also tried to make meaning out of the
lems or fatigue (Tiedtke, de Rijk, Dierckx de breast cancer experience. This could give their
Casterle, Christiaens, & Donceel, 2010). In the lives a sense of purpose and was part of a larger
Gartner study (2010), 36 % of working women redefinition of the self, including the experience of
reported that their work had been affected after new inner power and growth. For some women this
the treatment for breast cancer. A supportive also involved a spiritual reflection. Some stated
Breast Cancer 441 B
that having faith made them realize the value of which the breast cancer experience causes certain
their life and that they had the strength to handle problems, such as sexual problems or fatigue.
this situation (Bertero & Chamberlain Wilmoth, Some problems may erroneously be attributed to
2007; Denieffe & Gooney, 2011). breast cancer. Recall bias is a challenge in retro-
The positive changes that may be part of spective study designs. Further, a wide variety of B
a traumatic experience can be summed up methods of assessment and study designs impedes
with the term posttraumatic growth. Cancer survi- comparisons between studies.
vors commonly report changes in three life We can, however, conclude that women may
domains: changes in the self (e.g., feeling encounter many different aspects of HRQoL in the
stronger), changes in interpersonal relationships trajectory of breast cancer. Breast cancer touches
(e.g., strengthened ties with other people), and specifically upon issues related to femininity and
changes in spirituality or the philosophy of life sexuality. Women react differently, but some gen-
(e.g., a greater appreciation of what one has). eral patterns can be identified. Many women expe-
Some researchers view posttraumatic growth as rience distress and related problems at some point,
the result of the struggle against the adverse but most adapt well in the long term. Yet, for
event. Adverse events shatter ones basic beliefs a considerable number of women pain, lymph-
and are thus the basis for identity change. Others, edema or similar physical late effects of treatment
however, consider posttraumatic growth illusory, persist for years and may impact on everyday life.
arguing that the changes are not real though they Breast cancer seems to be more disturbing for
do represent a means of reducing the distress pro- younger than for older women, for example,
duced by the threat of cancer. For posttraumatic concerning pain, depression, fertility issues, and
growth to occur, the persons subjective perception family roles. Strong social relationships, a sense of
of threat and uncertainty seems to be more impor- mastery over ones life, and other psychosocial
tant than objective rates of illness severity. resources seem to foster adaptation. Many
Sociodemographic factors, such as younger age women go through a process of existential
at diagnosis, also seem to play a minor role reorientation that may lead to a different outlook
(Sumalla, Ochoa, & Blanco, 2009). or appreciation of life following the experience of
breast cancer.
Concluding Remarks
This essay has surveyed salient aspects of
HRQoL for women treated for breast cancer.
The range of issues has been illustrated by Cross-References
a model consisting of five broad clusters
(Fig. 1). The five clusters are not exhaustive but Oncology
highlight particularly relevant aspects. We left
out interventions to improve HRQoL and aspects
of HRQoL specific to the terminal phase. The
interrelations between the aspects in the model
are complex and indicated through examples. Bertero, C., & Chamberlain Wilmoth, M. (2007). Breast
Our model highlights femininity and sexuality cancer diagnosis and its treatment affecting the self:
and existential issues. These aspects are A meta-synthesis. Cancer Nursing, 30, 194202.
Bower, J. E. (2008). Behavioral symptoms in patients with
important in the context of breast cancer, but breast cancer and survivors. Journal of Clinical Oncol-
less visible in the generic classification into ogy, 26, 768777.
physical, mental, and social well-being. Boyle, P., & Levin, B. (2008). World cancer report. Lyon:
The existing literature has some methodologi- International Agency for Research on Cancer.
Carlsen, K., Dalton, S. O., Diderichsen, F., & Johansen, C.
cal limitations. Because of a baseline prevalence
(2008). Risk for unemployment for cancer survivors.
in the general population it is important to include A Danish cohort study. European Journal of Cancer,
a control group in order to determine the degree to 44, 18661874.
B 442 Breast Cancer and Adaptation

Carlsen, K., Dalton, S. O., Frederiksen, K., Diderichsen, Koch, L., Jansen, L., Brenner, H., & Arndt, V. (2013).
F., & Johansen, C. (2007). Are cancer survivors at an Fear of recurrence and disease progression in
increased risk for divorce? A Danish cohort study. long-term (>/5 years) cancer survivors-a systematic
European Journal of Cancer, 43, 20932099. review of quantitative studies. Psycho-Oncology, 22,
Coleman, M. P., Quaresma, M., Berrino, F., Lutz, J. M., de 111. doi:10.1002/pon.3022.
Angelis, R., Capocaccia, R., et al. (2008). Cancer Lee, T. S., Kilbreath, S. L., Refshauge, K. M.,
survival in five continents: A worldwide population- Herbert, R. D., & Beith, J. M. (2008). Prognosis of
based study (CONCORD). The Lancet Oncology, 9, the upper limb following surgery and radiation for
730756. breast cancer. Breast Cancer Research and Treatment,
Denieffe, S., & Gooney, M. (2011). A meta-synthesis of 110, 1937.
womens symptoms experience and breast cancer. Lemieux, J., Maunsell, E., & Provencher, L. (2008). Che-
European Journal of Cancer Care, 20, 424435. motherapy-induced alopecia and effects on quality of
Dorval, M., Guay, S., Mondor, M., Masse, B., Falardeau, M., life among women with breast cancer: A literature
Robidoux, A., et al. (2005). Couples who get closer after review. Psycho-Oncology, 17, 317328.
breast cancer: Frequency and predictors in a prospective Meyerowitz, B. E., Desmond, K. A., Rowland, J. H.,
investigation. Journal of Clinical Oncology, 23, Wyatt, G. E., & Ganz, P. A. (1999). Sexuality
35883596. following breast cancer. Journal of Sex and Marital
Falk Dahl, C. A., Reinertsen, K. V., Nesvold, I. L., Therapy, 25, 237250.
Fossa, S. D., & Dahl, A. A. (2010). A study of body Minton, O., & Stone, P. (2008). How common is fatigue in
image in long-term breast cancer survivors. Cancer, disease-free breast cancer survivors? A systematic
116, 35493557. review of the literature. Breast Cancer Research and
Fayers, P. M., & Machin, D. (2009). Quality-of-life: Treatment, 112, 513.
The assessment, analysis and interpretation of Mitchell, A. J., Chan, M., Bhatti, H., Halton, M., Grassi,
patient-reported outcomes (2nd ed.). Chichester, L., Johansen, C., et al. (2011). Prevalence of
England: Wiley. depression, anxiety, and adjustment disorder in
Gartner, R., Jensen, M. B., Kronborg, L., Ewertz, M., oncological, haematological, and palliative-care
Kehlet, H., & Kroman, N. (2010). Self-reported arm- settings: A meta-analysis of 94 interview-based
lymphedema and functional impairment after breast studies. The Lancet Oncology, 12, 160174.
cancer treatment - A nationwide study of prevalence Rosedale, M. (2009). Survivor loneliness of women
and associated factors. The Breast, 19, 506515. following breast cancer. Oncology Nursing Forum,
Gartner, R., Jensen, M. B., Nielsen, J., Ewertz, M., 36, 175183.
Kroman, N., & Kehlet, H. (2009). Prevalence of and Sharp, L., Carsin, A. E., & Timmons, A. (2012). Associ-
factors associated with persistent pain following breast ations between cancer-related financial stress and
cancer surgery. The Journal of the American Medical strain and psychological well-being among individuals
Association, 302, 19851992. living with cancer. Psycho-Oncology (Epub ahead of
Gilbert, E., Ussher, J. M., & Perz, J. (2010). Sexuality after print). doi:10.1002/pon.3055.
breast cancer: A review. Maturitas, 66, 397407. Stamatakos, M., Stefanaki, C., & Kontzoglou, K. (2011).
Hagedoorn, M., Sanderman, R., Bolks, H. N., Tuinstra, J., Lymphedema and breast cancer: A review of the
& Coyne, J. C. (2008). Distress in couples coping with literature. Breast Cancer, 18, 174180.
cancer: A meta-analysis and critical review of role and Sumalla, E. C., Ochoa, C., & Blanco, I. (2009).
gender effects. Psychological Bulletin, 134, 130. Posttraumatic growth in cancer: Reality or illusion?
Henselmans, I., Helgeson, V. S., Seltman, H., de Vries, J., Clinical Psychology Review, 29, 2433.
Sanderman, R., & Ranchor, A. V. (2010). Identifica- Tiedtke, C., de Rijk, A., Dierckx de Casterle, B.,
tion and prediction of distress trajectories in the first Christiaens, M. R., & Donceel, P. (2010). Experiences
year after a breast cancer diagnosis. Health Psychol- and concerns about returning to work for women
ogy, 29, 160168. breast cancer survivors: A literature review. Psycho-
Holland, J. C. (2002). History of psycho-oncology: Oncology, 19, 677683.
Overcoming attitudinal and conceptual barriers. Zimmermann, T., Scott, J. L., & Heinrichs, N. (2010).
Psychosomotic Medicine, 64, 206221. Individual and dyadic predictors of body image in
Howard-Anderson, J., Ganz, P. A., Bower, J. E., & women with breast cancer. Psycho-Oncology,
Stanton, A. L. (2012). Quality of life, fertility 19, 10611068.
concerns, and behavioral health outcomes in younger
breast cancer survivors: a systematic review. Journal
of the National Cancer Institute, 104, 386405.
Janelsins, M. C., Kohli, S., Mohile, S. G., Usuki, K.,
Ahles, T. A., & Morrow, G. R. (2011). An update on
cancer- and chemotherapy-related cognitive dysfunc-
Breast Cancer and Adaptation
tion: Current status. Seminars in Oncology, 38,
431438. Breast Cancer
Breast Cancer Patients, Surgery, and Quality of Life 443 B
Breast Cancer and Body Image Breast Cancer Femininity
and Sexuality
Breast Cancer
Breast Cancer B

Breast Cancer and Depression

Breast Cancer Patients, Surgery,
Breast Cancer and Quality of Life

Brenda den Oudsten1, Jan Anne Roukema2 and

Jolanda De Vries3
Breast Cancer and Emotional Department of Medical Psychology, Tilburg
Sharing University, Tilburg, The Netherlands
Tilburg University, Tilburg, The Netherlands
Breast Cancer 3
Department of Medical Psychology, Tilburg
University St. Elisabeth Hospital, Tilburg,
The Netherlands

Breast Cancer and Fatigue

Breast Cancer
Breast carcinoma/breast neoplasm; Breast-
conserving therapy/lumpectomy; Mastectomy;
Breast Cancer and Financial Stress

Breast Cancer Definition

Breast cancer or breast neoplasm, or breast

Breast Cancer and Intimate Partner carcinoma is a malignant growth that begins
Support with tissues in the breast, usually the ducts (i.e.,
the tubes that carry milk to the nipple) and lobules
Breast Cancer (i.e., the glands that make milk). Cancer is
a disease in which abnormal cells grow in an
uncontrolled way.
Quality of life (QOL) is often interchange-
Breast Cancer and Sexual ably used with terms, like health status (HS) and
Functioning health-related quality of life (HRQOL). How-
ever, although the concepts overlap, there are
Breast Cancer different features which make them distinct
(Van der Steeg et al., 2008). There is a debate
on how to conceptualize QOL. If one adopts
a critical approach, then a large number of
Breast Cancer and Spirituality published studies actually have not assessed
QOL, but have measured related concepts, such
Breast Cancer as HS and/or HRQOL.
Breast Cancer Patients, Surgery, and Quality of Life, Table 1 Overview of studies on (HR)QOL and HS after surgical treatment of breast cancer (20082012)
Author Concept Study design size Instruments Findings

Den QOL Prospective assessment before diagnosis, 1 month n 163 WHOQOL- The WHOQOL-100 domains psychological health and social
Oudsten and 3 months, 6 months and 12 months after 100 relationships and the facets positive feelings and personal relationships
et al., 2009 diagnosis/surgery predicted overall QOL at all time points. Other QOL facets did predict
overall QOL, but at different time points. For instance, sexual activity
contributed to overall QOL only at 3 and 6 months after diagnosis/surgery
Van der QOL Prospective (before diagnosis and 1, 3, 6, and 12 N 222 WHOQOL- The two treatment groups (BCT and MTC) did not differ on overall QOL.
Steeg months after surgery) 100 At all measurement times, the influence of trait anxiety on overall QOL
et al., 2010 was substantial in the BCT group. Women with a high score on trait
anxiety were seven times more likely to have a low overall QOL 1 year
after BCT. In the MTC group, overall QOL was influenced mainly by
Rabin QOL Cross-sectional n 73 WHOQOL- Physical health and psychological health were predicted by women who
et al. 2008 Mean time since disease, 3.1 (SD 3.2) in years BREF underwent mastectomy and scored higher on depressive symptoms. Other
factors, i.e., demographic variables, staging, time of disease, and
chemotherapy did not play a significant role
Aerts et al. QOL Cross-sectional n 89 WHOQOL- Patients after axillary lymph node dissection (n 25) experienced more
2011 Mean time since disease, > 2 years (mean and SD BREF shoulder symptoms, limitations in daily life, and imposed more
unknown) restrictions on themselves than patients with sentinel lymph node biopsy
(n 51). However, no significant differences during physical
examination were found. A decreased range of motion and a higher score
on trait anxiety resulted in a lower QOL
He et al. QOL Cross-sectional n 180 FACT-B The scores of the physical, functional, and emotional domains and breast-
(epub) The median follow-up after completion of specific concerns of FACT-B were not significantly different between
radiotherapy was 60 months in the BCT group and 65 BCT and MTC. The social domain score of the BCT group was
months in the MTC group significantly higher than the MAS group
Zhong QOL Prospective (assessment at preoperative and 3 weeks n 55 BREAST- BREAST-Q subscale scores (breast, sexual well-being, and psychosocial
et al., 2012 and 3 months after reconstruction) Q well-being) improved significantly postoperatively. However, the other
subscale scores (i.e., physical well-being of the chest and abdomen)
deteriorated significantly 3 weeks after reconstruction. At 3 months after
reconstruction, both subscale scores improved significantly. Large effect
sizes for improvements in satisfaction, psychosocial well-being, and
sexual well-being were observed (1.88, 1.2, and 1.31, respectively),
whereas deterioration in the effect size for abdominal donor site was
reported (1.56). After adjusting for postoperative complications,
differences remained significant
Breast Cancer Patients, Surgery, and Quality of Life
Arndt HRQOL Prospective (assessment at 1,3, and 5 year after n 315 EORTC- Women treated with BCT reported better physical and role functioning,
et al., 2008 diagnosis) QLQ C30 were sexually more active, and were more satisfied with their body image
EORTC- at all time points. Differences in overall QOL and social functioning were
QLQ-BR23gradually improving over time. At 5 years after diagnosis, women with
BCT scored better on overall QOL and social functioning than women
treated with MTC
Shi et al., HRQOL Prospective (assessment at 1 and 2 years after n 172 EORTC- All breast cancer surgery patients had significantly improved QLQ-C30
2011 surgery) QLQ C30 and QLQ-BR23 subscale scores at the 1-year follow-up survey. Assuming
EORTC- a baseline of first-year scores, score improvements by the second year
QLQ-BR23 were noted only in QLQ-C30 global quality of life, physical functioning,
role functioning, emotional functioning, cognitive functioning, social
functioning, and QLQ-BR23 future perspective. Our findings
demonstrated that BCT outperforms MTC for measuring role functioning,
emotional functioning, cognitive functioning, and body image. Compared
with the BCT groups, however, the MTC with reconstruction groups
revealed significantly larger subjective improvements in physical
Breast Cancer Patients, Surgery, and Quality of Life

functioning, emotional functioning, sexual functioning, and sexual

Van Esch HRQOL Prospective (assessment before diagnosis, six and 12 n 223 EORTC- Trait anxiety was the only factor that significantly and negatively
et al. months after surgery) QLQ-BR predicted body image, future perspective, and sexual functioning at 6 and
(epub) 23 12 months after surgery, implying that other factors such as disease stage
and treatment have less impact on HS than this personality trait. Type of
surgery had a significant relation with body image: women that had BCT
had a better body image than women that had MTC, during the 12 months
after surgery. Women with BCT had more arm symptoms
Freitas- HS Cross-sectional (assessment at least 6 months after N 70 SF-36 No difference in HS was found between women who received BCT or
Silva et al., completion of oncological treatment and free of MTC and immediate breast reconstruction
2010 disease)

B 446 Breast Cancer Patients, Surgery, and Quality of Life

In general, definitions of QOL emphasize that restrictions in functioning (HS), but evaluate
it is a multidimensional concept representing them differently in terms of (HR)QOL. For
(at least) the physical, psychological, and social instance, not being able to climb stairs does not
domains. QOL represents subjective evaluations mean that the QOL is also impaired.
of oneself, ones social and material world, and
reflects the extent to which the individual is sat-
isfied with them or is bothered by problems in Description
those areas. In line with this principle, the World
Health Organization Quality of Life Group Breast cancer is the most frequently diagnosed
(WHOQOL Group, 1995) defined QOL as an cancer in women in the developed countries.
individuals perception of his/her position in life When breast cancer is diagnosed in an early
in the context of the culture and value systems in stage, i.e., a tumor smaller than 5 cm in diame-
which he/she lives and in relation to his/her goals, ter, no metastases beyond the axilla, and a breast
expectations, standards, and concerns. It is that is large enough in relation to the tumor size,
a broad-ranging concept incorporating in women can choose between breast-conserving
a complex way the persons physical health, psy- therapy (BCT) and mastectomy (MTC). BCT
chological state, level of independence, social refers to lumpectomy and a staging operation
relationships, personal beliefs, and their relation- of the axillary lymph nodes followed by radia-
ship to salient features of the environment tion therapy of the remaining breast. In MTC,
(p. 1,405). Thus, this concept is more than just all breast tissue, including the nipple, is
physical, psychological, and social functioning/ removed, and a staging operation is performed
well-being. on the axillary lymph nodes. Depending on the
Compared to QOL, both HS and HRQOL tumor characteristics and the presence of axil-
focus more exclusively on health aspects lary metastases, surgery can be followed by
(De Vries, 2001; de Vries & Drent, 2007): adjuvant chemotherapy, hormonal therapy,
HS reflects solely the functioning in the phys- and/or radiation of the area around the collar
ical, psychological, and social domains and bone. BCT and MTC have proven to be equal
does not focus on the subjective satisfaction with respect to long-term survival, although
of the individual, whereas QOL revolves disease-free survival is somewhat less after
entirely around the contentment with func- BCT. Besides BCT and MTC, it is possible to
tioning. Patients are asked about their physical undergo MTC with (immediate) breast recon-
possibilities, state of mind, and social activi- struction. In recent years, BCT has become an
ties (e.g., Are you able to walk 100 m?). alternative to mastectomy. Most women with
HS questionnaires usually employ a negative early-stage BC have a choice between these
approach (e.g., ask patients about fatigue), two surgical options, which have equivalent sur-
while (HR)QOL questionnaires also use the vival rates (Fisher et al., 2002; Litiere et al.,
positive approach (e.g., assess patients 2012; Veronesi et al., 2002). However, this deci-
energy levels). sion is not easy to make. Therefore, concepts
HRQOL reflects QOL in relation to the impact like QOL are important because they can inform
of disease and treatment of patients. Thus, surgeons and patients in the decision-making
HRQOL is QOL, but restricted to the physical, process of determining which treatment options
psychological, and social domains of health. to use.
Individual expectations about health, ambi- HRQOL and HS have been studied exten-
tions that one can no longer realize, the capacity sively in breast cancer patients; also, the effects
to cope with limitations, the tolerance threshold of surgical treatment on QOL, HRQOL, and HS
for discomfort, and the attitude toward have been addressed. The results are inconsistent
disease play an important role in QOL. As (Pockaj et al., 2009). This may be partly due to
a consequence, two persons can have identical differences in conceptualization of QOL and the
Breast Cancer Patients, Surgery, and Quality of Life 447 B
subsequent choice of instruments. Other reasons cancer-specific module EORTC-QLQ-BR 23,
for inconsistent findings are small sample sizes which measures mainly symptoms but also con-
from select populations, the lack of baseline char- tains one general item on QOL. The findings are
acteristics, cross-sectional studies, and somewhat inconsistent. Van Esch et al. (2011)
a relatively short follow-up, up to 2 years after showed that women with BCT had a better body B
treatment. image than women that had MTC, during the
Several meta-analyses (e.g., Moyer 1997; 12 months after surgery. Arm symptoms were
Goodwin et al., 2003) and (systematic) reviews more often reported by women with BCT. Shi
have been performed on (HR)QOL and HS in BC et al. (2011) found that women treated with
(e.g., Chen et al., 2010; Kiebert, de Haes, & van BCT score better on role functioning, emotional
de Velde, 1991; Pockaj et al., 2009). For these functioning, cognitive functioning, and body
meta-analyses and systematic reviews, one could image during a two-year follow-up period.
conclude that there is no solid proof of a better Arndt, Stegmaier, Ziegler and Brenner (2008)
(HR)QOL after BCT compared to MTC. How- found that the differences between BCT and
ever, the results with respect to some MTC on global health/QOL and social function-
subdomains, such as body image and sexual ing gradually increased overtime. These differ-
functioning seemed to favor the use of BCT ences became statistically significant at 5 years
(Kiebert et al., 1991; Goodwin et al., 2003). after diagnosis/treatment. Women treated with
The present manuscript shows an overview of MTC showed a greater decline in global health/
the studies comparing BCT and MTC (with breast QOL scores than women treated with BCT.
reconstruction) on HR(QOL) and HS from 2009 After controlling for potential confounders,
to 2012. Studies before this time period can be women with BCT reported better physical and
found in the four review articles mentioned. role functioning, were sexually more active, and
were more satisfied with their body image com-
QOL After Surgical Treatment pared with women treated with MTC already at
In the prospective study of van der Steeg, de Vries one year after diagnosis. No difference in HS,
and Roukema (2010), scores on the facet overall assessed with the SF-36, was found between
QOL and the separate domains (i.e., Physical BCT and MTC in women who completed
Health, Psychological Health, Social Relation- their cancer treatment at least 6 months (Freitas-
ships, and Environment) of the WHOQOL-100 Silva, Conde, de Freitas-Junior, & Martinez,
did not show significant differences between the 2010).
BCT and MTC (Van der Steeg et al., 2010).
Compared with the reference scores (derived Breast Reconstruction and (HR)QOL/HS
from the WHOQOL manual), the BCT group One prospective study evaluated the impact of
scored higher in the psychological domain breast reconstruction using a single-stage,
(p < 0.001). There were no other differences microsurgically transferred, muscle-sparing
(Van der Steeg et al., 2010). In general, these transverse rectus abdominis myocutaneous (MS-
findings are in line with two cross-sectional studies TRAM) flap or a deep inferior epigastric artery
(He et al., 2012; Rabin et al., 2008). Specifically, (DIEP) flap on QOL (Zhong et al., 2012). Com-
these studies also found that women with BCT pared to preoperative scores, the BREAST-Q
scored better on the WHOQOL-Bref domains subscale scores breast, sexual well-being, and
Physical Health and Psychological Health (Rabin psychosocial well-being improved significantly
et al., 2008), as well as the FACT-C subscale postoperatively. However, the physical well-
Social Adjustment (He et al., 2012). being of the chest and abdomen deteriorated
significantly 3 weeks after reconstruction. At
HRQOL and HS After Surgical Treatment 3 months after reconstruction, both subscale
Three studies examined the role of surgical scores improved significantly. The effectiveness
treatment with EORTC-QLQ C30 and the of immediate versus delayed reconstruction
B 448 Breast Cancer Patients, Surgery, and Quality of Life

following surgery for BC is still unclear Cross-References

(DSouza, Darmanin, & Fedorowicz, 2011).
Other Factors that Affect (HR)QOL/HS Body Image
Several prospective studies have now shown the Breast Cancer
influence of trait anxiety on overall QOL, espe- Cognitive Function
cially in women treated with BCT (Van der Steeg Meta-analysis
et al., 2011; Van der Steeg et al., 2010). When Oncology
women were divided into four groups based on
their scores on trait anxiety (high versus low) and
surgical treatment (BCT versus MTC), trait References
anxiety turned out to have more impact on
QOL than surgical treatment. For the women Aerts, P. D., De Vries, J., Van der Steeg, A. F., &
Roukema, J. A. (2011a). The relationship between
treated with MTC, the personality trait neuroti-
morbidity after axillary surgery and long-term quality
cism significantly influenced the overall QOL, of life in breast cancer patients: The role of anxiety.
and, again, this influence exceeded the influence European Journal of Surgical Oncology, 37(4),
of surgical treatment. However, the effect of neu- 344349.
Aerts, P. D. M., de Vries, J., van der Steeg, A. F. W., &
roticism on overall QOL was not as strong as the
Roukema, J. A. (2011b). The relationship between
effect of trait anxiety. morbidity after axillary surgery and long-term quality
The role of lymphedema secondary to axillary of life in breast cancer patients: The role of anxiety.
dissection, chronic pain, impaired range of motion, European Journal of Surgical Oncology, 37(4),
and decreased muscle strength occurs quite fre-
Arndt, V., Stegmaier, C., Ziegler, H., & Brenner, H.
quently (i.e., up to 51 %; Pockaj et al., 2009). (2008). Quality of life over 5 years in women with
The extent to which such complications play breast cancer after breast-conserving therapy versus
a significant role in (HR)QOL is not well mastectomy: A population-based study. Journal of
Cancer Research and Clinical Oncology, 134(12),
documented (Pockaj et al., 2009). One study
examined the QOL in patients after axillary Chen, C. M., Cano, S. J., Klassen, A. F., King, T.,
lymph node dissection and sentinel lymph node McCarthy, C., Cordeiro, P. G., et al. (2010). Measuring
biopsy and found that patients who had an axillary quality of life in oncologic breast surgery:
A systematic review of patient-reported outcome
lymph node dissection experienced more shoulder
measures. The Breast Journal, 16(6), 587597.
symptoms, limitations in daily life, and imposed DSouza, N., Darmanin, G., Fedorowicz, Z. (2011).
more restrictions on themselves than patients with Immediate versus delayed reconstruction following
sentinel lymph node biopsy. However, no signifi- surgery for breast cancer. Cochrane Database System-
atic Review, Jul 6;(7):CD008674.
cant differences during physical examination were
de Vries, J. (2001). Quality of life assessment. In
found. A decreased range of motion and a higher A. J. J. M. Vingerhoets (Ed.), Assessment in behavioral
score on trait anxiety resulted in a lower QOL medicine (pp. 353370). Hove, UK: Brunner-
(Aerts et al., 2011). Routledge.
de Vries, J., & Drent, M. (2007). Quality of life and
health status in sarcoidosis: A review. Seminars in
Conclusion Respiratory and Critical Care Medicine, 28(1),
Numerous studies have been performed to eval- 121127.
uate (HR)QOL and HS; however, pure QOL is, den Oudsten, B. L., de Vries, J., van der Steeg, A. F. W.,
Roukema, J. A., & van Heck, G. L. (2009). Determi-
compared to the other concepts, less often stud-
nants of overall quality of life in women over the first
ied. Although the available studies often are lim- year after surgery for early stage breast cancer. Quality
ited by methodological concerns, it seems that of Life Research, 18(10), 13211329.
BCT does not outperform MTC in providing Goodwin, P. J., Black, J. T., Bordeleau, L. J., & Ganz, P.
A. (2003). Health-related quality of life measurement
a better QOL. Also, immediate breast reconstruc-
in randomized clinical trials in breast cancer- taking
tion after MTC does not demonstrate an improve- stock. Journal of the National Cancer Institute, 95(4),
ment in HRQOL. 263281. Review.
Breathlessness 449 B
Fisher, B., Anderson, S., Bryant, J., Margolese, R. G., mammogram on quality of life. British Journal of
Deutsch, M., Fisher, E. R., et al. (2002). Twenty-year Surgery, 98(4), 537542.
follow-up of a randomized trial comparing total Van Esch, L., Roukema, J. A., Van der Steeg, A. F., & De
mastectomy, lumpectomy, and lumpectomy plus Vries, J. (2011). Trait anxiety predicts disease-specific
irradiation for the treatment of invasive breast health status in early-stage breast cancer patients.
cancer. The New England Journal of Medicine, 347, Quality of Life Research, 20(6): 865-873. B
12331241. Veronesi, U., Cascinelli, N., Mariani, L., Greco, M.,
Freitas-Silva, R., Conde, D. M., de Freitas-Junior, R., & Saccozzi, R., Luini, A., et al. (2002). Twenty-year
Martinez, E. Z. (2010). Comparison of quality of follow-up of a randomized study comparing breast-
life, satisfaction with surgery and shoulder-arm conserving therapy with radical mastectomy for early
morbidity in breast cancer survivors submitted to breast cancer. The New England Journal of Medicine,
breast-conserving therapy or mastectomy followed by 347, 12271232.
immediate breast construction. Clinics, 65(8), 781787. WHOQOL Group. (1995). The world health organization
He, Z. Y., Tong, Q., Wu, S. G., Li, F. Y., Lin, H. X., & quality of life assessment (WHOQOL): Position paper
Guan, X. X. (2012). A comparison of quality of life from the World Health Organization. Social Sciences
and satisfaction of women with early-stage breast can- in Medicine, 41, 14031409.
cer treated with breast conserving therapy vs. mastec- Zhong, T., McCarthy, C., Min, S., Zhang, J., Beber, B.,
tomy in southern China. Supportive Care in Cancer, Pusic, A., et al. (2012). Patient satisfaction and
20(10): 2441-2449. health-related quality of life after autologous tissue
Kiebert, G. M., de Haes, J. C., & van de Velde, C. J. breast reconstruction. A prospective analysis of
(1991). The impact of breast-conserving treatment early postoperative outcomes. Cancer, 118(6),
and mastectomy on the quality of life of early-stage 17011709.
breast cancer patients: A review. Journal of Clinical
Oncology, 9(6), 10591070.
Litiere, S., Werutsky, G., Fentiman, I. S., Rutgers, E.,
Christiaens, M. R., Van Limbergen, E., et al. (2012).
Breast conserving therapy versus mastectomy for Breast Carcinoma
stage I-II breast cancer: 20 year follow-up of the
EORTC 10801 phase 3 randomised trial. The Lancet Breast Cancer
Oncology, 13(4), 412419.
Moyer, A. (1997). Psychological outcomes of breast-con-
serving surgery versus mastectomy - a meta-analytic
review. Health psychology, 16(3) 284298.
Pockaj, B. A., Degnim, A. M., Boughey, J., Gray, R. J.,
McLaughlin, S. A., Dueck, A. C., et al. (2009). Quality Breast Carcinoma/Breast Neoplasm
of life after breast cancer surgery: What have we
learned and where should we go next? Journal of
Surgical Oncology, 99, 447455. Breast Cancer Patients, Surgery, and Quality
Rabin, E. G., Heldt, E., Hirakata, V. N., & Fleck, M. P. of Life
(2008). Quality of life predictors in breast cancer
women. European Journal of Oncology Nursing, 12
(1), 5357. Epub 2007 Sep 19.
Shi, H. Y., Uen, Y. H., Yen, L. C., Culbertson, R., Juan,
C. H., & Hou, M. F. (2011). Two-year quality of life
after breast cancer surgery: A comparison of three Breast-Conserving
surgical procedures. European Journal of Surgical
Oncology, 37(8), 695702. Therapy/Lumpectomy
van der Steeg, A. F. W., de Vries, J., & Roukema, J. A.
(2008). The value of quality of life and health status Breast Cancer Patients, Surgery, and Quality
measurements in the evaluation of the well-being of of Life
breast cancer survivors. European Journal of Surgical
Oncology, 34(11), 12251230.
van der Steeg, A. F., De Vries, J., & Roukema, J. A.
(2010). Anxious personality and breast cancer: Possi-
ble negative impact on quality of life after breast-
conserving therapy. World Journal of Surgery, 34(7),
van der Steeg, A. F., Keyzer-Dekker, C. M., De Vries, J., &
Roukema, J. A. (2011). Effect of abnormal screening Asthma
B 450 BR-I

Brief History
The aim of the Brundtland Commission was to help
Bereavement Response Scale direct the nations of the world towards the goal of
sustainable development. The commission is also
known as the World Commission on Environment
and Development (WCED). It operated from
Bribe Payers Index (BPI) 1984 to 1987. The commission published its results
in the Brundtland report in 1987. Thereafter,
Corruption sustainable development became an important
concept in the vocabulary of politicians, practi-
tioners, and planners (WCED, 1987; Burton,
Brief Derogatis Psychiatric Rating The report by the Brundtland Commission
Scale (BDPRS) developed the most widely used definition of
sustainable development as development
Derogatis Psychiatric Rating Scale (DPRS) which meets the needs of current generations
without compromising the ability of future gen-
erations to meet their own needs (WCED, 1987).
The idea of sustainable development emphasized
Brief Symptom Inventory (BSI) lifting those at the base of the economic pyramid
to higher standards of living. Simultaneously, it
Methadone Treatment for Opiate-Dependent promoted decoupling environmental degradation
Persons and economic prosperity.
After the commission presented the idea of
sustainable development, the phrase often
was discussed alongside the idea of quality of
BR-II life. For example, the UK government
published A Better Quality of Life:
Bereavement Response Scale A Strategy for Sustainable Development for
the United Kingdom in 1999 (DETR, 2000)
and claimed that the core of sustainable devel-
opment is the simple idea of ensuring a better
Brundtland Commission (World quality of life for everyone, now and for gener-
Commission on Environment and ations to come. Similarly, the sustainable
Development) development act of the government of Quebec
stipulated quality of life in its first principles
Noriko Kono (PoQ, 2002). It declared that human health and
Padeco Co., Ltd, Minato-ku, Tokyo, Japan improved quality of life are at the center of
sustainable development concerns.
The foreword of the Brundtland report
Address declared that What is needed now is a new era
of economic growth- growth that is forceful
The Brundtland Commission, also known as the and at the same time socially and environmen-
World Commission on Environment and Devel- tally sustainable. It emphasized the importance
opment (WCED), disbanded in 1987. In the of economic growth, which is coexistent with
United Nations, it is also called the UN Special social and environmental sustainability.
Commission on the Environment. A famous report by Max-Neef (1995) asserts
Brundtland Commission (World Commission on Environment and Development) 451 B
that when a certain level of economic growth world leaders discussed environmental and devel-
is increasing, there exists a great level of thresh- opment issues (The Regeneration Project, 2012).
old which the quality of life is declining. There- The Brundtland report and the United Nations
fore, careful attention should be paid to attain concomitant events made governments world-
both sustainable development and quality wide begin to examine their programs and poli- B
of life. cies to find ways to promote sustainable
development. In this process of focusing on sus-
tainable development, consumers were encour-
Activities/Major Accomplishments/ aged to redefine the meaning of quality of life
Contributions and separate it from the economic concept of
standard of living.
Led by Madam Gro Harlem Brundtland, the com-
mission initiated international discussions on
how to reconcile the environmental and social
justice challenges created by uneven economic Cross-References
development. It held hearings and made site visits
to diverse locations such as Canada, Japan, and Sustainability
the Soviet Union. Its initiatives to consult widely Sustainable Development
were considered a notable contribution during the Sustainable Development Indicators
time of the Cold War. Its work made contribu-
tions to introducing inclusive discussion styles
open to all nations in considering environmental
problems (Encyclopedia Britannica, 2012). References
The widespread publicity around and interest in
the commission helped to make the phrase sustain- Bartelmus, Peter & Graham Douglas. (2012). Indicators of
sustainable development. Cutler J. Cleveland (Ed.),
able development an important vocabulary addi-
Encyclopedia of earth. Washington, D.C.: Environ-
tion for politicians, administrators, and planners. mental Information Coalition, National Council for
In defining sustainable development as develop- Science and the Environment.
ment which meets the needs of current generations Burton, I. (1987). Our common future: The world com-
mission on environment and development. Environ-
without compromising the ability of future gener-
ment, 29(5), 2529.
ations to meet their own needs, the commission Department of the Environment, Transport and the
changed the terms of the development debate by Regions, London-DETR. (2000). Building a better
making economics compatible with environmen- quality of life: A strategy for move sustainable con-
struction DETR free literature.
tal concerns (UNECE, 2012). It stated that eco-
Encyclopedia Britannica. (2012). Gro Harlem Brundtland.
nomics and environment were closely linked and Retrieved from http://www.britannica.com/
that economic development and reduction of EBchecked/topic/82112/Gro-Harlem-Brundtland
poverty were essential to protecting the environ- Max-Neef, M. (1995). Economic growth and quality of
life a threshold hypothesis. Ecological Economics, 15,
ment. Where previous approaches to economic
growth expected environmental and social costs, Nss, P. (2001). Urban planning and sustainable develop-
the concept of sustainable development promoted ment. European Planning Studies, 9(4), 503524.
the idea of a three-legged school where elements Province of Quebec-PoQ. 2002. Sustainable Development
Act. http://www.mddep.gouv.qc.ca/developpement/
were balanced (Venkataraman, 2009). loi_en.htm
The commission led to the United Nations Con- The Regeneration Project. (2012). Bringing Rio closer:
ference on Environment and Development Brundtland Commission Research Note. Sustain ability
(UNCED), a 2-year series of preparatory meetings whats next. Policy Brief by The Regeneration Project.
United Nations Economic Commissions for Europe-
culminating in the Earth Summit in Rio de Janeiro,
UNECE. (2012). Retrieved from http://www.unece.org/
June 1992. The meeting followed up on the Stock- oes/nutshell/2004-2005/focus_sustainable_development.
holm Conference in 1972, an earlier event where html
B 452 Brunswikian Model

Venkataraman, B. (2009). Education for sustainable the first empirically validated frameworks for con-
development. Environment, 51(9), 810. ceptualizing dimensions of organizational capac-
World Commission on Environment and Development.
(1987). Report of the World Commission on Environ- ity that can be enhanced as an outcome of
ment and Development: Our Common Future. UN collaborative membership. The Nowell and
Documents: Gathering a Body of Global Agreements. Foster-Fishman (2011) framework was developed
based on a mixed methods study of 51 multi-sector
midwestern collaboratives formed to improve
their communities responses to domestic vio-
Brunswikian Model lence. Through asking key informants to describe
the different ways in which involvement in
Self-Confidence a collaborative enhances or reduces the capacity
of involved organizations, three types of mutually
reinforcing outcomes were identified:
(1) increased knowledge and awareness, des-
Building Adaptive Capacity cribed as an enriched awareness of the complex
dynamics of problem domain, increased staff
Community Adaptation, Arctic understanding of their organizations role within
that system, and better access to general informa-
tion and feedback related with their work;
(2) expanded social capital, described as
Building Organizational Capacity improvements in an organizations reputation
with Community Collaboratives among other participating organizations as well
as other organizations becoming more accessible
Anne M. Izod1, Zheng Yang2 and Mary C. Hano2 and responsive to their needs; (3) enhanced orga-
Department of Public Administrtation, North nizational opportunity and impact, an organiza-
Carolina State University, Raleigh, NC, USA tions enhanced ability to attain resources, resolve
North Carolina State University, Raleigh, problems, fulfill missions, utilize services, and
NC, USA increase influence in important decision-making
processes. The original three-dimension frame-
work was modified in the second phase of the
Definition empirical study to include resource acquisition
as a separate dimension after confirmatory factor
Organizational capacity as described in this con- analysis was used to test the fitness of the model,
text by Nowell and Foster-Fishman (2011) refers and the overall pattern of fit statistics for the four
to an organizations knowledge and awareness of factor model suggests adequate fit.
systems, issues, and information; the organiza- Nowell and Foster-Fishman (2011) also inves-
tions social capital; and the organizations tigated potential negative impacts to organiza-
opportunity and impact. tional capacity in both phases of their study
but found these impacts to be infrequent and
described as minor. Informants in phase
Description one mainly mentioned the potential downside
of strengthened relationships, including
Despite academic interest in understanding the a heightened level of accountability to other
impact of community collaboration on organiza- stakeholders, the potential for lines of confiden-
tional capacity, there are few studies present in the tiality to be crossed, and the potential for the
literature that present a method for analyzing these work of the collaborative to compete for grants
benefits as the targeted intermediate outcome. with service providers. In phase two, negative
Nowell and Foster-Fishman (2011) offer one of impacts mentioned were a perceived lack of
Building Organizational Capacity with Community Collaboratives 453 B
respect within the collaborative for ones organi- together, organizations participating in CEY
zation and having ones organization more achieved or improved within the four organiza-
exposed to scrutiny by other organizations. tional capacity domains that the study measured:
In examining the relationship of organizational (1) leadership development, (2) organizational
characteristics and their representatives to each development, (3) program development, and B
outcome, the study found that there were no sig- (4) community engagement. Partner organiza-
nificant differences between public, for profit, non- tions reported some statistically significant
profit, and community-based groups for building increases in all four capacity domains, and lead
organizational capacities. However, management organizations reported some increases in three
level, depth of involvement, and representative domains (Francis et al., 2011). In addition, Fetsch
experience and expertise are significant predictors and DeBasio introduced a study examining how
in one or more categories of capacity building for a unique model of collaborative partnership
collaboratives member organizations. Executive between two major nursing organizations, the
directors were found to report significantly greater Greater Kansas City Area Collegiate Nurse
outcomes related to social capital and knowledge Educators and the Kansas City Area Nurse Exec-
and awareness relative to program staff. Also, utives, has enhanced organizational efficiency
when organizations had been with the collabora- and efficacy between the groups, which has
tive longer and when representatives held leader- directly benefited the organizational members
ship positions and attended meetings more (Fetsch & DeBasio, 2011). Lastly, Anderson-
frequently, participants reported greater outcomes Butcher et al. introduced the Ohio Community
related to expanded knowledge and awareness, Collaboration Model for School Improvement
increased social capital, and enhanced opportuni- (OCCMSI) which is a new genus of district and
ties and impact. In addition, when representatives school improvement models that connects part-
perceived their collaboratives leadership and nerships with other organizations and new work-
decision-making practices as effective, they also ing relationships with families, community
reported greater positive impact to their organiza- leaders, and youths. Their study found that key
tion as a result of their participation in the collab- capacities were developed by six schools and six
orative. Thus, in addition to identifying what kinds districts piloting the OCCMSI based on
of organizational capacity outcomes and negative a qualitative research, the changes including
impacts may result from involvement in collabo- leveraging family and community resources for
ratives, findings from this study help to show some learning, healthy development, and overall
characteristics that may be associated with receiv- success in school (Anderson-Bucher et al., 2010).
ing the greatest benefit out of ones membership. The development of a framework for under-
standing and measuring these intermediate out-
Discussion comes is a key addition to both practice and
There have been a few other studies published future research. Furthermore, the finding that
since 2010 that have also examined the impacts collaboratives in this study were able to promote
on an organizations capacity as a result of its both issue and system awareness has particularly
participation in a community collaborative. significant implications for practice.
While Nowell and Foster-Fishmans
(2011) framework was developed in the context
of study domestic violence collaboratives,
these findings support the benefits since Cross-References
discussed elsewhere. A study published in 2011,
which is based on a survey between 2008 and Community-Based Planning
2010 on 131 Communities Empowering Youth Community Capacity Building
(CEY) grants and over 500 associated partner Community Planning
organizations, found that through working Community-University Partnership(s)
B 454 Built Environment

National Neighborhood Indicator Partnership Definition

Pornography and Mens Attitudes Supporting
Violence Against Women Built environment is a general concept that can
Public Attitudes Toward Partner Violence be related with all the structures built by man to
Against Women support human activity. This term comprises
Violence Against Women everything that is physically part of a city,
a town, or village, such as buildings, roads,
squares, parks, sidewalks, commercial signage,
street furniture, and so on (see Fig. 1). We need
References to take into account that, in most cases, we eval-
uate the built environment in terms of its visual
Anderson-Butcher, D., Lawson, H., Iachini, A., Bean, G., quality, and it is the aspect that makes better cities
Flaspohler, P., & Zullig, K. (2010). Capacity-related
innovations resulting from the implementation of
and urban spaces. In this sense, the built environ-
a community collaboration model for school improve- ment can contribute to making peoples life
ment. Journal of Educational and Psychological a pleasure or a pain. This entry attempts to focus
Consultation, 20(4), 257287. on the visual quality to understand the impor-
Fetsch, S. H., & DeBasio, N. O. (2011). Academic service
tance and the impact of the built environment in
partnerships: Organizational efficiency and efficacy
between organizations. Journal of Professional peoples quality of life in order to help further
Nursing, 27(6), e82e89. discussion in the fields of architecture, planning,
Francis, K., Minzner, A., Fisman, L., Fox, L., & urban design, and environment psychology.
Fink, B. (2011). Building non-profit capacity and com-
munity partnerships: Findings from the Communities
Empowering Youth (CEY) evaluation Final Report,
OPRE Report # 201135. Washington, DC: Office of Description
Planning, Research and Evaluation, Administration for
Children and Families, U.S. Department of Health and
Human Services.
The process of user evaluation of the built envi-
Nowell, B., & Foster-Fishman, P. (2011). Examining ronment involves two principles: perception and
multi-sector community collaboratives as vehicles for cognition. Perception is related to the process
building organizational capacity. American Journal of by which users get visual information of places
Community Psychology, 48(34), 193207.
through stimuli. In city centers, for example,
these stimuli are physical elements of public
spaces, such as commercial signs, shapes and
colors of buildings, street furniture, and so on.
Cognition does not need to be related directly to
Built Environment visual stimuli linked to physical characteristics of
places. The cognition process concerns symbolic
Adriana Araujo Portella meanings associated with places and can be
Faculty of Architecture and Planning, Federal influenced by the users urban context, values,
University of Pelotas, Brazil culture, and individual experiences. This defini-
The Bartlett School of Planning at University tion agrees with the statement by Meader, Uzzell,
College London, London, UK and Gatersleben (2006, p. 61): people do not
Joint Centre for Urban Design at Oxford Brookes perceive the environment through clear eyes,
University, Oxford, UK but through perceptual lenses coloured by their
world view.
An approach suggested by Lang (1987, p. 191)
Synonyms says that the process of perception and cognition
of the built environment involves three
Built form; City environment; Physical environ- interlinked factors: (1) multisensorial perception,
ment; Streetscape; Urban environment (2) symbolic meanings, and (3) the relationship
Built Environment 455 B
Built Environment,
Fig. 1 The diversity of the
built environment of the
City of York in England
(Source: Author)

between these symbolic meanings and the phys- in the following way: it is the quiet and the
ical characteristics of the built environment. In noise; the street signs and the street art; the orga-
this way, user perception involves more than nized trip and the unexpected discovery; the sky-
a mere intellectual association related to an scrapers and the green space.
observed object; this is also linked with the cog- Taking an architectural approach, formal fac-
nitive process from the first stage. The result of tors refer to the physical characteristics of ele-
the processes of perception and cognition consti- ments that compose the built environment; they
tutes the mental representation of the built envi- concern appreciation of shapes, rhythms, com-
ronment, and this representation is what people plexities, and sequences of the visual world,
evaluate as positive or negative when the built although they can also be extended to a sonic,
environment is analyzed. In other words, we do olfactory, and haptic dimension (Lang in Nasar,
not see the built environment itself but the image 1988, p. 11). As defended by Lang (2005,
that it has in our minds (see Fig. 2). This image pp. 9798) and Curran (1983, p. 125), the per-
can be positive or negative depending on how the ceived quality of a city is very much dependent
parts that form the built environment are on the visual quality of its streets, which depends
organized. on formal factors such as lengths of blocks, cross
Formal and symbolic factors influence judg- sections, widths of roadbeds and sidewalks,
ments of the built environment. In this case, the building setbacks and heights, frequencies of
character of city can be built by physical charac- entrances to buildings, presence or absence of
teristics of building facades and symbolic mean- shop windows and shopfronts, and so on. Sym-
ings attributed to these by users. For example, the bolic factors are related to the cognition process
character of the city centers of New York and Las and involve connotative meanings that users
Vegas in the United States is formed by physical associate with places (Nasar, 1988, p. 3; Lang,
and nonphysical elements of the urban space 1987, pp. 188215). They are constituted by dif-
related to shopfronts, advertisements, buildings, ferent, but overlapping, images and interpreta-
landscape, and so on. According to Kelly and tions, which can vary among individuals (Rogers,
Kelly (2003, p. 16), New York can be described 1992, p. 245). Kong and Yeoh (2004, p. 2) argue
B 456 Built Environment

Built Environment, Fig. 2 The process of mental representation of the built environment (Source: Author)

that people are active participants in the process perception and evaluation of the built environ-
of making places and meanings attributed to the ment. Although user evaluation can be influenced
built environment. by particular experiences, preferences, and feel-
ings, the perception of order is evaluated as pos-
Visual Quality in the Built Environment itive by almost all people. Nasar (1998, p. 260)
The concept of visual quality in the built environ- defends that an ordered built environment will
ment is related to the level of order among the always be evaluated positively by people who
physical elements of built space such as the fea- live in different cultures and physical environ-
tures of buildings, roads, sidewalks, and commer- ments. On the other hand, disordered public
cial signs. Weber (1995, p. 113) describes the spaces will always be evaluated negatively
following relationship: the more orderly because, when people are exposed to a series of
a configuration, the higher its aesthetic disconnected aesthetic elements (such as com-
value (see Fig. 3). According to Gestalt psychol- mercial signs, buildings, and urban furniture), it
ogy principles, high visual quality of public provokes user saturation. This saturation experi-
places consists in the good form or pragnanz ence means that people lose the enjoyment of
of the city. Good in this case concerns how variety, and their senses become insensitive to
elements in an aesthetic composition are related the succession of visual stimulus without order
to each other such as regularity, orderliness, sim- (Lozano quoted in Nasar, 1988, p. 405).
plicity, symmetry, and so on, which then refer to The importance of high visual quality in the
specific Gestalt laws. Places where there is no built environment is analyzed in several studies
aesthetic conflict between their physical elements (Herzog, 1992; Nasar, 1988; Russell & Ward,
are recognized as having high visual quality or 1981; Stamps, 2000; Weber, 1995). These studies
high order. On the other hand, low visual quality support the argument that built environment
is linked to disordered places. According to Lang influences human behavior, and they also identify
(1987, p. 189): a disordered environment is one aesthetic compositions of buildings evaluated
where the relationship of components to each positively and negatively by users. According to
other is purely haphazard and not governed by Kelly and Kelly (2003, p. 9), the importance of
some overall principle. high visual quality is also emphasized because it
Weber (1995, p. 109) and Arnheim (1977, promotes safe, better behavior from users and can
p. 162) argue that order is an indispensable aspect create interaction between people and local
in all kinds of configuration (physical and authorities in order to get a better sense of com-
mental). According to these authors, ordered munity. Lang (2005, p. 75) says that the visual
compositions cause positive reactions on user quality of built environment is essential to
Built Environment 457 B
Built Environment,
Fig. 3 An example of
a well-ordered built
environment: City of Ouro
Preto in Brazil (Source:
Author) B

experiencing cities and the perceptions of their in ordered areas, and treatment of public spaces
quality; the high visual quality of places built by helps to determine pleasurable and interesting
street morphology, squares, parks, and buildings shopping experiences. Users will prefer cities
that face public areas forms the international with qualities that make them stand out from
images of global cities such as London, Paris, other cities in terms of the level of order.
and Singapore. In addition, Gehl (2001) argues Since 1960 we know what can help people
that the extent and character of outdoor life can be prefer one city instead another one. The concepts
influenced by physical planning, stating that there come from a well-known study developed by
is a relationship between outdoor visual quality Kevin Lynch in three American cities Boston,
and outdoor activity. In this regard, the visual Jersey City, and Los Angeles. His theory states
quality of built environment influences the that two elements are fundamental in the under-
users evaluation of the functions of cities (such standing of built environment legibility and
as places of leisure, work, or for passing through) imageability. The concepts of legibility and
and affects how people use the city, how long imageability concern an exploration of how peo-
individual activities last, and which activity types ple use and visualize the built environment.
may develop (Hass-Klau, Crampton, Dowland, & Legibility can be related to the term
Nold, 1999, pp. 2527). wayfinding. Wayfinding can be applied in the
Urban design principles can help to increase built environment context as the user experience
the visual quality of built environment. Sherlock of orientation and choosing a path within a place,
(1991) suggests that cities need to have decent with regard to a set of architectural and design
environments, without which people and their elements that may influence orientation (Passini,
activities will eventually melt away. According 1992, p. 66; Trulove, 2000, pp. 116117). In
to him, the expression decent environment other words, this term concerns the users capac-
does not simply mean pleasant buildings. This ity to form cognitive maps and involves two
term has to mean that users feel pleased and abilities cognitive and behavioral applied to
interested with the appearance of streetscapes get to a destination (Golledge, 1999; Herzog &
(Sherlock, 1991, pp. 164165). For example, Leverich, 2003). In this case, legibility embraces
Sherlock demonstrates that people like shopping character and sense of place with clarity and
B 458 Built Environment

Built Environment, Fig. 4 City center of Bath in England as an example of a place with high legibility (Source:

helps wayfinding (Butina & Bentley, 2007, authorities to improve legibility and imageability
pp. 242243; Urban Design for Retail Environ- of public areas can be seen in Bristol, England.
ments, 2002, p. 40). In this regard, legibility is One of the aims of the Development Plan adopted
related to the ease with which people understand in Bristol is to create a comprehensible image of
the layout of places. On the other hand, the city by means of signs, routes, street furniture
imageability is the quality in a physical object design, public art, publicity, and marketing
which gives it a high probability of evoking (Kelly & Kelly, 2003). Similarly, practices in
a strong image in any given observer. Physical development controls in Bath emphasize the
characteristics of built environment, such as importance of legibility in terms of landmarks
shapes of buildings and colors, are elements that and the relationship to existing and past urban
compose mental images of the built environment form (see Fig. 4).
and help people remember a place as unique
(Lynch, 1960, 2007). A highly imageable city Order, Complexity, and Chaos in the Built
would be well formed, contain very distinct Environment
parts, and be instantly recognizable by people Even though user evaluation of the built environ-
(Nasar, 1998, pp. 89). In this sense, legibility ment can be influenced by user background, user
and imageability increase user perception of per- evaluation of order is the result of an environment
sonal safety and make people become more in which parts form the whole in such a way that
familiar with their surroundings. redundancy, self-contradiction, and conflict are
Passini (1992) suggests that post-Kevin Lynch avoided (Lang, 1987, p. 189). According to
studies have confirmed that the importance of Weber (1995, p. 110), perceptual order is
legibility and imageability in built environment a consequence of physiological processes that
is valid in other cities outside the United States. are based on innate biological principles, each
In many cases, there are minor differences in the individuals sense of cognitive order will, to
relative importance of different elements over some degree, be intersubjective. The segrega-
different cultures. Consequently, Lynchs find- tion and unification of visual stimuli from the
ings (1960) have been implemented in city plan- built environment, which result in the perception
ning operations in several places in recent years. of order, are determined by the principles of
As a result, people are benefiting from the use of Gestalt Theory related to the psychological orga-
more legible and imaginable city elements and nization of visual compositions. The principles of
clearer forms. Strategies applied by local Gestalt explain why a determined place is
Built Environment 459 B
perceived as orderly, pleasant, and interesting by environment is characterized by an ordered aes-
users from different backgrounds despite the thetic composition formed by many visual points
complexity of stimulation this place presents. of attention and different aesthetic relationships
These principles indicate how human beings between them (Kaplan in Nasar, 1988, p. 48;
tend to organize their perceptions so as to give Stamps, 1998, pp. 14071417; Weber, 1995, B
preference to more regular configurations. One of p. 125).
the most sustained analyses of the content of There is agreement in the literature that com-
architecture based on the Gestalt Theory of per- plexity is a necessary condition for user satisfac-
ception was conducted by Arnheim (1977). The tion with the built environment. Venturis (1977)
approach adopted in his work can be summarized and Berlynes (1960) early studies were the first
by his following words: Shapes can be analysed to explore the principle of complexity in urban
in detail by describing their forms in terms of streetscapes. Venturi confronted ideas related to
geometry, size, quantity and location, also there modernist architecture which promoted places
are visual forces which expand and contract, push with low complexity, while Berlyne addressed
and pull, rise and fall, advance and recede the same propositions as Venturi, but in an
which determine meaning and expression in art approach which attempted to identify variables
(Arnheim, 1977, p. 10). that may result in places being perceived posi-
The principle of good Gestalt or law of tively. Kaplans work (1976b) identified negative
pragnanz is defined as a tendency of users to implications of environments perceived as too
take on as much regularity as possible, and this complex or too monotonous on user behavior,
is focused on pattern perception. Seven Gestalt such as difficult wayfinding due to too high or
laws form the factors that influence user evalua- too low visual stimulations and lack of interest. In
tion of the built environment: proximity, similar- addition, other studies show that complex street-
ity, closure, good continuance, closeness, area, scapes are evaluated more positively than simple
and symmetry. A study conducted in Brazil and streetscapes because they provide more informa-
England (Portella, 2007) shows that the principle tion (Elsheshtawy, 1997, p. 303; Lang, 1987,
of complexity, related to the Gestalt laws, has the p. 196; Weber, 1995, p. 124). At the same time,
highest influence on user evaluation of the built studies show that user preferences are associated
environment. The relevance of complexity has with moderate levels of complexity; the
been highlighted by early studies such as the extremes low and high complexities are not
one of Birkhoff (1933) which indicated that evaluated positively by observers (Portella, 2003,
visual quality depends on two factors: order and 2007; Nasar & Hong, 1999; Nasar, 1988, 1998,
complexity. 1983). At the same time, people who live in
Complexity refers to a variety of elements and different places can have different levels of tol-
relationships in an ordered aesthetic configura- erance to the variation of physical characteristics
tion, which is structured according to some over- of the built environment.
all principle based on Gestalt Theory. This Weber (1995, p. 123) and Lang (1987, p. 196)
concept is related to the level of order of elements suggest that, according to user perception and
that form the built environment; places where evaluation, there is a relationship between the
order does not exist are perceived and evaluated affective dimensions of pleasure and interest
as chaotic and irregular, and not as complex. with complexity. In terms of the dimension of
Salingaros (2000, pp. 292293) argues that: In pleasure, this relationship is directly propor-
a general complex system (. . .) certain rules of tional until an optimum is reached; when this
assembly are followed so that the parts cooperate limit is exceeded, the relationship becomes
and the whole functions well. Most streetscapes inversely proportional. There have been several
lie between disorder and order in which the ones attempts to define this optimum level, but the
in this last group can reflect different levels of number of factors that influence user perception
complexity. In this regard, a complex built and evaluation of the physical environment is so
B 460 Built Environment


Arnheim, R. (1977). Dynamic of architectural form.

Berkeley, CA: University of California Press.
Berlyne, D. E. (1960). Conflict, arousal and curiosity.
New York: MacGraw-Hill. Birkhoff 1933.
Birkhoff, G. D. (1933). Aesthetic measure. Cambridge:
Harvard University Press.
Butina, G. W., & Bentley, I. (2007). Identity by design.
London: Architectural Press.
Curran, R. (1983). Architecture and the urban experience.
New York: Van Nostrand Reinhold Company.
Elsheshtawy, Y. (1997). Urban complexity: Toward the
measurement of the physical complexity of street-
scapes. Journal of Architecture and Planning
Research, 14(4), 301328.
Gehl, J. (2001). Life between buildings. Copenhagen: The
Built Environment, Fig. 5 Relationship between plea-
Danish Architectural Press.
sure, interest, and order regarding user evaluation of the
Golledge, R. (1999). Wayfinding behaviour: Cognitive
built environment (Source: Lang, 1987, p. 196)
mapping and other spatial processes. Baltimore: The
John Hopkins University Press.
Hass-Klau, C., Crampton, G., Dowland, C., & Nold, I.
high that no clear definition can be made. On the (1999). Streets as living space. Helping public places
other hand, in terms of the dimension of inter- play their proper role. London: Landor Publishing.
est, the relationship with complexity is always Herzog, T. R. (1992). A cognitive analysis of preference
for urban spaces. Journal of Environmental Psychol-
directly proportional (see Fig. 5). ogy, 12(3), 237248.
Herzog, T. R., & Leverich, O. L. (2003). Searching for
Points for Consideration legibility. Environment and Behavior, 35(4), 459477.
It is unclear why people from different cultures Kaplan, R. (1976). Wayfinding in the natural environ-
ment. In G. T. Moore & R. G. Golledge (Eds.), Envi-
tend to have a similar sense of satisfaction when ronmental knowing: Theories, perspectives and
visiting global cities as Paris, London, and Rome, methods (pp. 324). Stroudsburg: Dowden, Hutchin-
for example. Even people who have never been to son and Ross.
these places would state that they like them. In Kelly, A., & Kelly, M. (2003). Building legible cities 2.
Bristol: Bristol Cultural Development Partnership.
this way, it is assumed that users preference Kong, L., & Yeoh, B. (2004). The meaning and making of
and satisfaction for the built environment go place: Exploring history, community and identity.
beyond personal experiences and are more Retrieved April 26, 2004, from http://www.fas.nus.
related to concepts of order, visual quality, com- edu.sg.
Lang, J. (1987). Creating architectural theory, the role of
plexity, and contrast than we think. If this is the behavioral sciences in environmental design. New
the case, it is possible to help to define general York: Van Nostrand Reinhold.
guidelines principles to enhance the built envi- Lang, J. (2005). Urban design, a typology of procedures
ronment and, consequently, improve peoples and products. London: Architectural Press.
Lynch, K. (1960). The image of the city. Cambridge: MIT
quality of life. Press.
Lynch, K. (2007). The image of the environment and
the city image and its elements. In M. Larice & E.
Cross-References Macdonald (Eds.), The urban design reader
(pp. 153166). New York: Routledge.
Meader, N., Uzzell, D., & Gatersleben, B. (2006). Cultural
Aesthetic Value theory and quality of life. European Review of Applied
Cognition Psychology, 56(1), 6169.
Housing and Quality of Life Nasar, J. L. (1988). Environmental aesthetics: Theory,
research and applications. Cambridge: University
Restorative Natural Environments Press.
Sense of Place Nasar, J. L. (1998). The evaluative image of the city.
Urban Design London: Sage.
Bullying 461 B
Nasar, J., & Hong, X. (1999). Visual preferences in urban
signscapes. Environment and Behavior, 31(5), 671691. Bulimia Nervosa and Caregivers
Passini, R. (1992). Wayfinding in architecture. New York:
Van Nostrand Reinhold.
Portella, A. A. (2003). A Qualidade Visual dos Centros de Caregivers of Patients with Eating Disorders,
Comercio e a Legibilidade dos Anuncios Comerciais Quality of Life B
(Visual Quality of Commercial City Centres and Leg-
ibility of Commercial signs), Master Dissertation in
Regional and Urban Planning, Federal University of
Rio Grande do Sul, Porto Alegre. Dissertation
unpublished. Bullying
Portella, A. A. (2007). Evaluating commercial signs in
historic streetscapes: The effects of the control of adver-
tising and signage on users sense of environmental Susan Limber and Weijun Wang
quality., Ph.D. Thesis concluded at Oxford Brookes Institute on Family & Neighborhood Life,
University in the Joint Centre for Urban Design. Clemson University, Clemson, SC, USA
Rogers, A. (1992). Key themes and debates. In A. Rogers,
H. Viles, & A. Goudie (Eds.), A Students companion
to geography (p. 245). Oxford: Blackwell.
Russell, J. A., & Ward, L. M. (1981). The psychological Definition
representation of molar physical environments. Jour-
nal of Experimental Psychology, 110(2), 121152. Bullying is unwanted aggressive behavior
Salingaros, N. A. (2000). Complexity and urban coher-
ence. Journal of Urban Design, 5(3), 291316. that involves an imbalance of power between
Sherlock, H. (1991). Cities are good for us. London: two or more individuals (Nansel et al., 2001;
Paladin. Olweus, 1993, 2010). This imbalance of power
Stamps, A. E. (1998). Complexity of architectural facades: may be characterized by differences in size or
From vague impression to define design features.
Perceptual and Motor Skills, 87(2), 14071417. 3. strength, popularity, abilities, or numbers,
Stamps, A. E. (2000). Psychology and the aesthetics of the among other characteristics. Typically, bullying
built environment. San Francisco: Kluwe Academic is repeated over time. Bullying may include
Publisher. direct actions (such as hitting, taking or damaging
Trulove, J. G. (2000). This way, signage design for public
spaces. New York: Rockport Publishers. possessions, taunting, or name-calling) or
Urban Design for Retail Environments. (2002). Produced indirect actions (such as social exclusion,
by the building design partnership with support from rumor-spreading or manipulation of friendships).
CABE and English heritage for the British Council of Relational and social bullying are terms used
Shopping Centres (BCSC). London: BCSC.
Venturi, R. (1977). Complexity and contradiction in to describe behaviors that are meant to damage
architecture. London: Architectural Press. a childs social standing or reputation with peers
Weber, R. (1995). On the aesthetic of architecture, a or that use the threat of the loss of a relationship
psychological approach to the structure and the to manipulate others. Cyber bullying, or elec-
order of perceived architectural space. San Francisco:
Ashgate. tronic bullying, is a form of bullying that involves
the use of electronic or cyber communications
to bully (Hinduja & Patchin, 2009; Kowlaski,
Limber, & Agatston, 2012).
Built Form

Built Environment Description

National estimates of the rates of bullying vary

considerably depending on the definitions of
Bulimia Nervosa bullying that are used, measurement strategies,
and the ages of participants. However, studies
Eating Disorder(s) and Health-Related Quality consistently show that bullying is a relatively
of Life common experience for children and youth.
B 462 Bullying

According to the School Crime Supplement to the bullying, on the other hand, typically emerges in
National Crime Victimization Survey, 28 % of the middle school years (Kowlaski, Limber, &
students aged 1218 had been bullied at school Agatston, 2012).
during the 2009 school year and 6 % reported Although both boys and girls are involved in
having been cyber bullied anywhere (Robers, bullying, most studies have found that boys are
Zhang, Truman, & Snyder, 2012). Another somewhat more likely than girls to bully or to
national survey, the 2009 Youth Risk Behavior be characterized as bully-victims (Cook,
Survey published by the Centers for Disease Williams, Guerra, Kim, & Sadek, 2010; Craig
Control and Prevention reported that 20 % of et al., 2009). Most studies show small differences
high school students were bullied on school between boys and girls in their likelihood of
property at least once in the previous 12 being bullied (Cook et al., 2010; Robers et al.,
months and 16 % had been electronically bul- 2012), but there are fairly consistent gender dif-
lied (Eaton et al., 2012). The most common ferences in the types of bullying that boys and
forms of bullying that children and youth expe- girls experience. For example, boys are more
rience are verbal (e.g., being made fun of, likely than girls to be physically bullied by
called names, insulted, being the subject of peers, while girls are more likely to be bullied
rumors) (Robers et al., 2012). through rumor-spreading and social exclusion
Not only are students involved in bullying (Robers et al., 2012). Although boys are usually
as victims, but they also may bully others, or bullied by other boys, girls are bullied by
they may bully others and also be bullied them- boys and girls (Finkelhor et al., 2005; Nansel
selves. This latter group is often referred to as et al., 2001).
bully-victims. In a recent study of more than There is no single cause of bullying. Rather,
520,000 3rd12th grade students in the USA, individual, peer, family, and environmental
researchers found that 20 % of girls and 25 % of factors may make it more or less likely
boys had been involved in bullying on a regular that a child will be involved in bullying
basis (23 times/month or more often) as victim (Swearer, Espelage, Koenig, Berry, Collins, &
only (14 % of girls and 13 % of boys), bully Lembeck, 2012). For example, an individuals
only (4 % of girls and 8 % of boys), or temperament may play a role. Children and
bully-victim (3 % of girls and 4 % of boys) youth who are bullied are more likely to have
(Olweus & Limber, 2010). quiet, passive personalities, lack social skills,
The frequency and forms of bullying that and have internalizing problems (such as depres-
children experience and engage in vary sion). Those who bully are more likely to have
depending upon their age and gender. Children impulsive temperaments, have negative attitudes
are most likely to be bullied during elementary about themselves and others, and have problems
school grades (Finkelhor, Ormrod, Turner, & resolving problems with others (Cook et al.,
Hamby, 2005; Olweus & Limber, 2010), and 2010; Olweus, 1993). Peer factors also play
their likelihood of being bullied decreases through- a role. Children and youth are more likely to
out middle and high school years (Nansel et al., bully if they have friends who bully or who
2001; Robers et al., 2012). On the other hand, have positive attitudes toward violence (Cook
children and youth are most likely to bully others et al., 2010; Olweus, 1993). Bullied children
during early to middle adolescence (Espelage & tend to be socially isolated and report having
Swearer, 2010). Children are involved in different few friends (Cook et al., 2010; Swearer et al.,
forms of bullying at different ages, depending on 2012). Family factors are also related to
their verbal, cognitive, and social development a childs likelihood of being involved in bullying.
(Rubin, Ceah, & Menzer, 2010). For example, Children are more likely to bully if there is a lack
while physical bullying is more common among of parental warmth and engagement, a lack of
elementary school children, it is less frequent parental supervision, inconsistent discipline, and
among middle or high school students. Electronic harsh physical punishment within their families
Bullying 463 B
(Cook et al., 2010; Olweus, 1993). Exposure to Raasnen, & Puura, 2001). Bullied children are
parental conflict and domestic violence and the also more likely than non-bullied children to
experience of child abuse have been found to be experience psychosomatic problems such as
related to greater likelihood of bullying others headaches, stomach aches, sleep problems, poor
and being bullied (Baldry, 2003; Bowes et al., appetite, and bed wetting (Fekkes, Pijpers, & B
2009; Shields & Cicchetti, 2001). Aspects of the Verloove-Vanhorick, 2004; Gini & Pozzoli,
school and broader environment may also affect 2009). They are more likely than peers to want
childrens likelihood of involvement in bullying. to avoid school (Kochenderfer & Ladd, 1996)
For example, students who have a sense of and to have lower academic achievement
belonging to the school and perceive they are (Aresneault et al., 2006; Buhs, Ladd, & Herald,
treated with respect and fair treatment are less 2006; Nakamoto & Schwartz, 2010). Conse-
likely to be involved in bullying (Cook et al., quences of bullying may last years after the
2010). Bullying is also particularly prevalent bullying has ended. In adulthood, individuals
where there are indifferent or accepting attitudes who were bullied as children have higher rates
about bullying by school staff and students and of depression and anxiety and lower self-
where there is poor adult supervision (Olweus, esteem than peers who were not bullied as
1993; Pellegrini & Barini, 2000). children (Olweus, 1993; Roth, Coles, &
Although any child may be bullied, some Heimberg, 2002).
groups of children and youth are at higher risk There is also reason to be concerned about
for being bullied than others, including children children who bully others. They are more likely
with learning disabilities (Mepham, 2010; than their peers to be involved in other antisocial,
Mishna, 2003), children with attention-deficit violent, or troubling behavior, including fighting,
hyperactivity disorder (ADHD; Twyman et al., vandalism, stealing, weapon-carrying, school
2010; Weiner & Mak, 2009), children and youth dropout, poor school achievement, drinking
with autism spectrum disorder (ASD; Twyman alcohol, and smoking, and thinking about and
et al., 2010), those with special health-care needs attempting suicide (Byrne, 1994; Cook et al.,
or chronic diseases (Dawkins, 1996; Magin, 2010; Gini & Pozzoli, 2009; Haynie et al.,
Adams, Heading, Pond, & Smith, 2008; Storch 2001; Nansel et al., 2001).
et al., 2004; Hamiwka et al., 2009), those who are Although adults often view bullying as
obese (Fox & Farrow, 2009; Gray, Kahhan, & a problem between two children, it is more
Janicke, 2009), and those who are underweight accurate to understand it as a group phenome-
(Wang, Iannotti, & Luk, 2010). Adolescents who non, in which children may play a variety of
identify themselves as lesbian, gay, bisexual, or roles, including active or passive supporters of
transgender (LGBT); those who are questioning the bullying, disengaged onlookers, and
their sexual identity; and those who are perceived defenders (Olweus, 1993). These roles may
to be gay or lesbian also are at greater risk of change from one situation to the next. Large
being bullied (Eisenberg, Neumark-Sztainer, percentages of children indicate that they have
Story, & Perry, 2005; Harris Interactive & witnessed bullying (Trach, Hymel,
GLSEN, 2005). Waterhouse, & Neale, 2010). Most have nega-
The experience of bullying may have negative tive reactions to bullying and feel sympathy
effects on the health, mental health, and academic for bullied children (Baldry, 2004; Olweus &
work of bullied children and youth. They are Limber, 2010).
more likely than non-bullied peers to be anxious, In recent years, the prevention of bullying in
have low self-esteem, be depressed, think about schools has received considerable attention
suicide, and attempt suicide (Craig, 1998; from the federal government, state legislators
Hinduja & Patchin, 2010; Juvonen, Graham, & (Alley & Limber, 2009), and researchers
Shuster, 2003; Klomek, Marrocco, Kleinman, (Jimerson, Swearer, & Espelage, 2010; Ttofi &
Schonfeld, & Gould, 2008; Kumpulainen, Farrington, 2009).
B 464 Bullying

Cross-References Baldry, A. C. (2003). Bullying in schools and exposure to

domestic violence. Child Abuse & Neglect, 27,
Anxiety Baldry, A. C. (2004). What about bullying? An experi-
Child Maltreatment: Physical Abuse mental field study to understand students attitudes
Child Maltreatment: Psychological towards bullying and victimization in Italian middle
Maltreatment schools. British Journal of Educational Psychology,
74, 583598.
Child Obesity Bowes, L., Arseneault, L., Maughan, B., Taylor, A., Caspi,
Childhood Anxiety A., & Moffitt, T. E. (2009). School, neighborhood, and
Childrens Victimization in School family factors are associated with childrens bullying
Cigarette Smoking and Drinking involvement: A nationally representative longitudinal
study. Journal of the American Academy of Child and
Disability Adolescent Psychiatry, 48, 545553.
Early School Leaving Buhs, E. S., Ladd, G. W., & Herald, S. L. (2006). Peer
Education exclusion and victimization: Processes that mediate
Emotional Well-Being the relation between peer group rejection and
childrens classroom engagement and achievement?
Feeling Safe Journal of Educational Psychology, 98, 113.
Friendship and Happiness Byrne, B. J. (1994). Bullies and victims in school settings
Health with reference to some Dublin school. Irish Journal of
Health and Violence Psychology, 15, 574586.
Cook, C. R., Williams, K. R., Guerra, N. G., Kim, T. E., &
Health Outcomes Sadek, S. (2010). Predictors of bullying and victimiza-
Obesity, an Overview tion in childhood and adolescence: A meta-analytic
Parent-Child Relationship(s) investigation. School Psychology Quarterly, 25, 6583.
Physical Well-Being Craig, W. M. (1998). The relationship among bullying,
victimization, depression, anxiety, and aggression in
School Attendance elementary school children. Personality and Individ-
School Climate ual Differences, 24, 123130.
School Dropout Craig, W., Harel-Fisch, Y., Fogel-Grinvald, H., Dastaler,
School Satisfaction S., Hetland, J., Simons-Morton, B., et al. (2009).
A cross-national profile of bullying and victimization
School Sense of Community among adolescents in 40 countries. International
School Violence Journal of Public Health, 54, S216S224.
School-Based Interventions Dawkins, J. L. (1996). Bullying, physical disability and
Self-Esteem the paediatric patient. Developmental Medicine and
Child Neurology, 38, 603612.
Social Ecology Eaton, D. K., Kann, L., Kinchen, S., Shanklin, S.,
Stress Flint, K. H., Hawkins, J., et al. (2012). Youth risk
Student Quality of Life behavior surveillance United States, 2011. MMWR
Well-Being, Student Surveill Summ, 61, 1162. Retrieved February 22,
2013 from http://www.cdc.gov/mmwr/preview/
Violence in the Workplace mmwrhtml/ss6104a1.htm?s_cid=ss6104a1_w
Youth Violence Eisenberg, M. E., Neumark-Sztainer, D., Story, M., &
Perry, C. (2005). The role of social norms and friends
influences on unhealthy weight-control behaviors
References among adolescent girls. Social Science & Medicine,
60, 11651173.
Alley, R., & Limber, S. P. (2009). Legal issues for school Espelage, D. L., & Swearer, S. M. (Eds.). (2010). Bullying
personnel. In S. M. Swearer, D. L. Espelage, & S. A. in North American school: A social-ecological per-
Napolitano (Eds.), Bullying prevention and interven- spective on prevention and intervention (2nd ed.).
tion: Realistic strategies for schools (pp. 5373). New York: Routledge.
New York: Guilford. Fekkes, M., Pijpers, F. I., & Verloove-Vanhorick, S. P.
Aresneault, L., Walsh, E., Trzesniewski, K., Newcombe, (2004). Bullying behavior and associations with psy-
R., Caspi, A., & Moffitt, T. E. (2006). Bullying chosomatic complaints and depression in victims. The
victimization uniquely contributes to adjustment prob- Journal of Pediatrics, 144, 1722.
lems in young children: A nationally representative Finkelhor, D., Ormrod, R., Turner, H., & Hamby, S. L.
cohort study. Pediatrics, 118, 130138. (2005). The victimization of children and youth.
Bullying 465 B
A comprehensive national survey. Child Mishna, F. (2003). Learning disabilities and bullying:
Maltreatment, 10, 525. Double jeopardy. Journal of Learning Disabilities,
Fox, C. L., & Farrow, C. V. (2009). Global and physical 36, 336347.
self-esteem and body dissatisfaction as mediators of Nakamoto, J., & Schwartz, D. (2010). Is peer victimiza-
the relationship between weight status and being tion associated with academic achievement? A meta-
a victim of bullying. Journal of Adolescence, 32, analytic review. Social Development, 19, 221242. B
12871301. Nansel, T., Overpeck, M., Pilla, R. S., Ruan, W. J.,
Gini, G., & Pozzoli, T. (2009). Association between bul- Simmons-Morton, B., & Schmidt, P. (2001). Bullying
lying and psychosomatic problems: A meta-analysis. behaviors among US youth. Journal of the American
Pediatrics, 123, 10591065. Medical Association, 285, 20942100.
Gray, W. N., Kahhan, N. A., & Janicke, D. M. (2009). Olweus, D. (1993). Bullying at school: What we know and
Peer victimization and pediatric obesity: A review what we can do. Oxford, UK: Blackwell.
of the literature. Psychology in the Schools, 46, Olweus, D. (2010). Understanding and researching
720727. bullying: Some critical issues. In S. R. Jimerson,
Hamiwka, L. D., Yu, C. G., Himiwka, L. A., Sherman, S. M. Swearer, & D. L. Espelage (Eds.), The handbook
E. M. S., Anderson, B., & Wirrell, E. (2009). Are of school bullying: An international perspective
children with epilepsy at greater risk for bullying (pp. 933). New York: Routledge.
than their peers? Epilepsy & Behavior, 15, 500505. Olweus, D., & Limber, S. P. (2010, November). What do
Harris Interactive & GLSEN. (2005). From teasing to we know about bullying? Information from the olweus
torment: School climate in America, a survey of bullying questionnaire. Paper presented at the annual
students and teachers. New York: GLSEN. meeting of the International Bullying Prevention
Haynie, D. L., Nansel, T., Eitel, P., Crump, A. D., Sayor, Association. Seattle, WA.
L., Yu, K., et al. (2001). Bullies, victims and Pellegrini, A. D., & Barini, M. (2000). An empirical
bully/victims: Distinct groups of at-risk youth. Journal comparison of methods of sampling aggression and
of Early Adolescence, 21, 2949. victimization in school settings. Journal of Educa-
Hinduja, S., & Patchin, J. W. (2009). Bullying beyond the tional Psychology, 92, 360366.
schoolyard: Preventing and responding to Robers, S., Zhang, Jijun, Z., Truman, J., & Snyder, T. D.
cyberbullying. Thousand Oaks, CA: Sage/Corwin (2012). Indicators of school crime and safety: 2011.
Press. Retrieved February 22, 2013 from http://bjs.ojp.usdoj.
Hinduja, S., & Patchin, J. W. (2010). Bullying, gov/content/pub/pdf/iscs11.pdf.
cyberbullying, and suicide. Archives of Suicide Roth, D. A., Coles, M. E., & Heimberg, R. G. (2002). The
Research, 14, 206221. relationship between memories for childhood teasing
Jimerson, S. R., Swearer, S. M., & Espelage, D. L. (Eds.) and anxiety and depression in adulthood. Journal of
(2010). The handbook of bullying in schools: An inter- Anxiety Disorders, 16, 149164.
national perspective. New York: Routledge. Rubin, K. H., Ceah, C., & Menzer, M. M. (2010). Peers. In
Juvonen, J., Graham, S., & Shuster, M. A. (2003). M. H. Bornstein (Ed.), Handbook of cultural develop-
Bullying among young adolescents: The strong, the mental science (pp. 223237). New York: Psychology
weak, and the troubled. Pediatrics, 112, 12311237. Press.
Klomek, A. B., Marrocco, F., Kleinman, M., Schonfeld, Shields, A., & Cicchetti, D. (2001). Parental maltreatment
I. S., & Gould, M. S. (2008). Peer victimization, and emotion dysregulation as risk factors for bullying
depression, and suicidiality in adolescents. Suicide & and victimization in middle childhood. Journal of
Life-Threatening Behavior, 38, 166180. Clinical Child Psychology, 30, 349363.
Kochenderfer, B. J., & Ladd, G. W. (1996). Peer Storch, E. A., Lewin, A. B., Silverstein, J. H., Heidgerken,
victimization: Cause or consequenceof school A. D., Strawser, M. S., Baumeister, A., et al. (2004).
maladjustment? Child Development, 67, 13051317. Peer victimization and psychosocial adjustment in
Kowlaski, R., Limber, S. P., & Agatston, P. (2012). children with type 1 diabetes. Clinical Pediatrics, 43,
Cyberbullying: Bullying in the digital age. 467471.
New York: Blackwell. Swearer, S. M., Espelage, D. L., Koenig, B., Berry, B.,
Kumpulainen, K., Raasnen, E., & Puura, K. (2001). Collins, A., & Lembeck, P. (2012). A Social-ecological
Psychiatric disorders and the use of mental model of bullying prevention and intervention in early
health services among children involved in bullying. adolescence. In S. R. Jimerson, A. B. Nickerson,
Aggressive Behavior, 27, 102110. M. J. Mayer, & M. J. Furlong (Eds.), The handbook of
Magin, P., Adams, J., Heading, G., Pond, D., & Smith, W. school violence and school safety: International
(2008). Experiences of appearance-related teasing and research and practice (pp. 333355). NY: Routledge.
bullying in skin diseases and their psychological Trach, J., Hymel, S., Waterhouse, T., & Neale, K. (2010).
sequelae: Results of a qualitative study. Scandinavian Bystander responses to school bullying: A
Journal of Caring Sciences, 22, 430436. cross-sectional investigation of grade and sex differ-
Mepham, S. (2010). Disabled children: The right to feel ence. Canadian Journal of School Psychology, 25,
safe. Child Care in Practice, 16, 1934. 114130.
B 466 Burden of Illness

Ttofi, M. M., & Farrington, D. P. (2009). What works in Definition

preventing bullying: Effective elements of anti-
bullying programs. Journal of Aggression, Conflict
and Peace Research, 1, 1324. What Is Burnout?
Twyman, K. A., Saylor, C. F., Saia, D., Macias, M. M., In general, burnout (BO) is conceived as
Taylor, L. A., & Spratt, E. (2010). Bullying and ostra- a response mechanism to chronic stress.
cism experiences in children with special health care A person is subject to chronic stress when the
needs. Journal of Developmental and Behavioral
Pediatrics, 31, 18. dose of stress accumulated surpasses the optimal
Wang, J., Iannotti, R. J., & Luk, J. W. (2010). Bullying threshold for adaptation, and his (or her) organ-
victimization among underweight and overweight U.S. ism begins to show signs of exhaustion such as
youth: Differential associations for boys and girls. ulcers, allergies, and migraine, among others. The
Journal of Adolescent Health, 47, 99101.
Weiner, J., & Mak, M. (2009). Peer victimization in moment when this exhaustion manifests itself is
children with attention-deficit/hyperactivity disorder. variable and depends both in the psychological
Psychology in the Schools, 46, 116131. profile of the person and the amount and
frequency of experienced adjustments.
BO manifests regularly in human services
Burden of Illness professions. It is a subjective experience that
has a negative connotation for the individual
Duke Severity of Illness Checklist who suffers from it, since it involves emotional
disturbances, interaction problems with other
people, psychophysiological alterations, and neg-
Burden to Others ative repercussions that affect not only for the
individual, but the organization where he works
Self-Perceived Burden to Others (Sandoval, 2000).
Maybe the more widely accepted definition is
the one by Maslach and Jackson (1981), where
Bureaucratic Politics BO is defined as a response to chronic work
stress characterized by negative attitudes and
Democracy and Bureaucracy feelings toward co-workers and the professional
role itself, as well as the experience of being
emotionally exhausted. In this definition,
Burnout according to the authors, three dimensions that
constitute BO can be identified:
Arturo Juarez-Garcia1, Aldo Vera-Calzaretta2,3 Emotional exhaustion: It refers to the lack of
and Cinthya A. Flores-Jimenez4 ones own emotional resources and the feeling
Universidad Autonoma del Estado de Morelos, that nothing can be offered to the other person,
Cuernavaca, Mexico that one can give no more from oneself at the
Escuela de Salud Publica, Universidad de Chile, affective level. It is an experience of being
Santiago, Chile emotionally tired due to daily and continuous
Fellow Program ITREOH, Mount Sinai contact with people who are the subject of the
University, New York, NY, USA work.
Unidad de Investigaciones y Servicios Depersonalization: It is the development of
Psicologicos, Universidad Autonoma del Estado negative feelings and attitudes, cynical and
de Morelos, Cuernavaca, Mexico insensitive, toward the recipients of the ser-
vices given, who are seen by the professionals
Synonyms in a dehumanized way due to emotional
Burnout syndrome; Chronic stress; Psychosocial Lack of personal accomplishment: It is
stress a perception that possibilities for personal
Burnout 467 B
achievement at work have disappeared, which lack of a fixed work-schedule, very high number
diminishes personal expectations and com- of working hours, scarce payment, and very
prises a negative self-evaluation, including demanding social context, which was usually
rejection of oneself and of ones personal tense and difficult. Another element was the
achievements, as well as feelings of failure common lack of systematic preparation of B
and low self-esteem. workers, who tried to replace their lack
In the beginning, since this problem came of professional preparation with enthusiasm.
from the social work, it was minimized Freudenberger took a word that was commonly
and taken lightly by popular psychology. used during the 1960s to refer to the effects of
Nonetheless, today there are substantial works chronic drug abuse and began utilizing it in order
and theoretical models that rest upon the first to characterize the state of exhaustion experi-
questions about scholarly research on this field. enced by himself and some of his colleagues
But, according to the definition by Maslach and when they started to look tired, depressed, apa-
Jackson (1981), a person with burnout claims to thetic, and with signs of guilt, paranoia, and
be exhausted and emotionally empty; in other omnipotence that interfered with their capacity
words, the person feels that he cannot offer to reduce their activity level. At the same time, he
anything psychologically to others and, in many found a particular susceptibility among young,
cases, chooses to act coldly, distantly, and even idealist students who wanted to be productive to
negatively, toward people whom he is servicing. human kind by becoming doctors, nurses, or
On top of that, he has a negative perception teachers. Later, he defined BO as a state of
of himself, where his accomplishments and job fatigue or frustration caused by the devotion
performance are not valued as something positive to a cause, lifestyle, or relationship that failed to
but as a failure or somewhat lacking, which grant the expected gratification.
increases his low self-esteem and poor perception Meanwhile, Christina Maslach (1982),
of himself and those around him. a social psychologist, studied the ways in which
It is important to mention that attempts at people faced emotional stress, particularly cogni-
translating the term burnout to other languages tive strategies such as detached concern and
have failed in the sense that a general convention dehumanization in self-defense. Soon she
in its use and/or definitive adoption within each discovered that both techniques play a relevant
country. Maybe the only way to maintain the role in peoples identity and behavior at their
convention when referring to this phenomenon work place. Incidentally, she commented on
is to keep naming it in English, as it is the case these results with a poverty lawyer who pointed
of a global construct. out that they referred to this phenomenon as
burnout. Once Maslach and her colleagues
adopted this term, they realized that this phenom-
Description enon was recognized by their interviewees, so
a new colloquial expression was born: Burnout
Background syndrome.
The term burnout (BO) was first used in 1974 Freudenberger, together with University of
by the American psychoanalyst Herbert California at Berkeley psychologists Christina
Freudenberger (Freudenberger & Richelson, Maslach and Ayala Pines, made this concept
1981), to indicate a state of physical and popular during the 1970s, and began studies that
emotional tiredness that results in certain work legitimized its status as a social issue (Pines &
environments. This author introduced the term Aronson, 1988). Nonetheless, while the two last
referring to a phenomenon that he had observed authors, as social psychologists, focused their
in himself and his colleagues when they worked BO studies on psychosocial factors directing
at a free clinic for drug addicts. The type of work their research toward the relation between
that these people performed was characterized by environmental and individual determinants,
B 468 Burnout

Freudenberger, a psychoanalyst, contemplated The Teacher Burnout Scales (TBS), built by

a BO model that emphasized the psychology of Seidman and Zager (19861987). It has 21
the individual and focused on the capabilities and items that show four factors: professional
vulnerabilities of the individual in stressful satisfaction, perceived administrative support,
situations. coping with job-related stress, and attitudes
BO presented as the description to toward students.
a generalized problem in multiple fields, which Teacher Attitude Scales (TAS), which is
affected job satisfaction, professional involve- a modified version of MBI that has 25 items
ment, and job efficacy and quality. The novelty of the MBI and are extended by author with 40
of the concept was that, unlike many others, it did items specific to teachers. These additional
not originate as a result of laboratory research, items describe situations of satisfaction
but as the finding of a real problem experienced or work-related stress designed by Farber
within the wide core of professional occupations. (1984).
The colloquial term burnout (BO), and The Staff Burnout Scales for Health Profes-
its underlying theoretical model, became like sionals (SBS-HP), elaborated by Jones in
rubbing salt into the open wound of many profes- 1982, is used to measure burnout in healthcare
sional workers. The phenomenon described professionals. It has 30 items in a 6-degree
corresponded, not to an intellectual or academic scale, and it measures 4 factors: dissatisfaction
problem, but to a felt concern within different or job stress, psychological or interpersonal
professional groups. From then on a true stress, illness and stress, and lack of profes-
proliferation of papers has occurred; they are sional relationships toward patients.
mostly descriptive in nature, presenting the The Tedium Measure (TM) of Pines and
misfortunes that go along with BO. Aronson (1988), the TM is used in profes-
sionals of any occupational sector to measure
Measurement of Burnout tedium and, in human services professionals,
The gold-standard measurement for Burnout to calculate burnout, where it is called BM. It
evaluation is the self-report. Different evaluation is made up of 21 questions that are arranged
questionnaires have been developed in the last in three subscales: physical exhaustion,
decades, many of which are within the frame- emotional exhaustion, and mental exhaustion.
work of methodological requirements and have Spanish Burnout Inventory (Cuestionario para
been tested for validity and reliability. Among la Evaluacion del Sndrome de Quemarse por
them are: el Trabajo-CESQT). Developed by Gil-Monte
The Maslach Burnout Inventory (MBI), (2003), it suggests the components of psychic
created by Maslach and Jackson in 1981, is wear and tear, sloth, and lack of enthusiasm
the most widely used instrument to measure for the work (Gil-Monte et al., 2006). Also, it
this syndrome, and the one instrument that tries to identify two profiles in the process of
the largest number studies have used to burnout, one that progresses without feelings
demonstrate their validity and reliability. It of guilt, and the other where feelings of guilt
comprises 22 items that measure three compo- are present (the latter one being more severe).
nents: emotional fatigue, low sense of Today, this is the second most used instrument
achievement, and depersonalization. Also, (after MBI) for the Spanish-speaking
Maslach has developed a new version to eval- population.
uate the Burnout syndrome in occupational In addition to the instruments briefly described
sectors where human service is not necessarily here, there is a wide array of instruments that one
present and, therefore, is applicable to a wider can find in the literature. Nevertheless, informa-
range of existing work sectors. It is called tion related to validity reported reliability uses
MBI-General Survey (GS), and it comprises and limits of such instruments should be
16 items. explicitly.
Burnout 469 B
Causes of Burnout Work life (SAW), in order to frame the research
More than causes, one can talk about predicting of preceding conditions that could lead to the
variables or, in the words of some authors, development of Burnout syndrome. Within this
trigger/facilitating variables for Burnout. frame, Leiter and Maslach introduced six areas
Professionals vulnerable to presenting which suggest that there be equilibrium between B
Burnout syndrome have various characteristics employees and employers inside organizations;
in common, which represent the variables that the areas are: workload, control, reward, commu-
have been majorly associated with the occurrence nity, fairness, and values. These will be described
or worsening of the syndrome. These variables in the following subsections.
can present themselves singly or in combined, but
it has been found that they are important predic- Workload
tors that can lead to think that the worker will According to Leiter and Maslach (1999), work-
develop Burnout syndrome at some point during load is defined as the amount of work that has to
his work activities. be done at a certain time. It has a predictable and
The variables can be grouped mainly into consistent relationship, particularly with
characteristics of the worker and characteristics emotional exhaustion. One of the problems of
of the organization or of the work environment. the workload is the continuous or regular intensi-
Regarding the first ones one can find the fication of work which exceeds the human limits
following: of what one person can do.
Sex. Maslach (1982) pointed out that women Sonnentag and Kruel (2006) presented
experience more emotional exhaustion, and findings regarding the impact of workload on
less personal realization than men (Maslach the health of employees. They explain that,
& Jackson, 1981). The double role of women when employees have to take work home in
at work and home is also a source of stress. order to finish it, the opportunities of detaching
Age. Different studies have found a significant from work and recovering are hindered because
relation between age and Burnout syndrome people preserve the emotions caused by their
(Seltzer & Numerof, 1988). It is possible that work, feeling physically tired.
the relationship between the two is associated Leiter and Maslach (1999) emphasized that
to experience inside the profession. a maladjustment or role conflict occurred when
Marital status. According to Maslach, having there was a mismatch between the characteristics
children can be a protective factor against of the job and an elevated work volume that
Burnout syndrome. Authors such as Cooke originated without any control. There is evidence
and Rousseau (1984) point out that this that suggests the impact of workload and its
situation also contributes something positive, potential effect in the mental health of workers,
for having the possibility of sharing work but this can be alleviated through other resources
issues with the family can be an opportunity such as social support, recognition of skills, and
to receive support, advice, or simply to vent. control (Bakker, Demerouti, & Euwema, 2005).
Personality. Dispositional variables that are
more or less stable in the personality of Control
an individual, such as self-esteem, type-A According to Ashforth and Saks (2000), control is
behavior pattern, or introversion, have been a combination of work autonomy and the
associated to components of burnout. Also, capability of the workers to participate in the
an association has been found between low decisions that affect them. Control provides
emotional control, low self-efficacy, and workers with the liberty, or task domain, in
burnout (Juarez-Garca, 2005). order to determine the appropriate work methods,
Regarding the organizational or work environ- schedules, and objectives, by themselves.
ment characteristics, recently Leiter and Maslach From the point of view of the employee, sat-
(1999) proposed the model The Six Areas of isfactory control of the workplace allows for
B 470 Burnout

ideas and creativity to flow consistently with the Community

demands of work (Schaufeli & Bakker, 2003); According to Leiter and Maslach (2004),
the results are then better for organizations. community is the quality of the social interaction
When there is conflict over control, it usually at work, which includes matters such as conflicts,
reflected in hierarchical organizations, and mutual support, proximity, and ability to work
individuals caught up in such hierarchies are together. People grow through the community,
incapable of exercising control over their work. and community is the social support that
According to Leiter and Maslach (1999), malad- reaffirms the membership of the person to
justment in the workers control makes it, so they a group that shares his values. Unfortunately,
are obligated to act in a manner that is at odds some jobs isolate people from one another or
with their own values and principles; workers, promote impersonal social contact, creating
therefore, have a lack of autonomy. conflicts with other peoples work. Constant
According to Jimenez and Moyano (2008), conflicts give way to negative feelings of frustra-
more personal control at work simultaneously tion and hostility, and reduce the possibility of
renders with organizational benefits, reduces social support (Leiter & Maslach, 2004).
absenteeism, and increases productivity. Organi- Community has an important role in the health
zational cultures with high degrees of formality of workers. Leiter and Maslach (1999, 2004) iden-
and hierarchy, and less self-determination tified community as an aspect of work life that
and intimacy, show less well-being and more could have influence in exhaustion, but they con-
difficulties to integrate work and family. cluded that social support within organizations,
from both supervisors and coworkers, helped face
Reward the demands of work and Burnout syndrome. Gill
Leiter (2010) indicates that reward can be finan- (1999) saw work as a creative effort of workers,
cial or social, and that it is received by a person which allowed them to escape social isolation.
for his contribution to work. Within an organiza-
tion, the reward creates a reason for significant Fairness
contributions to work. Nonetheless, when people Fairness makes reference to administrative
experience lack of recognition, they perceive leadership of the organizations, which should be
a devaluation of their work and of themselves, considered, same as all of its staff members, with
experiencing feelings such as not being worthy of clear procedures of promotion and awards
an increase in pay for the work they do, dissatis- without discrimination or favoritism (Maslach
faction toward work, or feeling unchallenged. & Leiter, 2005).
Paid work gives more than only income to Fairness shares some qualities with commu-
support the standard of living. In modern society, nity and reward. Justice is a clear quality of
work covers personal needs at psychological communion, especially related to the distribution
levels, such as giving a sense of personal worth of recognition, rewards, and opportunities. The
and individual welfare (Gill, 1999). main focus of fairness is the spirit of mutual trust
Effort at work is recognized as part of a process between people in the organization. Fairness is
of socially organized exchange that favors the quality that all people who have authority
rewards, which can be distributed in three subsys- within the organization and who have
tems: economic, esteem, and promotion opportu- a responsibility to be fair and to make decisions
nities. Nonetheless, the lack of reciprocity between that affect the work and the environment of the
the costs of effort and the received rewards causes personnel in the organization. Fair decisions are
reactions of sustained tension at the emotional and those that give a certain amount of consideration
psychological levels (Siegrist, 1996). According to to various staff conditions, and designate
Leiter and Maslach (1999), maladjustments in resources and opportunities according to the
reward increase the vulnerability of workers to objectives of the organization and not to personal
suffer from Burnout syndrome. advantage of privileged individuals or groups.
Burnout 471 B
A fair decision is one in which people have an These are some of the environmental
opportunity to present their arguments, and in work factors that Maslach and Leiter (1999)
which they feel treated with courtesy and respect have considered as the most important
(Maslach & Leiter, 1999). predictors (or precursors) the apparition of burn-
Hasty and unfair decisions alienate people out. Nonetheless, research continues to identify B
from their community. Research ascertains that other potential stressors that could vary according
the fact of personnel perceiving their supervisors to context, occupational sector, specific
as being fair and supportive contributes to better duties, etc.
acceptance of organizational change by
staff members of the organization, and reduces Consequences of Burnout
susceptibility to Burnout syndrome (Leiter & The concept of Burnout syndrome brings
Maslach, 1999). together a number of symptoms that occur
If workers consider that they are being together for the disease to develop. These
treated unfairly, their perception will generate symptoms represent a manifestation of workers
tensions, perception of unfairness at work, exposure to a chronic form of stress according to
absenteeism, (De Boer, Bakker, Syroit, & the literature, a series of alterations have been
Schaufeli, 2002), feelings of dissatisfaction and described as consequence to this exposure and
demotivation, lack of productivity, and decrease as direct manifestation of the syndrome (Ortega &
of the quality of the work (Wayne, Shore, Lopez, 2004). They are divided in three groups:
Bommer, & Tetrick, 2002). Consequences that have direct incidence in
physical health (physical alterations). Cardio-
Values vascular system alterations (hypertension,
According to Maslach and Leiter (1999) the values coronary disease, sudden heart attacks)
area of worklife is at the heart of staff members (Selye, 1979), chronic fatigue, headache and
relationships with their work, and encompasses the migraine (International Labour Organization,
ideals and motivations that originally attracted 2012), gastrointestinal alterations (abdominal
them to the organization. Values go beyond the pain, irritable bowel syndrome, duodenal and
utilitarian exchange of time for money; in this gastric ulcers), respiratory disorders (asthma)
sense, the mismatch between personal values (Henry et al., 1991), sleep disturbances, and
with those of the organization has the potential to alterations of the muscular-skeletal system,
alter relations between people and their work. such as muscle and joint pain (Ortega &
Some types of work require full participation of Lopez, 2004).
the staff members of the organization. Thus, the Consequences that affect mental health
decision to make a commitment of this depth to an (emotional alterations). Anxiety, depression
organization calls for a thorough personal consid- (Gil-Monte, 1994), low self-esteem and lack
eration. When the balance is mutually favorable, of motivation (Maslach & Jackson, 1981),
the process may result in a productive psycholog- emotional detachment (Schaufeli & Enzmann,
ical contract that serves as a basis for an enduring 1998), feelings of professional frustration and
work relationship for both parts (Maslach & desire to quit their job (Shirom, 2009).
Leiter, 1999). Consequences related to the work environ-
Due to their deeply personal character, ment. Aggressive behaviors toward coworkers
mismatch of values has the potential to disrupt and the recipients of services given (patients,
the relationship between individuals and their students, etc.) (Gil-Monte & Peiro, 1997),
work. So, when people have values which are absenteeism (Maslach, 1982), increased
different from those adopted by the organization violent behavior, decreased productivity, lack
for which they work, the job becomes irrelevant, of competition, and deterioration of the
exhausting, and is associated to risk of experienc- quality of work (Ortega & Lopez, 2004;
ing Burnout syndrome (Leiter & Maslach, 1999). Shirom, 2009).
B 472 Burnout

Even today, it is difficult to establish what all Gil-Monte, P. R. (2003). Burnout syndrome: sndrome de
the specific effects of burnout are. However, quemarse por el trabajo, desgaste profesional, estres
laboral o enfermedad de Tomas? Revista de Psicologa
research still continues in hopes that it will del Trabajo y de las Organizaciones, 19(2), 181197.
continue to have clarity regarding the impact Gil-Monte, P. R., Garca-Juesas, J. A., Nunez, E.,
and scope of this phenomenon. Carretero, N., Roldan, M. D., & Caro, M. (2006).
Validez factorial del Cuestionario para la
Evaluacion del Sndrome de Quemarse por el
Trabajo (CESQT). Available from Psiquiatria
Cross-References Web site www.psiquiatria.com
Gil-Monte, P. R., & Peiro, J. M. (1997). Desgaste psquico
en el trabajo: El sndrome de quemarse. Madrid,
Distress Spain: Sntesis.
Emotional Well-being Henry, M., Gonzalez de Rivera, J. L., De las Cuevas, C.,
Main and Buffering Effect of Social Support Gonzalez, I., Garcia, R., Abreu, J., et al. (1991). El
ndice de reactividad al estres en pacientes asmaticos
Occupational Attitudes
cronicos. Psiquis, 12, 249254.
Occupational Stress in a Multicultural International Labour Office (2012). Work-related stress.
Workplace En V. Forastieri (Ed.), Solve: Integrating Health
Psychosocial Adjustment (Includes Promotion into Workplace OSH Polices: Participants
Workbook. Available at www.ilo.org/global
Psychosocial Functioning and Well-Being)
Jimenez, F. A., & Moyano, D. E. (2008). Factores
Psychological Stress and Employee laborales de equilibrio entre trabajo y familia: Medios
Engagement para mejorar la calidad de vida. Universum,
Stress Reactivity 23, 116133.
Jones, J. W. (1982). Dishonesty, staff burnout, and
Work Stress
employee theft. Journal of Security Administration,
5(2), 2136.
Juarez-Garca, A. (2005). Factores psicosociales
y personalidad en relacion a la salud laboral
References (Tesis doctoral). Universidad Nacional Autonoma de
Mexico, Mexico.
Ashforth, B. E., & Saks, A. M. (2000). Personal control in Leiter, M. P. (2010). Reward. Work engagement.
organizations: A longitudinal investigation with Retrieved October 12, 2012, from http://www.
newcomers. Human Relations, 53, 311339. workengagement.com/6awls/reward-understood
Bakker, A. B., Demerouti, E., & Euwema, M. (2005). Job Leiter, M. P., & Maslach, C. (1999). Six areas of worklife:
resources buffer the impact of job demands on burnout. A model of the organizational context of burnout.
Journal of Occupational Health Psychology, 10, Journal of Health and Human Services Administra-
170180. doi:10.1037/1076-8998.10.2.170. tion, 21, 472489.
Cooke, R. A., & Rousseau, D. M. (1984). Stress and strain Leiter, M. P., & Maslach, C. (2004). Areas of worklife:
from family roles and work role expectation. Journal A structured approach to organizational predictors of
of Applied Psychology, 69, 252260. job burnout. In P. L. Perrewe & D. C. Ganster (Eds.),
De Boer, E., Bakker, A., Syroit, J., & Schaufeli, W. Emotional and physiological processes and positive
(2002). Unfairness at work as a predictor of absentee- interventions strategies research in occupational
ism. Journal of Organizational Behavior, stress and well being (Vol. 3, pp. 91134). Amster-
23, 181197. dam: JAI Press.
Farber, B. A. (1984). Stress and burnout in suburban Maslach, C. (1982). Burnout: The cost of caring. Engle-
teachers. Journal of Educational Research, wood Cliffs, NJ: Prentice-Hall.
77(6), 325331. Maslach, C., & Jackson, S. (1981). Maslach burnout
Freudenberger, H. J., & Richelson, G. (1981). Burnout: inventory. Palo Alto, CA: Consulting Psycholgists
How to beat the high cost of success. New York: Press.
Bantam Books. Maslach, C., & Leiter, M. P. (1999). Teacher burnout:
Gill, F. (1999). The meaning of work: Lessons from A research agenda. In R. Vandenberghe &
sociology, psychology, and political theory. The Jour- A. M. Huberman (Eds.), Understanding and
nal of Socio-Economics, 28, 725743. preventing teacher burnout (pp. 295303). New
Gil-Monte, P. R. (1994). El sndrome de burnout: Un York: Cambridge University Press.
modelo multicausal de antecedentes y consecuentes Maslach, C., & Leiter, M. P. (2005). How to rekindle your
en profesionales de enfermera (Tesis doctoral). passion for your work. Stanford Social Innovation
Facultad de Psicologa, Universidad de La Laguna. Review, 3, 4349.
Business Ethics 473 B
Ortega, R. C., & Lopez, R. F. (2004). El burnout
o sndrome de estar quemado en los profesionales Business Ethics
sanitarios: Revision y perspectivas. International
Journal of Clinical and Health Psychology,
4(1), 137160. Alex C. Michalos
Pines, A., & Aronson, E. (1988). Career burnout: Causes University of Northern British Columbia, Prince B
and cures. New York: The Free Press. George, BC, Canada
Sandoval, J. (2000). El estudio de la alteracion mental
y el trabajo: El sndrome del trabajador quemado (residence) Brandon, MB, Canada
o burnout. Nueva Epoca/Salud Problema, 5(8), 5164.
Schaufeli, W., & Bakker, A. (2003). Utrecht work engage-
ment scale: Preliminary manual [version Adobe Synonyms
Digital Editions]. Retrieved October 12, 2012, from
20manual%20UWES.pdf Corporate responsibility; Corporate social
Schaufeli, W. B., & Enzmann, D. (1998). The burnout responsibility
companion to study and practice: A critical analysis.
London: Taylor & Francis.
Seidman, S. A., & Zager, J. (19861987). The teacher
burnout scale. Educational Research Quarterly, Definition
11(1), 2633.
Seidman, S. A., & Zager, J. (1987). The teacher burnout Business here refers to all systems and activi-
scale. Educational Research Quarterly, 11(1), 2633.
Seltzer, J., & Numerof, R. E. (1988). Supervisory ties involved in the commercial exchange of
leadership and subordinate burnous. Academy of goods and services. Ethics refers to all human
Management Journal, 31(2), 439446. action aimed at securing a good quality of life.
Selye, H. (1979). The stress of my life, a scientists mem- So business ethics refers to all activities and
oirs. New York: Van Nostrand Reinhold.
Shirom, A. (2009). Burnout and health: Expanding our systems concerned with the commercial
knowledge. Stress and Health, 25, 281285. exchange of goods and services with respect to
doi:10.1002/smi.1283. their impact on the quality of peoples lives.
Siegrist, J. (1996). Adverse health effects of high-effort/
low-reward conditions. Journal of Occupational
Health Psychology, 1, 2741.
Sonnentag, S., & Kruel, U. (2006). Psychological Description
detachment from work during off-job time: The role
of job stressors, job involvement, and recovery-related The connection between business ethics and the
self-efficacy. European Journal of Work and
Organizational Psychology, 15, 197217. quality of life may be regarded as very close and
Wayne, S., Shore, L., Bommer, W., & Tetrick, L. (2002). direct if one is a moral consequentialist, in partic-
The role of fair treatment and rewards in perceptions of ular if one is some kind of an act utilitarian.
organizational support and leader-member exchange. Generally speaking, moral philosophers may be
Journal of Applied Psychology, 87, 590598.
divided into two very broad groups, deontologists
and consequentialists. Deontologists hold that
some human actions are inherently morally good
or evil; for example, murder is inherently bad, and
telling the truth is inherently good. Consequen-
Burnout Scale tialists hold that no human actions are inherently
morally good or evil, but all human actions are
Emergency Workers Quality of Life subject to evaluation from a moral point of view.
The moral point of view may be based on one of
the following two principles.
1. Principle of Beneficence: One ought to try to
Burnout Syndrome act so that ones actions tend to impartially
improve the quality of life of those affected
Burnout by the actions.
B 474 Business Ethics

2. No Harm Principle: One ought to try to act so i.e., business people, through their business
that ones actions tend not to harm anyone activities, ought to try to improve the quality of
affected by the actions. peoples lives.
Depending on how one regards ones When people use the phrase quality of life,
basic moral principles, there may not be they sometimes intend to contrast it with quanti-
much difference between a deontologist and a ties or numbers of something. There are, then,
consequentialist. If, for example, a consequen- two quite different sorts of things that one might
tialist believes that either the Principle of Benef- want to refer to when using the phrase quality of
icence or the No Harm Principle specifies a kind life. In the first place, one might want to refer to
of action that is inherently moral, then at that sorts, types, or kinds of things rather than to mere
level the consequentialist is also a deontologist. numbers of things; for example, one might want
If, on the other hand, a consequentialist believes to know not merely how many people were
that the institution of morality is constructed by admitted to a hospital last year and for how
human beings, for whatever reason, then that sort long, but also what sorts of people they were,
of consequentialist is not a deontologist. The male or female, young or old, rich or poor, and
present essay is written from the point of view so on. When the term quality in the phrase quality
of the latter sort of consequentialist. of life is used in this sense, one may say that it and
Assuming that one is going to try to act in the phrase in which it occurs is intended to be
accordance with the Principle of Beneficence, primarily descriptive. In the second place,
again broadly speaking, there are two ways to however, one might want to refer to the value or
go. One can: worth of things by using the term quality in the
1. Try to improve relatively objective circum- phrase quality of life. For example, one
stances that are measured by objective frequently hears of people making a trade-off
social indicators, e.g., things like ensuring between, say, a high salary on the one hand and
that people have access to freshwater and better working or living conditions on the other.
clean air, to full employment with fair Presumably the exchange here involves monetary
wages, cleaner and safer workplaces, and some other value. That is, one exchanges the
longer lives free of disability and disease, value of a certain amount of money for the value
elimination of poverty and homelessness, of a certain set of working or living conditions.
and the reduction of crime. When the term quality in the phrase quality of life
2. Try to improve relatively subjective circum- is used in this sense, one may say that it and the
stances that are measured by subjective social phrase in which it occurs is intended to be
indicators, for example, such things as peoples primarily evaluative. Both senses of the phrase
reported peace of mind, contentment, hap- quality of life are important. It is important to be
piness, and satisfaction. able to describe human existence in a fairly
Clearly, if ones relatively objective and reliable and valid fashion, and it is important
subjective circumstances are improved, then the to be able to evaluate human existence in the
quality of ones life is improved. It is evidently same way.
trivially true that if ones total circumstances are There is a long historical tradition of moral
improved, one is better off and the quality of consequentialists that may be traced very far back
ones life has improved. So, generally speaking, in time to Platos Protagoras or somewhat less
ones moral obligation is to try to act so that the farther back to Jeremy Benthams ideas about
quality of peoples lives is improved objectively a felicific calculus that would allow decision
and subjectively. makers to calculate the net pleasure or pain
Since actions performed by business people connected to every action for everyone affected
are species of human actions, morally speaking, by that action, with public policy choices made to
one ought to conduct ones business activities in get the greatest net pleasure or least net pain for
accordance with the Principle of Beneficence, the greatest number of people (Bentham, 1789).
Business Ethics 475 B
Since pleasure and pain are relatively transient 1. Affected population: Who will be affected by
experiences, something more durable would have the action, from the actor alone to everyone
better suited Benthams purpose. If happiness is else?
regarded as a relatively long-lasting positive 2. Spatial coordinates: Across what amount of
experience and/or attitude (Veenhoven, 1984), space should one look, from ones own home B
then that would distinguish it from transient plea- to the whole world?
surable mood states and would justify moving 3. Temporal coordinates: Across what length of
from Benthams greatest pleasure principle to time should one look how far into the future?
Mills utilitarian principle of the greatest happi- 4. Population composition: How should the
ness for the greatest number (Mill, 1861). For affected individuals be characterized, if at
economists, utility theory is the apparent heir of all, in terms of sex, age, education, ethnic
Bentham and Mill (Mitchell, 1918). Utility background, income, etc.?
theory is formally elegant and has been an 5. Domains of life composition: What domains
enormously fruitful source of research programs of life should be examined, for example,
in individual and group decision making related health, job, family life, and housing?
to commercial markets, social and political 6. Objective versus subjective indicators:
relations, bargaining, conflict resolution, gaming, Supposing one grants that both kinds of
and scarce resource allocation in practically all indicators are important, how should one
areas. It is the heart of microeconomics. Unfor- decide exactly which kind to use for which
tunately, utility theory (as many other theories) is domains?
much better on paper and in classroom exercises 7. Positive versus negative indicators: Negative
than it is in practice, especially in public policy indicators seem to be easier to craft for some
making. What is worse, utility theory begins with domains, which may create a biased assess-
revealed preferences which are the mere tips of ment; for example, in the health domain
socially, psychologically, and pragmatically measures of morbidity and mortality may
constructed icebergs of more or less coherent crowd out positive measures of well-being.
systems of knowledge, opinions, attitudes, 8. Input versus output indicators: Should one
desires, and needs (Michalos, 1967, 1978, 1985; measure only what one invests, what comes
Schwarz & Strack, 1999). However, for present of the investment, or both?
purposes, the defect of utility theory as 9. Benefits and costs: What particular benefits
a psychosocial theory of perceived well-being is and costs should be counted, for which
not its biggest problem. Its biggest problem is that individuals and groups?
it merely provides information about the 10. Discount rates: How much should one dis-
subjective states of people, although we know count costs and benefits delivered sometime
that peoples objectively measurable circum- in the future, compared to those delivered
stances are also important features of the quality today?
of their lives. Because, morally speaking, our 11. Measurement scales: There are usually dif-
commitment ought to be not merely to improve ferent ways to measure the same and differ-
peoples (subjective) feelings and attitudes about ent things. How should one choose the best
their lives but as well to improve the very sort of scale or measuring device?
(objective) conditions in which they live their 12. Distributions: How should central tendencies
lives, defining our basic Principle of Beneficence and variation be measured in diverse fields?
in terms of the quality of life seems to be most 13. Interaction effects: Prior to taking action, one
appropriate. ought to have some idea of what causes what
An ideal consequentialist assessment of the and what might be jointly interacting with
quality of life of an individual or group would what, which requires some sort of common
have to satisfactorily address the following criti- sense and perhaps some relatively main-
cal issues: stream scientific research.
B 476 Business for Social Responsibility

14. Confidence levels: Since one often lacks Michalos, A. C. (1978). Foundations of decision-making.
complete certainty regarding the truth of Ottawa: Canadian Library of Philosophy.
Michalos, A. C. (1985). Multiple discrepancies theory
claims, what level of confidence should one (MDT). Social Indicators Research, 16, 347413.
require to accept any particular claim? Mill, J. S. (1861). Utilitarianism. London: Routledge.
15. Research procedures: Since ones data are as Mitchell, W. C. (1918). Benthams Felicific calculus.
good as ones search and research proce- Political Science Quarterly, 33, 161183.
Schwarz, N., & Strack, F. (1999). Reports of subjective
dures, what adequacy criteria should be well-being: Judgmental processes and their methodo-
used to assess procedures? logical implications. In D. Kahneman, E. Diener, &
16. Research personnel: The procedures one N. Schwarz (Eds.), Well-being: The foundations of
uses are likely to be as reliable as the people hedonic psychology (pp. 6184). New York: Russell
doing the research. How should one identify Veenhoven, R. (1984). Conditions of happiness.
generally acceptable experts, if indeed Dordrecht: D Reidel.
experts are to be chosen at all?
17. Aggregation function: How should all the
diverse elements of the assessment be
18. Assessment assessor: Supposing one believes Business for Social Responsibility
such overall life assessment is possible,
a reasonable person might ask: Who should Anete Farina1 and Maria Jose Chambel2
decide (audit) if the assessment is adequate Department of Social Psychology, University of
or appropriate? S. Paulo, Sao Paulo, Brazil
19. Assessment criteria: Supposing we were able Department of Social and Organizational
to settle on some suitably able and willing Psychology, University of Lisbon, Lisbon,
auditor, what criteria should be used to audit Portugal
the adequacy of the assessment?
In the presence of so many questions to be
answered, it is not surprising that even people Definition
who share the same general approach to moral
appraisal might reach different conclusions about Social responsibility in business is a broad con-
the same cases. In such cases, those who answer cept that has been applied to the entire production
different questions in different ways will have to chain. It is intrinsically linked to both factors that
negotiate a common approach, which of course define the essence of organizations practices:
may or may not work depending on the cases and ethics and transparency in business management.
the appraisers. In any event, for moral consequen- These factors should be reflected in the daily
tialists the connection between business ethics decisions that impact on society, on the environ-
and the quality of life is very close and direct. ment, and on the future of business (Ethos, 2003).
While moral consequentialism certainly has
its disadvantages, they are probably not more Description
troublesome than the disadvantages of other
theories. Social responsibility is the moral principle that
guides the individual and social actions that
express the principles and values adopted in the
business behavior. Ethics and social responsibil-
References ity have aroused the interest of organizations as
an important variable in their relations with their
Bentham, J. (1789). An introduction to the principles of
morals and legislation. London: T. Payne & Son.
stakeholders who participate directly or indi-
Michalos, A. C. (1967). Postulates of rational preference. rectly in the business (Frazao, Costa, & Neves,
Philosophy of Science, 34, 1822. 2007).
Business for Social Responsibility 477 B
The European Commission defines corporate strategy of adopting a socially responsible atti-
social responsibility as the organizations com- tude is a process that must be incorporated into
mitment in analyzing and preventing the negative the companys culture (Coutinho, & Soares,
impacts of their actions on society and their 2002). In fact, the fulfillment of social responsi-
respect for laws and collective agreements bility requires that the organizations integrate the B
(European Commission, 2011). respect for employees, consumers, and environ-
This theme of corporate social responsibility ment rights in their values. In addition, it is nec-
has evolved from charity and altruism to essary that organizations establish a closer
a relationship with the business strategy (Smith, collaboration with stakeholders, in order to max-
1994). In other words, now we should consider imize the creation of shared value among their
that if an organization acts as a social responsible owners/shareholders and the society in general.
institution, it acquires a source of competitive The complexity of this process will depend on
advantage (Serpa & Fourneau, 2007). In fact, factors related to company size and nature of its
from the 1960s to the 1990s, the movement operations (Catalin & Carmen, 2008).
of social responsibility in business gained Nowadays, organizations are encouraged to
a high projection in the USA and Europe, adopt strategies for social responsibility and to
and the development of the organizations cultivate opportunities for developing innovative
culture of social responsibility became almost products, services, and business models that con-
an imperative for management if the compa- tribute to the social welfare and lead to higher
nies hoped to remain competitive in their quality life on the planet (European Commission,
respective markets. 2011). Thus, the social responsibility of business
The starting point of this trend was the trans- comprises a broad set of actions that should ben-
formation of the globalized production system, efit the society, namely, the economy, the educa-
which weakened considerably the regulation by tion, the environment, the health, the local
governments. The priority on employment and activity, and the government. The actions should
the imposition of production standards in order improve social programs aimed at improving the
to reduce the social costs generated the depen- quality of life (Oliveira, 2005).
dence of governments on large companies This standpoint implies multiple require-
(Chandler & Mazilish, 2005). These companies ments, such as respect for the citizens rights;
have been given unprecedented trading power good relationships with partners, customers, and
that allowed them to transfer responsibilities to suppliers; promotion of quality in production,
the stakeholders. However, complaints about employee participation in decision-making, and
the processes of dehumanization in employ- investments in safety at the workplace; and pro-
ment mobilized the public opinion to demand fessional development, user satisfaction assur-
the adoption of an approach of corporate social ance, contributions to community development,
responsibility that involved an ethical practice and investments in technological research and
of production: the elimination of child labor, environmental conservation (Carroll, 1999).
subcontracting, and other forms of exploitation Thus, it is necessary to adopt an attitude of trans-
of human labor (Thiery, 2005). Moreover, the parency in business management that implies
adoption of this practice promotes the advan- policies, practices, activities, and behaviors usu-
tage in domestic and international markets ally expected by any members of the society and
because it increases the companys positive the adherence of a set of rules and standards that
image, which in turn drives the consumers meet the expectations of various audiences
preference. (Veloso, 2002). The contemporary world
However, the adoption of socially responsible demands for transparency and requires the sub-
practices needs an organizational paradigm in its mission of an environmental performance and
current business strategy that can support those measures for accident prevention (Montana &
practices. Therefore, the appropriateness of the Charnov, 1999).
B 478 Business for Social Responsibility

Transparency in business supports the ethical Cross-References

action and exists to meet social expectations,
ensuring consistency between discourse and Business Ethics
practice in the communication of important Perspectives of Social Agents
information about products and services (Rico, Social Inclusion
2004). One tool that encourages this transparent Social Institutions
communication with the public is the Social Social Integration
Responsibility Report. This annual document Social Justice
presents a set of information on economic, envi- Social Marketing
ronmental, and social activities developed by Social Sustainability
the company and its main commitments and
public goals for the future. This is an instru-
ment by the company that discloses investment
in projects and/or actions from the perspective
of social responsibility (Menegasso, 2002). In Carroll, A. B. (1999). Corporate social responsibility:
fact, the involvement with social responsibility Evolution of a definitional construct. Business & Soci-
calls for economic planning to achieve the ety, 38, 268295.
Catalin, D. R., & Carmen, C. N. (2008). The growth of
desired goals and relies on a multidimensional
organizations competitiveness through the development
approach to ensure civil, political, economic, of social responsibility investments projects. Accessed
social, cultural, and environmental rights Mars 02, 2012, from http://steconomice.uoradea.ro/
(Stoner & Freeman, 1994). anale/volume/2008/v4-management-marketing/039.pdf
Chandler, A., & Mazlish, B. (2005). Leviathans: Multina-
Social responsibility in business, therefore,
tional corporations and the new global history. Cam-
concerns the criteria used by the organization bridge: Cambridge University Press.
for making decisions, the values that define its Coutinho, R. B. G., & Soares, D. M. T. (2002). Gestao
priorities, and the relationships with all the estrategica com responsabilidade social: Arcabouco
analtico para auxiliar sua implementacao em
stakeholders it interacts with. Thus, investing
empresas no Brasil [Strategic management and social
in social responsibility means investing in an responsibility: Analytic framework to assist its imple-
image crucial to add more value to products mentation in companies in Brazil]. Revista
and services and attract new customers. How- Administracao Contemporanea, 6(3), 7596.
Ethos, Instituto Ethos. (2003). Accessed Febrary 16, 2012,
ever, social responsibility in business depends
from www.ethos.org.br
on its representation as an organization with European Commission. (25, October 2011). A renewed
a culture of values (Ghemawat, 2000). The EU strategy for 201114 for corporate social respon-
emergence of such kind of company, able to sibility, Brussels. COM(2011) 681 final.
Frazao, M. F., Costa, S. S., Neves, F. N. O. (2007). A
achieve an economic growth sustained in social
Dimensao Etica da Responsabilidade Social nas
concern, has been increasingly demanded by Organizacoes. Maieutica Digital, 1, 196210.
society. Investments in social responsibility Ghemawat, P. A. (2000). Estrategia e o Cenario de
add to the society, by considering the interests Negocios [Strategy and scenario of business]. Porto
Alegre: Bookman.
of society, the company, and the business
Livro Verde. (18/07/2001). Promover um quadro europeu
itself. para a responsabilidade social das empresas
However, corporate social responsibility [Promoting a European framework for corporate
also requires focus on the legislation in the social responsibility]. Bruxels: European Community
Commission. Accessed Februry 16, 2012, from www.
field of social rights or environmental stan-
dards. In countries where such regulations do Menegasso, M. E. (2001). Responsabilidade social das
not exist, efforts should be made to establish empresas: Um desafio para o Servico Social [Social
such an appropriate legal and regulatory responsibility of companies: A challenge for social
service] (Vol. 1(5), pp. 6371). Florianopolis: Revista
framework that allows the developing of
socially responsible practices (Livro Verde, Menegasso, M. E. Responsabilidade social das empresas:
2001). um desafio para o Servico Social. Revista Katalysis,
Business Well-Being 479 B
num. 5, julio-diciembre (pp. 6371). Universidade Description
Federal de Santa Catarina.
Montana, P. J., & Charnov, B. H. (1999). Administracao
[Management]. Sao Paulo: Editora Saraiva. There are two theoretical perspectives which
Oliveira, J. A. (2005). Uma avaliacao dos balancos sociais explain how individual well-being and
das 500 maiores [An assessment of the social respon- performance at work are shaped by organiza- B
sibility report of the 500 largest companies]. Revista de tional factors. The first draws on the job
Administracao de Empresas, 4(1, Art. 2).
Rico, E. M. (2004). A responsabilidade social empresarial demands-resources model (Demerouti, Bakker,
e o estado: Uma alianca para o desenvolvimento Nachreiner, & Schaufeli, 2001) and proposes
sustentavel. Perspectiva, 18, 4. that psychological well-being and job perfor-
Serpa, D. A. F., & Fourneau, L. F. (2007). mance will be negatively affected if a job or
Responsabilidade social corporativa: Uma
investigacao sobre a percepcao do consumidor [Social work environment imposes too much challenge
responsibility of business: A research about consumer (leading to strain) or too little challenge (leading
perception] RAC-eletronica. Revista Administracao. to boredom). Organizations which promote busi-
Contemporanea, 11(3), 83103. ness well-being therefore provide the right
Smith, C. (1994). The new corporate philanthropy (pp.
105116). Boston: Harvard Business School Publication. job design (e.g., social support, feedback,
Stoner, J., & Freeman, R. (1994). Administracao decision-making latitude) to promote positive
[Management]. Rio de Janeiro: LTC. job challenges without overwhelming individuals
Thiery, P. (2005). Ethique Marketing et responsabilite in terms of demands. The second perspective
societale de lentreprise: Entre civisme et cynisme.
Decisions Marketing, 38, 5969. draws on literature from the positive psychology
Veloso, L. H. M. (2002) Etica, valores e cultura: field to argue that positive emotional states, rela-
especificidades do conceito de responsabilidade social tionships, and appraisals accentuate psychologi-
corporativa. In: ASHLEY, Patrcia Almeida. (Coord). cal well-being and build an organizational
Etica e Responsabilidade Social nos Negocios. Sao
Paulo: Saraiva. climate characterized by motivating, meaningful,
and engaging work experiences. The integration
of these two perspectives allows to highlight
the four most crucial factors for creating
effective work communities and enabling busi-
Business Regulation Measure ness well-being: authentic leadership, effective
people management, positive emotional environ-
Ease of Doing Business Index ments, and work engagement.

Authentic Leadership
As a result of advancing technology, financial
Business Well-Being pressures, global competition, governmental
initiatives, and an evolving economic and ethical
Joanne Lyubovnikova1, Reena Govindji2 and climate, leaders are facing a high degree of com-
Michael West1 plexity in their environment. These demands
Aston Business School, Aston University, require extraordinary leadership skills where
Birmingham, UK leaders have the capacity to both enable profound
Centre for Applied Positive Psychology, change and sustain the well-being of their
Coventry, UK employees. Naumann and Bennett (2000)
described leaders as being climate engineers;
what they convey through their personality,
Definition values, beliefs, preferences, and behaviors leaves
an imprint on the character and well-being of those
Business well-being encompasses a number of they lead. Recent research shows that leaders are
factors concerned with an individuals psycho- most at their best when they are being authentic.
logical responses to their job and workplace. Authentic leadership has been defined as leaders
B 480 Business Well-Being

who are deeply aware of how they think and employee, well-being and good performance are
behave and are perceived by others as being likely to be fostered.
aware of their own and others values/moral per- Individuals at work are also more likely to
spectives, knowledge and strengths (Avolio, have high levels of commitment and satisfaction
Griffith, Wernsing, & Walumbwa, 2010). when they find appropriate opportunities for
Through increased self-awareness, self- growth and development in their work.
regulation, and positive modeling, authentic Well-being at work is therefore also dependent
leaders develop authentic followers, who demon- on good job design. Research demonstrates the
strate parallel qualities of their leaders and who importance of five dimensions of job design
together develop an engaged, positive, and ethical (Hackman & Oldham, 1976). Task identity refers
organizational climate in which leaders and fol- to the need for a job to be whole piece of work,
lowers sustain their well-being (Gardner, Avolio, giving the satisfaction of tangible achievement.
Luthans, May, & Walumbwa, 2005). Skill variety refers to the value to the individual of
Authentic leaders also seek to understand the doing a job that demands a range of skills, thus
unique strengths of their employees and create enhancing their feelings of competence and
opportunities to build upon these towards achiev- ensuring skill development. Task significance
ing organizational goals (Kaplan & Kaiser, describes the importance of doing a job that
2010). Together with this, individuals who use makes a difference to the performance of the
their strengths have better well-being and vitality team, the organization, to customers, or to soci-
(Govindji & Linley, 2007). Leaders therefore ety. Autonomy gives the individual a sense of
have a significant role to play in cultivating control and competence, contributing to well-
business well-being. being and effectiveness. Finally, feedback gives
employees clarity about their work performance,
Effective People Management contributing to feelings of accomplishment and
Key to the well-being of people at work are that satisfaction while enabling targets to be set for
they are clear about what it is they are required to skill development and improved performance.
do and that they feel valued, respected, and Learning and development opportunities are
supported. Ensuring that this is true for all staff also helpful for human health and well-being,
is a first step in creating a work community char- and people generally respond positively to the
acterized by well-being and effectiveness. This opportunity to acquire new skills at work. When
means ensuring that all staff are set clear objec- employees are learning, either through formal
tives relevant to organizational goals. Objectives training or informally through team member or
should be clear and challenging (in order to be supervisor coaching, their individual well-being
motivating), and, ideally, their achievement and that of the organization as a learning entity
should be measurable, so the individual has are enhanced.
clear feedback on their performance (Locke &
Latham, 1990). Second, employees in organiza- Positive Emotional Relationships
tions are likely to report well-being and commit- Research evidence shows convincingly how
ment when they are treated with respect by important positive emotions, such as hope, plea-
supervisors and employers and are given the nec- sure, happiness, humor, excitement, joy, pride,
essary support and resources they need to do their and involvement, are as a source of human
jobs effectively. The person who is generally strength (Fredrickson, 2001). When individuals
most influential for better or worse in translating feel positive emotions, they think in a more flex-
organizational policies into practices that affect ible, open-minded way and consider a much
employee well-being is the individuals line man- wider range of possibilities than if they feel anx-
ager. To the extent that she or he gives guidance, ious, depressed, or angry. This enables them to
support, positive feedback, and respect and cre- accomplish tasks and make the most of the situ-
ates a positive working environment for the ations they find themselves in. They are also more
Business Well-Being 481 B
likely to see challenges as opportunities rather connotations and definitions exist, work engage-
than threats. When they feel positive, they exer- ment is most frequently conceptualized in the
cise greater self-control, cope more effectively, literature as . . .a positive, fulfilling, work-
and are less likely to react defensively in work- related state of mind that is characterized by
place situations. The benefits do not stop there. vigor, dedication, and absorption (Schaufeli, B
They spill over too into what is called pro-social Salanova, Gonzalez-Roma, & Bakker, 2002,
behavior cooperation and altruism. When they p. 74). Vigor refers to an individuals willing-
feel positive emotion, they are more likely to be ness to exert high levels of effort, energy, and
helpful, generous, and to exercise a sense of mental resilience when executing tasks. Dedica-
social responsibility (Fredrickson, 2001). The tion is characterized by experiences of meaning-
implications for the workplace are that by devel- fulness, inspiration, involvement, and pride in
oping an environment where people feel positive, ones work. Absorption describes the high
organizational citizenship can be encouraged, or levels of concentration, engrossment, and attach-
the tendency of people at work to help each other ment experienced while carrying out tasks,
and those in other departments, to do that bit extra whereby time flies by and one finds it difficult
which is not part of their job. Increasingly, to detach from work. Overall, work engagement
researchers suggest that organizational citizenship is a persistent and pervasive affective-cognitive
is what probably makes the difference between the state in which employees feel compelled to strive
most profitable organizations and most of the rest towards a challenging goal, applying all of their
(Podsakoff, MacKenzie, Paine, & Bachrach, energy and resources, and becoming intensely
2000). involved in their work. This heightened sense of
There is a strategic role for human resource excitement is what demarcates work engagement
management leaders to encourage a culture of from the construct of job satisfaction, whereby
positive emotion given the links to stronger orga- employees are simply contented with their expe-
nizational performance, lower employee turn- rience in the workplace.
over, and better health (Fredrickson, 2001). So why is this unique form of well-being so
This means encouraging good humor, positive important for creating effective work communi-
feedback, confidence, and enthusiasm through ties? Work engagement has been shown to pre-
socialization of new employees, through the mes- dict a number of bottom line organizational
sages given by the leaders in the organization and outcomes including increased job performance,
through the modeling of relationships across the financial returns, and client satisfaction (e.g.,
organization. Discouraging the use of aggressive Bakker & Bal, 2010). Work engagement is also
emails is one small step. Encouraging celebra- associated with heightened organizational com-
tions of success and appreciation of contributions mitment, lower turnover intentions, and
is vital. Moreover, organizations that practice increased organizational citizenship behavior.
corporate social responsibility by contributing As a result, there has been a sharp increase in
to their communities, practicing ethical scientific research exploring the key drivers of
business principles, and taking vigorous steps to work engagement.
preserve the environment have higher levels of So what can organizations do to facilitate
commitment from employees and customers experiences of vigor, dedication, and absorption?
(Collier & Esteban, 2007). A recent meta-analysis found that autonomy,
feedback, social support, and organizational cli-
Work Engagement mate are consistently associated with work
Work engagement is a distinct and powerful engagement (cf. Halbesleben, 2010). Therefore,
kind of employee well-being and is often consid- supporting and empowering employees to take
ered to be the direct antipode of employee more control over their work is likely to facilitate
unwell-being or burnout (Schaufeli, Taris, & experiences of work engagement. Personal
Van Rhenen, 2008). Although many everyday resources such as optimism and self-efficacy
B 482 Buyer Satisfaction

have also been shown to be particularly impor- Fredrickson, B. L. (2001). The role of positive emotions in
tant, reiterating the importance of a positive positive psychology: The broaden-and-build theory of
positive emotions. American Psychologist, 56,
emotional climate in the workplace to stimulate 218226.
such individual strengths and attributes. Gardner, W. L., Avolio, B. J., Luthans, F., May, D. R.,
& Walumbwa, F. O. (2005). Can you see the
Conclusion real me? A self-based model of authentic leader
and follower development. The Leadership Quar-
What is known about well-being at work contra- terly, 16, 343372.
dicts that can create effective organizations, Govindji, R., & Linley, P. A. (2007). Strengths use,
focusing only on performance. It is possible to self-concordance and well-being: Implications
work with and not against human needs, capabil- for strengths coaching and coaching psychologists.
International Coaching Psychology Review, 2(2),
ities, and potential and create effective working 143153.
communities that have successfully and at the Hackman, J. R., & Oldham, G. R. (1976). Motivation
same time promote the health and well-being of through the design of work: Test of a theory. Organi-
those who work within them. The four key prin- zational Behavior and Human Performance, 16,
ciples that have been proposed here represent Halbesleben, J. R. B. (2010). A meta-analysis of work
powerful ways to facilitate such results in todays engagement: Relationships with burnout, demands,
workplace. resources, and consequences. In A. B. Bakker &
A. P. Leiter (Eds.), Work engagement: Recent devel-
opments in theory and research. New York: Psychol-
ogy Press.
Cross-References Kaplan, R. E., & Kaiser, R. B. (2010). Toward a positive
psychology for leaders. In P. A. Linley, S. Harrington,
Business Ethics & N. Garcea (Eds.), Oxford handbook of positive psy-
chology and work. Oxford, UK: Oxford University
Confidence Press.
Corporate Social Responsibility Locke, E. A., & Latham, G. P. (1990). A theory of goal
Decision Making setting and task performance. Englewood Cliffs, NJ:
Emotions, Sociology of Prentice Hall.
Naumann, S. E., & Bennett, N. (2000). A case for proce-
Health dural justice climate: Development and test of
Motivation a multilevel model. Academy of Management Journal,
Personality, an Overview 43, 881889.
Psychological Well-Being Podsakoff, P. M., MacKenzie, S. B., Paine, J. B., &
Bachrach, D. G. (2000). Organizational citizenship
Social Support behaviors: a critical review of the theoretical and
empirical literature and suggestions for future
research. Journal of Management, 26, 513563.
References Schaufeli, W. B., Salanova, M., Gonzalez-Roma, V., &
Bakker, A. B. (2002). The measurement of engage-
ment and burnout: A two sample confirmatory factor
Avolio, J. B., Griffith, J., Wernsing, T. S., & Walumbwa, analytic approach. Journal of Happiness Studies, 3,
F. O. (2010). What is authentic leadership develop- 7192.
ment? In P. A. Linley, S. Harrington, & N. Garcea Schaufeli, W. B., Taris, T. W., & Van Rhenen, W. (2008).
(Eds.), Oxford handbook of positive psychology and Workaholism, burnout and engagement: Three of
work. Oxford, UK: Oxford University Press. a kind or three different kinds of employee well-
Bakker, A. B., & Bal, P. M. (2010). Weekly work engage- being? Applied Psychology: An International Review,
ment and performance: A study among starting 57, 173203.
teachers. Journal of Occupational and Organizational
Psychology, 83, 189206.
Collier, J., & Esteban, R. (2007). Corporate social respon-
sibility and employee commitment. Business Ethics:
A European Review, 16(1), 1933.
Demerouti, E., Bakker, A. B., Nachreiner, F., & Schaufeli,
Buyer Satisfaction
W. B. (2001). The Job Demands-Resources model
of burnout. Journal of Applied Psychology, 86, 499512. Customer Satisfaction