Conceptual Mapping of Health-Related Quality of Life, Quality of Life, and Wellbeing: A Systematic Review and Assessment of Commonly Used Patient-Reported Outcomes Measures

Conceptual Mapping of Health-Related Quality of Life, Quality of Life, and Wellbeing: A Systematic Review and Assessment of Commonly Used Patient-Reported Outcomes Measures | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Conceptual Mapping of Health-Related Quality of Life, Quality of Life, and Wellbeing: A Systematic Review and Assessment of Commonly Used Patient-Reported Outcomes Measures Federico Augustovski, Fernando Argento, Natalí Ini, Joaquin Cantos, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6976096/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Health-Related Quality of Life (HRQoL), Quality of Life (QoL), and Wellbeing (WB) are widely used outcome constructs in health research, clinical care, and policy. These concepts often overlap but are used in different contexts and disciplines, raising concerns regarding their comparability and relevance in health assessments and policy-making. This study review aims to perform a conceptual mapping of these commonly used concepts, propose evidence-informed frameworks, and map them to commonly used Patient-Reported Outcome Measures (PROMs). Methods We conducted a qualitative systematic review of conceptual frameworks for HRQoL, QoL, and WB published between 1990 and 2023. We searched PubMed, Scopus, and PsycINFO for peer-reviewed publications explicitly describing conceptual models. A thematic synthesis approach was used to analyze domains, subdomains and facets. We also assessed domain coverage of 10 widely used PROMs to explore alignment with the conceptual models. Results From 14,114 records, we included 35 studies reporting 36 conceptual frameworks (HRQoL = 10; QoL = 12; WB = 14). We retrieved 168 first-level, 225 second-level, and 79 third-level domains, curated into 118 unique entities: 82 for HRQoL, 49 for QoL, and 69 for WB. Overlap analysis revealed 26 shared domains, 26 unique to WB, 29 to HRQoL, and 7 to QoL. Final models included 18 HRQoL, 22 QoL (18 from HRQoL plus 4), and 10 WB dimensions. PROMs mapping showed heterogeneous coverage of commonly used PROMS. The EQ-HWB had the broadest coverage of HRQoL (17/18) and WB (5/10). Conclusions Conceptual inconsistency and overlap exist in the literature across HRQoL, QoL, and WB. The absence of clear conceptual and operational definitions limits their measurement validity. This study supports the development of clearer frameworks to enhance measurement and policy relevance. The conceptual coverage of commonly used PROMS appears sub-optimal and heterogeneous. These findings have implications for instrument selection, outcome interpretation, and the design of patient-centered evaluations. Greater clarity in conceptual definitions and improved alignment between theory and measurement tools are needed to support meaningful assessments of people’s lived experiences. Systematic review registration OSF, CRD42023469014. Health-related quality of life quality of life well-being conceptual models PROMs. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Health-Related Quality of Life (HRQoL), Quality of Life (QoL), and Wellbeing (WB) are commonly used terms in contemporary health and social science research, strongly enriching the spectrum of outcomes used in health and social policy and research, aiming to describe or address the impact of a wide range of aspects and interventions on an individual's overall life, and not just focusing on any symptom, disease, condition, or specific dimension in particular. 1 As a partial reflection of this, a simple search in PubMed shows nearly three quarters of a million citations using these terms. 2 A similar search in Social Science Citation Index Database, one of the most popular social science databases, brings nearly 300,000 citations. 3 Despite being nearly ubiquitous concepts and outcomes in health and social science, there is no commonly embraced definition of each of these three high-level concepts of HRQoL, QoL and WB; and there is considerable disagreement and conceptual overlaps that challenge their clarity and precision. 4 Promoting sound advances in outcomes research and measurement of these non-disease specific broad health measures is clearly hindered by these conceptual conundrums. Historically, the interchangeable use of terms like WB and QoL has led to potential misinterpretations and misapplications in health sciences. 1 Salvador-Carulla et al. have delved into these issues, proposing a conceptual framework that aids in disentangling these terms and offering clarity on their distinctions. 5 Ferrans' exploration into the definitions and conceptual models of quality of life emphasizes the intricate nuances that often go overlooked, highlighting the imperative for a more rigorous and standardized approach to their definition and measurement in health research. 6 The ambiguity surrounding these terms is not just an academic concern; it has tangible implications in the realm of health research, practice and policy. 7 Inconsistent or overlapping definitions can lead to challenges in health policy design and monitoring, instrument or survey development, validation, and interpretation, potentially undermining the validity of research and policy findings. 8 For example, Smith et al. underscored the importance of distinguishing between quality of life and health status in research, shedding light on the potential pitfalls of conflating the two. 9 Such conflation may result in the misalignment of interventions with patient priorities and reduced effectiveness in improving health, QoL and WB. Recent scholarly endeavors have attempted to navigate this complex terrain. 10 Mukuria's scoping review, for instance, delved into health status conceptual definitions with a specific focus on the development of a new instrument, the EuroQol Health and Wellbeing instrument (EQHWB). 10 Similarly, Mulhern et al argue for a novel multi-layered 'Deep Dive' approach, aiming to inform the measurement of HRQoL having an holistic approach. 11 These efforts and the current somewhat confusing situation around the concepts HRQoL, QoL and WB highlight the pressing need for their systematic exploration, including their definitions, dimensions and their intricate interrelationships. 12 Recognizing this gap, our work embarks on an attempt to bring more clarity on these three high-level concepts. 5 This endeavor can be instrumental to both health and social sciences, from health or social policy design or monitoring to inform the development, validation, and application of generic instruments in health research. Thus, the aim of this study was to perform a qualitative systematic literature review and to report an updated and inclusive conceptual mapping of HRQoL, QoL and WB in order to understand its commonalities and differences. Finally, we also aimed to create a conceptual map about the coverage of commonly used Patient Reported Outcomes Measures (PROMs) of these concepts, as well as their domains/dimensions (considering the concepts of domains and dimensions as synonyms), sub-domains/sub-dimensions, and subthemes/facets. The current study was funded by a competitive grant of the EuroQol Research Foundation (grant number 1605-RA). Methods We followed three sequential steps: 1) Systematic literature review. Its focus was on studies that proposed a conceptual framework or map of any of the three high-level concepts targeted by our study, in order to retrieve their definition, their structure (domains/dimensions, subdomains, and facets) as described by the authors; 2) Conceptual analysis and development of conceptual frameworks for HRQoL, QoL, and WB. This process involved a detailed iterative analysis and curation of domains identified in the literature. The research team grouped conceptually similar or hierarchically related domains, drawing on the evidence retrieved and arriving at a proposed conceptual framework of each high-level concept; and 3) Conceptual mapping, depicting the coverage of commonly used generic instruments-measures of HRQoL, QoL, and WB. - Systematic review and concept analysis The study was categorized as a systematic literature review, as it complies with the current accepted definitions of this study methods. 13 The PRISMA checklist 2020 was also completed and is available to the readers as supplementary material 1. 14 The protocol of the systematic review was published and registered in OSF Registries (CRD42023469014). 15 We performed a systematic review of studies without methodological restrictions, including qualitative, quantitative or mixed-methods research. 16 , 17 Search strategy We included studies with a specific focus on analyzing, developing, identifying, or describing these three high-level target concepts: HRQoL, QoL and WB. We searched for empirical and theoretical studies that report their conceptualization. If applied to a specific target population, we focused on studies targeted to the adult population -regardless of age, gender or geographic area- including all types of persons with health conditions; formal and informal carers as well as the general public. Search period: from inception to Dec 2023. We selected only publications written in English, as the main studies in the academic world in all countries are typically published in English. We conducted a comprehensive search across the following databases: PubMed, EMBASE, SocINDEX (EBSCO), and Scopus. The search strategy was developed in collaboration with an experienced librarian specializing in systematic reviews to ensure methodological rigor. The full search strategy is detailed in supplementary material 2. Eligibility criteria and study selection Two authors independently screened titles and abstracts to exclude records that were not relevant. For all studies selected by at least one author during the initial screening, full-text articles were retrieved. Subsequently, three researchers independently assessed full texts to check if they fulfilled the inclusion criteria. Disagreements were solved by discussion with another team member, and in case of remaining disagreement by final deliberatioan by all study team. As we wanted to be exhaustive, and as studies included had broad and heterogeneous methodological approaches, and as we did not want to exclude any study fulfilling our inclusion criteria, as is common in this type of systematic reviews, we did not assess study quality or risk of bias. We extracted from each framework several charactaristics, such as were the target concept assessed, the domains, subdomains and facets and the relationships between domains, the conceptual definitions of each concept and domain, subdomains and facets, the methods used to develop the conceptual framework and whether it was used to generate an instrument/PROM. - Conceptual analysis We carried out a content analysis following the steps described below. Articles were included and coded in ATLAS.ti 23. 18 Coding was developed iteratively and revised continuously in discussions with all team members. a) Descriptive Stage: In the initial stage of the coding process, we engaged in a meticulous examination of the high-level concepts of interest: QoL, HRQoL, and WB. We retrieved all the dimensions that composed these concepts and their different hierarchies: higher-order dimensions-domains, subdimensions-subdomains (i.e components of dimensions-domains), and facets (or conceptual components of subdimensions-subdomains). We also use the terms first, second, and third-level domains or dimensions as synonyms of dimensions-domains, subdimensions-subdomains and facets. We did not begin with any pre-established codebook; rather, we formulated codes for each dimension as it was presented in the conceptual models or frameworks, initially using the terminology employed by the respective authors. For a visual representation of dimensions, we developed individual conceptual models for each paper, depicting their hierarchical structure -if any-, with first-level domains/dimensions and, where present, second or third-level dimensions as well. The reported conceptual structures (i.e, different dimensions and their relationship) proposed by the authors were maintained in all these initial descriptive visual models. b) Harmonization of dimensions: In the second stage of the coding process, a comprehensive synthesis of the dimensions and sub-dimensions was performed by unifying those dimensions that were synonyms or very similar, considering the definitions provided by the original authors where available, or relying on the authors’ team collective judgment. This was done with the purpose of clarifying an initial long list of dimensions and avoiding overlaps and redundancy. This work was carried out by two researchers and in case of lack of agreement, a third researcher intervened. Some dimensions were common or very similar across multiple conceptual models, while others were unique to specific ones. c) Iterative analysis for the curation of dimensions: To comprehensively describe all dimensions outlined in the literature, regardless of whether they were categorized as first, second, or third-level domains, a process of curation and conceptual unification was initiated. To arrive at the final dimensions for each high-level concept, a qualitative analysis was conducted. Researchers scrutinized each dimension/sub-dimension/facet, grouping them according to categories. The construction of these categories and groupings was done by the team based on the interpretation of information described in the preceding stages and through an iterative deliberative process grounded in the evidence and work done in the initial two previously described coding stages. The grouping occurred in several stages. Initially, after reading all dimensions, the entire research team deliberated on the similarities and differences among them. Subsequently, two researchers collaborated in the first round of grouping (FJA and MB). The grouping was then reviewed by another three researchers (JC, FA and NI), who conducted a second round of grouping. The results of the second round were subsequently reviewed by the initial pair of researchers (FJA and MB), who performed a third and final round of grouping. The final listing was reviewed and agreed upon by the entire team. This rigorous and meticulous process enabled us to compile a comprehensive list of dimensions mentioned in the literature as reproducible and scientifically grounded as possible. d) Construction of final Conceptual Models: We developed separate conceptual models for Health-Related Quality of Life (HRQoL), Quality of Life (QoL), and Wellbeing (WB) based on synthesized frameworks from the included literature. Domains were hierarchically structured (first-, second-, and third-level where applicable) based on frequency, conceptual clarity, and qualitative analysis. We initiated the process of building the conceptual model of HRQoL. Once this model was constructed, we advanced with the QoL model, acknowledging -as several organizations such as the International Society of Quality of Life Research ISOQOL and the World Health Organization do- that HRQoL is a concept nested within Qol. 19 , 20 Finally, the Wellbeing conceptual model was constructed, incorporating some categories curated in the other two high-level conceptual frameworks as well as unique domains. During this last phase, we had the input of two experts to assess the high-level concepts´ conceptual face validity and other general insights: Vilma Irazola (IECS, University of Buenos Aires), with background in HRQoL and QoL work and knowledge, and Tessa Peasgood (University of Sheffield) with more background on Wellbeing and HRQoL. Mapping of a set of generic instruments to our conceptual models. Finally, in this phase, we mapped the conceptual models developed during the previous phase with the main instruments commonly used to assess HRQOL (COOP- WONCA, SF-36, EQ-5D, SICKNESS IMPACT PROFILE, PROMIS-29, HUI, EQ-HWB, 15D), QoL (AQOL-8D, WHO-QOL), and WB (ICECAP-A, QUALITY OF WELLBEING SCALE, ICECAP-O, IWB). Our criteria for inclusion of these PROMs were based on the initial list used in the Mukuria paper and expanded to other PROMs that either the authors considered were in scope or were detected by our search, which enriched the instruments included in Mukuria´s paper. 10 Results We sequentially describe the different sections of our results: 1) Qualitative systematic literature review and concept analysis; 2) HRQol, Qol and WB conceptual model construction; and 3) Mapping of a set of generic instruments/PROMs to the HRQol, Qol and WB conceptual models. Systematic review and concept analysis Descriptive Stage A total of 14,114 studies were identified among the different databases and gray literature. Of these, 52 were surveyed and evaluated in full text, 19 of which were eliminated for various reasons (incorrect objective (n = 11), incorrect patient population (n = 4), incorrect study design (n = 2) incorrect outcome (n = 1), other reasons (n = 1), leaving a total of 35 studies, with 36 total reported conceptual frameworks included in the final review. See PRISMA flowchart in the supplementary material 3. Table 1 provides a brief description of the 36 frameworks surveyed, with the high-level concepts and first-level domains as established by the authors. In the supplementary material 4 we report the graphical representation of the conceptual models of each reported framework, with the concepts and domains/dimensions as defined by the authors. Table 1 Papers and frameworks included for HRQoL, QoL and WB. Main domains and selected characteristics of the included frameworks* Author Year Variable / Construct -as reported by the authors- (as judged by the research team) Level 1 Domains Methods Country/Region Sample Intrument Arthaud-day 21 2005 Wellbeing (WB) Negative affect, Cognitive evaluation, Positive affect Survey and factor analysis US Subjects (n = 880, item level; n ¼= 897, scale level). second sample (n ¼= 731) No Bragin 22 2022 Psychosocial wellbeing (WB) Peace, security, justice, love/support in the family, freedom, physical health, participation in cultural/religious practices, friendship/support outside the family, self-efficacy/self-esteem, leisure activities or time to enjoy living, economic security, independent power and authority, personal capabilities/attributes, successful fulfillment of obligations Focus groups Afghanistan 440 No Breslow 23 2016 Human Wellbeing (WB) connections, capabilities, conditions, cross-cutting literature review US 0 The 4C Cella 24 2010 Health-related quality of life (HRQoL) Mental health, Physical health, social health, global health Others not specified 21133 PROMIS Colleen 25 1993 Health and wellbeing (WB) Social functioning, role-physical, mental health, pain, general health perceptions, role-emotional, vitality, physical functioning Survey US 22462 The MOS 36 Item short-form health Survey (SF-36) Dolan 26 2021 Wellbeing (WB) Objective circumstances of people's lives, people's subjective selves, people's time use, people's experiential subjective wellbeing Experts opinion not specified - Welleye Espinosa 27 2020 Health (HRQoL and WB) Family, finances, work-life, lifestyle behaviors, sense of self, physical health, resilience, spirituality and religiosity Interviews Taiwan 24 No Euroqol 1990 28 1990 Health-related quality of life (HRQoL) Mobility, self-care, main activity, social relationships, pain/discomfort & Survey Europe 522 Euroqol Instrument Felce 29 1995 Quality of life (QoL) Material wellbeing, physical wellbeing, development and activity, social wellbeing, emotional wellbeing Experts opinion Wales - No Gallagher 30 2009 Wellbeing (WB) Eudaimonic wellbeing, social wellbeing, hedonic wellbeing Survey and factor analysis US 591 No Hunt 31 1985 Health (QoL) Problems with health, Areas of daily life most often affected by health Survey Nottingham 215 Nottingham Health Profile Huppert 32 2013 Flourishing (WB) Positive appraisal, positive characteristics, positive functioning Literature review and experts opinion Europe 4 No Janabi 33 2012 Capability wellbeing (WB) Enjoyment, achievement, stability, attachment, autonomy Interviews England 36 ICEpop CAPability measure for adults - ICECAP -A Kaplan 34 1976 Wellbeing (WB) Function levels, Symptom/Problem Complexes Experts opinion not specified - the index of wellbeing Kim 35 2017 Health-related quality of life (HRQoL) Pain/discomfort, anxiety/depression, mobility, vision, self-care, usual activities, hearing, communication, cognitive function, social relationships, vitality, sleep Survey, literature review, experts opinion Korea 4 experts, 600 survey EQ-5D and EQ-5d-5L + bolt ons Krabbe 53 2019 Health (HRQoL) Social, mental, meta, physical Literature review Netherlands - CS-Base Larsen 36 2023 Prosocial wellbeing (WB) Happiness, meaning Interviews, secondary database analysis Ukrainian refugees in Norway 32 No Manolom 37 2015 Wellbeing (WB) Doing, Having enough for sustaining living, Community unity, Forest and environment, Family, Thinking Focus groups and interviews Lao 35 household No Mao 38 2021 Health-related quality of life (HRQoL) Cognitive function, mind-frame, physical functioning, social wellbeing, physical senses, emotional experiences Literature review, interviews China 110 No Marsh 39 2019 Wellbeing (WB) Prosocial behavior, empathy, resilience, self-acceptance, positive emotions, clear thinking, self-esteem, optimism, engagement, autonomy, vitality, positive relationships, emotional stability, meaning, competence Survey, factor analysis US 2559 No Mukuria 10 2022 Health and wellbeing (HRQoL) Cognition, physical sensations, copíng, autonomy and control, activity, feelings and emotions, self-identity, relationships Literature review UK - No Olsen 40 2020 Health-related quality of life (HRQoL) Mental health, social health, physical health Others not specified - No Park 2023 Emotional Wellbeing (WB) Ability to pursue self-defined goals, insight, sense of meaning and purpose, acceptance, feeling cared for, secure, awareness, autonomy, transcendence connected to something beyond one-self, life satisfaction, overall positive state of emotions, certain types of personality, sense of agency, optimism Literature review, experts opinion US - No Richardson 41 2009 Quality of life (QoL) Relationships, mental health, self worth, pain, senses, independent living, life satisfaction, coping Focus group and interviews Australia 29 participants in four groups. 711 individuals completed the survey AQoL Schalock 42 2016 Quality of life (QoL) Interpersonal relations, emotional wellbeing, self-determination, physical wellbeing, material well being, social inclusion, rights, personal development Literature review, experts opinion not specified - No Suavansri 43 2022 Wellbeing (WB) Sense of self, experience of emotions, self-care, thoughts and feelings about the future, personal health, spirituality and religiosity, social relationships, finances Interviews Thailand 50 No Thumboo 44 2018 Health-related quality of life (HRQoL) Social health, mental health, physical health, Interviews, focus groups Singapore interview 121 members of the general public. 21 FGs was comprised of two to eight partici- pants, with majority of the focus groups having six to seven participants No Touré 45 2022 Health-related quality of life (HRQoL) Citizenship and social inclusion, pain and physical discomfort, self-esteem and self-acceptance, social and interpersonal relationships, sleep and energy, body functioning, mobility and physical capacity, anxiety/depression, cognition, sense and language, wellbeing, daily activities and work, autonomy, social activities and leisure Surveys, factor analysis, delphi method Canada Delphi procedure was held in four rounds, gathering 18 participants. Online survey involving 2273 general population of Quebec. 13-MD Van Weel 46 1995 Functional Status (HRQoL) Feelings, social activities, daily activities, physical activities, pain, change in health, overall health Survey Netherlands 2775 COOP/WONCA Vries 47 2016 Health-Related Subjective WellBeing (WB) Autonomy, positive affect/happiness, personal growth, physical independence, negative affect/feeling lost and lonely Interviews, survey and factor analysis Netherlands 10 participantes for Interviews, 1143 participants For survey No WHOQOL 48 1994 Quality of life (QoL) Environment, Psychological domain, Spirituality/religion/personal beliefs, social relationships, physical health, level of independence Experts opinion and focus group International series of focus groups of six to eight people. WHOQOL Willroth 49 2023 Psychosocial Wellbeing (WB) Hedonic, intrapersonal aspects, interpersonal aspects, eudaimonic Experts opinion not specified - No Wilson and Cleary 50 1995 Health-related quality of life (HRQoL) General health perceptions, biological and physiological factors, symptoms, overall quality of life, functioning Experts opinion not specified - No Sintonen 51 1995 Health-related quality of life (HRQoL) Sleep, breathing, eating, speech, mental function, mobility, hearing, vitality, distress, usual activities, elimination, depression, vision Questionnaires, survey Finland 1815 patients 15D Feeny 52 2002 Health-related quality of life (HRQoL) Vision, hearing, speech, ambulation, emotion, cognition, pain Surveys Canada 248 survey HUI3 HRQoL: Health-related quality of life, QoL:Quality of life, WB: Wellbeing. FG: Focus Groups Included studies were published between 1976 and 2023. Of the publications that reported where the study was conducted, the majority were from Europe (n = 10), Asia (n = 7) and North America (n = 5). In the initial analysis we found eleven different “author-defined” high-level concepts evaluated among the 35 included studies (QoL, HRQoL, Capability Wellbeing, Emotional Wellbeing, Flourishing, Functional Status, Health, Health and Wellbeing, Health-Related Subjective Wellbeing, Psychosocial Wellbeing, Wellbeing). These were categorized -if judged adequate by the research team and based on the author's definitions -and after the team consensus, in one of the three main constructs of interest targeted by this work (HRQoL, Qol and WB). Fifteen conceptual frameworks targeted HRQoL, five described QoL, and 16 WB. Conceptual frameworks used different methodologies, and several studies used more than one methodology for their generation. The most commonly used methods included surveys (n = 12), interviews (n = 10), expert opinion (n = 7), focus groups (n = 6), factor analysis (n = 5) and literature review (n = 6). A total of 168 top or first-level domains, 225 second-level domains (subdomains) and 79 third-level domains (or facets) were retrieved from all the included frameworks. These domains were initially based on each author's definition and transcribed verbatim. The median number of top-level domains per framework was five (with a minimum of 2 to a maximum of 15). Eighteen frameworks only contemplated first-level domains, 16 included second-level domains, and only three contemplated third-level domains. Harmonization of dimensions The domains-dimensions were unified into a total of 118 unique entities (without initially taking into consideration domain hierarchical level). In supplementary material 5, the unified dimensions are listed and described. Each dimension may contain one original dimension or a set of original dimensions (if these dimensions were considered synonyms or were conceptually equivalent). In most cases, final dimensions contained only one (n = 45) or two (n = 21) dimensions reported by the original authors. The median number of original dimensions contained per final dimension was 2. The final dimensions that included the most original dimensions were Feelings and emotions (n = 40); Social and interpersonal relationships (21), and Usual activities (21). Findings from Iterative Analysis for Dimension Curation If we consider all reported non-duplicated and curated dimensions, HRQoL had a total of 82 associated unique dimensions, QoL had 49, and WB had 69. Many of these domains were considered by only one or just a few reported conceptual frameworks, so the number of dimensions could change significantly if we took into consideration the proportion of frameworks where dimensions were shared. Figure 1 shows how the number of dimensions of HRQol, QoL and WB decrease based on the percentage of frameworks that incorporate each of them within each high-level concept. As can be seen in the graph, for the three concepts, most dimensions were mentioned in a low proportion of frameworks. Very few domains showed high consistency (being included in almost all frameworks that assess the same concept) in each case. This indicates a low consistency/robustness in the domains that comprise each concept. Supplementary material 6 shows all initial dimensions included in each concept based on different stringency criteria (i.e the number of times each domain is repeated in different frameworks of the same concept). Figure 1 about here. Analyzing the degree of overlap and singularity among the concepts, it can be observed that out of the 118 total curated domains, 26 were shared by the three concepts; 3 by WB and QoL; 14 by WB and HRQoL; and 13 by QoL and HRQoL. Regarding unique dimensions included in only a single high-level concept, WB had 26, HRQoL 29 and QoL 7 (Fig. 2 ). Figure 2 about here. Construction of final Conceptual Models In order to generate conceptual models as robust as possible based on the data obtained, dimensions that were covered by at least 1/3 of the frameworks for each high-level concept were evaluated and considered as potential candidates for the final conceptual model. Based on this, graphic representations were made, showing the dimensions and their connections, hierarchies, directionality, structure, and relative frequency of each of the high-level concepts of interest. Supplementary Material 7 shows graphical representations of the three concepts that were used as a key input for arriving at the final high-level conceptual models. Each concept was simplified based on the previously observed domains and connections. Figures 3 , 4 and 5 show the final conceptual models. For better schematization, a color scheme was used based on the independence and the connections between the domains. As can be seen in the graphs, the second-level domains share the colours of the first-level domains they are part of. In turn, the third-level domains have the color -or color combination in case of a mixed structure- of the second-level domains to which they are connected. The final HRQoL conceptual model includes a total of 18 domains, grouped in three levels of hierarchy. We considered HRQoL to be nested within the broader concept of QoL, to be consistent with insights from other key sources 19 , 20 . So, the final Qol conceptual model includes HRQoL, and in turn, it includes 4 additional first-level domains. WB conceptual model shared three first level domains with HRQoL (Feeling and Emotions; Physical Functioning; and Social and Interpersonal relationships) and an additional one with QoL (Finances). However, for the first level domains shared with HRQoL we didn´t include the second level domains in the final models, because despite most of these (excluding Senses and Pain) were mentioned by at least one author, none met the criterion of being referenced by at least one third of the frameworks of the particular high-level concept. WB was the high-level concept with the more inconsistent domain inclusion, so fewer domains were finally incorporated. Figure 3 about here. Figure 4 about here. Figure 5 about here. Mapping of a set of PROMs to our final conceptual models. Eight commonly used PROMs -generic instruments were mapped for HRQoL (COOP-WONCA, SF-36, EQ-5D, SICKNESS IMPACT PROFILE, PROMIS-29, HUI-3, 15D and EQ-HWB), two instruments to QoL (AQOL-8D, WHO-QOL) and five instruments to Wellbeing (ICECAP-A, QUALITY OF WELL BEING SCALE, ICECAP-O, IWB, EQ-HWB). The EQ-HWB was primarily mapped to the high level concept HRQoL, but, having WB in its name, it was also mapped to Wellbeing. Of the conceptual frameworks developed, the tools mapped on average 59.4% of the domains for HRQoL (minimum and maximum of 33.3% and 94.4%; respectively), 65.9% for Qol (59.1 and 72.7), and for 34% Wellbeing (minimum and maximum of 30% and 50%; respectively). Of the eight instruments mapped to HRQoL, the EQ-HWB was the one that was shown to include fully or partially more domains concerning the domains of the conceptual model of HRQoL (17 out of 18). In the case of Wellbeing, all instruments had moderate to poor coverage, and the EQ-HWB the best performing one, with partial or full coverage of 5 out of 10 domains. In the Supplementary material 8 we show the detailed results of instrument mapping to the final high level conceptual models. Discussion In this qualitative systematic review, we performed an exhaustive survey of current conceptual frameworks of three key high-level concepts commonly used in health, policy and social science: Health-Related Quality of Life, Quality of Life, and Wellbeing. Based on synthesized frameworks from the literature, and after an in-depth inter-conceptual, intra-conceptual, and sub-conceptual analysis and curation, we propose a single conceptual framework for each of these concepts. Additionally, we map commonly used Patient Reported Outcomes Measures (PROMs) to these three concepts and domains, showing their almost universal partial coverage. This is to our knowledge the first systematic and comprehensive endeavor that aims to perform this task. We found no other studies that describe or contrast these high-level concepts and propose a unified definition based on the systematic retrieval and analysis of the existing reported frameworks. However, several authors have already pointed out the problem of their current conceptual “noise” regarding their definitions, and the possibility of clearly differentiating them. Moore et al. highlighted the conceptual difficulties in defining QoL and posited that HRQoL is an artificial measure, as patients must distinguish between the part of their life influenced by health and other areas not appreciably influenced by health. 54 Other studies support this view, noting that the concepts of HRQoL and many definitions of QoL are not clearly differentiated from the concepts of health. 1 Similarly, the concepts of QoL and WB are oftentimes umbrella terms that encompass many interpretations and methods of assessment, according to Gasper. 55 Although WB tends to focus more on satisfaction and affective states, while QoL encompasses a broader, multifaceted assessment of the living conditions and resources available to an individual or group, these concepts are interrelated and often overlap. This confusion is understandable, as the concepts themselves are not well defined. A review of the term "wellbeing" highlighted the lack of a consistent definition. 56 In addition, these concepts may have different interpretations in different regions or cultures, 57 which makes it even more difficult to have unified concepts. Strengths Our review shows that, in addition to the lack of clear conceptual definitions both within and between concepts, the different domains assigned to each concept are also not sufficiently consistent and oftentimes overlap. As health research continues to evolve, establishing clear, coherent, and consistent conceptual frameworks is of utmost importance. This effort represents a significant advance, bringing unprecedented depiction and depth to the understanding and application of these three high-level health-related concepts. By moving in this direction, we aim not only to improve our understanding of HRQoL, QoL, and WB but also to contribute to the quality and impact of health research, policy and practice that incorporates these concepts. This research highlights the need to continually reflect on the definitions, domains, methods, and applications of these concepts to ensure that health policies and programs meaningfully address the areas of life that are important to people, thereby improving their quality of life and wellbeing in a comprehensive manner. Limitations It is crucial to recognize some limitations of this study. Firstly and fundamentally -similarly to all non-objectively verified constructs or high-level concepts-, and though there are thousands of studies reporting and “measuring” HRQoL, QoL and WB, our study does not provide “definitive proof” that these concepts exist or are truths in nature, or that our proposed models are the truth. An inherent assumption of our study is that these concepts exist and are, though sharing common dimensions, distinct entities, and we simply try to depict them and clarify their boundaries. Secondly, we were -purposefully- “quality or methodologically agnostic” and we included all conceptual frameworks found in the literature, not distinguishing or weighting more heavily those that were derived in one manner or another (i.e expert derived conceptual frameworks were similarly treated to those derived by qualitative or quantitative research methods). As we wanted to be exhaustive in retrieving existing frameworks, and due to the heterogeneity of study designs, and many designs such as “expert-defined high-level concepts” do not have a bias assessment tool, we did not critically assess their quality or their risk of bias. Thirdly, though the proposed conceptual models are based on the exhaustive evidence review, including the frequency of domains in each concept, the final conceptualization included a qualitative research component, which included the authors' best collective judgment. Fourthly, the conceptualization of these high-level concepts may vary across countries and cultures, or in different population groups. Nevertheless, our goal was to develop a broad description of "mainstream conceptual models" used in the general population, which could be refined in future studies to examine aspects such as cultural, geographic, or other differences. Fifthly, we had a commonly found weakness in systematic reviews: we only included studies published in English, which could potentially introduce a selection bias. Nevertheless, we included several conceptual frameworks from non-English-speaking countries, and we do not consider this to be a significant shortcoming. Fifthly, most of the conceptual frameworks lacked clear definitions both the high-level concept as well as of the included domains. Thus, concept and domain harmonization were performed based on the best authors' judgment. Importantly, transparency was maintained by having the complete list of domains and a clear description of the process that arrived at the final proposed conceptual frameworks. Finally, in our work, we did not include another high-level concept commonly found in the literature: health status. We did not include health status as a central construct in our review because, although it is an important term in health research, its definitional scope is broader and less specific to the experiential focus of our work. The methodological and conceptual ambiguity sets health status apart from the three constructs we focused on. This could signal, nevertheless, a path for future studies. Further steps Future research can improve and strengthen our work in several ways a) Empirical and methodologically sound studies can explore and test -both with qualitative and quantitative psychometric research- the validity of these proposed high-level conceptual frameworks, b) Further research can explore the geographic and cultural diversity of these high-level concept frameworks, and also include non-English conceptual frameworks not detected or included in our study, c) Other studies can incorporate other related high-level concepts such as health status in order to broaden the scope of our study. Conclusions The absence of clear conceptual definitions poses a major challenge in differentiating health-related quality of life, quality of life, and wellbeing, which has a significant impact on the validity of measurement tools in health, social research, and policy. This paper serves as an initial step, shedding some light, as well as highlighting the existing darkness, on the conceptual frameworks of these three common high-level concepts, as well as assessing the comprehensiveness of common instruments for their assessment. Recognizing the need for clearer conceptual definitions and aligned frameworks, is an important step towards new analyses and developments in the understanding and measurement of these essential concepts, as well as empirical validation exercises to test their soundness and utility. Abbreviations HRQoL – Health-Related Quality of Life QoL – Quality of Life WB – Wellbeing PROMs – Patient-Reported Outcome Measures EQ-HWB – EuroQol Health and Wellbeing instrument EQ-5D – EuroQol 5-Dimension instrument COOP-WONCA – COOP Functional Health Assessment Charts / World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians HUI – Health Utilities Index 15D – 15-Dimensional Measure of Health-Related Quality of Life SIP – Sickness Impact Profile SF-36 – 36-Item Short Form Survey PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses Declarations Ethics approval and consent to participate Not applicable. This study is a systematic review of published literature and does not involve human participants. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study, including the extracted domains and PROMs mapping tables, are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was supported by [insert funder’s name, e.g., the EuroQol Research Foundation under grant number 1605-RA. The funder had no role in the design of the study, data collection, analysis, interpretation, or writing of the manuscript. Authors' contributions [F Augustovski] and [MB] conceptualized the study. [F Argento], [NI], [MB] and [JC] conducted the literature search and data extraction. All authors did the thematic synthesis. All authors contributed to the interpretation of findings. [F Augustovski] drafted the manuscript. All authors critically revised the manuscript and approved the final version. Acknowledgements Daniel Comandé, librarian, IECS. 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Supplementary Files Supplementarymaterial1PRISMAchecklist.docx Supplementarymaterial2SearchStrategy.docx Supplementarymaterial3PRISMAFlowchart.docx SupplementaryMaterial4ConceptualFrameworks.docx Supplementarymaterial5UnifiedDimensions.xlsx Supplementarymaterial6Dimensionsbyfrequency.xlsx SupplementaryMaterial7ConceptMapping.docx Supplementarymaterial8PROMMapping.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 04 Dec, 2025 Reviews received at journal 02 Dec, 2025 Reviewers agreed at journal 27 Oct, 2025 Reviews received at journal 27 Jul, 2025 Reviewers agreed at journal 14 Jul, 2025 Reviewers agreed at journal 06 Jul, 2025 Reviewers invited by journal 02 Jul, 2025 Editor assigned by journal 27 Jun, 2025 Submission checks completed at journal 27 Jun, 2025 First submitted to journal 25 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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08:35:10","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":64630,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial7ConceptMapping.docx","url":"https://assets-eu.researchsquare.com/files/rs-6976096/v1/5ac5333360911f2e7e163656.docx"},{"id":86143548,"identity":"8d7ca2ec-b76d-45c1-a96a-749e41d04b17","added_by":"auto","created_at":"2025-07-07 08:43:10","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":36216,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial8PROMMapping.docx","url":"https://assets-eu.researchsquare.com/files/rs-6976096/v1/2f8ec64b8d3ecf071457b7fc.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Conceptual Mapping of Health-Related Quality of Life, Quality of Life, and Wellbeing: A Systematic Review and Assessment of Commonly Used Patient-Reported Outcomes Measures","fulltext":[{"header":"Background","content":"\u003cp\u003eHealth-Related Quality of Life (HRQoL), Quality of Life (QoL), and Wellbeing (WB) are commonly used terms in contemporary health and social science research, strongly enriching the spectrum of outcomes used in health and social policy and research, aiming to describe or address the impact of a wide range of aspects and interventions on an individual's overall life, and not just focusing on any symptom, disease, condition, or specific dimension in particular.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e As a partial reflection of this, a simple search in PubMed shows nearly three quarters of a million citations using these terms.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e A similar search in Social Science Citation Index Database, one of the most popular social science databases, brings nearly 300,000 citations.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite being nearly ubiquitous concepts and outcomes in health and social science, there is no commonly embraced definition of each of these three high-level concepts of HRQoL, QoL and WB; and there is considerable disagreement and conceptual overlaps that challenge their clarity and precision.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Promoting sound advances in outcomes research and measurement of these non-disease specific broad health measures is clearly hindered by these conceptual conundrums.\u003c/p\u003e \u003cp\u003eHistorically, the interchangeable use of terms like WB and QoL has led to potential misinterpretations and misapplications in health sciences.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Salvador-Carulla et al. have delved into these issues, proposing a conceptual framework that aids in disentangling these terms and offering clarity on their distinctions.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Ferrans' exploration into the definitions and conceptual models of quality of life emphasizes the intricate nuances that often go overlooked, highlighting the imperative for a more rigorous and standardized approach to their definition and measurement in health research.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe ambiguity surrounding these terms is not just an academic concern; it has tangible implications in the realm of health research, practice and policy.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Inconsistent or overlapping definitions can lead to challenges in health policy design and monitoring, instrument or survey development, validation, and interpretation, potentially undermining the validity of research and policy findings.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e For example, Smith et al. underscored the importance of distinguishing between quality of life and health status in research, shedding light on the potential pitfalls of conflating the two.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Such conflation may result in the misalignment of interventions with patient priorities and reduced effectiveness in improving health, QoL and WB.\u003c/p\u003e \u003cp\u003eRecent scholarly endeavors have attempted to navigate this complex terrain.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Mukuria's scoping review, for instance, delved into health status conceptual definitions with a specific focus on the development of a new instrument, the EuroQol Health and Wellbeing instrument (EQHWB).\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Similarly, Mulhern et al argue for a novel multi-layered 'Deep Dive' approach, aiming to inform the measurement of HRQoL having an holistic approach.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThese efforts and the current somewhat confusing situation around the concepts HRQoL, QoL and WB highlight the pressing need for their systematic exploration, including their definitions, dimensions and their intricate interrelationships.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Recognizing this gap, our work embarks on an attempt to bring more clarity on these three high-level concepts.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e This endeavor can be instrumental to both health and social sciences, from health or social policy design or monitoring to inform the development, validation, and application of generic instruments in health research.\u003c/p\u003e \u003cp\u003eThus, the aim of this study was to perform a qualitative systematic literature review and to report an updated and inclusive conceptual mapping of HRQoL, QoL and WB in order to understand its commonalities and differences. Finally, we also aimed to create a conceptual map about the coverage of commonly used Patient Reported Outcomes Measures (PROMs) of these concepts, as well as their domains/dimensions (considering the concepts of domains and dimensions as synonyms), sub-domains/sub-dimensions, and subthemes/facets. The current study was funded by a competitive grant of the EuroQol Research Foundation (grant number 1605-RA).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe followed three sequential steps: 1) Systematic literature review. Its focus was on studies that proposed a conceptual framework or map of any of the three high-level concepts targeted by our study, in order to retrieve their definition, their structure (domains/dimensions, subdomains, and facets) as described by the authors; 2) Conceptual analysis and development of conceptual frameworks for HRQoL, QoL, and WB. This process involved a detailed iterative analysis and curation of domains identified in the literature. The research team grouped conceptually similar or hierarchically related domains, drawing on the evidence retrieved and arriving at a proposed conceptual framework of each high-level concept; and 3) Conceptual mapping, depicting the coverage of commonly used generic instruments-measures of HRQoL, QoL, and WB.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e- Systematic review and concept analysis\u003c/h2\u003e \u003cp\u003eThe study was categorized as a systematic literature review, as it complies with the current accepted definitions of this study methods.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e The PRISMA checklist 2020 was also completed and is available to the readers as supplementary material 1.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The protocol of the systematic review was published and registered in OSF Registries (CRD42023469014).\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e We performed a systematic review of studies without methodological restrictions, including qualitative, quantitative or mixed-methods research.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSearch strategy\u003c/p\u003e \u003cp\u003eWe included studies with a specific focus on analyzing, developing, identifying, or describing these three high-level target concepts: HRQoL, QoL and WB. We searched for empirical and theoretical studies that report their conceptualization. If applied to a specific target population, we focused on studies targeted to the adult population -regardless of age, gender or geographic area- including all types of persons with health conditions; formal and informal carers as well as the general public. Search period: from inception to Dec 2023. We selected only publications written in English, as the main studies in the academic world in all countries are typically published in English. We conducted a comprehensive search across the following databases: PubMed, EMBASE, SocINDEX (EBSCO), and Scopus. The search strategy was developed in collaboration with an experienced librarian specializing in systematic reviews to ensure methodological rigor. The full search strategy is detailed in supplementary material 2.\u003c/p\u003e \u003cp\u003eEligibility criteria and study selection\u003c/p\u003e \u003cp\u003eTwo authors independently screened titles and abstracts to exclude records that were not relevant. For all studies selected by at least one author during the initial screening, full-text articles were retrieved. Subsequently, three researchers independently assessed full texts to check if they fulfilled the inclusion criteria. Disagreements were solved by discussion with another team member, and in case of remaining disagreement by final deliberatioan by all study team. As we wanted to be exhaustive, and as studies included had broad and heterogeneous methodological approaches, and as we did not want to exclude any study fulfilling our inclusion criteria, as is common in this type of systematic reviews, we did not assess study quality or risk of bias. We extracted from each framework several charactaristics, such as were the target concept assessed, the domains, subdomains and facets and the relationships between domains, the conceptual definitions of each concept and domain, subdomains and facets, the methods used to develop the conceptual framework and whether it was used to generate an instrument/PROM.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e- Conceptual analysis\u003c/h3\u003e\n\u003cp\u003eWe carried out a content analysis following the steps described below. Articles were included and coded in ATLAS.ti 23.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Coding was developed iteratively and revised continuously in discussions with all team members.\u003c/p\u003e \u003cp\u003ea) Descriptive Stage: In the initial stage of the coding process, we engaged in a meticulous examination of the high-level concepts of interest: QoL, HRQoL, and WB. We retrieved all the dimensions that composed these concepts and their different hierarchies: higher-order dimensions-domains, subdimensions-subdomains (i.e components of dimensions-domains), and facets (or conceptual components of subdimensions-subdomains). We also use the terms first, second, and third-level domains or dimensions as synonyms of dimensions-domains, subdimensions-subdomains and facets. We did not begin with any pre-established codebook; rather, we formulated codes for each dimension as it was presented in the conceptual models or frameworks, initially using the terminology employed by the respective authors. For a visual representation of dimensions, we developed individual conceptual models for each paper, depicting their hierarchical structure -if any-, with first-level domains/dimensions and, where present, second or third-level dimensions as well. The reported conceptual structures (i.e, different dimensions and their relationship) proposed by the authors were maintained in all these initial descriptive visual models.\u003c/p\u003e \u003cp\u003eb) Harmonization of dimensions: In the second stage of the coding process, a comprehensive synthesis of the dimensions and sub-dimensions was performed by unifying those dimensions that were synonyms or very similar, considering the definitions provided by the original authors where available, or relying on the authors\u0026rsquo; team collective judgment. This was done with the purpose of clarifying an initial long list of dimensions and avoiding overlaps and redundancy. This work was carried out by two researchers and in case of lack of agreement, a third researcher intervened. Some dimensions were common or very similar across multiple conceptual models, while others were unique to specific ones.\u003c/p\u003e \u003cp\u003ec) Iterative analysis for the curation of dimensions: To comprehensively describe all dimensions outlined in the literature, regardless of whether they were categorized as first, second, or third-level domains, a process of curation and conceptual unification was initiated. To arrive at the final dimensions for each high-level concept, a qualitative analysis was conducted. Researchers scrutinized each dimension/sub-dimension/facet, grouping them according to categories. The construction of these categories and groupings was done by the team based on the interpretation of information described in the preceding stages and through an iterative deliberative process grounded in the evidence and work done in the initial two previously described coding stages. The grouping occurred in several stages. Initially, after reading all dimensions, the entire research team deliberated on the similarities and differences among them. Subsequently, two researchers collaborated in the first round of grouping (FJA and MB). The grouping was then reviewed by another three researchers (JC, FA and NI), who conducted a second round of grouping. The results of the second round were subsequently reviewed by the initial pair of researchers (FJA and MB), who performed a third and final round of grouping. The final listing was reviewed and agreed upon by the entire team. This rigorous and meticulous process enabled us to compile a comprehensive list of dimensions mentioned in the literature as reproducible and scientifically grounded as possible.\u003c/p\u003e \u003cp\u003ed) Construction of final Conceptual Models: We developed separate conceptual models for Health-Related Quality of Life (HRQoL), Quality of Life (QoL), and Wellbeing (WB) based on synthesized frameworks from the included literature. Domains were hierarchically structured (first-, second-, and third-level where applicable) based on frequency, conceptual clarity, and qualitative analysis. We initiated the process of building the conceptual model of HRQoL. Once this model was constructed, we advanced with the QoL model, acknowledging -as several organizations such as the International Society of Quality of Life Research ISOQOL and the World Health Organization do- that HRQoL is a concept nested within Qol.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Finally, the Wellbeing conceptual model was constructed, incorporating some categories curated in the other two high-level conceptual frameworks as well as unique domains.\u003c/p\u003e \u003cp\u003eDuring this last phase, we had the input of two experts to assess the high-level concepts\u0026acute; conceptual face validity and other general insights: Vilma Irazola (IECS, University of Buenos Aires), with background in HRQoL and QoL work and knowledge, and Tessa Peasgood (University of Sheffield) with more background on Wellbeing and HRQoL.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eMapping of a set of generic instruments to our conceptual models.\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eFinally, in this phase, we mapped the conceptual models developed during the previous phase with the main instruments commonly used to assess HRQOL (COOP- WONCA, SF-36, EQ-5D, SICKNESS IMPACT PROFILE, PROMIS-29, HUI, EQ-HWB, 15D), QoL (AQOL-8D, WHO-QOL), and WB (ICECAP-A, QUALITY OF WELLBEING SCALE, ICECAP-O, IWB). Our criteria for inclusion of these PROMs were based on the initial list used in the Mukuria paper and expanded to other PROMs that either the authors considered were in scope or were detected by our search, which enriched the instruments included in Mukuria\u0026acute;s paper.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe sequentially describe the different sections of our results: 1) Qualitative systematic literature review and concept analysis; 2) HRQol, Qol and WB conceptual model construction; and 3) Mapping of a set of generic instruments/PROMs to the HRQol, Qol and WB conceptual models.\u003c/p\u003e \u003cp\u003eSystematic review and concept analysis\u003c/p\u003e \u003cp\u003eDescriptive Stage\u003c/p\u003e \u003cp\u003eA total of 14,114 studies were identified among the different databases and gray literature. Of these, 52 were surveyed and evaluated in full text, 19 of which were eliminated for various reasons (incorrect objective (n\u0026thinsp;=\u0026thinsp;11), incorrect patient population (n\u0026thinsp;=\u0026thinsp;4), incorrect study design (n\u0026thinsp;=\u0026thinsp;2) incorrect outcome (n\u0026thinsp;=\u0026thinsp;1), other reasons (n\u0026thinsp;=\u0026thinsp;1), leaving a total of 35 studies, with 36 total reported conceptual frameworks included in the final review. See PRISMA flowchart in the supplementary material 3.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides a brief description of the 36 frameworks surveyed, with the high-level concepts and first-level domains as established by the authors. In the supplementary material 4 we report the graphical representation of the conceptual models of each reported framework, with the concepts and domains/dimensions as defined by the authors.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePapers and frameworks included for HRQoL, QoL and WB. Main domains and selected characteristics of the included frameworks*\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVariable / Construct -as reported by the authors- (as judged by the research team)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLevel 1 Domains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMethods\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCountry/Region\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIntrument\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArthaud-day\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWellbeing\u003c/p\u003e \u003cp\u003e(WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNegative affect, Cognitive evaluation, Positive affect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey and factor analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSubjects (n\u0026thinsp;=\u0026thinsp;880, item level; n \u0026frac14;= 897, scale level). second sample (n \u0026frac14;= 731)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBragin\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePsychosocial wellbeing\u003c/p\u003e \u003cp\u003e(WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePeace, security, justice, love/support in the family, freedom, physical health, participation in cultural/religious practices, friendship/support outside the family, self-efficacy/self-esteem, leisure activities or time to enjoy living, economic security, independent power and authority, personal capabilities/attributes, successful fulfillment of obligations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFocus groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAfghanistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e440\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreslow\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHuman Wellbeing\u003c/p\u003e \u003cp\u003e(WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003econnections, capabilities, conditions, cross-cutting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eliterature review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eThe 4C\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCella\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth-related quality of life\u003c/p\u003e \u003cp\u003e(HRQoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMental health, Physical health, social health, global health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003enot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePROMIS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColleen\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1993\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth and wellbeing\u003c/p\u003e \u003cp\u003e(WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSocial functioning, role-physical, mental health, pain, general health perceptions, role-emotional, vitality, physical functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e22462\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eThe MOS 36 Item short-form health Survey (SF-36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDolan\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWellbeing\u003c/p\u003e \u003cp\u003e(WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eObjective circumstances of people's lives, people's subjective selves, people's time use, people's experiential subjective wellbeing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExperts opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003enot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eWelleye\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEspinosa\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth\u003c/p\u003e \u003cp\u003e(HRQoL and WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFamily, finances, work-life, lifestyle behaviors, sense of self, physical health, resilience, spirituality and religiosity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTaiwan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEuroqol 1990\u003csup\u003e28\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1990\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth-related quality of life\u003c/p\u003e \u003cp\u003e(HRQoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMobility, self-care, main activity, social relationships, pain/discomfort \u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEurope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e522\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEuroqol Instrument\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFelce\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1995\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuality of life\u003c/p\u003e \u003cp\u003e(QoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMaterial wellbeing, physical wellbeing, development and activity, social wellbeing, emotional wellbeing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExperts opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWales\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGallagher\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWellbeing\u003c/p\u003e \u003cp\u003e(WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEudaimonic wellbeing, social wellbeing, hedonic wellbeing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey and factor analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e591\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHunt\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1985\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth\u003c/p\u003e \u003cp\u003e(QoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProblems with health, Areas of daily life most often affected by health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNottingham\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNottingham Health Profile\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHuppert\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFlourishing\u003c/p\u003e \u003cp\u003e(WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePositive appraisal, positive characteristics, positive functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLiterature review and experts opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEurope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJanabi\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCapability wellbeing\u003c/p\u003e \u003cp\u003e(WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnjoyment, achievement, stability, attachment, autonomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEngland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eICEpop CAPability measure for adults - ICECAP -A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKaplan\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1976\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWellbeing\u003c/p\u003e \u003cp\u003e(WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFunction levels, Symptom/Problem Complexes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExperts opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003enot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ethe index of wellbeing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKim\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth-related quality of life\u003c/p\u003e \u003cp\u003e(HRQoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePain/discomfort, anxiety/depression, mobility, vision, self-care, usual activities, hearing, communication, cognitive function, social relationships, vitality, sleep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey, literature review, experts opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKorea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4 experts, 600 survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEQ-5D and EQ-5d-5L\u0026thinsp;+\u0026thinsp;bolt ons\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKrabbe\u003csup\u003e\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth (HRQoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSocial, mental, meta, physical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLiterature review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNetherlands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCS-Base\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarsen\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProsocial wellbeing\u003c/p\u003e \u003cp\u003e(WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHappiness, meaning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterviews, secondary database analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUkrainian refugees in Norway\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManolom\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWellbeing\u003c/p\u003e \u003cp\u003e(WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDoing, Having enough for sustaining living, Community unity, Forest and environment, Family, Thinking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFocus groups and interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLao\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e35 household\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMao\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth-related quality of life\u003c/p\u003e \u003cp\u003e(HRQoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCognitive function, mind-frame, physical functioning, social wellbeing, physical senses, emotional experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLiterature review, interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarsh\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWellbeing\u003c/p\u003e \u003cp\u003e(WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProsocial behavior, empathy, resilience, self-acceptance, positive emotions, clear thinking, self-esteem, optimism, engagement, autonomy, vitality, positive relationships, emotional stability, meaning, competence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey, factor analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2559\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMukuria\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth and wellbeing\u003c/p\u003e \u003cp\u003e(HRQoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCognition, physical sensations, cop\u0026iacute;ng, autonomy and control, activity, feelings and emotions, self-identity, relationships\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLiterature review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOlsen\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth-related quality of life\u003c/p\u003e \u003cp\u003e(HRQoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMental health, social health, physical health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003enot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePark\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmotional Wellbeing\u003c/p\u003e \u003cp\u003e(WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAbility to pursue self-defined goals, insight, sense of meaning and purpose, acceptance, feeling cared for, secure, awareness, autonomy, transcendence connected to something beyond one-self, life satisfaction, overall positive state of emotions, certain types of personality, sense of agency, optimism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLiterature review, experts opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRichardson\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuality of life\u003c/p\u003e \u003cp\u003e(QoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRelationships, mental health, self worth, pain, senses, independent living, life satisfaction, coping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFocus group and interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e29 participants in four groups. 711 individuals completed the survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAQoL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchalock\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuality of life\u003c/p\u003e \u003cp\u003e(QoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInterpersonal relations, emotional wellbeing, self-determination, physical wellbeing, material well being, social inclusion, rights, personal development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLiterature review, experts opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003enot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuavansri\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWellbeing\u003c/p\u003e \u003cp\u003e(WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSense of self, experience of emotions, self-care, thoughts and feelings about the future, personal health, spirituality and religiosity, social relationships, finances\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThailand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThumboo\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth-related quality of life\u003c/p\u003e \u003cp\u003e(HRQoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSocial health, mental health, physical health,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterviews, focus groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSingapore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003einterview 121 members of the general public. 21 FGs was comprised of two to eight partici- pants, with majority of the focus groups having six to seven participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTour\u0026eacute;\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth-related quality of life\u003c/p\u003e \u003cp\u003e(HRQoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCitizenship and social inclusion, pain and physical discomfort, self-esteem and self-acceptance, social and interpersonal relationships, sleep and energy, body functioning, mobility and physical capacity, anxiety/depression, cognition, sense and language, wellbeing, daily activities and work, autonomy, social activities and leisure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurveys, factor analysis, delphi method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDelphi procedure was held in four rounds, gathering 18 participants. Online survey involving 2273 general population of Quebec.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13-MD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVan Weel\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1995\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFunctional Status\u003c/p\u003e \u003cp\u003e(HRQoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFeelings, social activities, daily activities, physical activities, pain, change in health, overall health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNetherlands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2775\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCOOP/WONCA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVries\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth-Related Subjective WellBeing\u003c/p\u003e \u003cp\u003e(WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAutonomy, positive affect/happiness, personal growth, physical independence, negative affect/feeling lost and lonely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterviews, survey and factor analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNetherlands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10 participantes for Interviews,\u003c/p\u003e \u003cp\u003e1143 participants\u003c/p\u003e \u003cp\u003eFor survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWHOQOL\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1994\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuality of life\u003c/p\u003e \u003cp\u003e(QoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnvironment, Psychological domain, Spirituality/religion/personal beliefs, social relationships, physical health, level of independence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExperts opinion and focus group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInternational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eseries of focus groups of six to eight people.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eWHOQOL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWillroth\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePsychosocial Wellbeing\u003c/p\u003e \u003cp\u003e(WB)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHedonic, intrapersonal aspects, interpersonal aspects, eudaimonic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExperts opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003enot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWilson and Cleary\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1995\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth-related quality of life\u003c/p\u003e \u003cp\u003e(HRQoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGeneral health perceptions, biological and physiological factors, symptoms, overall quality of life, functioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExperts opinion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003enot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSintonen\u003csup\u003e\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1995\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth-related quality of life\u003c/p\u003e \u003cp\u003e(HRQoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSleep, breathing, eating, speech, mental function, mobility, hearing, vitality, distress, usual activities, elimination, depression, vision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQuestionnaires, survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFinland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1815 patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15D\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeeny \u003csup\u003e\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth-related quality of life\u003c/p\u003e \u003cp\u003e(HRQoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVision, hearing, speech, ambulation, emotion, cognition, pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurveys\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e248 survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHUI3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cem\u003eHRQoL: Health-related quality of life, QoL:Quality of life, WB: Wellbeing. FG: Focus Groups\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIncluded studies were published between 1976 and 2023. Of the publications that reported where the study was conducted, the majority were from Europe (n\u0026thinsp;=\u0026thinsp;10), Asia (n\u0026thinsp;=\u0026thinsp;7) and North America (n\u0026thinsp;=\u0026thinsp;5). In the initial analysis we found eleven different \u0026ldquo;author-defined\u0026rdquo; high-level concepts evaluated among the 35 included studies (QoL, HRQoL, Capability Wellbeing, Emotional Wellbeing, Flourishing, Functional Status, Health, Health and Wellbeing, Health-Related Subjective Wellbeing, Psychosocial Wellbeing, Wellbeing). These were categorized -if judged adequate by the research team and based on the author's definitions -and after the team consensus, in one of the three main constructs of interest targeted by this work (HRQoL, Qol and WB). Fifteen conceptual frameworks targeted HRQoL, five described QoL, and 16 WB. Conceptual frameworks used different methodologies, and several studies used more than one methodology for their generation. The most commonly used methods included surveys (n\u0026thinsp;=\u0026thinsp;12), interviews (n\u0026thinsp;=\u0026thinsp;10), expert opinion (n\u0026thinsp;=\u0026thinsp;7), focus groups (n\u0026thinsp;=\u0026thinsp;6), factor analysis (n\u0026thinsp;=\u0026thinsp;5) and literature review (n\u0026thinsp;=\u0026thinsp;6).\u003c/p\u003e \u003cp\u003eA total of 168 top or first-level domains, 225 second-level domains (subdomains) and 79 third-level domains (or facets) were retrieved from all the included frameworks. These domains were initially based on each author's definition and transcribed verbatim. The median number of top-level domains per framework was five (with a minimum of 2 to a maximum of 15). Eighteen frameworks only contemplated first-level domains, 16 included second-level domains, and only three contemplated third-level domains.\u003c/p\u003e \u003cp\u003eHarmonization of dimensions\u003c/p\u003e \u003cp\u003eThe domains-dimensions were unified into a total of 118 unique entities (without initially taking into consideration domain hierarchical level). In supplementary material 5, the unified dimensions are listed and described. Each dimension may contain one original dimension or a set of original dimensions (if these dimensions were considered synonyms or were conceptually equivalent). In most cases, final dimensions contained only one (n\u0026thinsp;=\u0026thinsp;45) or two (n\u0026thinsp;=\u0026thinsp;21) dimensions reported by the original authors. The median number of original dimensions contained per final dimension was 2. The final dimensions that included the most original dimensions were Feelings and emotions (n\u0026thinsp;=\u0026thinsp;40); Social and interpersonal relationships (21), and Usual activities (21).\u003c/p\u003e \u003cp\u003eFindings from Iterative Analysis for Dimension Curation\u003c/p\u003e \u003cp\u003eIf we consider all reported non-duplicated and curated dimensions, HRQoL had a total of 82 associated unique dimensions, QoL had 49, and WB had 69. Many of these domains were considered by only one or just a few reported conceptual frameworks, so the number of dimensions could change significantly if we took into consideration the proportion of frameworks where dimensions were shared. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows how the number of dimensions of HRQol, QoL and WB decrease based on the percentage of frameworks that incorporate each of them within each high-level concept. As can be seen in the graph, for the three concepts, most dimensions were mentioned in a low proportion of frameworks. Very few domains showed high consistency (being included in almost all frameworks that assess the same concept) in each case. This indicates a low consistency/robustness in the domains that comprise each concept. Supplementary material 6 shows all initial dimensions included in each concept based on different stringency criteria (i.e the number of times each domain is repeated in different frameworks of the same concept).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e about here.\u003c/p\u003e \u003cp\u003eAnalyzing the degree of overlap and singularity among the concepts, it can be observed that out of the 118 total curated domains, 26 were shared by the three concepts; 3 by WB and QoL; 14 by WB and HRQoL; and 13 by QoL and HRQoL. Regarding unique dimensions included in only a single high-level concept, WB had 26, HRQoL 29 and QoL 7 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e about here.\u003c/p\u003e \u003cp\u003eConstruction of final Conceptual Models\u003c/p\u003e \u003cp\u003eIn order to generate conceptual models as robust as possible based on the data obtained, dimensions that were covered by at least 1/3 of the frameworks for each high-level concept were evaluated and considered as potential candidates for the final conceptual model. Based on this, graphic representations were made, showing the dimensions and their connections, hierarchies, directionality, structure, and relative frequency of each of the high-level concepts of interest. Supplementary Material 7 shows graphical representations of the three concepts that were used as a key input for arriving at the final high-level conceptual models.\u003c/p\u003e \u003cp\u003eEach concept was simplified based on the previously observed domains and connections. Figures\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e show the final conceptual models. For better schematization, a color scheme was used based on the independence and the connections between the domains. As can be seen in the graphs, the second-level domains share the colours of the first-level domains they are part of. In turn, the third-level domains have the color -or color combination in case of a mixed structure- of the second-level domains to which they are connected. The final HRQoL conceptual model includes a total of 18 domains, grouped in three levels of hierarchy. We considered HRQoL to be nested within the broader concept of QoL, to be consistent with insights from other key sources\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. So, the final Qol conceptual model includes HRQoL, and in turn, it includes 4 additional first-level domains.\u003c/p\u003e\u003cp\u003eWB conceptual model shared three first level domains with HRQoL (Feeling and Emotions; Physical Functioning; and Social and Interpersonal relationships) and an additional one with QoL (Finances). However, for the first level domains shared with HRQoL we didn\u0026acute;t include the second level domains in the final models, because despite most of these (excluding Senses and Pain) were mentioned by at least one author, none met the criterion of being referenced by at least one third of the frameworks of the particular high-level concept. WB was the high-level concept with the more inconsistent domain inclusion, so fewer domains were finally incorporated.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e about here.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e about here.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e about here.\u003c/p\u003e \u003cp\u003eMapping of a set of PROMs to our final conceptual models.\u003c/p\u003e \u003cp\u003eEight commonly used PROMs -generic instruments were mapped for HRQoL (COOP-WONCA, SF-36, EQ-5D, SICKNESS IMPACT PROFILE, PROMIS-29, HUI-3, 15D and EQ-HWB), two instruments to QoL (AQOL-8D, WHO-QOL) and five instruments to Wellbeing (ICECAP-A, QUALITY OF WELL BEING SCALE, ICECAP-O, IWB, EQ-HWB). The EQ-HWB was primarily mapped to the high level concept HRQoL, but, having WB in its name, it was also mapped to Wellbeing. Of the conceptual frameworks developed, the tools mapped on average 59.4% of the domains for HRQoL (minimum and maximum of 33.3% and 94.4%; respectively), 65.9% for Qol (59.1 and 72.7), and for 34% Wellbeing (minimum and maximum of 30% and 50%; respectively). Of the eight instruments mapped to HRQoL, the EQ-HWB was the one that was shown to include fully or partially more domains concerning the domains of the conceptual model of HRQoL (17 out of 18). In the case of Wellbeing, all instruments had moderate to poor coverage, and the EQ-HWB the best performing one, with partial or full coverage of 5 out of 10 domains. In the Supplementary material 8 we show the detailed results of instrument mapping to the final high level conceptual models.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this qualitative systematic review, we performed an exhaustive survey of current conceptual frameworks of three key high-level concepts commonly used in health, policy and social science: Health-Related Quality of Life, Quality of Life, and Wellbeing. Based on synthesized frameworks from the literature, and after an in-depth inter-conceptual, intra-conceptual, and sub-conceptual analysis and curation, we propose a single conceptual framework for each of these concepts. Additionally, we map commonly used Patient Reported Outcomes Measures (PROMs) to these three concepts and domains, showing their almost universal partial coverage.\u003c/p\u003e \u003cp\u003eThis is to our knowledge the first systematic and comprehensive endeavor that aims to perform this task. We found no other studies that describe or contrast these high-level concepts and propose a unified definition based on the systematic retrieval and analysis of the existing reported frameworks. However, several authors have already pointed out the problem of their current conceptual \u0026ldquo;noise\u0026rdquo; regarding their definitions, and the possibility of clearly differentiating them. Moore et al. highlighted the conceptual difficulties in defining QoL and posited that HRQoL is an artificial measure, as patients must distinguish between the part of their life influenced by health and other areas not appreciably influenced by health.\u003csup\u003e\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e Other studies support this view, noting that the concepts of HRQoL and many definitions of QoL are not clearly differentiated from the concepts of health.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSimilarly, the concepts of QoL and WB are oftentimes umbrella terms that encompass many interpretations and methods of assessment, according to Gasper.\u003csup\u003e\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e Although WB tends to focus more on satisfaction and affective states, while QoL encompasses a broader, multifaceted assessment of the living conditions and resources available to an individual or group, these concepts are interrelated and often overlap. This confusion is understandable, as the concepts themselves are not well defined. A review of the term \"wellbeing\" highlighted the lack of a consistent definition.\u003csup\u003e\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e In addition, these concepts may have different interpretations in different regions or cultures,\u003csup\u003e\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e which makes it even more difficult to have unified concepts.\u003c/p\u003e \u003cp\u003eStrengths\u003c/p\u003e \u003cp\u003eOur review shows that, in addition to the lack of clear conceptual definitions both within and between concepts, the different domains assigned to each concept are also not sufficiently consistent and oftentimes overlap. As health research continues to evolve, establishing clear, coherent, and consistent conceptual frameworks is of utmost importance. This effort represents a significant advance, bringing unprecedented depiction and depth to the understanding and application of these three high-level health-related concepts. By moving in this direction, we aim not only to improve our understanding of HRQoL, QoL, and WB but also to contribute to the quality and impact of health research, policy and practice that incorporates these concepts.\u003c/p\u003e \u003cp\u003eThis research highlights the need to continually reflect on the definitions, domains, methods, and applications of these concepts to ensure that health policies and programs meaningfully address the areas of life that are important to people, thereby improving their quality of life and wellbeing in a comprehensive manner.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eIt is crucial to recognize some limitations of this study. Firstly and fundamentally -similarly to all non-objectively verified constructs or high-level concepts-, and though there are thousands of studies reporting and \u0026ldquo;measuring\u0026rdquo; HRQoL, QoL and WB, our study does not provide \u0026ldquo;definitive proof\u0026rdquo; that these concepts exist or are truths in nature, or that our proposed models are the truth. An inherent assumption of our study is that these concepts exist and are, though sharing common dimensions, distinct entities, and we simply try to depict them and clarify their boundaries. Secondly, we were -purposefully- \u0026ldquo;quality or methodologically agnostic\u0026rdquo; and we included all conceptual frameworks found in the literature, not distinguishing or weighting more heavily those that were derived in one manner or another (i.e expert derived conceptual frameworks were similarly treated to those derived by qualitative or quantitative research methods). As we wanted to be exhaustive in retrieving existing frameworks, and due to the heterogeneity of study designs, and many designs such as \u0026ldquo;expert-defined high-level concepts\u0026rdquo; do not have a bias assessment tool, we did not critically assess their quality or their risk of bias. Thirdly, though the proposed conceptual models are based on the exhaustive evidence review, including the frequency of domains in each concept, the final conceptualization included a qualitative research component, which included the authors' best collective judgment. Fourthly, the conceptualization of these high-level concepts may vary across countries and cultures, or in different population groups. Nevertheless, our goal was to develop a broad description of \"mainstream conceptual models\" used in the general population, which could be refined in future studies to examine aspects such as cultural, geographic, or other differences. Fifthly, we had a commonly found weakness in systematic reviews: we only included studies published in English, which could potentially introduce a selection bias. Nevertheless, we included several conceptual frameworks from non-English-speaking countries, and we do not consider this to be a significant shortcoming. Fifthly, most of the conceptual frameworks lacked clear definitions both the high-level concept as well as of the included domains. Thus, concept and domain harmonization were performed based on the best authors' judgment. Importantly, transparency was maintained by having the complete list of domains and a clear description of the process that arrived at the final proposed conceptual frameworks. Finally, in our work, we did not include another high-level concept commonly found in the literature: health status. We did not include health status as a central construct in our review because, although it is an important term in health research, its definitional scope is broader and less specific to the experiential focus of our work. The methodological and conceptual ambiguity sets health status apart from the three constructs we focused on. This could signal, nevertheless, a path for future studies.\u003c/p\u003e \u003cp\u003eFurther steps\u003c/p\u003e \u003cp\u003eFuture research can improve and strengthen our work in several ways a) Empirical and methodologically sound studies can explore and test -both with qualitative and quantitative psychometric research- the validity of these proposed high-level conceptual frameworks, b) Further research can explore the geographic and cultural diversity of these high-level concept frameworks, and also include non-English conceptual frameworks not detected or included in our study, c) Other studies can incorporate other related high-level concepts such as health status in order to broaden the scope of our study.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe absence of clear conceptual definitions poses a major challenge in differentiating health-related quality of life, quality of life, and wellbeing, which has a significant impact on the validity of measurement tools in health, social research, and policy. This paper serves as an initial step, shedding some light, as well as highlighting the existing darkness, on the conceptual frameworks of these three common high-level concepts, as well as assessing the comprehensiveness of common instruments for their assessment. Recognizing the need for clearer conceptual definitions and aligned frameworks, is an important step towards new analyses and developments in the understanding and measurement of these essential concepts, as well as empirical validation exercises to test their soundness and utility.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eHRQoL\u003c/strong\u003e \u0026ndash; Health-Related Quality of Life\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eQoL\u003c/strong\u003e \u0026ndash; Quality of Life\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eWB\u003c/strong\u003e \u0026ndash; Wellbeing\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePROMs\u003c/strong\u003e \u0026ndash; Patient-Reported Outcome Measures\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEQ-HWB\u003c/strong\u003e \u0026ndash; EuroQol Health and Wellbeing instrument\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEQ-5D\u003c/strong\u003e \u0026ndash; EuroQol 5-Dimension instrument\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCOOP-WONCA\u003c/strong\u003e \u0026ndash; COOP Functional Health Assessment Charts / World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHUI\u003c/strong\u003e \u0026ndash; Health Utilities Index\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003e15D\u003c/strong\u003e \u0026ndash; 15-Dimensional Measure of Health-Related Quality of Life\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSIP\u003c/strong\u003e \u0026ndash; Sickness Impact Profile\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSF-36\u003c/strong\u003e \u0026ndash; 36-Item Short Form Survey\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePRISMA\u003c/strong\u003e \u0026ndash; Preferred Reporting Items for Systematic Reviews and Meta-Analyses\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This study is a systematic review of published literature and does not involve human participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study, including the extracted domains and PROMs mapping tables, are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by [insert funder\u0026rsquo;s name, e.g., the EuroQol Research Foundation under grant number\u0026nbsp;1605-RA. The funder had no role in the design of the study, data collection, analysis, interpretation, or writing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e[F Augustovski] and [MB] conceptualized the study. [F Argento], [NI], [MB] and [JC] conducted the literature search and data extraction. All authors did the thematic synthesis. All authors contributed to the interpretation of findings. [F Augustovski] drafted the manuscript. All authors critically revised the manuscript and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDaniel Comand\u0026eacute;, librarian, IECS.\u003c/p\u003e\n\u003cp\u003eClara Mukuria\u003c/p\u003e\n\u003cp\u003eTessa Peasgood, University of Sheffield\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKarimi M, Brazier J. Health, Health-Related Quality of Life, and Quality of Life: What is the Difference? \u003cem\u003ePharmacoeconomics\u003c/em\u003e. 2016;34(7):645-649. doi:10.1007/s40273-016-0389-9\u003c/li\u003e\n\u003cli\u003ePubMed - National Institutes of Health (NIH). Accessed November 4, 2024. https://pubmed.ncbi.nlm.nih.gov/?term=quality+of+life+OR+wellbeing+OR+health+related+quality+of+life\u003c/li\u003e\n\u003cli\u003eSocial Sciences Citation Index. 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Understanding the diversity of conceptions of well-being and quality of life. \u003cem\u003eJ Socio Econ\u003c/em\u003e. 2010;39(3):351-360. doi:10.1016/j.socec.2009.11.006\u003c/li\u003e\n\u003cli\u003eBautista TG, Roman G, Khan M, et al. What is well-being? A scoping review of the conceptual and operational definitions of occupational well-being. \u003cem\u003eJ Clin Transl Sci\u003c/em\u003e. 2023;7(1):e227. doi:10.1017/cts.2023.648\u003c/li\u003e\n\u003cli\u003eMao Z, Ahmed S, Graham C, Kind P, Sun YN, Yu CH. Similarities and Differences in Health-Related Quality-of-Life Concepts Between the East and the West: A Qualitative Analysis of the Content of Health-Related Quality-of-Life Measures. \u003cem\u003eValue Health Reg Issues\u003c/em\u003e. 2021;24:96-106. doi:10.1016/j.vhri.2020.11.007\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"health-and-quality-of-life-outcomes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hqlo","sideBox":"Learn more about [Health and Quality of Life Outcomes](http://hqlo.biomedcentral.com)","snPcode":"12955","submissionUrl":"https://submission.nature.com/new-submission/12955/3","title":"Health and Quality of Life Outcomes","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health-related quality of life, quality of life, well-being, conceptual models, PROMs.","lastPublishedDoi":"10.21203/rs.3.rs-6976096/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6976096/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth-Related Quality of Life (HRQoL), Quality of Life (QoL), and Wellbeing (WB) are widely used outcome constructs in health research, clinical care, and policy. These concepts often overlap but are used in different contexts and disciplines, raising concerns regarding their comparability and relevance in health assessments and policy-making. This study review aims to perform a conceptual mapping of these commonly used concepts, propose evidence-informed frameworks, and map them to commonly used Patient-Reported Outcome Measures (PROMs).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a qualitative systematic review of conceptual frameworks for HRQoL, QoL, and WB published between 1990 and 2023. We searched PubMed, Scopus, and PsycINFO for peer-reviewed publications explicitly describing conceptual models. A thematic synthesis approach was used to analyze domains, subdomains and facets. We also assessed domain coverage of 10 widely used PROMs to explore alignment with the conceptual models.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom 14,114 records, we included 35 studies reporting 36 conceptual frameworks (HRQoL = 10; QoL = 12; WB = 14). We retrieved 168 first-level, 225 second-level, and 79 third-level domains, curated into 118 unique entities: 82 for HRQoL, 49 for QoL, and 69 for WB. Overlap analysis revealed 26 shared domains, 26 unique to WB, 29 to HRQoL, and 7 to QoL. Final models included 18 HRQoL, 22 QoL (18 from HRQoL plus 4), and 10 WB dimensions. PROMs mapping showed heterogeneous coverage of commonly used PROMS. The EQ-HWB had the broadest coverage of HRQoL (17/18) and WB (5/10).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptual inconsistency and overlap exist in the literature across HRQoL, QoL, and WB. The absence of clear conceptual and operational definitions limits their measurement validity. This study supports the development of clearer frameworks to enhance measurement and policy relevance. The conceptual coverage of commonly used PROMS appears sub-optimal and heterogeneous. These findings have implications for instrument selection, outcome interpretation, and the design of patient-centered evaluations. Greater clarity in conceptual definitions and improved alignment between theory and measurement tools are needed to support meaningful assessments of people’s lived experiences.\u003c/p\u003e\n\u003cp\u003eSystematic review registration OSF, CRD42023469014.\u003c/p\u003e","manuscriptTitle":"Conceptual Mapping of Health-Related Quality of Life, Quality of Life, and Wellbeing: A Systematic Review and Assessment of Commonly Used Patient-Reported Outcomes Measures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-07 08:35:04","doi":"10.21203/rs.3.rs-6976096/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-04T08:34:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-02T19:45:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"285000814200579066255649682450429671629","date":"2025-10-27T10:29:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-28T01:11:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124723893838717328358124378455548080828","date":"2025-07-14T14:37:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58079445953301021736586916909861971051","date":"2025-07-06T05:11:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-02T13:54:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-27T09:51:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-27T09:49:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"Health and Quality of Life Outcomes","date":"2025-06-25T15:06:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"health-and-quality-of-life-outcomes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hqlo","sideBox":"Learn more about [Health and Quality of Life Outcomes](http://hqlo.biomedcentral.com)","snPcode":"12955","submissionUrl":"https://submission.nature.com/new-submission/12955/3","title":"Health and Quality of Life Outcomes","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8b923443-1907-457c-808f-47d630237e48","owner":[],"postedDate":"July 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T19:38:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-07 08:35:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6976096","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6976096","identity":"rs-6976096","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}