B
Baby Hunger and Australian Women illness. The scale was originally developed to
Childbearing Desires Among Australian
Women
Bad Jobs
Dead-End Jobs
Bakas Caregiving Outcomes Scale
Tamilyn Bakas
Indiana University School of Nursing,
Indianapolis, IN, USA
Synonyms
Caregiver burden; Caregiving outcomes;
Caregiving outcomes measurement; Caregiving
questionnaire; Caregiving scale; Life changes
and caregiving outcomess; Measurement of care-
giving outcomes; Quality of life of caregivers;
Definition
The Bakas Caregiving Outcomes Scale (BCOS)
is an instrument designed to measure life changes
in family caregivers of persons with chronic
A.C. Michalos (ed.), Encyclopedia of Quality of Life and Well-Being Research,
DOI 10.1007/978-94-007-0753-5, # Springer Science+Business Media Dordrecht 2014
measure life changes in family caregivers of
stroke survivors, but has also been used in family
caregivers of those with heart failure and
a variety of other chronic conditions.
Description
Family caregivers are known to experience many
negative outcomes as a result of providing care for a
stroke survivor after discharge to the home setting
(Bakas, 2009; Miller et al., 2010). The Bakas Care-
giving Outcomes Scale (BCOS) was originally
developed in 1994 to measure life changes in family
caregivers of stroke survivors. Details regarding the
development and psychometric testing of the first
two versions of the BCOS are provided by Bakas
and Champion (1999). The BCOS has since been
revised to a 15-item version with psychometric
evidence being published in Bakas, Champion,
Perkins, Farran, and Williams (2006).
Development and psychometric testing of the
BCOS was based upon a conceptual model derived
from Lazarus transaction-based approach to stress
(Bakas & Champion, 1999; Bakas, Champion,
et al., 2006; Lazarus, 1991; Lazarus & Folkman,
1984). Within this model, antecedent personality
factors (e.g., self-esteem or optimism) and care-
giver tasks (e.g., providing personal care) are medi-
ated by cognitive appraisal to produce caregiver
emotional distress and adaptational outcomes.
The BCOS items were developed based upon Laz-
arus (1991) definition of adaptational outcomes,
B 320
defined as changes in social functioning, subjective
well-being, and health specifically as a result of
a stressful situation, such as providing care.
Of the 48 BCOS items that were initially devel-
oped, 27 exhibited 100 % agreement by a panel of
experts as having evidence of content validity. The
27 BCOS items were then tested in a sample of 92
family caregivers of stroke survivors, where the
scale was further reduced to 12 items using item
analysis (Bakas & Champion, 1999). Further test-
ing of the BCOS in another sample of 104 family
caregivers of stroke survivors further shortened the
scale to 10 items (Bakas & Champion, 1999). Both
12-item and 10-item versions had good evidence
of internal consistency reliability (Cronbach
alphas .90 and .77), and unidimensionality was
supported by factor analysis. Using hierarchical
multiple regression, concepts in the conceptual
model explained 63 % of the variance in the
12-item BCOS scores in the first sample and
45 % of the variance in the 10-item BCOS scores
in the second sample. Criterion-related validity
was supported in both samples with significant
BCOS correlations with the SF-36 Health
Survey, a life satisfaction instrument (LIFE-3),
and a single item asking caregivers how their
lives had changed overall as a result of providing
care (Bakas & Champion, 1999). Although both
12-item and 10-item versions of the BCOS
exhibited promising psychometric properties, low
correlations with some of the SF-36 Health Survey
subscales and the deletion of two poorly worded
financial items led to the addition of five new items
to the 10-item BCOS (Bakas, Champion, et al.,
2006). These new items included changes in finan-
cial well-being, physical functioning, general
health, roles in life, and level of energy. This
revised 15-item BCOS was then tested in a third
sample of 147 family caregivers of stroke survi-
vors (Bakas, Champion, et al., 2006). Satisfactory
evidence was provided for internal consistency
reliability (Cronbach alpha .90) and 2-week
test-retest reliability (intraclass coefficient .66).
Confirmatory factor analysis provided further sup-
port for unidimensionality of the 15-item BCOS,
and hierarchical multiple regression showed that
the constructs in the conceptual model explained
36 % of the variance in the 15-item BCOS scores.
Bakas Caregiving Outcomes Scale
Correlations between the 15-item BCOS and the
SF-36 Health Survey subscales improved, provid-
ing stronger support for criterion-related validity
(Bakas, Champion, et al., 2006).
Although the 15-item BCOS is recommended
for use with family caregivers of stroke survivors
(Bakas, 2009; Bakas & Champion, 1999; Bakas,
Champion, et al., 2006; Miller et al., 2010), it
has also been used in a variety of other caregiving
populations, such as with family caregivers of
persons with heart failure (Bakas, Pressler,
et al., 2006; Nauser, Bakas, & Welch, 2011;
Pressler et al., 2009), coronary artery bypass sur-
gery (Halm & Bakas, 2007), and bone marrow
transplant (Fife, Monahan, Abonour, Wood, &
Stump, 2009). The 15-item BCOS has also been
used as an outcome measure in stroke caregiver
intervention studies (Bakas et al., 2009; King,
Hartke, & Denby, 2007) and was used to describe
the impact of stroke caregiving in a population-
based study in Auckland, New Zealand (Parag
et al., 2008). Two comprehensive reviews of
caregiving burden measures have cited the
BCOS as having the most psychometric testing
of all of the tools reviewed (Deeken, Taylor,
Mangan, Yabroff, & Ingham, 2003) and of hav-
ing the highest rate of agreement among authors
for representing key caregiver concepts (Visser-
Meily, Post, Riphagen, & Lindeman, 2004).
The current 15-item BCOS consists of items
that address changes in social functioning, sub-
jective well-being, and health specifically as
a result of providing care for a family member.
Items are rated on a 7-point scale ranging from
3 (changed for the worst) to +3 (changed for the
best), with 0 meaning did not change. The 3 to
+3 ratings are recoded to 17 so that positive
numbers can be used for analyses. The advantage
of the BCOS over most caregiving scales is
the ability for caregivers to express positive
changes in their lives as a result of providing
care. For example, on average, caregivers rate
their self-esteem and relationship with the stroke
survivor as changing for the best as a result of
providing care (Bakas & Champion, 1999;
Bakas, Champion, et al., 2006). The most nega-
tive life changes include time for family and
social activities, relationship with friends,
Balance in Life
financial well-being, emotional well-being, level
of energy, and physical health (Bakas & Cham-
pion, 1999; Bakas, Champion, et al., 2006). Not
only can the BCOS be used as a research instru-
ment, but it could also be used as an assessment
tool at the item level to identify problem areas for
family caregivers in clinical practice (Bakas,
2009; Miller et al., 2010). Other advantages of
the BCOS include the fact that it is brief and
easily administered by mail, telephone, or by
face-to-face interviews (Bakas & Champion,
1999; Bakas, Champion, et al., 2006). For more
information or permission to use the BCOS in
research or practice, please contact Dr. Tamilyn
Bakas, Professor, Indiana University School of
Nursing, 1111 Middle Drive, Indianapolis, IN,
(317) 2744695, tbakas@iupui.edu.
Cross-References
Caregiver Burden
Caregiver Quality of Life
Caregiving
Family Caregiving
Quality of Life
References
Bakas, T. (2009). Chapter 42: Stroke and the family. In
J. Stein, R. Harvey, R. Macko, C. Winstein, &
R. Zorowitz (Eds.), Stroke recovery and rehabilita-
tion. Woodbridge, CT: Demos Publishing.
Bakas, T., & Champion, V. (1999). Development and
psychometric testing of the Bakas Caregiving
Outcomes Scale. Nursing Research, 48(5), 250259.
Bakas, T., Champion, V., Perkins, S. M., Farran, C. J., &
Williams, L. S. (2006). Psychometric testing of the
Revised 15-item Bakas Caregiving Outcomes Scale.
Nursing Research, 55(5), 346355.
Bakas, T., Farran, C. J., Austin, J. K., Given, B. A.,
Johnson, E. A., & Williams, L. S. (2009). Stroke care-
giver outcomes from the Telephone Assessment and
Skill-Building Kit (TASK). Topics in Stroke Rehabil-
itation, 16(2), 105121.
Bakas, T., Pressler, S. J., Johnson, E. A., Nauser, J. A., &
Shaneyfelt, T. (2006). Family caregiving in heart
failure. Nursing Research, 55(3), 180188.
Deeken, J. F., Taylor, K. L., Mangan, P., Yabroff, K. R., &
Ingham, J. M. (2003). Care for the caregivers:
321 B
A review of self-report instruments developed to mea-
sure the burden, needs, and quality of life of informal
caregivers. Journal of Pain and Symptom Manage-
ment, 26, 922953.
Fife, B. L., Monahan, P. O., Abonour, R., Wood, L. L., &
Stump, T. E. (2009). Adaptation of family caregivers B
during the acute phase of adult BMT. Bone Marrow
Transplantation, 43, 959966.
Halm, M. A., & Bakas, T. (2007). Factors associated with
caregiver depressive symptoms, outcomes, and per-
ceived physical health following coronary artery
bypass surgery. Journal of Cardiovascular Nursing,
22(6), 508515.
King, R. B., Hartke, R. J., & Denby, F. (2007). Problem-
solving early intervention: A pilot study of stroke
caregivers. Rehabilitation Nursing, 32(2), 6876, 84.
Lazarus, R. S. (1991). Emotion and adaptation.
New York: Oxford University Press.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal,
and coping. New York: Springer.
Miller, E. T., Murray, L., Richards, L., Zorowitz, R. D.,
Bakas, T., Clark, P. (2010). Comprehensive overview
of nursing and interdisciplinary rehabilitation care of
the stroke patient. A scientific statement from the
American Heart Association. Stroke, 41, 24022448.
Nauser, J. A., Bakas, T., & Welch, J. L. (2011). A new
instrument to measure quality of life of heart failure
family caregivers. Journal of Cardiovascular Nursing,
26(1), 5364.
Parag, V., Hackett, M. L., Yapa, C. M., Kerse, N.,
McNaughton, H., Feigin, V. L., Anderson, C. S., on
behalf of the Auckland Regional Community Stroke
(ARCOS) Study Group. (2008). The impact of stroke
on unpaid caregivers: Results from the Auckland
Regional Community Stroke Study, 20022003.
Cardiovascular Disease, 25, 548554.
Pressler, S. J., Gradus-Pizlo, I., Chubinski, S. D., Wheeler,
S., Wu, J., & Sloan, R. (2009). Family caregiver out-
comes in heart failure. American Journal of Critical
Care, 18(2), 149159.
Visser-Meily, J. M. A., Post, M. W. M., Riphagen, I. I., &
Lindeman, E. (2004). Measures used to assess burden
among caregivers of stroke patients: A review. Clini-
cal Rehabilitation, 18, 601623.
Balance and Happiness
Balanced Life
Balance in Life
Balanced Life
B 322
Balanced Life
M. Joseph Sirgy
Department of Marketing, Virginia Polytechnic
Institute & State University, Blacksburg,
VA, USA
Synonyms
Balance and happiness; Balance in life; Role
balance; Work-family conflict; Work-life
balance; Work-nonwork balance
Definition
Balance in life is an important dimension of sub-
jective well-being. It is defined as a state
reflecting satisfaction or fulfillment in several
important domains with little or no negative
affect in other domains. Achieving balance in
life allows people to satisfy the full spectrum of
human development needs, both basic and
growth needs, which in turn contributes to
long-term happiness.
Description
Martin Seligman, in his very popular book
Authentic Happiness (Seligman, 2002), argued
that authentic happiness is derived from three
major sets of experiences in life, namely,
experiencing pleasantness regularly (the pleasant
life), experiencing a high level of engagement in
satisfying activities (the engaged life), and
experiencing a sense of connectedness to
a greater whole (the meaningful life). Sirgy and
Wu (2009) built on Seligmans three dimensions
of happiness by adding a fourth dimension: the
balanced life. They argued that balance in life
contributes significantly to subjective well-
being. This may be due to the fact that only
a limited amount of satisfaction can be derived
from a single life domain. People have to be
Balanced Life
involved in multiple domains to satisfy the full
spectrum of human development needs (biologi-
cal, safety, social, esteem, self-actualization,
knowledge, and aesthetics needs). Different life
domains tend to focus on different human devel-
opment needs. More specifically, balance
contributes to subjective well-being because sub-
jective well-being can only be attained when both
survival (basic) and growth needs are met.
In other words, high levels of subjective well-
being cannot be attained with satisfaction of
basic needs or growth needs alone. Both sets of
needs have to be met to contribute significantly to
subjective well-being in the long run.
Research on imbalance between work and
family roles has shown that work-family role
conflict is associated with life dissatisfaction as
well as low marital and family satisfaction and
symptoms of low mental and physical well-
being (Edwards & Rothbard, 2000; Sturges &
Guest, 2004). Family-work conflict occurs
when one domain consumes resources needed
for another domain. With respect to balance,
there is some evidence suggesting that people
are more satisfied with life when the source of
the satisfaction derives from multiple life
domains than a single domain. For example,
Marks and McDermid (1996) described
a theory of role balance that suggests that peo-
ple who have well-balanced role systems,
which they conceptualize as full engagement
in and enjoyment of all roles, have higher levels
of well-being. Using a sample of employed
mothers, they showed that those who were
more role-balanced and enjoyed every part
of their life equally well reported less role
overload, had higher self-esteem, and lower
depression levels.
Bhargava (1995) conducted a study in which
subjects were asked to discuss life satisfaction
of others. Most subjects inferred life satisfac-
tion of others as a direct function of their satis-
faction in multiple domains. They calculated
happiness by summing satisfaction across sev-
eral important domains the more positive
affect in multiple domains, the higher the sub-
jective well-being. Additional evidence comes
Balanced Life
from a study conducted by Chen (1996) who
found that those who believe they will achieve
some of their goals (and receive satisfaction
from multiple domains) report higher levels of
life satisfaction than those who do not believe
that they will achieve these goals.
Balance theory of subjective well-being has
three main postulates. These are:
Postulate 1: People who have balance in their
lives (life satisfaction stemming from multiple
life domains) are likely to experience higher
levels of subjective well-being than those who
have imbalance (life satisfaction stemming
from a single life domain).
Postulate 2: Balance contributes to subjective
well-being because of the satisfaction limit
that people can derive from a single life
domain. People have to be involved in multi-
ple domains to satisfy the full spectrum of
human development needs. Different life
domains tend to focus on different human
development needs.
Postulate 3: Balance contributes to subjective
well-being because subjective well-being can
only be attained when both survival and
growth needs are met. High levels of subjec-
tive well-being cannot be attained with satis-
faction of basic needs or growth needs alone.
Both needs have to be met to induce subjective
well-being.
Discussion
Balance theory of subjective well-being posits
that people who have balance in their lives
(life satisfaction stemming from multiple life
domains) are likely to experience higher levels
of subjective well-being than those who have
imbalance (life satisfaction stemming from
a single life domain). That balance contributes
to subjective well-being because of the satisfac-
tion limit that people can derive from a single
life domain. People have to be involved in mul-
tiple domains to satisfy the full spectrum of
human development needs. Different life
domains tend to focus on different human
323 B
developmental needs. Furthermore, balance
contributes to subjective well-being because
subjective well-being can only be attained
when both survival and growth needs are met.
High levels of subjective well-being cannot be B
attained with satisfaction of basic needs or
growth needs alone. Both needs have to be met
to induce subjective well-being.
This balance phenomenon has an important
clinical implication. Balance implies that put-
ting all your eggs in one basket may not be
effective in enhancing subjective well-being.
That is, one should not allow one life domain to
overwhelm ones satisfaction or dissatisfaction
with life. It is best to be invested emotionally in
several domains. Doing so allows one to compen-
sate for the dissatisfaction of some domains with
satisfaction of other domains.
Cross-References
Happiness
Life Satisfaction, Concept of
Meaningfulness of Work
Role Theory
Work-Family Enrichment
Work-Family Facilitation
Work-Family Fit
Work-Life Balance
Work-Life Harmony
References
Bhargava, S. (1995). An integration-theoretical analysis
of life satisfaction. Psychological Studies, 40,
170180.
Chen, N. (1996). Individual differences in answering the
four questions of happiness. Ph.D. dissertation,
University of Georgia, Athens, GA.
Edwards, J. R., & Rothbard, N. C. (2000). Mechanisms
linking work and family: Clarifying the relationship
between work and family constructs. Academy of
Management Review, 25, 178199.
Marks, S. R., & MacDermid, S. M. (1996). Multiple roles
and the self: A theory of role balance. Journal of
Marriage and the Family, 58, 417432.
B 324
Seligman, M. E. P. (2002). Authentic happiness: Using the
new positive psychology to realize your potential for
lasting fulfillment. New York: The Free Press.
Sirgy, M. J., & Wu, J. (2009). The pleasant life, the
engaged life, and the meaningful life: What about the
balanced life? Journal of Happiness Studies, 10(2),
183196.
Sturges, J., & Guest, D. (2004). Working to live or living
to work? Work/life balance early in the career. Human
Resource Management Journal, 14(4), 515.
Ballet
Arts and Quality of Life
Bankruptcy
Benedicto Lukanima
Business School, Universidad del Norte,
Barranquilla, Colombia
Definition
Bankruptcy refers to inability of a person or orga-
nization to meet debt repayment obligations.
Therefore, bankruptcy means endeavors to settle
debt problems, which is generally associated with
a legal insolvency status. Usually, this legal status
is a result of either a petition made by the debtor
and imposed by a court order or by own applica-
tion to be declared bankrupt.
Description
Although it can help to clear debts, bankruptcy
tends to have negative implications too; hence, it
is often considered a last resort after exhausting
other measures. For example, bankruptcy may
entail giving up any possessions of value and
any interest in your home or business. For
a business, it will become necessary to close or
Ballet
dismiss all employees. Overall, it implies finan-
cial failure. Lehman Brothers is a good case the
consequence of bankruptcy (see Thomas, 2008).
However, bankruptcy may allow for a financial
recovery of individual or business finances
(Daily & Dalton, 1994).
The treatment of bankruptcy differs across
countries, depending on distinctive legal defini-
tions of bankruptcy (Darydenko & Franks,
2008). For example, in India, the legal mean-
ing of the terms bankruptcy, insolvency, liqui-
dation, and dissolution is contested in the Indian
legal system: there is no regulation or statute
legislated upon bankruptcy which denotes
a condition to meet a demand of a creditor, as
is common in many other jurisdictions (Kang &
Nayar, 2003). In the United Kingdom, bank-
ruptcy relates only to individuals and partner-
ships: companies and other corporations enter
into differently named legal insolvency proce-
dures. The USA defines six types of bankruptcy
under the Bankruptcy Code, Title 11 of the
United States Code. In Switzerland, bankruptcy
can be a consequence of insolvency, whereby all
assets of the debtor are liquidated under the
administration of the creditors. In Canada, bank-
ruptcy is filed when a person or an organization
becomes insolvent and cannot pay their debts as
they become due. However, a person can file
a consumer proposal (a negotiated settlement
between a debtor and their creditors) as an alter-
native to bankruptcy.
As a result of difference bankruptcy codes,
there is evidence of different implications
across countries, such as creditors rights also
vary across countries, thereby influencing the
way banks adjust their lending and reorganiza-
tion practices (Darydenko & Franks, 2008); the
way firms in different countries respond to mac-
roeconomic instability is associated with differ-
ences in bankruptcy codes (Battacherjee,
Higson, Chris, Kattuman, & Paul, 2004); for-
eign ownership and domestic ownership in
the United States reflect differences in the
frequency of financial failure, in which foreign-
controlled firms fail less frequently (Li &
Guisinger, 1991).
Barthel Index
Cross-References
Economic and Financial Literacy
Federal Debt to GDP, Ratio of
Personal Household Debt to GDP, Ratio of
Public Debt
References
Battacherjee, A., Higson, C., Holly, S., & Kattuman, P.
(2004). Business failure in UK and US quoted firms:
Impact of macroeconomic instability and the role of
legal institutions, Cambridge Working Papers in
Economics, CWPE 0420, accessed at: http://www.
dspace.cam.ac.uk/handle/1810/399.
Daily, C. M., & Dalton, D. R. (1994). Bankruptcy and
corporate governance: The impact of board composi-
tion and structure. The Academy of Management
Journal, 37(6), 16031617.
Darydenko, S. A., & Franks, J. R. (2008). Do bankruptcy
codes matter? A study of defaults in France, Germany
and the UK. Journal of Finance, 63(2), 565608.
Kang, N., & Nayar, N. (2003), The evolution of corporate
bankruptcy law in India, ICRA Bulletin, Money and
Finance, October 2003 March 2004, 3758.
Li, J., & Guisinger, S. (1991). Comparative business failure
of foreign-controlled firms in the united states. Journal
of International Business Studies, 22(2), 209224.
Thomas, L. (2008). Examining the ripple effect of
the Lehman bankruptcy, New York Times. Accessed
at http://www.nytimes.com/2008/09/15/business/
worldbusiness/15iht-lehman.4.16176487.html
Barthel ADL Index
Barthel Index
Barthel Index
Michaela Saisana
Econometrics and Applied Statistics, Joint
Research Centre, European Commission,
Ispra, Italy
Synonyms
Barthel ADL index; Barthel scale
325 B
Definition
The Barthel index measures the likelihood
of being able to live at home with a degree of
independence following discharge from hospital. B
Ten basic activities of daily living (ADL) are
captured: bowels, bladder, grooming, toilet use,
feeding, transfers, walking, dressing, climbing
stairs, and bathing.
Description
The Barthel index was introduced in 1965 and
was measured in a 020 scale (Mahoney &
Barthel, 1965). Although this original version
is still widely used, it was modified by Granger,
Dewis, Peters, Sherwood, and Barrett (1979)
when it came to include 010 points for every
item (total possible score of 0100). Further
refinements were introduced by Shah, Vanclay,
and Cooper (1989).
The ten performance items of the Barthel
index (with original scales and scores as
introduced in 1965) are shown in Table 1.
Discussion
The Barthel index is one of the first contribu-
tions to the functional status literature and it
represents physical therapists lengthy period
of inclusion of functional mobility and ADL
measurement within their scope of practice
(OSullivan & Schmitz, 2007). The scale is
regarded as reliable, although its use in clinical
trials in stroke medicine is inconsistent (Sulter,
Steen, & De Keyser, 1999). It has, however,
been used extensively to monitor functional
changes in individuals receiving in-patient
rehabilitation, mainly in predicting the func-
tional outcomes related to stroke. The Barthel
index has demonstrated high interrator reliabil-
ity (0.95) and test-retest reliability (0.89)
as well as high correlations (0.740.8)
with other measures of physical disability
(Collin, Wade, Davies, & Horne, 1988; Wade
& Collin, 1988).
B 326 Barthel Scale

Barthel Index, Table 1 Barthel index items

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

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

References Basic Capabilities Index (BCI)

Collin, C., Wade, D. T., Davies, S., & Horne, V. (1988). Ian Percy
The Barthel ADL Index: A reliability study. Interna- Instituto del Tercer Mundo (ITeM), Montevideo,
tional Disability Studies, 10, 6163. Uruguay
Granger, C. V., Dewis, L. S., Peters, N. C., Sherwood,
C. C., & Barrett, J. E. (1979). Stroke rehabilitation:
Analysis of repeated Barthel index measures. Archives
of Physical Medicine and Rehabilitation, 60, 1417. Synonyms
Mahoney, F. I., & Barthel, D. W. (1965). Functional
evaluation: The Barthel Index. Meryland State
Medical Journal, 14, 6165.
BCI; QLI; Quality of Life Index
OSullivan, S. B., & Schmitz, T. J. (2007). Physical
rehabilitation (5th ed.). Philadelphia: F.A. Davis
Company. Definition
Shah, S., Vanclay, F., & Cooper, B. (1989). Improving the
sensitivity of the Barthel Index for stroke rehabilita-
tion. Journal of Clinical Epidemiology, 42, 703709. The Basic Capabilities Index (BCI) was designed
Sulter, G., Steen, C., & De Keyser, J. (1999). Use of the by Social Watch as an alternative way to monitor
Barthel index and modified Rankin scale in acute the situation of poverty in the world. Most of the
stroke trials. Stroke, 30, 15381541.
Wade, D. T., & Collin, C. (1988). The Barthel ADL Index:
available poverty-measurement indicators are
A standard measure of physical disability? based on the premise that poverty is a monetary
International Disability Studies, 10, 6467. phenomenon. The BCI, like other alternative
Basic Capabilities Index (BCI)
(nonmonetary) ways of measuring poverty, is
based instead on a persons capability of accessing
a series of services that are indispensable for sur-
vival and human dignity. The indicators that make
up the BCI are among the most basic of those used
to measure the Millennium Development Goals.
Description
In the 2001 Philippines Social Watch Report,
Rene R. Raya wrote an article outlining the meth-
odology for the Quality of Life Index. This
index was derived from the Capability Poverty
Index proposed by Professor Amartya Sen and
popularized as the UNDP Human Development
Index. The Quality of Life Index was an approach
for measuring poverty and welfare based purely
on capabilities. The index was based on indica-
tors directly linked to development goals and
excluded variables relating to income. In 2004,
Social Watch (SW), an international watchdog
citizens network on poverty eradication and gen-
der equality, published the first (and last) interna-
tional Quality of Life Index (QLI). In 2005, SW
created the Basic Capabilities Index (BCI) using
the same methodology as the QLI.
The BCI compares and classifies countries
according to their progress in social develop-
ment. Most of the available poverty-
measurement indicators are based on the premise
that poverty is a monetary phenomenon, and they
measure, for example, how many persons live
with an income of less than two dollars a day.
Social progress does not automatically follow
economic growth, and better indicators are
needed to more accurately monitor the evolution
of nonmonetary poverty in the world. The indi-
cators that make up the BCI are among the most
basic of those used to measure the Millennium
Development Goals.
Beginning in 1996, the Social Watch Annual
Report included a listing of the countries of the
world ranked by their situation in a series of
dimensions considered important for evaluating
social development, the Social Watch Score-
card. The method used before the introduction
of the BCI/QLI was to calculate the unweighted
327 B
average of all the scores obtained by a country in
each of the thematic areas related to develop-
ment. Given the practical difficulties involved in
taking so many different dimensions into
account, SW had been working on designing an B
index that would provide a functional summary
of the overall situation of a given country using
available information. Until 2004, the Social
Watch methodology had produced an index rank-
ing countries in relation to each other, based on
the average values of their current situations by
area. In contrast, the BCI/QLI aimed not only to
provide a criterion for ranking the countries in
relation to each other but also to allow the situa-
tion in a given country to be monitored over time,
by tracking changes in its summary value.
There are several possible strategies for
constructing such an index. One is to take into
account the different thematic areas and their
component indicators, in order to obtain (through
factorial analysis) a statistical index that, by
reducing the number of dimensions, comes closer
in empirical terms to explaining variance
between countries. This option, however, is sig-
nificantly hampered by the heterogeneity of the
set of available indicators, both in terms of the
number of countries for which information is
available and the degree of comparability
between countries. A second approach, which
has been adopted in several summary indexes in
use by various international organizations, is to
select certain indicators for which the above-
mentioned difficulties can be minimized since
there is sufficient and comparable data available
for them and which in empirical terms show an
evolution that reflects a series of basic indicators
of economic and social development. In princi-
ple, opting for summary measurements means
consciously leaving out certain dimensions that
on a conceptual level may be considered essen-
tial. However, by reducing the analytic dimen-
sions and selecting a set of variables that has
a strong correlation with the range of original
variables allows us to explain the same levels of
variance between countries while using fewer
variables.
The BCI/QLI is an approach for measuring
poverty and welfare based purely on capabilities.
B 328
The index is based on indicators directly linked
to development goals and excludes variables
relating to income. The dimensions included
in the BCI/QLI are infant health, reproductive
health, and education. The indicators of the BCI/
QLI are mortality in under-fives, percentage of
births attended by skilled health personnel, and
the proportion of children enrolled in first grade
who reach fifth grade. These indicators are
approximate measures of human capabilities
and have been shown to be sensitive enough to
summarize a populations overall situation with
respect to health, educational performance, and
literacy.
On a conceptual level, the choice of the vari-
able relating to staying in primary school until 5th
grade is justified on the grounds that if just the
rate of coverage were taken into consideration,
the phenomenon of high primary school drop-out
rates present in less developed countries would be
ignored. The variable infant mortality is an indi-
cator that shows a high correlation with food
security and child malnutrition and is more
widely available in national statistical records
than direct malnutrition or food security indica-
tors. The percentage of births attended by skilled
health personnel is in practical terms an accurate
measure of levels of health care, which enjoys
a degree of independence from geographical or
climatic factors that could distort analyses of the
health situation. Indicators based on the preva-
lence of diseases would be biased in this way. The
selection of these three indicators was also deter-
mined by the criterion of seeking to obtain the
highest possible number of units of analysis with
information available at national and local levels,
in order to ensure consistency with international
standards of measurement, and thus allow com-
parisons to be made and links identified with
existing indicators of welfare.
The BCI/QLI was calculated using the non-
weighted average of the original values of the
three indicators in question (in the case of infant
mortality, a lineal transformation was previously
applied to the indicator). To simplify the calcula-
tions, all three indicators were given the
same weight. Child health is represented as
I1 (100  M), where M is the under-5 mortality
Basic Capabilities Index (BCI)
rate (expressed as a percentage) or the probability
of death in the first five years of life per 100 live
births. Education is represented as I2, where I2 is
the rate of school retention or the percentage of
children enrolled in the first grade who reach the
fifth grade. Reproductive health is shown as I3,
where I3 is the percentage of births assisted by
skilled health personnel (doctors, nurses, or mid-
wives). The BCI/QLI value for a particular coun-
try is obtained by taking a simple average of the
three components: BCI/QLI (I1 + I2 + I3)/3.
Using this methodology, the BCI/QLI proved
to be a good tool for measuring aspects relating to
the quality of life and presented a strong correla-
tion with other indicators and indexes that are
generally used to measure development or to
classify countries according to their levels of
well-being: the Human Development Index, the
Human Poverty Index, the international poverty
line, and per capita gross domestic product
(GDP).
Poverty, quality of life, and welfare are com-
plex concepts. It is almost impossible to reflect
the complexity and dynamic nature of a particular
situation by using a simple numerical value.
However, a well-designed index can be an effi-
cient tool for identifying the incidence of poverty,
defining objectives, and monitoring and evaluat-
ing strategies. Indicators cannot replace a more
comprehensive social analysis of the situation,
but they can provide a good starting point for
the development and design of programs since
they provide tools for measuring and comparing
situations.
Income-based measurements of poverty have
functional limitations that make precise monitor-
ing of their evolution difficult. These indices
depend on household-level surveys of spending
and consumption which, because of the high
cost that they entail, are not always carried out in
a systematic manner in all countries. The BCI/QLI
has comparative advantages in that it is relatively
simple to calculate and inexpensive because it
does not depend on household surveys to estimate
levels of income. It is compatible with the various
national and international statistical systems, and
it can be calculated easily from indicator data that
are regularly issued by governments and agencies.
Basic Needs
In addition to being an instrument for classifying
the relative situation of countries or of particular
sectors within a country (e.g., population groups or
geographical areas), it can also be used to generate
time series for monitoring situations related to
poverty.
The BCI/QLI makes it possible to distinguish
between countries which have not yet reached the
minimum conditions represented by the three
indices, but it is less sensitive when detecting
differences between countries that have reached
a relatively high level of development. Thus, it is
more suitable for identifying critical situations
than for detecting slight differences between
more developed countries.
Without doubt there is a great need to improve
the series and the accuracy and consistency of the
data used in the generation of the key indicators
of social development. The gaps in the informa-
tion available are a constant problem plaguing the
definition of objectives and the process of moni-
toring. The BCI/QLI was designed precisely to
fill these gaps and so to contribute toward ana-
lyses of poverty and policy design and planning
for development.
Cross-References
Capabilities
Development
Education
Gender Equity Index
Happiness
Health
Quality of Life Research
Welfare
References
Raya, R. R. (2001). An alternative measure of poverty and
human capability: Introducing the Quality of Life
Index. Social Watch Philippines 2001 Report.
Accessed April 21 2011, http://www.socialwatch.org/
node/12450
Social Watch. (1997). Methodological Appendix. Social
Watch Annual Report 1997. Accessed April 21 2011,
http://www.socialwatch.org/node/11326
329 B
Social Watch. (2003). Social Watch Report 2003 The
poor and the market. Accessed April 21 2011, http://
www.socialwatch.org/node/11120
Social Watch. (2004). General classification of countries:
situation by thematic area and Quality of Life Index
(QLI). The Social Watch 2004 Scorecard. Accessed B
April 21 2011, http://www.socialwatch.org/node/11944
Social Watch. (2005). Methodology. The Social Watch
2005 Scorecard. Accessed April 21 2011, http://www.
socialwatch.org/node/11939
Social Watch. (2006). The Social Watch 2006 Scorecard.
Accessed April 21 2011, http://www.socialwatch.org/
taxonomy/term/51
Social Watch. (2007). The Basic Capabilities Index
2007 Far from where we should be. Accessed April
21 2011, http://www.socialwatch.org/sites/default/
files/ICB_2007_eng/BasicCapabilitiesIndex2007.pdf
Social Watch. (2008). The Basic Capabilities Index
2008 Way too slow. Accessed April 19 2011,
http://www.socialwatch.org/node/9239
Social Watch. (2009). Basic Capabilities Index: A starting
point. Basic Capabilities Index 2009. Accessed April
19 2011, http://www.socialwatch.org/node/11389
Social Watch. (2010). The current picture as shown by the
BCI. Basic Capabilities Index 2010. Accessed April 19
2011, http://www.socialwatch.org/node/12259
Basic Child Care and Well-Being
Parental Time and Child Well-Being
Basic Emotions Recognition
Measuring Emotion Recognition Ability
Basic Needs
Enrica Chiappero-Martinetti
Department of Political and Social Sciences,
University of Pavia, Pavia, Italy
HDCPIRC, Institute for Advanced Study,
Pavia, Italy
Synonyms
Core needs; Human needs; Minimal needs
B 330
Definition
Basic needs (BN) are generally defined in
terms of a minimal list of elements that
human beings necessitate, in order to fulfill
basic requirements and achieve a decent life.
Typically, the list includes basic commodities,
such as food, clothing, and shelter, as well as
essential services, as access to drinking water,
to sanitation, to education, to healthcare facil-
ities, and to public transportation. Broader
definitions of basic needs further extend the
attention to other psychological and social
needs such as participation, self-reliance,
autonomy, and self-expression.
A basic needs approach (BNA) to
development is a strategy according to which
development is defined by the fulfillment of every-
ones basic necessities, together with the participa-
tory involvement of people in the decision-making
process of policies that shall affect them.
Description
Concepts
The concept of basic needs dates back to the first
half of the nineteenth century, and it originally
stemmed from a variety of disciplinary perspec-
tives. In fact, this notion can be traced back to the
field of psychology (see, for example, Maslows
Hierarchy of Needs (Maslow, 1943) and Douglas
McGregors Managerial and Human Motivation
Theories (McGregor, 1960)). Afterwards, it
benefitted from the contribution of anthropology
(Malinowskis Basic Human Needs (Langness,
1987)), to social and political theory (Bradshaws
Taxonomy of Social Need (Bradshaw, 1972) and
The Theory of Human Need, formulated by
Doyal and Gough (1991), to philosophy (for
example, Wiggins definition of absolute and
entrenched needs (Reader, 2005; Wiggins,
1987)), to economics (starting from Marxs con-
cepts of primary and secondary needs and
Keynes juxtaposition between basic but limited
needs and relative but limitless needs), and also to
development economics and development policy
Basic Needs
(as can be seen in the works of Max-Neef, 1991;
Streeten et al., 1981; Stewart, 1985).
In this extract, we will restrict the attention
to the contributions offered to this debate by
economists and development experts.
From the common notion of basic needs,
a variety of conceptions have been formulated
on the basis of different interpretations of
what is to be essential to human life. There are
two main definitions, both formed by
a dichotomy, which are particularly worth men-
tioning: First, basic needs can either be defined
in absolute or in relative terms and, secondly,
basic needs can be intended as ends or as means.
With regard to the prior definition and
dichotomy, basic needs can be defined either in
absolute or relative terms similarly to abso-
lute and relative approaches to poverty. In the
case of absolute basic needs, the attention is
restricted to a minimal list of aspects that are
considered to be necessary for mere survival of
individuals and without which human life would
be seriously impaired. In this case, the attention
is usually focused on things such as food,
shelter, clothing, access to basic healthcare and
educational services, and availability of clean
water and transportation. For each of these
basic necessities, a minimum threshold might
be defined by technical experts such as nutri-
tionists, medical doctors, teachers, and engi-
neers or by policy-makers, or even by the
people themselves. The resulting lists and
thresholds need not be the same across different
basic needs. Moreover, this absolute view does
not limit the essential elements to material needs
but allows for taking into account also other
dimensions such as human rights, freedom,
participation, and self-reliance. However, the
absolute view strictly assumes that the same
basic necessities are to be equally relevant for
everybody in every country thus being basic
needs in absolute or universal terms.
On the other hand, a relative perspective to
the concept of basic needs acknowledges that
the social construction process of selecting and
defining basic necessities can significantly
differ across countries and cultures. Thus,
according to this second approach, the lists of
Basic Needs
basic needs would have to be identified and
structured depending on what is in fact consid-
ered as essential in a particular society they
should not be defined in absolute terms. For
example, from the relative point of view, what
could be considered to be a basic necessity for
a person living in a rural community in
Africa may differ significantly from that of
a person living in a European capital or from
an inhabitant of the same region but in
a different period of time.
However, the absolute and relative perspectives
may not actually conflict as much as it might
appear at first sight. Indeed, these two views
can at least in principle be combined. The
general concept of basic needs can be,
and frequently is, considered of universal applica-
bility as it refers to all people in all countries.
Nevertheless, the particular specification of the
list of basic needs and the corresponding thresh-
olds of commodities and resources required to
fulfill them can be country-specific and reflect
prevailing customs and cultural trends. Moreover,
basic needs need not necessarily be fixed in time:
In fact, from a dynamic perspective, they can
change across years and incorporate new emerging
needs in addition to the existing ones, or following
their fulfillment.
Ultimately, the distinction between an
absolute and relative view of basic needs opens
the way to other related and controversial issues
that need to be taken into account (Streeten,
1984), as to the following: Who is to determine
and define basic needs? To what extent can the
definition of a basic necessity be arbitrary or
objective? How can a consensus be reached on
what is to be considered as essential for human
beings? And, would the fulfillment of a basket of
basic necessities be the ultimate goal of
a given society, or do human needs expand and
build upon their satisfaction, giving rise to
other needs? (See also Ghai and Alfthan (1977))
While consensus on these queries is not reached,
what seems to generally prevail, especially from
a development perspective, is that it is both
urgent and legitimate that the basic needs of
the poorest people are to be met (International
Labour Organization [ILO], 1976).
331 B
A second dichotomy is related to the interpre-
tation of basic needs as either means or ends.
This differentiation reflects the investment and
consumption roles that basic needs might have
in human life. For example, education can be B
considered as a consumption good that has an
intrinsic value for those who enjoy it; however,
it may also have an instrumental role as a human
capital investment that will pay off for both
the individual and for society as a whole.
Also in this case, there is not a strict dichotomy
whereby the means vs. ends views are necessarily
opposing and conflicting. On the other hand, these
views are often integrated, because in most cases
the fulfillment of a basic necessity is not only an
end that is valuable in itself but it is also
a means, which contributes to the attainment of
other goals. For instance, health, education, and
employment are good examples of the twofold
instrumental and intrinsic roles that these basic
needs have: A better nourished, healthy, educated,
and skilled labor force allows to increase produc-
tivity and reduce reproductivity, which in turn are
both central goals for economic and human devel-
opment. Nevertheless, as pointed out by Streeten
(1984), conflicts may arise between a means-/pro-
ductivity-based approach and an instrumental/
human development view of basic needs, in
terms of which groups are to be targeted as not
all human beings are members of the labor force
as well as regarding the content of human capital
investment; for instance, should education be only
productivity-oriented? Thus, the two visions can
only partially overlap.
An official definition of basic needs first arose
from the works of the World Employment Con-
ference, organized by the International Labour
Organization (ILO) in 1976. In this occasion,
a nearly unanimous adoption of the Declaration
of Principle and Programme of Action was taken
by the member states, in which basic needs were
defined in terms of a minimum standard of liv-
ing which a society should set for the poorest
groups of its people (ILO, 1976, p. 7).
The established bundle of basic needs
included two elements: first, a minimum require-
ment of private consumption in terms of food,
shelter, and clothing, and, secondly, access to
B 332
essential services, such as safe drinking water,
sanitation, transport, health, and education
provided by and for a community at large
(ILO, 1976, p. 6). Moreover, a specific goal was
also agreed: increasing the rate of employment of
the labor force and its productivity indeed,
[the basic needs approach] implies that each
person available for and willing to work should
have an adequately remunerated job. Special
attention was placed on employment, as in this
occasion it had been conformed as the main
instrument for achieving the ultimate goal of
a minimum standard of living for all people.
In the same report, it was also specified that
these minimum standards should be universally
regarded as essential to a decent life: Whereas
basic needs targets can in principle vary from
country to country, a minimum level of basic
needs [were to be] targets to be achieved by the
world community (ILO, 1976, pp. 67).
Finally, the importance of participation and in
particular, the participation of the poorest people,
whose basic needs had to be met was strongly
emphasized. It was affirmed that ideally, the people
themselves should directly, or indirectly through
a representative institution, decide the scope, con-
tent, and priority of their own basic necessities.
However, it was neither clear nor obvious how
this could concretely be done: People, and disad-
vantaged groups in particular, can be severely ham-
pered in expressing their views and interests, even
more so if they live in the most destitute contexts.
Yet, even in more promising conditions and in
general, it is not easy to understand what form of
participation should be taken or what kind of sup-
port is needed in order to give actual effect to the
participatory opinions. In other words, while there
seems to be a broad consensus on the necessity to
engage people in the decision-making process, as
Streeten (1984, p. 975) remarks, the call for par-
ticipation is (still) too vague.
Indicators
A year after the above-mentioned document,
an ILOs volume was published (Ghai, Khan, Lee,
& Alfthan, 1977) in order to discuss the main con-
ceptual and empirical issues connected with a
basic needs strategy and to develop a general
Basic Needs
methodology for identifying and measuring basic
needs targets (Ghai & Alfthan, 1977).
Measuring basic needs is not an easy task. First
of all, it requires the identification of the material
and nonmaterial aspects that are to be considered
basic necessities. This could imply a rather exten-
sive list or a restricted core set of basic needs. In
any case, as previously outlined, it is not at all
obvious who should be in charge of compiling
this list and how it should be done. Once a list of
basic necessities is identified, the subsequent step
is to define the corresponding level at which the
basic needs might be fulfilled this may, for
example, be in terms of a threshold of calorie
intake, or educational contents, or housing charac-
teristics. These minimum requirements could be
interpreted as basic needs targets to be reached
within a given time period: as in the case of
the 1976 ILOs document, where the objective
was to meet basic necessities within one genera-
tion thus, by the year 2000 or as in the more
recent case of the Millennium Development Goals
that are to be reached by 2015.
At the individual or household level, the
fulfillment of basic needs can be directly observed
in terms of the thresholds defined: for instance,
checking that the minimum amount of calorie
intake per day per person is met or calculating
the number of people per room in the household
or the level of education completed. These are
known as direct methods of measurement.
Alternatively, an indirect measure of basic
needs can be employed, by calculating the cost of
the basic needs (BNI basic needs income level
method: cfr. Khan, 1977). This indirect method,
first used by Rowntree (1901) in his seminal stud-
ies of poverty in York, is still commonly used by
the World Bank and other agencies for estimating,
for example: the amount of money required to buy
enough food for an adequate level of nutrition
(usually considered to be 2,100 cal per person per
day), or of clothing and shelter, as well as for other
elements considered to be essential to human life
(Haughton & Khandker, 2009).
At the level of the country, aggregate or aver-
age indicators such as child nutritional status, life
expectancy at birth, morbidity schooling, enroll-
ment ratio, or percentage of household with access
Basic Needs
to clean water are used as a proxy for measuring
the basic needs that were met or unmet. Streeten
et al. (1981) suggested a list of core indicators for
five basic needs health, education, food, water
supply, and sanitation by focusing mainly on the
results (direct measures), more than the inputs
(indirect measures). Streetens list included the
following: life expectancy at birth, literacy and
primary school enrollment at ages 5 and 14, calo-
rie supply per head or as a percentage of require-
ments, infant mortality, percentage of population
with access to potable water, and percentage of the
population with access to sanitation facilities.
Overall, significant progress towards reaching
a common definition of basic needs and appropri-
ate methodologies has been made; however,
unsettled issues (Streeten et al., 1981; Streeten,
1984) in the basic needs literature remain when
one moves towards their empirical analysis. First,
it is unclear whether input or output indicators
should be used: that is, should we focus on the
availability and provision of a specific bundle of
goods, or should we look at the capacity and
autonomy of individuals and households to
achieve a minimal level of living conditions?
Second, most social indicators are average mea-
sures, which reflect the living conditions of the
overall population and not those of the poorest:
Ad hoc indicators that focus on the most disad-
vantaged groups and on the distributive dimen-
sion between and within subgroups of the
population can provide a better understanding of
peoples effective living conditions.
Development Policies
The notion of basic needs had a pivotal role in the
international debate on development strategies,
which took place throughout the end of the
1970s and the beginning of the 1980s.
The origin of a basic needs approach (BNA)
to development dates back to the aforemen-
tioned World Employment Conference promoted
by the International Labour Office (1976). Since
then, for several years, the World Bank and
a variety of UN agencies (UNEP, UNICEF,
USAID) strongly supported this view and many
countries (including China, Taiwan, Mexico,
Cuba, Sri Lanka, and Tanzania) incorporated
333 B
a basic needs strategy in their development
agenda.
The focus on basic needs in the development
debate arose as a reaction to the predominant
macroeconomic development policies which B
paid very little attention to the poor ultimately,
it aimed at putting the living condition of the poor
in the international agenda. Moreover, it was also
a consequence of the failure of economic growth
to guarantee the attainment of basic needs for all
people (Streeten et al., 1981; Stewart, 1985,
1989; see also Jolly, Emmerij, & Weiss, 2009;
Jolly, 2010 for an overview of the contribution of
BNA in the development debate).
However, the BNA was not against growth
per se which, on the contrary, was considered
an essential instrument in order to allow basic
needs to be met but a coherent and consistent
macroeconomic strategy at national and interna-
tional level was set out in order to combine eco-
nomic growth with redistributive policies (see ILO,
1976). Compared to more standard development
strategies based on redistribution with growth or
inclusive growth, the BNA had a greater concern
of the living conditions of the poorest people and
called for restructuring the production process in
order to provide income-earning opportunities
to the poorest and give them access to the goods
and services that they needed.
As outlined by Jolly (2010), the BNA has had
a rather short, even if remarkable, story. The
world economic recession and the rising debt
crisis of the early 1980s determined the decline
of the concerns for BNs and a shift towards sta-
bilization and structural adjustment policies
within the major international organizations.
Today, the BNA has lost its identity as an auton-
omous theoretical paradigm, although the impor-
tance of basic necessities for human lives remain
an important source of inspiration and are some-
how encompassed by other theoretical frame-
works included by the human development
and capability approach.
Links with the Human Development and
Capability Approach
The human development approach, first presented
by the UNDP in 1990, shows some noticeable
B 334
commonalities with the BNA. They are both
people-centered development theories, as they
equally claim that improving human well-being
should be the ultimate goal of development. Sim-
ilarly, they both emphasize that economic growth
is an essential means for improving human well-
being, but that it is not the end to development.
Moreover, in both cases, attention is placed on
dimensions of human life such as material living
conditions, education, and health that should be
universally regarded as essential for human beings.
Nevertheless, there are also some remarkable
differences between the two theoretical frame-
works. These are more clearly understandable if
we refer to the capability approach as pioneered
by Amartya Sen (1981) which deeply inspired
the human development approach and can indeed
be seen as its main theoretical foundation.
Amartya Sen recognizes the centrality of the
BNA for development strategies in fact, he
claims: the strategic relevance of basic needs is
not a controversial matter (Sen, 1987, p. 2). How-
ever, he also addresses several fundamental cri-
tiques to the BNA (Sen, 1984): (1) It is largely
focused on commodity possession, rather than
functioning achievements; (2) it lacks an adequate
philosophical foundation and leaves open some
unsettled questions; (3) it neglects that individ-
ual commodity requirements are connected to the
actions or judgments of other people and, there-
fore, social interdependence should also be taken
into account; (4) it confines attention to quantita-
tively minimal thresholds of basic needs and
thereby restricts its application to poor countries;
and (5) the concept of need is more passive than
the concept of capability, and thus, the emphasis
is on what can be done for the person more than on
what can the person do (see Crocker, 1992).
The human development and capability
approach tries to overcome these limits and gives
a more substantial importance to human freedom. It
also makes explicit some implicit assumptions in
the basic needs approach about the value of choice
and participation (Alkire, 2002, p. 170). Finally,
the human development approach powerfully
reintroduced some of the essential ideas that also
laid behind the BNA, into the international devel-
opment debate.
Basic Needs
Cross-References
Capabilities
Human Development
Human Needs
Human Rights
Relative Poverty Rate
Social Indicators
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Beauty 335 B
McGregor, D. (1960). The human side of enterprise.
New York: MacGraw Hill. BD I
Reader, S. (2005). The philosophy of need. Royal Institute
of Philosophy Supplement 57. Cambridge, UK:
Cambridge University Press. Bipolar Disorder (BD)
Rowntree, B. S. (1901). Poverty: A study of town life. B
London: Macmillan.
Sen, A. K. (1981). Poverty and famines. An essay on
entitlement and deprivation. Oxford: Clarendon Press.
Sen, A. K. (1984). Goods and people. In A. K. Sen (Ed.), BD II
Resources, values and development. Oxford:
Blackwell. Bipolar Disorder (BD)
Sen, A. K. (1987). The standard of living. Cambridge, UK:
Cambridge University Press.
Stewart, F. (1985). Planning to meet basic needs. London:
Macmillan.
Stewart, F. (1989). Basic needs strategies, human rights, BDI-II
and the right to development. Human Rights
Quarterly, 11(3), 347374.
Streeten, P. (1984). Basic needs: Some unsettled Beck Depression Inventory
questions. World Development, 12(9), 973978.
Streeten, P., Burki, S.J., ul Haq, M., Hicks, N., & Stewart, F.
(1981). First things first. Meeting basic human needs in
developing countries. Oxford: Oxford University Press.
Wiggins, D. (1987). Claims of need in his needs, values, Beauty
truth: Essays in the philosophy of value. Oxford:
Blackwell. Samantha Kwan
Department of Sociology, University of Houston,
Houston, TX, USA

Basic Values and Well-Being in

Europe Synonyms
Well-Being and Personal Values in Europe Attractiveness

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

BCI
Description
Basic Capabilities Index (BCI)
Societies typically have a set of norms dictat-
ing which physical traits are regarded as beauti-
ful. These cultural norms convey messages about
BD how bodies should appear aesthetically (e.g., in
shape or size) and vary by gender. For example,
Bipolar Disorder (BD) Western cultural norms celebrate a slender and
B 336
taut body type for women and a muscular and
toned body type for men (Bordo, 2003; Pope,
Phillips, & Olivardia, 2000). There is also some
evidence that many societies idealize youth,
unblemished fair skin, and symmetry, along
with a low waist-hip ratio and full breasts
for women and height and a V-shaped torso
for men (Etcoff, 1999; Rhode, 2010). Scholars
have noted, however, the existence of subcultural
aesthetic norms that celebrate alternate body
aesthetics. For instance, there is some evidence
that, compared to other ethnic groups, African-
Americans are less invested in the thin ideal
(Collins, 2000).
While some scholars argue that cultural
beauty norms are socially constructed by capital-
ist and patriarchal interests and disseminated via
mass media (Bartky, 1990; Bordo, 2003; Wolf,
1991), others argue that they are associated with
fertility, health, and reproduction and have
their roots in human nature and evolution (Buss,
2003; Etcoff, 1999). Social constructivists tend to
point out the changing nature of beauty ideals and
how they vary both historically and cross-cultur-
ally; in contrast, evolutionary psychologists
underscore the stable and universal element of
these ideals.
Research shows that hegemonic beauty
norms disparately impact social groups. For
example, women experience greater pressure to
conform to aesthetic norms and are penalized
more severely when they do not (Fikkan &
Rothblum, 2012). Western beauty ideals also
appear to be racially biased, favoring physical
characteristics (such as skin color, facial fea-
tures, and hair texture) that exclude some
racial/ethnic minorities from conforming to
these ideals (Collins, 2000). Moreover, body
modification aimed at achieving aesthetic ideals
often requires time and financial investments
that are more accessible to the economically
privileged, and there is some evidence that
members of the upper socioeconomic
status (SES) classes are more concerned with
body weight compliance than their lower SES
counterparts (Wardle & Griffith, 2001).
Beauty is a key factor impacting quality of
life. Attempts to conform to cultural beauty ideals
Beauty
can involve practices that compromise both
mental and physical health. Such is the case of
eating disorders, like anorexia nervosa, which
have been documented in young women striving
to achieve cultural ideals (Bordo, 2003). Beauty
can also impact social outcomes. As a diffuse
status characteristic, beauty is an accessible fea-
ture of an individual that people use in social
encounters to inform expectations about the abil-
ities of others (Webster & Driskell, 1983).
Research indicates that observers often assume
that physically attractive individuals are more
sociable, talented, happier, and successful in life
compared to their less physically attractive coun-
terparts (see Eagly, Ashmore, Makhijani, &
Longo, 1991). The association of physically
attractive individuals with positive traits that con-
fer status and favorably shapes expectations has
been labeled a halo effect.
Beauty not only shapes perceptions but results
in quality of life advantages for those who
embody cultural standards and, conversely, dis-
advantages to those who do not. Compliance or
deviation from aesthetic norms impacts an array
of social outcomes in various arenas including
education, employment, and marriage.
In education, studies report a relationship
between teachers perceptions of intelligence
and students physical attractiveness (Clifford &
Walster, 1973). Moreover, teachers are less likely
to label the transgressions of a physically attrac-
tive child as reflecting an enduring negative per-
sonality trait in comparison to a more physically
attractive child (Dion, 1972). Perceptions may
even impact actually educational achievement.
For example, researchers have documented
a positive relationship between physical attrac-
tiveness level and levels of educational attain-
ment (Umberson & Hughes, 1987). One
longitudinal study underscores the gendered
nature of beauty nonconformity; statistical anal-
ysis of a large national dataset found that obese
girls were less likely to enter college after high
school compared to their nonobese peers, even
though obese boys did not fair any worse than
their nonobese peers (Crosnoe, 2007).
The impact of physical attractiveness on qual-
ity of life is also evident in the workplace.
Beauty
A meta-analysis of experimental studies found
that physical attractiveness elicits benefits in
many stages of the employment process for both
men and women. These include advantages in
hiring outcomes, performance evaluation, and
promotion decisions (Hosoda, Stone-Romero, &
Coats, 2003). Moreover, experimental studies
examining workplace weight bias shows
a marked disadvantage for those who do not
conform to beauty ideals (Cort, Well, Weller, &
Baltes, 2009). Labor market participation rates,
as well as earnings, including both family and
personal income, are also stratified by physical
appearance (Conley & Glauber, 2005; Umberson
& Hughes, 1987).
Research also shows that beauty influences the
probability of marriage, particularly for women;
for example, higher body mass for women nega-
tively impacts the probability of marriage
(Conley & Glauber, 2005). Physically attractive
females are also more likely to marry highly
educated husbands with higher income (Udry &
Eckland, 1984).
In sum, cultural and social structures privilege
the beautiful. Individuals who conform to cul-
tural beauty ideals, whether because they are so
fortunately genetically endowed or because they
engage in body modification practices to achieve
such ideals, may encounter an array of social
benefits that ultimately influence overall quality
of life.
Cross-References
Aesthetic Value
Body Image
Educational Inequality
Employment Discrimination
Gender Discrimination
References
Bartky, S. L. (1990). Femininity and domination: Studies
in the phenomenology of oppression. New York:
Routledge.
337 B
Bordo, S. (2003). Unbearable weight: Feminism, western
culture, and the body (2nd ed.). Berkeley: University
of California Press.
Buss, D. M. (2003). The evolution of desire (Revised ed.).
New York: Basic Books.
Clifford, M. M., & Walster, E. (1973). The effect of B
physical attractiveness on teacher expectations.
Sociology of Education, 46, 248258.
Collins, P. H. (2000). Black feminist thought: Knowledge,
consciousness, and the politics of empowerment
(2nd ed.). New York: Routledge.
Conley, D., & Glauber, R. (2005). Gender, body mass
and economic status. Cambridge: National Bureau of
Economic Research Working Paper Series.
Cort, W. R., Well, C. L., Weller, M. D., & Baltes, B. B.
(2009). A meta-analysis of empirical studies of
weight-based bias in the workplace. Journal of
Vocational Behavior, 74, 110.
Crosnoe, R. (2007). Gender, obesity, and education.
Sociology of Education, 80, 241260.
Dion, K. (1972). Physical attractiveness and evaluation of
childrens transgressions. Journal of Personality and
Social Psychology, 24, 207213.
Eagly, A. H., Ashmore, R. D., Makhijani, M. G., & Longo,
L. C. (1991). What is beautiful is good, but . . .:
A meta-analytic review of research on the physical
attractiveness stereotype. Psychological Bulletin,
110, 109128.
Etcoff, N. L. (1999). Survival of the prettiest: The science
of beauty. New York: Doubleday.
Fikkan, J. L., & Rothblum, E. (2012). Is fat a feminist
issue? Exploring the gendered nature of weight bias.
Sex Roles, 66, 575592.
Hosoda, M., Stone-Romero, E. F., & Coats, G. (2003). The
effects of physical attractiveness on job-related
outcomes: A meta-analysis of experimental studies.
Personnel Psychology, 56, 431462.
Pope, H. G., Phillips, K. A., & Olivardia, R. (2000). The
Adonis complex: The secret crisis of male body obses-
sion. New York: The Free Press.
Rhode, D. L. (2010). The beauty bias: The injustice of
appearance in life and law. New York: Oxford
University Press.
Udry, J. R., & Eckland, B. K. (1984). The benefits of being
attractive: Differential payoffs for men and women.
Psychological Reports, 54, 4756.
Umberson, D., & Hughes, M. (1987). The impact of
physical attractiveness on achievement and psycho-
logical well-being. Social Psychology Quarterly, 50,
227236.
Wardle, J., & Griffith, J. (2001). Socioeconomic status
and weight control practices in British adults. Journal
of Epidemiology and Community Health, 55, 185190.
Webster, M., & Driskell, J. E. (1983). Beauty as
status. The American Journal of Sociology, 89,
140165.
Wolf, N. (1991). The beauty myth: How images of
beauty are used against women. New York:
W. Morrow.
B 338
Beck Depression Inventory
Anita M. Hubley
Measurement, Evaluation, & Research
Methodology (MERM), Adult Development and
Psychometrics Lab, The University of British
Columbia, Vancouver, BC, Canada
Synonyms
BDI-II; Beck inventory
Definition
The Beck Depression Inventory Second Edition
(BDI-II) is a 21-item self-report measure
designed to measure severity of depression
consistent with symptoms of depression as
presented in the Diagnostic and Statistical
Manual of Mental Disorders Fourth Edition
(DSM-IV; American Psychiatric Association,
1994) in both adolescents aged 13 years and
older and adults (Beck, Steer, & Brown, 1996).
Description
Overview
The BDI-II is a well-recognized self-report measure
designed to measure severity of depression consis-
tent with symptoms of depression as presented in
the DSM-IV (American Psychiatric Association,
1994). There are 21 items on the BDI-II; each
item references a symptom (e.g., sadness) and
typically contains four statements from which
respondents choose the statement that best reflects
the severity of the symptom for them over the past 2
weeks. The BDI-II can be used with both adoles-
cents aged 13 years and older and adults
(Beck et al., 1996).
Development
The BDI-II replaced both the original Beck
Depression Inventory (BDI; Beck, Ward,
Beck Depression Inventory
Mendelson, Mock, & Erbaugh, 1961) and
a slightly revised later version (BDI-IA; Beck,
Rush, Shaw, & Emery, 1979). The 21 items in
the original BDI reflected symptoms frequently
reported by depressed patient samples and
infrequently reported by nondepressed psychiat-
ric patients (Beck et al., 1961) and did not reflect
any particular theory of depression (Beck et al.).
According to the BDI-II manual, items covered
affective, cognitive, somatic, and vegetative
symptoms of depression. Each item contained
four to six self-evaluative statements organized
in order of increasing severity. The original BDI
was administered orally by trained interviewers.
Beginning in 1971, Beck and colleagues began to
use a modified version that included revised
wording for 15 items, avoided double negatives,
eliminated alternative phrasing for the same
symptoms, and limited the number of response
options to four for all items. The final amended
version resulted in the BDI-IA, which was
copyrighted in 1978 and published in 1979;
a technical manual was published later (Beck &
Steer, 1987). Beck, Steer, and Garbin (1988), in
their review of the literature on the BDI, noted
that most researchers seemed unaware that there
were two versions, as some cited the 1961 refer-
ence, but used the 1978 revision. Because of this,
it is difficult to tell not only which version is used
more often, but it is often impossible to tell which
version is being used in any given study.
Criticisms that the BDI/BDI-IA did not
adequately address Diagnostic and Statistical
Manual of Mental Disorders Third Edition
(DSM-III; American Psychiatric Association,
1980) symptoms of depression (e.g., Moran &
Lambert, 1983; Vredenburg, Krames, & Flett,
1985), the subsequent releases of the Diagnostic
and Statistical Manual of Mental Disorders
Third Edition, Revised (DSM-III-R; American
Psychiatric Association, 1987) and the DSM-IV,
and changes related to the definition, assessment,
and expression of depression resulted in the
development of the BDI-II beginning in 1994
(Beck et al., 1996). Item and factor analyses
were conducted on a 27-item pilot version of
the test given to 193 psychiatric outpatients. In
developing the final 21-item BDI-II, four BDI-IA
Beck Depression Inventory
items (i.e., Body Image Change, Work Difficulty,
Weight Loss, and Somatic Preoccupation) were
dropped and four new items (i.e., Agitation,
Worthlessness, Loss of Energy, and Concentra-
tion Difficulty) were added, several symptoms
were renamed, and the majority of the response
option statements were reworded (Beck et al.).
Administration and Scoring
Respondents are instructed to circle the number
for the one statement for each symptom that best
describes how they have felt during the past 2
weeks, including today (Beck et al., 1996).
The BDI-II takes about 510 min to
complete; patients with severe depression or
with obsessional disorders may take longer to
complete the measure. Although the BDI-II is
typically self-administered, it can also be admin-
istered orally.
As noted in the BDI-II manual (Beck et al.,
1996), responses to each of the 21 items on
the BDI-II range from 0 to 3. Two items
(#16 Changes in Sleeping Pattern and
#18 Changes in Appetite) each have seven
response options that allow for increases or
decreases in behavior, but they are still scored
using a range of 03. If a respondent has selected
multiple responses for any BDI-II item, the
response with the highest score value is used.
A total score is obtained by summing the
responses to each of the items; thus, total scores
range from 0 to 63. Higher scores suggest greater
severity of depression.
Cut-scores provided in the manual for the BDI-II
(Beck et al., 1996) were derived using receiver
operating characteristic (ROC) curves based on
101 patients who were classified as nondepressed,
mildly depressed, moderately depressed, or
severely depressed according to the outpatient ver-
sion of the Structured Clinical Interview (SCID) for
DSM-III. As a screening measure, sensitivity was
favored over specificity and the following cut-
scores were suggested for patients diagnosed with
major depression: 013 minimal, 1419 mild, to load on either cognitive or somatic factors (e.g.,
2028 moderate, and 2963 severe. When loss of interest in sex, pessimism Wiebe & Penley,
interpreting performance on the BDI-II, the authors
cautioned the test user (a) that the test is only
a screening measure and that diagnosis of
339 B
depression requires further assessment, (b) to
be aware of response biases (including both
under- and over-reporting of symptoms), and
(c) to pay particular attention to suicide ideation as
well as the overall pattern of depressive symptoms. B
For researchers or practitioners wanting to
compare scores, equivalent BDI-II and BDI-IA
scores, based on an equipercentile equating
method, are provided in the BDI-II manual
(Beck et al., 1996).
Factor Structure
In the manual, Beck et al. (1996) report
two principal components analyses (PCAs)
conducted with 500 psychiatric outpatients and
120 introductory psychology students. Both
analyses found two factors on the BDI-II;
a factor-matching procedure suggested that
there were two highly correlated cognitive-
affective and somatic factors with a couple of
affective symptoms (i.e., sadness, crying) that
may shift between cognitive and somatic factors
depending on the sample. Vanheule, Desmet,
Groenvynck, Rosseel and Fontaine (2008) noted
that five two-factor structures (e.g., somatic-
affective 12 items and cognitive 9 items,
Beck et al., 1996; cognitive-affective 10 items
and somatic-vegetative 8 items, Dozois, Dob-
son, & Ahnberg, 1998) and four three-factor
structures (e.g., cognitive 9 items, somatic
8 items, and affective 4 items, Buckley, Parker,
& Heggie, 2001; general factor plus cognitive
8 items and somatic 5 items that are all orthog-
onal, Ward, 2006) have been supported in the
literature. Most involve some combination of
cognitive, somatic, affective, and general factors.
Still other models have been identified that vary
based on which items load and on what factors. In
many cases, it is the loading of affective items such
as crying and sadness that tend to vary (Palmer &
Binks, 2008; Steer, Ball, Ranieri, & Beck, 1999;
Ward, 2006; Whisman, Perez, & Ramel, 2000).
There are several items that have been found not
2005; appetite Viljoen, Iverson, Griffiths, &
Woodward, 2003) or items that have been found
to cross-load on factors (e.g., loss of interest in sex,
B 340
concentration difficulty, self-dislike, indecisive-
ness Viljoen et al.; self-criticalness Arnau,
Meagher, Norris, & Bramson, 2001; sadness
Steer et al., 1999). It is also worth noting that
a variety of analyses (e.g., principal components
analysis, principal axis factoring, confirmatory fac-
tor analysis), dimension criteria (e.g., scree plot,
eigenvalues > 1, parallel analysis), rotation
approaches (e.g., varimax, Promax), and samples
(e.g., depressed outpatients, college students, male
substance abusers, low income African-American
adults, nonclinical adolescents, incarcerated adults,
various medical patient groups, youth offenders)
have been used; all of these factors can impact the
results of factor analytic studies.
A key issue that arises is that the scoring of the
BDI-II in studies often does not match
the obtained internal structure of the measure.
Specifically, the presence of two or three factors
does not support the use of a total score. This raises
concerns about findings (e.g., reliability and valid-
ity evidence, group differences) based on a total
score when a unidimensional factor structure or
a second order factor of depression has not been
found or supported. A few studies have found
evidence for a unidimensional structure (Hooper,
Qu, Crusto, & Huffman, 2012; Segal, Coolidge,
Cahill, & ORiley, 2008) and a number of studies
have examined and found evidence for a second
order factor of depression (e.g., Arnau et al., 2001;
Chilcot et al., 2011; Grothe et al., 2005; Joe,
Woolley, Brown, Ghahramanlou-Holloway, &
Beck, 2008; Siegert, Walkey, & Turner-Stokes,
2009; Steer et al., 1999; Ward, 2006). It is critical
that researchers find appropriate support for the
use of a total score before using such a score in
subsequent analyses.
Reliability
Internal consistency estimates of reliability for the
BDI-II have been obtained in a wide range of
samples. All of these studies use Cronbachs
alpha and most treat the items as though they
form a unidimensional scale. In college student
samples, alphas range from 0.89 to 0.93 (Beck
et al., 1996; Carmody, 2005; Dozois et al., 1998;
Hooper et al., 2012; Segal et al., 2008; Whisman
et al., 2000; Wiebe & Penley, 2005). Alphas are
Beck Depression Inventory
equally high in samples of medical outpatients
(0.900.94; Arnau et al., 2001; Beck et al., 1996;
Dutton et al., 2004; Grothe et al., 2005), neuro-
rehabilitative inpatients (0.89; Siegert et al., 2009),
depressed adult outpatients (0.90; Steer et al.,
1999), substance abusers (0.910.95; Buckley
et al., 2001; Dum, Pickren, Sobell, & Sobell, 2008;
Hepner, Hunter, Edelen, Zhou, & Watkins, 2009),
adolescents (0.92; Osman, Barrios, Gutierrez, Wil-
liams, & Bailey, 2008); adolescent psychiatric
inpatients (0.900.92; Krefetz, Steer, Gulab, &
Beck, 2002; Osman et al., 2008), adolescent psy-
chiatric outpatients (0.89; Krefetz, Steer, &
Kumar, 2003), young male offenders (0.90;
Palmer & Binks, 2008), troubled adolescents
(0.90; VanVorrhis & Blumentritt, 2007), older
adults (0.86; Segal et al., 2008), depressed older
psychiatric inpatients (0.89; Steer, Rismiller, &
Beck, 2000), adults with intellectual disabilities
(0.91; Ailey, 2009), depressed and nondepressed
adults with insomnia (0.89 and 0.82, respectively;
Carney, Ulmer, Edinger, Krystal, & Knauss,
2009), suicide attempters (0.94; Joe et al., 2008),
women who are pregnant or recently pregnant
(0.880.89; Bos et al., 2009), and low income
African-American women with chronic health
problems (0.94; Kneipp, Kairalla, Staccianni, &
Pereira, 2009).
Studies that examine internal consistency
estimates for subscale scores based on various
two- or three-factor structures for the BDI-II
tend to report Cronbachs alphas that are satisfac-
tory (>0.80) for cognitive-affective, cognitive,
and somatic-affective subscales (e.g., Bos et al.,
2009; Joe et al., 2008; Kneipp et al., 2009; Osman
et al., 2008; Siegert et al., 2009; Steer et al., 1999;
Ward, 2006). Cronbachs alphas for somatic sub-
scales tend to be more variable, ranging from
0.65 to 0.89 (e.g., Bos et al., 2009; Joe et al.,
2008; Kneipp et al., 2009; Siegert et al., 2009;
Ward, 2006).
Very little research has been conducted
examining test-retest reliability estimates for
the BDI-II. Beck et al. (1996) report a 1-week
test-retest reliability estimate of 0.93 in a small
sample of US outpatients. Wiebe and Penley
(2005) reported an ICC for agreement of 0.73
over a 1-week interval in a large sample of
Beck Depression Inventory
Hispanic college students that completed the
BDI-II in English.
Validity
Content Validation
No content validation evidence is provided in the
BDI-II manual (Beck et al., 1996). The only
content validation evidence appears to be offered
by Osman, Kopper, Barrios, Gutierrez, and
Bagge (2004), who had seven doctoral-level
clinical psychologists with expertise with chil-
dren and adolescents and at least 5 years of expe-
rience in research or clinical assessment rate each
BDI-II item for: (a) how relevant it is as
a symptom of a major depressive disorder
(MDD) and (b) how specific it is as a symptom
of MDD. In addition, Osman et al. asked 13
adolescent boys and girls in a long-term care
unit of a psychiatric hospital to rate: (a) the extent
to which each item was easy to read and under-
stand and (b) how useful the item statements
would be when talking to a mental health profes-
sional about how they feel. Overall, the findings
supported the inclusion of most items of the
BDI-II when used with an adolescent sample.
The most problematic item based on feedback
by both groups was loss of interest in sex. The
authors suggested that items focusing on loss
of interest in sex, past failure, and punishment
feelings may not correspond well to DSM-IV
depressive symptoms and that items related to
agitation, concentration difficulty, and loss of
interest in sex are the least specific to MDD. They
also questioned the unequal number of items
representing each of the DSM-IV depressive
symptoms.
Convergent and Discriminant Validation
In the BDI-II manual, Beck et al. (1996) reported
that the BDI-II correlated more strongly with
measures of depression (Revised Hamilton
Psychiatric Rating Scale for Depression,
r 0.71) and hopelessness (Beck Hopelessness
Scale, r 0.68) than measures of anxiety (Beck
Anxiety Inventory, r 0.60; Revised Hamilton
Psychiatric Rating Scale for Anxiety, r 0.47)
and suicidal ideation (Scale for Suicide Ideation,
r 0.37) in samples of psychiatric outpatients.
341 B
Arnau et al. (2001) reported that BDI-II total
scores and factor scores correlated more
highly with SF-20 mental health scores
(r 0.590.65) than with physical health
(i.e., health perceptions, physical pain, physical B
functioning, and role functioning) scores
(r 0.180.43) in an adult primary care sam-
ple. Dum et al. (2008) reported that the BDI-II
correlated more strongly with a depression inven-
tory (PHQ-9, r 0.84) than with measures of
alcohol (AUDIT, r 0.33) and substance
(DAST, r 0.26) abuse in a sample of outpatient
substance abusers. Similarly, Hepner et al. (2009)
reported that the BDI-II correlated more
strongly with a measure of depression (PHQ-9,
r 0.76) than with a measure of alcohol abuse
(AUDIT-Consumption, r 0.17) in a sample of
residential substance abuse treatment clients.
Kneipp, Kairalla, Stacciarini, Pereira, and Miller
(2010) found that the BDI-II was more
highly correlated with a depression measure
(PHQ-9, r 0.80) than with measures of stress
(Perceived Stress Scale, r 0.69) or anxiety
(Beck Anxiety Inventory, r 0.60) in a sample
of low income Black women with chronic health
conditions.
VanVorrhis and Blumentritt (2007) showed
promising construct validation evidence in that
the BDI-II was more highly correlated with
Adolescent Psychopathology Scale scales of
Major Depression (r 0.61), Dysthymic
Disorder (r 0.62), Generalized Anxiety
Disorder (r 0.64), Social Phobia (r 0.54),
and an Internalizing Disorder factor score
(r 0.61) than an Externalizing Disorder factor
score (r 0.34), Conduct Disorder (r 0.17),
Oppositional Defiant Disorder (0.30), Substance
Abuse (r 0.18), or Attention Deficit Hyperac-
tivity Disorder (r 0.41) in a sample of Mexican
American youth from three facilities; however,
the equally high correlations with both depres-
sion and anxiety scales are troubling. Similarly,
Segal et al. (2008) reported that the BDI-II
correlated significantly with measures of depres-
sion (CES-D, r 0.680.69; Coolidge Axis II
Inventory (CATI) Depression, r 0.530.66;
CATI Depressive Personality, r 0.560.59),
anxiety (CATI Anxiety, r 0.480.60),
B 342
well-being (Short Psychological Well-Being
Scale total scores, r 0.600.69), and stress
(Perceived Stress Scale, r 0.640.71), and
less so with overall perceived health
(r 0.130.27) for younger and older adult
samples; the equally high correlations with both
depression and anxiety suggest poor discrimina-
tion between these constructs. In a sample of
adolescents, Osman et al. (2008) reported that
the BDI-II correlated slightly higher with the
Beck Hopelessness Scale (r 0.63), but similarly
with the Brief Reasons for Living Inventory for
Adolescents (r 0.55), State-Trait Anxiety
Inventory-State (r 0.53), and Suicide
Behaviors Questionnaire Revised (r 0.57).
In a few studies, the BDI-II has shown good
convergent validity with other measures of
depression (e.g., r 0.66 with the Hamilton
Rating Scale for Depression in adult suicide
attempters, Joe et al., 2008; r 0.84 with the
Reynolds Adolescent Depression Scale in adoles-
cent psychiatric inpatients, Krefetz et al., 2002)
but no discriminant measures were examined to
provide appropriate comparisons.
Overall, there is some good convergent and
discriminant validation evidence available for the
BDI-II. It would be useful to see some more
comparisons made with other depression mea-
sures when the focus is on examining the BDI-II
and far more attention needs to be paid to rela-
tionships between the BDI-II and measures of
anxiety versus depression.
Known-Groups Validation
There has been strong known-groups validation
evidence for the BDI-II in both adult and adoles-
cent groups. Significantly higher scores on the
BDI-II have been reported for adults with MDD
than those without MDD in primary care clinic
samples (Arnau et al., 2001; Dutton et al., 2004)
and in adults with insomnia (Carney et al., 2009).
In a study of cardiac patients, Low and Hubley
(2007) reported significantly lower mean BDI-II
scores (and large effect sizes) for nondepressed
than depressed participants across each of three
SCID-I/NP diagnostic categories: (a) MDD,
(b) MDD + double depression, and (c) mixed
depression group. Beck et al. (1996) found that
Beck Depression Inventory
psychiatric outpatients scored significantly
higher on the BDI-II than undergraduate psychol-
ogy students.
Krefetz et al. (2002) reported significantly
higher scores on the BDI-II for adolescent
psychiatric inpatients with MDD than those who
were not depressed. Osman et al. (2008) found
that (a) an adolescent inpatient group from a state
psychiatric hospital with MDD, dysthymia,
conduct disorder, or oppositional defiant disorder
diagnoses scored significantly higher (with
a large effect size) on the BDI-II than
a nonclinical group of adolescents, and (b) an
adolescent outpatient group scored significantly
higher (with a moderate effect size) on the BDI-II
than a nonclinical group of adolescents.
Within clinical samples, there is also satisfac-
tory known-groups validation evidence for the
BDI-II. Beck et al. (1996) reported that outpa-
tients with mood disorders scored significantly
higher than groups with anxiety, adjustment,
and other psychiatric disorders. Steer et al.
(2000) found that geriatric inpatients with MDD
scored approximately 2.7 times higher on the
BDI-II than those with adjustment disorders
with depressed mood. In a group of adult psychi-
atric outpatients with MDD, significant differ-
ences were found on the BDI-II among those
with severe, moderate, and mild specifiers, such
that greater severity of specifiers was associated
with increasingly higher BDI-II scores (Steer,
Brown, Beck, & Sanderson, 2001). More mixed
results were found in Beck et al. (1996) whereby
no significant differences on BDI-II scores
were reported among five mood disorder groups
(i.e., MDD single episode, MDD recurrent epi-
sode, dysthymia, bipolar, depression NOS),
except between the MDD recurrent episode and
bipolar groups. Finally, Palmer and Binks (2008)
found that young male adult prisoners with
previous suicidal behavior scored significantly
higher on the BDI-II than those without
a history of such behavior.
Criterion-Related Validation
A number of studies have examined the useful-
ness of the BDI-II as a screening measure by
reporting the area under the curve (AUC) and
Beck Depression Inventory 343 B
Beck Depression Inventory, Table 1 Selected sample reflects low prevalence of depression in the sam-
of criterion-related validation studies ples (Wassertheil-Smoller, 1990).
Cut-
Study Sample Score Results
Ailey 75 adults with 11 Sensitivity 89 % Discussion B
(2009) intellectual Specificity 82 %
disabilities PPV 61.5 %
The BDI-II is a widely used self-report measure
NPV 95.8 %
designed to measure severity of depression in
Arnau 333 adults in 18 Sensitivity 94 %
both adolescents aged 13 years and older and
et al. a primary care Specificity 92 %
(2001) setting adults. Its 21 items were selected to be consistent
PPV 54 %
NPV 99 %
with symptoms of depression as presented in the
Carney 140 adults with >17 Sensitivity 81 %
DSM-IV. Administration of the BDI-II is straight-
et al. insomnia Specificity 79 % forward and takes about 510 min for most
(2009) individuals. Scoring of the BDI-II is also straight-
Dutton 220 African- 14 Sensitivity 88.2 % forward. Cut-scores for identifying severity of
et al. American Specificity 92.1 % depression in patients diagnosed with MDD are
(2004) patients PPV 69.5 %
recruited from provided in the manual. It is noteworthy,
NPV 94.2 % however, that the standardization sample is rela-
primary care
clinics tively small and does not appear to be diverse in
Huffman 131 post- 16 Sensitivity 87.7 % terms of race, culture, or socioeconomic status, or
et al. myocardial Specificity 83.9 % widely representative of the US population.
(2010) infarction
patients There is little agreement on the internal struc-
Krefetz 56 adolescent 24 Sensitivity 74 % ture of the BDI-II. Numerous two- and three-factor
et al. psychiatric Specificity 70 % structures have been identified for the BDI-II; in
(2002) inpatients PPV 76 % addition, some researchers have identified
NPV 67 % a general or second order factor of depression. It
Low & 119 cardiac 10 Sensitivity 100 % is troubling that the scoring of the BDI-II in studies
Hubley patients Specificity 75 % often does not match the identified internal struc-
(2007) PPV 18 % ture of the measure. This raises questions about
NPV 100 % reliability and validity evidence and other study
findings (e.g., group differences) based on use of
a total score when a unidimensional factor struc-
ture or a second order factor of depression has not
providing sensitivity, specificity, positive predic- been found or supported. Nonetheless, internal
tive value (PPV), and negative predictive value consistency alpha estimates of reliability for total
(NPV) information for various cut-scores on the or subscale scores on the BDI-II generally range
BDI-II. Most studies have found the BDI-II to be from satisfactory (>0.80) to excellent. Very few
an excellent case-finding screen for depression test-retest reliability estimates for the BDI-II are
with AUC values typically greater than 0.90 in available, but these report good to excellent
a variety of adult samples (e.g., Ailey, 2009; 1-week test-retest reliability.
Arnau et al., 2001; Dutton et al., 2004; Huffman Very little research has addressed the content
et al., 2010; Low & Hubley, 2007). Widely vary- validation of the BDI-II. Only one study has
ing cut-scores have been recommended for use in examined content validity and it focused on the
screening for depression in different samples as use of the BDI-II with adolescent inpatients.
seen in Table 1. Sensitivity and specificity values The findings supported the inclusion of most
tend to be satisfactory, at least with adult sam- items of the BDI-II with this group, with the
ples. In most general settings, NPVs are high; exception of loss of interest in sex. Overall,
PPVs tend to be relatively low and this often there is good convergent and discriminant
B 344
validation evidence available for the BDI-II with
a variety of samples. It would be useful to see
more comparisons made with other depression
measures and far more attention needs to be
paid to relationships between the BDI-II and
measures of anxiety versus depression as the
BDI-II has been found to be equally correlated
with both types of measures. Known-groups val-
idation evidence for the BDI-II in both adult and
adolescent groups tends to be strong; expected
differences have been found between depressed
and nondepressed groups, clinical and
nonclinical groups, inpatients and outpatients,
depressed and other psychiatric conditions, and
among severity levels of depression. Finally,
criterion-related validation studies have found
the BDI-II to be an excellent case-finding screen
for depression in a variety of adult samples.
Sensitivity, specificity, and NPV values tend to
be satisfactory; however, recommended cut-
scores for screening for depression vary widely
depending on the sample.
Cross-References
Confirmatory Factor Analysis (CFA)
Convergent Validity
Criterion Validity
Cronbachs Alpha
Discriminant Validity
Factor Analysis
Geriatric Depression Scale
Internal Consistency Reliability
Principal Component Analysis
Reliability
Test-Retest Reliability
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B 346 Beck Inventory

improve exercise tolerance and quality of life

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

Description
Behavior Therapy with Children
Historical Antecedents
Cognitive Behavior Therapy with Children Since 1960, exercise has been promoted as
a method of preventing diseases and extending
life (Durstine, Moore, Painter, & Roberts,
2009). However, it was restricted to healthy
Behavior, Social individuals, and in the presence of chronic
diseases, it was recommended to avoid exer-
Prosocial Behavior cises. However, in the 1980s, many studies
demonstrated that exercise had lots of benefits
for persons with chronic diseases and disabil-
ities. For this population, exercise became
Behavior, Sustainable a way to preserve their functional capacity and
independence with positive effects on QoL
Proenvironmental Behavior (Durstine et al.). Some studies reported
increases in survival rates in chronic patients
who participated in exercise programs, but the
effects on their QoL, rather than the quantity of
Behavioral Addictions life, are frequently reported.
Better control of chronic and infectious
Addiction, An Overview diseases is needed for the aging of the worlds
population. Exercise is an important tool to main-
tain the functional capacity and QoL in elderly
people (Spirduso, Francis, & MacRae, 2005) who
frequently enter into a spiral toward exercise
Behavioral Conditioning intolerance, because of the reduction in their
functional capacities and depressed status
Raquel Britto (Spirduso et al.). Exercise intervention programs
Physical Therapy, Universidade Federal de should contribute to enhance exercise tolerance
Minas Gerais, Belo Horizonte, Brazil and to discontinue the process of depressed
conditions. It could also increase the participation
in social activities and contribute to improve the
Synonyms QoL. There is also considerable and growing
evidence that physical activity and/or exercise
Aerobic training; Endurance exercise training behaviors play important roles in a persons
perception of QoL (Gillison, Skevington, Sato,
Standage, & Evangelidou, 2009; Wolin, Glynn,
Definition Colditz, Lee, & Kawachi, 2007). A recent
systematic review shows the effects of exercise
Conditioning is the process of improving global interventions on QoL in clinical and healthy
exercise capacity. It is commonly used to populations (Gillison et al., 2009).
Behavioral Conditioning
Multidisciplinary Health-Care Team
It is very important that exercise management is
provided by a wide variety of health care and
exercise professionals, including nurses, physi-
cians, nutritionists, exercise physiologists, physical
and occupational therapists, psychologists, social
workers, and other health and education specialists
and, most importantly, the individuals and the indi-
viduals families (Wolin et al., 2007).
Healthy People
Largely because of the success of conditioning
which modifies the risk factors for chronic dis-
eases and maintains their functional capacities
and independence, the number of healthy people
in conditioning programs has increased.
Depression, in particular, has been associated
with less energy, more fatigue, lower exercise
capacity, and reduced QoL and sense of
well-being. Subjects who do physical exercise
regularly have reduced risks of developing
chronic diseases (Perraton, Kumar, & Machotka,
2010). The benefits of conditioning to reduce
cardiac risks and depression and to improve
QoL have been described (Durstine et al., 2009;
Perraton et al., 2010).
According to Perraton et al., 2010, the majority
of trials that evaluate the impact of exercise on
depression used supervised aerobic exercise inter-
ventions and the most common exercise parame-
ters were set at 6080 % of the maximum heart
rate for 30 min, three times per week for an overall
duration of 8 weeks. According to the American
College of Sports Medicine (ACSM) (Haskell
et al., 2007), to promote and maintain health, all
healthy adults aged 1865 year need moderate-
intensity aerobic (endurance) for a minimum of
30 min for 5 days per week or vigorous-intensity
aerobic physical activity for a minimum of 20 min
for 3 days a week (evidence level IA).
Elderly People
Conditioning rapidly reverses the progression of
skeletal muscular metabolic changes, such as atro-
phies, and promotes independence and QoL in the
elderly. It is clearly an essential component of the
management for elderly patients with chronic dis-
eases, mainly the respiratory and cardiac disorders
347 B
(Padeletti, Jelic, & LeJemtel, 2008; Spirduso et al.,
2005). The ACSM recommendation for older
adults (Nelson et al., 2007) is similar to the updated
ACSM/AHA recommendations for adults (Haskell
et al., 2007) but has several important differences. B
For the elderly with risks of falls, the recommended
intensity of aerobic activity should take into
account their levels of aerobic fitness and include
activities which maintain or increase flexibility and
balance. In addition, older adults should have an
activity plan for achieving the recommended
physical activity which integrates preventive and
therapeutic recommendations (Nelson et al., 2007).
People with Chronic Diseases
For people with chronic diseases, the program
should include several facets designed to provide
interventions for restoring functional capacity,
reducing the impact of the disease, and promoting
positive psychosocial behavioral changes that lead
to the maintenance of health and social indepen-
dence and consequently to enhance their QoL
(Durstine et al., 2009). Exercise prescription
needs to consider the effects of the disease or
disability on both acute and chronic responses to
exercise (adaptations), on the interactions between
exercise and medications, and mental health
(Durstine et al.). It is also important to identify
the expectations of the patients and their families.
Problem-oriented exercise management was
developed in the late 1960s to provide helpful
ways to approach patient with chronic diseases
(Durstine et al., 2009). The SOAP technique
is defined as getting (1) subjective data, (2) objective
data, (3) assessment, (4) the formulation of a plan
based upon the list of problems, and (5) continuous
reassessments. The subjective data help identify the
persons history of physical activity, medical prob-
lems, and the reasons they are participating in exer-
cise. The objective data include appropriate tests to
provide measurements that confirm or refute possi-
ble causes of the symptoms during exercise. The
assessment lists the problems and defines priorities
for interventions to make a plan. In the past, much
emphasis was on aerobic exercise testing. However,
nowadays, measures of strength, flexibility, neuro-
muscular skills, and functional performance are
recommended (Durstine et al.). More than that,
B 348
the approach of the World Health Organization
(WHO) with the International Classification of
Functioning, Disability and Health (ICF) empha-
sizes that functioning and impairments are deter-
mined by the environmental context where the
people live (World Health Organization [WHO],
2001). Thus, it is also necessary to evaluate the
impact of exercise training on capacities, consider-
ing the activities which a person with impairments
in bodily functions and/or structures can perform,
and also on their social participation. In this way,
the use of questionnaires is very important to iden-
tify the levels of QoL during the progression of the
conditioning program.
Discussion
There is sufficient evidence showing the positive
effects of conditioning on QoL (Britto et al., 2011;
(Fallucca & Pozzilli, 2009); Gillison et al., 2009;
Lima et al., 2010; Perraton et al., 2010; Weening-
Dijksterhuis, de Greef, Scherder, Slaets, & van der
Schans, 2011). Exercise training resulted in signif-
icant improvements in self-reported health status.
Considering that these positive effects are related
to adherence, new studies have to consider strate-
gies to promote exercise adherence. According to
Gillison et al., 2009, it is also important to identify
which types of interventions are associated with
better gains in QoL. These authors also concluded
that there may be reciprocal relationships
between QoL and exercise behavior, such that,
rather than exercise behavior determining QoL
outcomes, having better QoL may increase ones
ability to engage in exercise behavior. It is the
positive spiral results of conditioning.
Cross-References
Elderly People
Exercise
QoL
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Physical Medicine & Rehabilitation, 90(2), 156168.
Wolin, K. Y., Glynn, R. J., Colditz, G. A., Lee, I. M., &
Kawachi, I. (2007). Long-term physical activity pat-
terns and health-related quality of life in U.S. Women.
Behavioral Dysfunction
American Journal of Preventive Medicine, 32(6),
490499.
World Health Organization, WHO. (2001). International
classification of functioning, disability and health:
ICF. Geneva: World Health Organization.
Behavioral Dysfunction
Filip Morisse1 and Eddy Weyts2
1 all the more striking is the mechanism of exclu-
Psychiatric Centre Dr. Guislain, Gent, Belgium
2 sion, which time and again leads to excluding
Academic Psychiatric Centre, UPC Sint
Kamillus, Bierbeek, Belgium
Synonyms
Challenging behavior; Dual diagnosis
Definition
Quality of life in adults with an intellectual dis-
ability and challenging behavior and/or mental
health problems.
Description
The field of intellectual disability (ID) is strongly
influenced by the quality of life (QOL) paradigm.
This framework supports the equality of persons,
which is reflected by concepts such as self-deter-
mination, emancipation, inclusion, and empow-
erment. In the daily practice, however, in which
concepts should be translated into actions, profes-
sionals are often confronted with the borders of
these leading principles. This seems especially
true when working with specific populations,
including persons with ID and challenging
behavior and/or mental health problems. The
application of QOL principles, which should in
ideal conditions lead to a better mental health,
seems to be at risk, as accounts from professionals
who indicate that emancipation is sometimes
replaced by actions aimed at controlling or
349 B
regulating clients (Claes, Morisse, Reynaert,
Andries, & Vandevelde, 2009).
Within this context, the question arises with
regard to the significance of inpatient treatment
of problems related to mental health and people B
with intellectual disability.
Over the years, there has been labored strongly
for the normalization, integration, and inclusion
as part of quality of life in favor of the general
group of people with intellectual disability. Here,
those persons within the group that do not come
up to the standards (Verstraete, 2009), in specific
those who suffer from problems of mental health.
Would it not be interesting to reflect upon the
community-based support that includes the
inpatient treatment, instead of one that avoids
hospitalization? To put it differently, can inpa-
tient treatment play a part in the movement of
community-based support and moreover when is
this possible?
We commence with a description of a few type
stories of people who ended up in admission
departments in a psychiatric hospital, in order to
question afterward why inpatient treatment was
necessary for each of them (Gardner, Dosen,
Griffiths, & King, 2006). Moreover, neither in
the type of pathology nor in the type of treatment,
we can discover criteria for residential care.
What then can be considered the relevance of
inpatient treatment?
P. has not been feeling well in the community
for some time now. Everyone that is worried about
her sees that she is suffering. Indeed, P. herself
affirms that she is not feeling well. In the past she
has already been admitted into a psychiatric clinic
because of her problems. She herself and her family
do not want to return to that clinic. The psychiatrist
associated with the facility where P. is accommo-
dated has already tried to increase her antipsy-
chotics, however, without success given that she
had suffered an epileptic attack. He insists upon an
admission to adapt her medication in a medical
context. Eventually everybody is convinced that
this is necessary. After been admitted, P. and her
family do not show any further signs of resistance.
P. gains some peace of mind in admission; and her
B 350
medication is adjusted, both antipsychotics and
antiepileptics. The community stays involved and
starts looking for ways that would improve their
method of identifying the first signals of illness of
P. After a few months, P. returns to her community.
Facility X asks if J. can be admitted urgently
because of his seriously aggressive outbursts in
the community. They feel they have tried every-
thing within their reach; however, J. breaks every
rule and engagement. J. does not notice any prob-
lem. At least, he believes that he himself does not
have any problems. Everything is fine with him.
He believes that the others actually have prob-
lems. We need to admit them instead of him and
leave him alone.
T.s dream has always been to go and live
independently. After many years in the commu-
nity, he can finally move to a studio. Everything
seems okay; however, after some time the super-
visors report more and more complaints. T. wan-
ders around in the city, frequently goes to cafes
where he drinks large amounts of coffee, and
neglects his daily activities. When they find him
in the city, introverted and talking to himself,
they decide to hospitalize him. He found this
extremely hard; however, very soon we
rediscover the happy T. who always offered him-
self spontaneously for tasks or who was always
interested in all sorts of things during the daily
activities.
From these stories we can derive some specific
situations in which inpatient treatment can be
useful:
1. The medical and psychiatric treatment in
a safe hospital environment.
Following the example of P., it is clear that
one needs a specific setting in order to receive
the necessary pharmacological treatment in
proper circumstances. In this case, the doctor
has to rely more strongly on his own observa-
tion and that of the supervisors in the daily
practice who are familiar with the side effects
of the medication.
2. The gravity of the problematic behavior is
dangerous for the patient himself or others.
A second situation in which an appeal is
often made to residential observation and
inpatient treatment unit is one where the
Behavioral Dysfunction
behavior of a person is of that kind that it
threatens the safety of the social situation.
This is possible with different types of pathol-
ogies, such as psychosis, mood disorders,
dementia, and behavioral disorder. This situa-
tion is characterized by a constant threat
toward the person himself and the others
(Dosen, 2005).
3. Non-corresponding support as multi-defining
factor.
The emancipatory thinking and the model
of citizenship have brought about plenty of
good things for people with intellectual dis-
ability. However, sometimes it can go wrong
when one overestimates the capacity of people
with intellectual disability. The capacity is of
course different than the capability. Over the
years, we have seen several admissions that
deal with the psychological incapability of
something that one is actually capable of.
A lot of people who have chosen to live inde-
pendently or with as little support as possible
following their dream of independence will
eventually be admitted because of their
psychological problems, connected with the
psychological incapability (leading to loneli-
ness) that is characteristic of independent
living.
4. Environmental factors as multi-defining factor
(Vandeweerdt, Travers, & Bauwens, 2007).
Over the last decades the care for people
with intellectual disability has been occupied
with the matter of small-scaled living. In itself
this is an effective evolution, however, it also
has a downside. We cannot forget that, as
small as the group counts, the persons living
in it did not choose to live together. The
smaller the group, the more intense the inter-
actions. This can be very positive and warm;
however, if the field of relations between the
residents substantially goes wrong, hell can be
broken loose.
5. The relapse position or key stone function of
a network.
In the case of severe problem behavior, it
often occurs that people only get new opportu-
nities when a facility makes a permanent appeal
to the observation and inpatient treatment unit.
Belief in a Just World (BJW)
Besides, most units have already had some part-
time treatments to make it possible; however,
there is still more to be done in this field. This
way it is logical that a facility is more willing to
resume the care of the client when they can fall
back on the treatment unit when necessary,
without being confronted with waiting lists.
6. The hospital functions as first aid for
unforeseen circumstances.
From a social perspective, there have
always been situations where the social sup-
port system as such does not have any answers.
A residential observation and treatment unit
can, from within her hospital function, carry
out a first investigation and report the problem.
In conclusion, inpatient mental health care of
people with intellectual disability is useful in
certain circumstances. However, in our opinion,
it is only possible if it is the intention to improve
the quality of life of people with intellectual
disability in their social situation (Williams &
Heslop, 2005). Automatically this implies that
one strives toward an admission period as short
as possible and that the goals of treatment aim at
the functioning in a regular social situation.
When the inpatient treatment units function in
this way, they contribute toward the idea of com-
munity-based support in their own way. They
can, however, only accept and fulfill this role
when they are part of the networks that in their
entirety aim at maximizing care in society, with
respect for everyones capacity. Of vital impor-
tance is the presence of a well-differentiated
vision on support in society, taking into account
not only the capacity as much as possible and the
functioning as normal as possible but also the
psychological welfare of these persons. Com-
bined with every other possibility of treatment
in the social situation, this seems to be the best
guarantee in order that no person with an intel-
lectual disability is excluded from this commu-
nity-based support.
Cross-References
Intellectual Disability
351 B
References
Claes, C., Morisse, F., Reynaert, D., Andries, J., &
Vandevelde, S. 2009. Do opposites really attract?
Exploring the borders of emancipation and control.
7th European congress of mental health in intellectual B
disability. Amsterdam, September 35, 2009.
Dosen, A. (2005). Psychische stoornissen,
gedragsproblemen en verstandelijke handicap.
Assen: Koninklijke Van Gorcum.
Gardner, W. I., Dosen, A., Griffiths, D., & King, R.
(2006). Practice guidelines for diagnostic, treatment
and related support services for people with develop-
mental disabilities and serious behavioral problems.
New York: NADD.
Vandeweerdt, M., Travers, E., & Bauwens, A. (2007).
Kom Binnen. therapeutische ontmoetingen met
mensen met een verstandelijke handicap. SEN-
publicaties (2). Antwerpen/apeldoorn: Garant.
Verstraete, P. (2009). Toen ook de Duivelskinderen naar
school mochten. APPeL. Magazine voor
Afgestudeerde Psychologen en Pedagogen K.U.Leu-
ven, 4(3), 2.
Williams, V., & Heslop, P. (2005). Mental health support
needs of people with learning difficulty: A medical or
social model? Disability & Society, 20(3), 231245.
Behavioral Systems
Faceted Action System Theory (FAST)
Belief in a Just World (BJW)
Adrian Furnham
University College London, London, UK
Definition
The belief in a just world pattern refers to the
tendency of people to blame victims of misfor-
tunes for their own fate.
Description
The belief in a just world pattern was identified
over 30 years ago and concentrates on the
B 352
tendency of people to blame victims of misfor-
tunes for their own fate (Lerner, 1980). The
essence of this hypothesis or theory was suc-
cinctly summarized by Lerner & Miller (1978,
pp. 10301031):
Individuals have a need to believe that they
live in a world where people generally get what
they deserve. The belief that the world is just
enables the individual to confront his physical
and social environment as though they were sta-
ble and orderly. Without such a belief it would be
difficult for the individual to commit himself to
the pursuit of long range goals or even to the
socially regulated behaviour of day-to-day life.
Since the belief that the world is just serves such
an important adaptive function for the individual,
people are very reluctant to give up this belief,
and they can be greatly troubled if they encounter
evidence that suggests that the world is not really
just or orderly after all.
The idea is that essentially many people from
all cultures and creeds have a fundamental need
to believe that the (social) world is a just place
and that this belief is functionally necessary for
them to develop principles of deservingness.
Many are confronted with difficult issues like
why some people get cancer, are sexually abused,
and descend into poverty, while others do not.
They also have to make sense of their own mis-
fortunes. The idea of the belief in a just world is
that it helps answer some of these very difficult
questions.
Considerable laboratory evidence has been
accumulated in support of the concept, most of
which has attempted to spell out exactly how and
when victims are blamed for their fate, how these
beliefs arise, and their consequences for those
who believe them.
Rubin and Peplau (1975) devised a self-report
inventory to measure the attitudinal continuity
between the two opposite poles of total accep-
tance and rejection of the notion that the world is
a just place. About half the items suggest that the
world is a just place where good deeds are
rewarded (i.e., 11: By and large people deserve
what they get), and half refer to an unjust world
where good deeds are no more likely to be
rewarded than bad deeds (i.e., 4: Careful drivers
Belief in a Just World (BJW)
are just as likely to get hurt in traffic accidents as
careless ones).
Many studies have used this scale to examine
further the relationship between just world and
other beliefs and behaviors (Furnham & Procter,
1989). The measure is not without its difficulties,
and numerous other self-report measures are
available, some measuring related issues about
a personal sense of justice. Others have distin-
guished between immanent and ultimate justice.
Nevertheless, the belief in a just world
(BJW) measure has been shown to correlate sig-
nificantly with demographic variables such as
age, income, and religion but also such personal-
ity factors as attitudes to authority, conservatism,
and locus of control. People with strong needs to
believe in a just world find it difficult to deal with
others misfortune, such as illness. Hence, they
may be particularly unsympathetic to colleagues
going absent with serious illnesses, because they
find it difficult to accept the idea that some ill-
nesses and diseases seem to strike people ran-
domly. Beliefs about justice are no doubt related
to such factors as pay and reward satisfaction at
work, as well as feelings about equity. All issues
concerning distribution and procedural justice at
work are, no doubt, related to just world
beliefs, as well as sensitivity to all issues to do
with fairness in the workplace.
The literature in this area has grown so much
that two big reviews have appeared in the past
decade. Furnham (2003) noted that two distinct
research interests have emerged over the past
decade. The first has been concerned with devis-
ing better and sensitive measures of the BJW. All
four self-report measures devised prior to 1991
attempted to provide an overall BJW score. Since
then, all measures have attempted to measure
particular facets of BJW beliefs. This has meant
making various distinctions between, for
instance, imminent versus ultimate justice and
hope for, versus ability to promote, a just world.
What most of these latter studies have been able
to show is that these different, but related, beliefs
are systematically associated with different
dependent variables.
The second major development has been to
view the BJW as a healthy coping mechanism
Beliefs About Poverty
rather than being the manifestation of antisocial
beliefs and prejudice (Dalbert, 2001). There has
been a subtle movement from focusing on victim
derogation to positive coping. Recent studies
have portrayed BJW beliefs as a personal
resource or coping strategy, which buffers against
stress and enhances achievement behavior. For
the first time, BJW beliefs have been seen as an
indicator of mental health and planning. This
does not contradict the more extensive literature
on BJW and victim derogation. Rather, it helps
explain why people are so eager to maintain their
beliefs which may be their major coping strategy.
BJW is clearly functional for the individual. One
important issue for future research is how BJW
related to other coping strategies and which are
favored by health individuals who have low BJW
beliefs. Again, the focus is on how BJW relates to
personal experiences rather than that of others.
In an important and comprehensive review,
Hafer and Begue (2005) described well over 50
studies done since 1980. They noted how
unsystematic the research has been and that
some researchers have in fact not understood the
theory upon which the study was based. They
also note various important developments in the
area. The first is to understand the psychological
function of believing in a just world to foster
a sense of well-being and a buffer against unfair
life experiences. The second is the strategies that
people use to maintain their belief in a just world
such as distancing themselves from victims and
developing just-world-restoring strategies for
reacting to those who perpetrate injustice. Third,
there is the consideration of injustice to obviously
innocent others and fourth reactions to ones own
suffering. A final new area of research is consid-
ering reactions to unjust benefits. This area of
research is related to all other social justice
theories and is a thriving area of research.
Cross-References
Locus of Control
Personality, an Overview
Social Justice
353 B
References
Dalbert, C. (2001). The justice motive as a personal
resource. New York: Plenum.
Furnham, A. (2003). Belief in a just world: Research
progress over the past decade. Personality and Indi- B
vidual Differences, 34, 795817.
Furnham, A., & Procter, E. (1989). Belief in a just world:
Review and critique of the individual difference liter-
ature. British Journal of Social Psychology, 28,
365384.
Hafer, C., & Begue, L. (2005). Experimental research on
just-world theory: Problems, developments and future
challenges. Psychological Bulletin, 131, 128167.
Lerner, M. (1980). The belief in a just world:
A fundamental delusion. New York: Plenum.
Lerner, M., & Miller, D. (1978). Just world research and
the attribution process: Looking back and looking
ahead. Psychological Bulletin, 85, 10301051.
Rubin, Z., & Peplau, L. (1975). Who believes in a just
world? Journal of Social Issues, 31, 6589.
Beliefs About Poverty
Ben Law1 and Daniel T. L. Shek2
1
Department of Social Work and Social
Administration, The University of Hong Kong,
Hong Kong, Peoples Republic of China
2
Department of Applied Social Sciences, The
Hong Kong Polytechnic University, Hong Kong,
Peoples Republic of China
Synonyms
Causal attributions for poverty; Perceived causes
of poverty; Perception of poverty
Definition
Beliefs about poverty are defined as personal
views and perceptions about the causes of pov-
erty. Originated from Feagin (1975), there are
three main types of reasons for poverty: individ-
ualistic, structuralist, and fatalistic. Individualis-
tic beliefs attribute poverty to the poor people
themselves (personal problems) like lack of
ability, effort, and morals. Structuralist beliefs
B 354
locate the causes in the social and economic
systems (social problems) like lack of opportuni-
ties, discrimination, and exploitation of poor
people. Fatalistic beliefs put the causes beyond
individual and environmental control (fate) such
as luck, sickness, and chance.
Description
Poverty is defined as the familys total income
being lower than an income threshold, based on
expenditures judged necessary for minimal
acceptable amounts of food, housing, and other
essentials (Feagin, 1975). However, beliefs
about poverty are defined as personal subjective
propositions and views about the causes of
poverty.
Three Types of Beliefs About Poverty
Beliefs are concerned with propositions about an
object or a relation between objects or concepts
(Jones & Nisbett, 1972). The proposition can be
causal or correlational. The belief is judged
with its subjective true-false and correct-
incorrect status. Beliefs can be classified into
three types based on the functional domains.
Individual beliefs are concerned with the
characteristics of individuals, social beliefs
about social interactions and social groups, and
environmental beliefs about the natural and
supernatural context.
The classification of beliefs about poverty by
Feagin (1975) follows the aforementioned con-
ceptualization. It consists of three categories:
individualistic, structuralist, and fatalistic.
Individualistic beliefs attribute poverty to the
poor people themselves (personal problems) like
lack of ability, effort, and morals. Structuralist
beliefs locate the causes in the social and eco-
nomic systems (social problems) like lack of
opportunities, discrimination, and exploitation
of poor people. Fatalistic beliefs put the causes
beyond individual and environmental control
(fate) such as luck, sickness, and chance.
Individualistic beliefs emphasize personal
problems as the cause of poverty. There are at
least four theories in explaining or elaborating
Beliefs About Poverty
individualistic beliefs. The first theory is the
dominant ideology thesis (Wilson, 1996). It is
suggested that America or other modern societies
tend to uphold values of equality, success, and
democracy. In this way, societies are perceived to
be full of equal opportunities. Being poor is an
individual problem rather than a social problem.
Dispositional factors are emphasized over situa-
tional factors. Adherence to this self-serving bias
could produce a logical justification of socioeco-
nomic inequality. The second theory is the cul-
ture-of-poverty model. It is proposed that the
poor have developed an alternative culture that
they cannot escape poverty (Kane, 1987). For
instance, the poor may use more slang and vulgar
language to the extent that they cannot climb up
the social ladder. The endorsement of a culture of
poverty prevents them from appreciating higher-
class culture, such as classical music and poetry,
which are more likely to be appreciated by people
without poverty. Besides, when some poor peo-
ple are accustomed to welfare, they lack the
motivation to look for career advancement. The
low motivation to work forms a vicious cycle
with a manifestation of laziness. Ultimately, this
forms a distinctive culture of poverty. The
intergenerational transmission of cultural values
of the poor further exacerbates the problems. The
third theory is actor-observer bias, which also
accounts for individualistic beliefs (Jones &
Nisbett, 1972). The nonpoor tend to attribute
their status to their own efforts instead of social
advantages. Following this line of thinking, they
also apply dispositional reasoning to the causes of
poverty. The fourth perspective is stress theory.
People in poverty tend to experience more stress
(Hayati & Karami, 2005). The stress of a poor
family results in a negative and pessimistic per-
sonal outlook. This forms a self-fulfilling proph-
ecy that disables the next generation from
breaking through the current predicament. The
stress stops the individuals from combating pov-
erty. The common feature of individualistic
belief for all these four theories is that they tend
to blame the poor for having immutable personal
pathology for their misfortunes.
Structuralist beliefs emphasize poverty as
social problems. Della-Fave (1974) suggested
Beliefs About Poverty
that egalitarianism and distributive justice consti-
tute the foundation of structuralist beliefs. The
formation of these two ideologies rests on five
beliefs: (1) a feeling of deprivation, (2) an attribu-
tion of blame to the organization of society,
(3) a belief that social justice requires equality,
(4) a belief that human nature will permit equality
in a complex society, and (5) a belief that the
transition from the present society to an egalitarian
one is practically possible and worth the effort.
Thus the cultivation of these two ideologies
paves the path toward a more equal and just soci-
ety. Poverty is a social problem instead of an
individual one. The second theory is public arena
theory (Lee, Jones, & Lewis, 1990). Beliefs about
poverty are influenced by what the citizens know
and perceive. However, many issues in societies
are competing with each other in order to gain
a high problem status. One major institution
shaping the public discourse of the poor is the
media and pressure groups. The depiction of
media and pressure groups for poverty often
exposes more eye-catching and flamboyant social
problems, exploitation, and inequalities to the
extent that structural beliefs prevail. For example,
one recurring theme is hardworking laborers that
fulfilled a need for cheap labor in the capitalist and
exploitative society. The third theory is the reci-
procity norms theory. The interaction between
people with the poor facilitates the development
of structuralist beliefs (Boarini & Le Clainche,
2009). People in advantageous positions can be
more empathetic toward poor people. Instead of
individualistic reasoning, they understand more
the social inequality during interaction. The reci-
procity norms theory is a reaction against actor-
observer bias. The fourth theory is the underdog
thesis (Robinson & Bell, 1978). Different groups
of people hold different beliefs. Advantaged
groups take the dominant ideologies, whereas dis-
advantaged groups are less likely to adopt domi-
nant ideologies and are more supportive of
ideological challenges (i.e., structuralist beliefs).
The underdog thesis is the foundation of social
action and postmodernism.
Fatalistic beliefs locate the causes of poverty
in nonstructural, but supra-individual forces such
as luck, chance, and sickness. It emphasizes that
355 B
poverty is beyond individuals control. One
prominent example is the Chinese culture.
Cross-cultural studies have shown that Chinese
use more passive coping to meet their fates.
Confucianism, Buddhism and Taoism advocate B
fatalistic beliefs in times of life adversity.
According to Confucian doctrines, individuals
should passively accept stress and suffering
because such experience may be lessons given
by the Heaven. Such negative experience can
train a persons resilience and will. Thus, there
is a Chinese saying of Thousand dollars cannot
buy poverty for youth. It is a positive reframing.
On the other hand, Buddhism suggests that
we have to cultivate the good deeds. However,
if we receive some mistreatment, it is because we
have to pay the debt of our previous actions, i.e.,
karma. Sometimes we even have to pay the debt
from our former lives. In reality, we cannot
understand and control many things. According
to Taoism, we have to attain harmony. We should
be contented and accept our fate. A core concept
of Taoist thinking is wu wei, implying noninter-
vention and following what is given in life.
Everything is actually relative, and there is no
absolute right or wrong. Besides, anything
pushing to the extreme brings evil. Thus, there
are idioms such as poverty would not last more
than three generations; richness would not last
more than three generations. We can see that
a sense of control does not come from mastery
of the environment but from the acceptance of
fate as the reality. Fatalistic beliefs of poverty
emphasize that it is beyond an individuals
control to be poor or not.
Not many studies focus on fatalistic beliefs.
Many studies have instead explored the relation-
ship between individualistic and structuralist
beliefs. Apparently they are antagonistic to each
other. However, this dichotomy is not always jus-
tified as inconsistent or contradictory beliefs can be
combined into compromise explanations. Then
they are not alternative or polar opposites. They can
coexist in each person. This phenomenon is called
the dual consciousness hypothesis, which is espe-
cially common among socially and economically
marginalized groups (Hunt, 2004). It means a per-
son understands that society favors the nonpoor
B 356
(structuralist belief). However, he or she will strive
to get a better position so as to get rid of poor status
(individualistic belief). There are two explanations
for this dual consciousness hypothesis. The first is
the omnipotence of individualistic explanation.
Although poor people experience injustice and
understand structuralist beliefs, individualistic
beliefs are so pervasive that they influence people
at all social positions (Lee et al., 1990). Structuralist
belief is like a layer onto the existing individualistic
beliefs. The individualistic belief is too deep-rooted
to be replaced. This positioning of structuralist
belief avoids acute group-based conflicts because
of the inconsistency of belief systems (Hunt, 2004).
The second reason is the denial of personal
discrimination. Poor people understand that they
are marginalized but they tend to underestimate
the effect of the discrimination. Otherwise, they
think they receive a better treatment than
other poor people. This denial also results in social
harmony and apparent social justice.
Assessment of Beliefs About Poverty
Despite heated discussions on the categories of
beliefs about poverty, there are not many
validated instruments measuring the perceived
causes of poverty. Alston and Dean (1972) used
a single item to measure this belief. Feagins
(1975) classic treatise adopted 11 items to
measure three domains of beliefs. Atherton et al.
(1993) developed a 37-item scale to measure three
domains of beliefs.
Shek (2004a) developed a Chinese Perceived
Causes of Poverty Scale. Four factors are
established (Shek & Ma, 2009): personal
problems, exploitation, lack of opportunities, and
bad fate. As exploitation and lack of opportunities
are structuralist beliefs, the factors fit the classic
tripartite classification of beliefs about poverty.
For the measurement of beliefs about Third-
World poverty, Hine and Montiel (1999) found
five factors based on the Causes of Third-World
Poverty Scale, namely, blaming the poor, the
government, nature, exploration, and conflicts.
Among all scales, the Chinese Perceived Causes
of Poverty Scale (Shek & Ma, 2009) has some of
the most psychometrically sound properties
because of its factorial validity and sizable
Beliefs About Poverty
respondents for validation. All other scales suffer
from the problems of too few subjects and explor-
atory factors.
Individual Correlates of Different Beliefs
About Poverty
People who believe in a meritocratic ethos tend to
attribute the causes of poverty to the lack of
individual effort and talent (Stephenson, 2000).
The dominant ideology thesis suggests that
people who have the greatest stake in the social
stratification system, greater authoritarianism, and
social dominance will endorse dominant ideolog-
ical explanations for poverty. Empirical research
has shown that males or white people tend to
adopt individualistic beliefs; being young tends
to be intolerant of the poor (Alston & Dean, 1972).
Education is a strong predictor of both individ-
ualistic beliefs and structuralist beliefs. People
with high education tend to be the group of
socially privileged, and they tend to adopt the
dominant ideology thesis (individualistic belief).
However, higher education also enlightens people
to an extent that they understand more structural or
distant causes of poverty (Hunt, 2004). Low-
income and ethnic minority groups tend to adopt
structuralist explanations; yet considerable sup-
port for individualistic causes was also found,
supporting the dual consciousness thesis. Reli-
gions also affect the beliefs about poverty. Protes-
tants and Catholics are strongest on individualistic
beliefs, Jews and other religions are strongest on
structuralist beliefs, and Catholics and Jews are
strongest on fatalistic beliefs (Hunt, 2004).
Social Correlates of Different Beliefs
When people think that the society is legitimate
and fair, they tend to attribute poverty to individ-
ual factors (Stephenson, 2000). The nonpoor tend
to see the poor as lazy and undeserving.
In affluent societies, people tend to blame the
poor as they do not utilize the resources available
(Feagin, 1975). In societies with a larger middle-
class population, individualistic beliefs also
outweigh structural factors. When wealth is get-
ting accumulated, individualistic explanations
would increase (Stephenson, 2000). In fact,
Feagin (1975) has already predicted the
Beliefs About Poverty
emergence of individualistic explanations for
better-off countries:
In affluent societies.. members may believe
that there is plenty to go around and that, even
though the poor have brought misfortune upon
themselves, they should have some part of the
plentiful resources that are available. Ones reac-
tions to inequalities would therefore depend upon
the sometimes harsh economic and social reali-
ties of how much is available and whether it can
be increased. (Feagin, 1975, p.216)
In a society with a larger poor population, they
tend to blame the economic system as the cause of
poverty. However, for blacks and Latinos, they
may attribute both individualistic and structuralist
reasons to the causes of poverty (Hunt, 2004).
People from different political orientations
have different attributions: those on the left wing
tend to endorse structuralist, whereas those on the
right tend to endorse individualistic beliefs
(Zucker & Weiner, 1993). In a similar vein, people
in welfare states, such as Finland (Niemela, 2008),
tend to have structuralist beliefs about poverty.
In cultures advocating personal efforts such as
the USA or China, individual beliefs about pov-
erty prevail because they think they can achieve
by efforts and perseverance regardless of
backgrounds.
Timing is also critical for the beliefs. Structural-
ist beliefs actually predominate in public opinion
during times of extreme social or economic strain,
such as the Great Depression, economic stagnation,
and persistent income inequality (Seipel, 2003).
Beliefs About Poverty and Quality of Life
There are not many studies related to the relation-
ship between beliefs about poverty and quality of
life. Perception of poverty is related to quality of
life. In Iran, people with individualistic beliefs
about poverty had a higher quality of life and
upward mobility, whereas people with fatalistic
beliefs had the lowest quality of life (Hayati &
Karami, 2005). African children who did not attri-
bute poverty to structuralist causes tend to have
higher academic goals (Murry et al., 2002). More-
over, their mothers psychological stress was
linked with childrens attributions about the causes
of poverty through its association with parenting.
357 B
Shek (2004b) found that the relationship is
bidirectional for Chinese populations. Beliefs
about poverty were concurrently and longitudinal
related to the psychological well-being of adoles-
cents and adults (Shek). In general, stronger B
beliefs in fate and externality (structuralist fac-
tors) would predict a decrease in mastery and an
increase in psychological symptoms for adoles-
cents, but not for fathers. However, a stronger
endorsement of fate and externality as the causes
of poverty actually predicted a higher sense of
existential well-being and life satisfaction for
Chinese mothers. A sense of exploitation would
predict a negative quality of life for parents but
not for adolescents. As well, psychological well-
being influences beliefs about causes of poverty.
Existential well-being and life mastery can affect
the formation of beliefs about poverty, especially
structuralist and fatalistic beliefs.
In short, perceived causation of poverty is
related to quality of life, the effect of which is
partly influenced by cultures.
Implications of Understanding Beliefs
About Poverty
Causal attributions are important mediators of
future behavior. Once a cause is described,
a following consequential action can be taken.
The perceived causes of poverty form a basis for
the explanation people offer and the policies they
endorse. Beliefs about poverty also mediate the
relationship between the political ideology people
hold and the involvement in antipoverty activism
(Hine & Montiel, 1999), which would eventually
influence the quality of life of poor people.
Individual explanations predict support for
restrictive policies. Individualistic beliefs are
directly related to feelings of stigma. Holding an
individual belief about poverty will engender the
proposal that those receiving public allowance
should be forced to find work or engaged
in mandatory vocational rehabilitation on the
assumption of their laziness and tendency to
avoid work. They are also associated with train-
ing programs with enhanced work orientation and
conscientiousness (Alston & Dean, 1972).
Beliefs in the structural causes of poverty sup-
port social provision of basic needs. Advocates call
B 358
for greater government intervention in distributive
justice such as community-based poverty reduction
intervention strategies or progressive policies with
increased welfare spending.
Understanding the beliefs about poverty is criti-
cal for human service professionals working with
the poor, such as social workers (Shek, 2004b).
Social work education should provide more training
in this aspect. Weiss-Gal, Benyamini, Ginzburg,
Savaya, and Peled (2009) have argued the inade-
quacy of social work education of beliefs about
poverty. Toporek and Pope-Davis (2005) observed
that counselors are ill equipped to provide compe-
tent services to people in oppressive situations
including living in poverty. They also observed the
persuasiveness of the culture of poverty (individu-
alistic beliefs) among professionals. The beliefs
about poverty among human service professionals
directly affect their interest and willingness to help
the poor or fight for social justice (Weiss-Gal et al.,
2009). Although social workers hold more structur-
alist beliefs than other professionals and social work
students also have more structuralist beliefs than
nonsocial work students, service users still attribute
more importance to individualist beliefs and to fatal-
istic causes compared with social workers (Weiss-
Gal et al.). Human service professionals should
understand the clients beliefs about poverty, as
well as their own beliefs about poverty. The under-
standing should include factors shaping beliefs and
the consequences of adopting the beliefs (Weiss-
Gal et al.). As such, multicultural training (MCT)
has shown that it is effective in facilitating coun-
selors sensitivity to the structural causes of poverty
(Toporek & Pope-Davis, 2005).
Cross-References
Chinese Beliefs About Adversity Scale
Chinese Culture
Poverty
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Alston, J. P., & Dean, K. I. (1972). Socioeconomic factors
associated with attitudes toward welfare recipients and
the causes of poverty. The Social Science Review,
46(1), 1323.
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Atherton, C. R., Gemmel, R. J., Haadenstad, S., Hold,
D. J., Jensen, L. A., OHara, D. F., et al. (1993).
Measuring attitudes toward poverty: A new scale.
Social Work Research & Abstracts, 29(4), 2830.
Boarini, R., & Le Clainche, C. (2009). Social preferences
for public intervention: An empirical investigation
based on French data. The Journal of Socio-Econom-
ics, 38(1), 115128.
Della-Fave, L. R. (1974). On the structure of egalitarian-
ism. Social Problems, 22, 199213.
Feagin, J. R. (1975). Subordinating the poor: Welfare and
American beliefs. Englewood Cliffs, NJ: Prentice-Hall.
Hayati, D., & Karami, E. (2005). Typology of causes of
poverty: The perception of Iranian farmers. Journal of
Economic Psychology, 26(6), 884901.
Hine, D. W., & Montiel, C. J. (1999). Poverty in develop-
ing nations: Cultural attributional analysis. European
Journal of Social Psychology, 29(7), 943959.
Hunt, M. O. (2004). Race/ethnicity and beliefs about wealth
and poverty. Social Science Quarterly, 85(3), 827853.
Jones, E. E., & Nisbett, R. E. (1972). The actor and the
observer: Divergent perceptions of the causes of the
behavior. In E. E. Jones, D. E. Kanouse, H. H. Kelley,
R. E. Nisbett, S. Valins, & B. Weiner (Eds.), Attribu-
tion: Perceiving the causes of behavior. Morristown,
NJ: General Learning Press.
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405419.
Lee, B., Jones, S. H., & Lewis, D. W. (1990). Public
beliefs about the causes of homelessness. Social
Forces, 69, 253265.
Murry, V. M., Brody, G. H., Brown, A., Wisenbaker, J.,
Cutrona, C. E., & Simons, R. L. (2002). Linking
employment status, maternal psychological well-
being, parenting, and childrens attributions about
poverty in families receiving government assistance.
Family Relations, 51(2), 112120.
Niemela, M. (2008). Perceptions of the causes of poverty
in Finland. Acta Sociologica, 51(1), 2340.
Robinson, R. V., & Bell, W. (1978). Equality, success, and
social justice in England and United States. American
Sociological Review, 43, 125143.
Seipel, M. M. O. (2003). Global poverty: No longer an
untouchable problem. International Social Work,
46(2), 191207.
Shek, D. T. L. (2004a). Beliefs about causes of poverty and
psychological well-being of parents and adolescents
experiencing economic disadvantage in Hong Kong.
American Journal of Family Therapy, 32(3), 239254.
Shek, D. T. L. (2004b). Beliefs about the causes of poverty
in parents and adolescents experiencing economic dis-
advantage in Hong Kong. The Journal of Genetic
Psychology: Research and Theory on Human Devel-
opment, 165(3), 272291.
Shek, D. T., & Ma, C. M. (2009). Dimensionality of the
Chinese Perceived Causes of Poverty Scale: Findings
based on confirmatory factor analyses. Social Indica-
tors Research, 90(2), 155164.
Bell, Daniel
Stephenson, S. (2000). Public beliefs in the causes of wealth
and poverty and legitimization of inequalities in Russia
and Estonia. Social Justice Research, 13(2), 83100.
Toporek, R. L., & Pope-Davis, D. B. (2005). Exploring the
relationships between multicultural training, racial
attitudes, and attributions of poverty among graduate
counseling trainees. Cultural Diversity & Ethnic
Minority Psychology, 11(3), 259271.
Weiss-Gal, I., Benyamini, Y., Ginzburg, K., Savaya, R., &
Peled, E. (2009). Social workers and service users causal
attributions for poverty. Social Work, 54(2), 125133.
Wilson, G. (1996). Toward a revised framework for exam-
ining beliefs about the causes of poverty. The Socio-
logical Quarterly, 37(3), 413428.
Zucker, G. S., & Weiner, B. (1993). Conservatism and
perceptions of poverty: An attributional analysis. Jour-
nal of Applied Social Psychology, 23(12), 925943.
Beliefs, Spiritual
Religious Beliefs and Psychiatric Symptoms
Bell, Daniel
Richard J. Estes
School of Social Policy & Practice (SP2),
University of Pennsylvania, Narberth,
PA, USA
Birth, Education, Work History, and
Main Contributions
Born Daniel Bolotsky on New York Citys Lower
East Side on May 10, 1919, Daniel Bell was to
become one of the worlds most prolific and influ-
ential sociologists, writers, editors, and professor
emeritus of social sciences at Harvard University.
He is best known for his seminal contributions to
the study of post-industrialism, i.e., the process
whereby economically advanced countries shift
from manufacturing to the service and, now,
knowledge-based economies. His major lines of
inquiry included the failures of socialism in Amer-
ica, the exhaustion of modern culture, and the
transformation of capitalism from an industrial-
based system to one built on consumerism.
359 B
He has been described as one of the leading
American intellectuals of the postwar era. His
three best known works are The End of Ideology,
The Coming of Post-Industrial Society, and The
Cultural Contradictions of Capitalism. B
Within the social indicators movement, he
is best known for his contributions related to
Toward a Social Report (Bell et al., 1969),
the first report of its type attempted by a major
economic power. The work built on that of
Wilbur Cohen, then secretary of the US Depart-
ment of Health, Education, and Welfare. The
goal throughout the two-decade-long planning
process was to prepare an annual report to the
nation concerning changing social conditions
occurring throughout all sectors of American
life. Many prominent American economists,
sociologists, philosophers, and others either pre-
ceded or joined with Bell in bringing the first such
report to fruition: William F. Ogburn, Wesley
Clair Mitchell, Otis Dudley Duncan, Louis
Brownlow, Charles Merriam, and Alice Rivlin,
among others. Owing to their perceived politi-
cally explosive nature, funding to conduct subse-
quent annual social reports was withdrawn from
subsequent efforts by the Nixon administration.
In Bells obituary that appeared in the January
25, 2011, edition of the New York Times (2011),
the same day as his death, the late journalist
Michael T. Kaufman noted:
. . .two of Bells books, The End of Ideology
(1960) and the Cultural Contradictions of Cap-
italism (1976), were ranked among the 100 most
influential books since World War II by The Times
Literary Supplement in London. In titling The
End of Ideology and another work, The Com-
ing of Post-Industrial Society (1973), Bell
coined terms that have entered common usage.
In The End of Ideology he contended - nearly
three decades before the collapse of communism -
that ideologies that had once driven global politics
were losing force and thus providing openings for
newer galvanizing beliefs to gain toeholds. In The
Coming of Post-Industrial Society, he foresaw the
global spread of service-based economies as gen-
erators of capital and employment, supplanting
those dominated by manufacturing or agriculture.
In Bells view, Western capitalism had come to
rely on mass consumerism, acquisitiveness and
widespread indebtedness, undermining the old
Protestant ethic of thrift and modesty that writers
B 360
like Max Weber and R. H. Tawney had long
credited as the reasons for capitalisms success.
He also predicted the rising importance of sci-
ence-based industries and of new technical elites.
Indeed, in 1967, he predicted something like the
Internet, writing: We will probably see a national
information-computer-utility system, with tens of
thousands of terminals in homes and offices
hooked into giant central computers providing
library and information services, retail ordering
and billing services, and the like.
Kaufman also reported that Bell became an
influential editor of periodicals, starting out
with The New Leader, a small social democratic
publication that he referred to as his intellectual
home. He joined Fortune magazine as its labor
editor and in 1965 helped establish and edit The
Public Interest with his old City College
classmate Irving Kristol, who died in 2009.
Though The Public Interest never attained
a wide readership, it gained great prestige, begin-
ning as a policy journal that questioned Great
Society programs and then broadening into one
of the most intellectually formidable of neocon-
servative publications. It has had more influence
on domestic policy than any other journal in the
country by far, the columnist David Brooks
wrote in The New York Times in 2005.
In addition to being such a prolific author, Bell
also maintained a distinguished academic career,
teaching at the University of Chicago in the
1940s, at Columbia University as a professor of
sociology from 1959 to 1969 the university
awarded him a Ph.D. for his work on The End of
Ideology and then at Harvard University, where
in 1980 he was appointed the Henry Ford II pro-
fessor of social sciences. As both a public intellec-
tual and an academic, according to Kaufman, Bell
saw a distinction between those breeds. In one of his
typical yeasty digressions in The End of Ideol-
ogy, he wrote: The scholar has a bounded field
of knowledge, a tradition, and seeks to find his place
in it, adding to the accumulated, tested knowledge
of the past as to a mosaic. The scholar, qua scholar,
is less involved with his self.
Bells contribution in adding momentum to the
now worldwide social indicators and social
reporting movements was second to none.
Bellagio Principles for Assessing Sustainable Development
He provided the intellectual leadership, concep-
tual clarity, and a well-honed sense of the future
that have contributed to the relevance of these data
in both public data gathering and public policy
formulation in countries throughout the world.
He also provided both fields of social inquiry
with a level of methodological integrity which,
until the 1940s and 1950s, seemed to be out of
reach for all but a few. Though now at rest, Bells
work will continue to inform the thinking of gen-
erations of social researchers well into the future,
especially those that seek to reconcile emerging
societal paradigms with existing norms, tradi-
tions, values, and modes of collective behavior.
References
Bell, D. (1960). The end of ideology: On the exhaustion of
political ideas in the fifties. Glencoe: Free Press.
Bell, D. et al. (1969). Toward a social report: 1The idea
of a social report. The Public Interest (15): 7284.
Retrieved March 12, 2011 from http://www.
nationalaffairs.com/doclib/20080522_196901507
theideaofasocialreportdanielbell.pdf
Bell, D. (1973). The coming of post-industrial society:
A venture in social forecasting. New York: Basic Books.
Bell, D. (1976). The cultural contradictions of capitalism.
New York: Basic Books.
Kaufman, M. T. (2011). Daniel Bell, ardent appraiser
of politics, economics and culture, dies at 91.
New York Times, January 25. Retrieved March 18,
2011 from http://www.nytimes.com/2011/01/26/arts/
26bell.html?_r1
Bellagio Principles for Assessing
Sustainable Development
Jochen Jesinghaus
JJ, European Commission, Ispra, Italy
Definition
On initiative of the International Institute for
Sustainable Development (IISD), in November
1996 a group of 24 experts from five continents
developed at the Rockefeller Foundations Study
BellagioSTAMP
and Conference Center in Bellagio, Italy, a set of
ten principles for assessing and measuring sus-
tainable development, called (1) guiding vision
and goals, (2) holistic perspective, (3) essential
elements, (4) adequate scope, (5) practical focus,
(6) openness, (7) effective communication,
(8) broad participation, (9) ongoing assessment,
and (10) institutional capacity.
Description
According to IISD, Principle 1 deals with the
starting point of any assessment - establishing
a vision of sustainable development and clear
goals that provide a practical definition of that
vision in terms that are meaningful for the deci-
sion-making unit in question. Principles 2
through 5 deal with the content of any assessment
and the need to merge a sense of the overall
system with a practical focus on current priority
issues. Principles 6 through 8 deal with key issues
of the process of assessment, while Principles 9
and 10 deal with the necessity for establishing
a continuing capacity for assessment.
The principles are intended as guidelines for
the whole of the assessment process including the
choice and design of indicators, their interpreta-
tion and communication of the result (Hardi &
Zdan, 1997).
Cross-References
Agenda 21
Sustainable Development
References
BellagioStamp: Sustainability assessment and measure-
ment principles. Retrieved October 30, 2012,
from http://www.iisd.org/pdf/2009/brochure_bella-
giostamp.pdf
Hardi, P., & Zdan, T. (Eds.). (1997). Assessing sustainable
development: Principles in practice. Winnipeg: The
International Institute for Sustainable Development.
ISBN 1-895536-07-3.
361 B
BellagioSTAMP
Laszlo Pinter
Department of Environmental Sciences and B
Policy, Central European University (CEU),
Budapest, Hungary
International Institute for Sustainable
Development (IISD), Winnipeg, MB, Canada
Synonyms
Assessing sustainability assessments; Auditing
sustainability assessments; Sustainability
assessment; Sustainability measurement
Definition
The Bellagio Sustainability Assessment
and Measurement Principles (BellagioSTAMP)
provide strategic guidance for the conceptualiza-
tion, development, and practical use of indicator
systems in tracking progress towards sus-
tainability. They also help guide the design of
future-oriented integrated assessments and out-
looks from the local level to the global.
Description
Inspired in part by Chap. 40 of Agenda 21, the
decades since the United Nations Conference on
Environment and Development (UNCED) in
1992 witnessed increasing interest in the
establishment of measurement and assessment
systems designed to track and assess progress
towards a broader range of environment
and development objectives than traditional
indicators (UN-DSD, 1992; Michalos 2011).
Despite the large number of sustainability
measurement and assessment initiatives and
many harmonization efforts, there has been
little consensus on common approaches,
potentially compromising comparability,
B 362
consistency, and credibility of these efforts and
raising the scepter of an indicator zoo
(Pinter et al., 2005). This is seen as a result
of various factors, including the ambiguity of
sustainable development, the plurality of
purposes related to its characterization and
measurement, and confusion in terminologies,
methods, and data (Parris & Kates, 2003).
Despite the ambiguities in indicator systems,
there has been growing political and scientific
interest in crosscutting, forward-looking
integrated assessments of sustainability at
various scales, resulting in a variety of assess-
ment processes and products. Complementarity
in the design of measurement and integrated
assessment approaches allowed the emergence
of best practices based on which common
principles could be identified (Bakkes, 2011).
An earlier version of BellagioSTAMP, the
Bellagio Principles, was developed in an
expert process, convened by the International
Institute for Sustainable Development (IISD),
involving a select group of international measure-
ment and assessment experts in a deliberative
process (IISD, 1997). These earlier principles
were accompanied by the publication of case
studies (Hardi & Zdan, 1997). Recognizing the
changing social, political, and scientific context
of the sustainability discourse, in 2008 the Orga-
nization for Economic Cooperation and Develop-
ment and IISD decided to launch a new process to
review and if necessary revise the principles
(IISD & OECD, 2009). BellagioSTAMP was
also developed in a deliberative expert process
by a diverse group of 19 globally recognized
experts in a workshop at the Bellagio Center of
the Rockefeller Foundation in Bellagio, Italy.
BellagioSTAMP is based on the notion that
sustainability indicator selection and assessment
are integral part of governance and need to be
approached as elements of the entire policy
cycle, from goal setting to implementation and
assessment of progress (Bakkes, 2011). The
principles cover conceptual, methodological,
technical, and policy aspects of measurement
and assessment. Without being prescriptive,
they offer a checklist intended for use by
policy-makers, practitioners, and researchers
BellagioSTAMP
interested in establishing measurement and
assessment systems grounded in specific
contexts but synergistic with approaches
elsewhere (Pinter et al., 2012).
BellagioSTAMP has been launched at the
3rd OECD World Forum on Statistics,
Knowledge and Policy in Busan, Republic of
Korea, in October 2009. Following their
launch, the principles have been used for the
analysis of international environment outlooks
(Bakkes, 2011) and in the design of global
assessments such as UNEPs 5th Global
Environment Outlook (UNEP, 2012). The
possibility of using BellagioSTAMP has also
been discussed in guiding the selection of
ndicators attached to the sustainable
development goals (SDGs) mandated through
the Rio +20 conferences outcome document
(Pinter, 2013; UN, 2012).
Cross-References
Environmental Management
Environmental Sustainability
Environmental Sustainability Index (ESI)
Genuine Progress Index
Index of Attitudes Favorable Toward
Sustainable Development
Index of Behaviors Favorable Toward
Sustainable Development
Index of Knowledge of Sustainable
Development
Progress of Societies: OECD Projects
Sustainable Development Indicators
Sustainable Governance
Sustainable Society Index, Tool for Measuring
Well-Being
Well-Being and Progress Measurement
Well-Being of Nations
References
Bakkes, J. A. (2011). Bellagio SusTainability Assessment
and Measurement Principles (BellagioSTAMP) Sig-
nificance and examples from international environ-
ment outlooks. In F. Rubik & A. von Raggamby
(Eds.), Sustainable development, evaluation and
Benchmarking
policy-making: Theory, practise and quality insur-
ance. Cheltenham: Edward Elgar Publishing Ltd.
Hardi, P., & Zdan, T. (1997). Assessing sustainable
development: Principles in Practice. Winnipeg: IISD.
http://www.iisd.org/publications/pub.aspx?pno279
IISD. (1997). Complete Bellagio Principles. Winnipeg:
IISD. http://www.iisd.org/measure/principles/pro-
gress/bellagio_full.asp
IISD & OECD. (2009). BellagioSTAMP: Sustainability
assessment and measurement principles. Winnipeg:
IISD. http://www.iisd.org/pdf/2009/brochure_bella-
giostamp.pdf
Michalos, A. C. (2011). What did Stiglitz, Sen and
Fitoussi get right and what did they get wrong? Social
Indicators Research, 102, 117129.
Parris, T. M., & Kates, R. W. (2003). Characterizing and
measuring sustainable development. Annual Review of
Environment and Resources, 28, 559586.
Pinter, L. (2013). Measuring progress towards
sustainable development goals. Winnipeg: IISD.
http://www.iisd.org/publications/pub.aspx?pno1729
Pinter, L., Hardi, P., & Bartelmus, P. (2005). Sustainable
development indicators proposals for the
way forward. Winnipeg: IISD. http://www.iisd.org/
measure/principles/progress/way_forward.asp
Pinter, L., Hardi, P., Martinuzzi, A., & Hall, J. (2012).
BellagioSTAMP: Principles for sustainability assessment
and measurement. Ecological Indicators, 17, 2028.
UN. (2012). The future we want. Rio + 20 United Nations
Conference on Sustainable Development. Resolution
adopted by the General Assembly, September 11,
2012. http://daccess-dds-ny.un.org/doc/UNDOC/
GEN/N11/476/10/PDF/N1147610.pdf?OpenElement
UN-DSD. (1992). Report of the United Nations
conference on environment and development.
United Nations Division for Sustainable Development:
New York. http://sustainabledevelopment.un.org/con-
tent/documents/Agenda21.pdf
UNEP. (2012). Global Environment Outlook-5.
Environment for the future we want. Nairobi: United
Nations Environment Programme. http://www.unep.
org/geo/geo5.asp
Benchmarking
Isabelle Bruno
Political Science, University of Lille 2 Lille
Center for Politics and Administration
(CERAPS)-CNRS, Lille, France
Definition
Benchmarking means evaluating or checking
something by comparison with a standard.
363 B
Etymologically, it derives from the term bench-
mark, a surveyors mark used as a reference point
in measuring altitudes. Besides land surveying,
the term is used in computing to refer to a process
for assessing the capabilities of software and B
hardware systems. In industry, it has become
widespread as a business method consisting in
searching for best practices that lead to superior
performance (Camp, 1989). Both in private and
public administration, benchmarking has become
well known as a key tool in quality management.
Description
Genealogy
First tested in the manufacturing area around
1980, Xerox executives started talking of com-
petitive benchmarking to refer to the continuous
process of measuring products, services, and
practices against the toughest competitors.
Robert C. Camp, who was responsible for
expanding benchmarking in Logistics and Distri-
bution units, pioneered a noncompetitor
approach. He identified L.L. Bean, an outdoor
sporting goods retailer and mail-order house, as
the best performer for warehouse operations.
Besides direct product competitors like Canon
or Kodak, Xerox selected its benchmarks among
the organizations renowned as the leaders in
a specific function or process, such as Ford for
assembly automation or the Federal Reserve for
bill scanning. In few years, benchmarking was
brought into general use and systematized
in a ten-step process (see Fig. 1). A rigorous
methodology was codified to investigate best
practices, collect data, measure performance
gap, quantify targets, develop action plans,
monitor progress, and recalibrate assessment to
take into account the fact that customer require-
ments and best-in-class change over time. It
was not meant to be a one-off experience but
a cycle, a never-ending exercise. To a certain
extent, benchmarking was thus devised as a
procedure that would be at the same time the
permanent measure of a gap in relation to an
inaccessible norm and the asymptotic movement
that strives to meet in infinity (Foucault, 1977).
B 364
Benchmarking, Fig. 1 Benchmarking process steps according to Robert C. Camp (1989)
More than a target-setting method, it exerts an
indefinite discipline (Bruno, 2009).
This process aims at improving any perfor-
mance in any organization by identifying and
applying best demonstrated practices, which can
be found externally or internally, potentially
everywhere. Unlike traditional competitive anal-
ysis, benchmarking does not limit the comparison
to direct competitors in a specific industry or
marketplace. In doing so, it opens an unlimited
space of commensuration and of competition,
integrating all organizations whatever are
their activities, their size, or their members, be
they factory workers, engineers, researchers,
teachers, students, doctors, pensioners, volun-
teers, or merely citizens. Everyone is a potential
competitor, even where there is no economic
competition, strictly speaking, as long as
there is an organization that can be broken up
into processes.
Benchmarking
As a consequence, benchmarking has been
devised and promoted as a universal method,
applicable everywhere and useful in every kind
of organizations. The goal of benchmarking is
simply to find examples of superior results and to
understand the processes driving that performance
in order to tailor and incorporate these best prac-
tices into ones own operations Not by imitat-
ing, but by innovating (Rigby, 2009).
Benchmarking thus consists in steering social cre-
ativity through the pressure of examples and num-
bers, of peers, and of emulation. It underpins
power relations which are evidence-based,
depersonalized, and mediated by hard facts and
so-called unquestionable data. And this kind of
power is all the more efficient since it is neither
coercive nor legal. Obedience relies on willing-
ness and incentives, rather than on constraint and
punishments. What is at stake is no longer to do
things well or to better them, but to be the best,
Benchmarking
always. The strength of benchmarking lies in this
competition-oriented rationality, which makes an
endless race to the top possible. It is often spoken
of a race without a finish line.
Dissemination
For the last 30 years, benchmarking has prolifer-
ated throughout the world and throughout sectors,
so much so that it is now deep rooted and wide-
spread in all kinds of organizations. Besides
the United States of America and Japan, it first
reached the Commonwealth (New Zealand,
Australia, the United Kingdom), the Continental
Europe, and then countries outside the Organisa-
tion for Economic Co-operation and Develop-
ment (OECD). As regards the sectors
concerned, taking a glance at the titles of articles
published in Benchmarking: An International
Journal (previously Benchmarking for Quality
Management & Technology) is quite revealing:
Successful implementation of Six Sigma:
benchmarking General Electric Company,
Benchmarking the port services: a customer
oriented proposal, Airport benchmarking: a
review of the current situation, Association-
sponsored benchmarking programs,
Benchmarking in the non-profit sector in
Australia, Benchmarking: achieving best
value in public-sector organisations, A system
dynamics framework for benchmarking policy
analysis for a university system, Benchmarking
the best practices of non-corporate R&D
[research and development] organizations,
Benchmarking in health services, etc. Here
are some examples displaying the wide scope of
benchmarking, which has been implemented
both in big firms and in small and medium
enterprises, in manufacturing or services, in non-
profit organizations and government sector, espe-
cially in education and health (Camp, 1998).
Benchmarking is not limited to business
processes. Everything is a potential object of
performance comparison. For instance, it seems
possible to benchmark organizational commit-
ment across nonprofit human services organiza-
tions in Pennsylvania (Guiler, Rutowski, &
Schimmel, 2009), and even to benchmark the
benchmarking models (Anand & Kodali, 2008).
365 B
Obviously, there is nothing natural and
self-evident about the dissemination of
benchmarking. Its success story cannot be
explained by its great effectiveness and common-
sensical usefulness. A thorough genealogical B
investigation would lead us from the U.S. Depart-
ment of Defense to the postwar Japanese
employers; from the Chief Executive Officer
(CEO) of Xerox Corporation, David T. Kearns,
who joined the U.S. Department of Education
under Bush Sr., to the European Roundtable of
Industrialists; and from the Public Management
service (PUMA) of the OECD, to the European
Union. To make a long story short, the spreading
of benchmarking was not supported by the weight
of evidence, but by powerful institutions, net-
works, and leaders who endeavored to promote it
as a multipurpose and policy-neutral method. For
instance, the European Commission and the Euro-
pean Roundtable of Industrialists (ERT) co-
organized in 1996 a joint seminar on
benchmarking in Brussels to induce policy-makers
to use benchmarking (ERT, 1996). From then on,
benchmarking has been used to compare national
performances first in the domain of industrial pol-
icies, then in the economic and monetary fields,
and finally in all domains where member states
need to cooperate in order to establish framework
conditions favorable to business and conducive to
international competitiveness of both European
companies and countries. This political program
was adopted by the heads of state and government
in March 2000. It is known as the Lisbon strat-
egy, and its ambition was to turn the European
Union into the most competitive knowledge-
based economy in the world by 2010 (European
Council, 2000). Such a shift to a cognitive
capitalism (Moulier-Boutang, 2012) was
supposed to be capable of improving citizens
quality of life and the environment, as well as
quality of employment, quality and sustainabil-
ity of public finances, quality of education, R&D,
or health services.
Benchmarking as a Cornerstone of Total
Quality Management
From the standpoint of management, quality can
be said to be indefinite in both senses of the word:
B 366
total, its scope is limitless, and it remains ill-
defined despite a long story which dates back to
the end of the nineteenth century (Miranti, 2005).
It is commonsense to consider quality two-sided,
both objective and subjective. According to
Shewhart, it is up to the engineer to satisfy
customers subjective wants by translating them
into standards expressed in terms of quantita-
tively measurable physical properties, and then
by set[ting] up ways and means of obtaining
a product which will differ from the arbitrarily
set standards for these quality characteristics by
no more than may be left to chance (Shewhart,
1980). After him, quality gurus replaced the
engineer by the customer who became the
most central to quality: Quality is a customer
determination, not an engineers determination,
not a marketing determination or a general man-
agement determination. It is based upon the cus-
tomers actual experience with the product or
service, measured against his or her require-
ments stated or unstated, conscious or merely
sensed, technically operational or entirely
subjective and always representing a moving
target in a competitive market (Feigenbaum
quoted in Hoyer & Hoyer, 2001).
From a Total Quality Management (TQM)
angle, all activities in whatever organization are
regarded as processes producing goods or ser-
vices intended for a final or intermediary
consumer, held to be the judge in the last resort,
the ultimate assessor, and the one whose sover-
eign choice falls on the most competitive option.
Insofar as the market is interpreted from
a neoclassical economic perspective, satisfying
customers requirements consists not only in
meeting his needs but in doing so better than
competitors. It is not enough to supply a product
free from deficiencies or adequate to the demand;
it has to be the best one can get. Consequently,
aiming at quality calls for knowing as much the
market as the competition. The former has been
domesticated by marketing (Cochoy, 1998), the
latter through competitive analyses and reverse
engineering. Managing total quality goes even
further. It demands neither to do well nor to do
better, but to be the best in each practice area.
This entails comparing ones performance
Benchmarking
against direct competitors and beyond: against
internal operations, functional leaders, and
generic processes. The field where to search for
best practices is presumed boundless. It poten-
tially embraces all sectors. And as every organi-
zation is supposed to constantly make progress,
the quest is endless. In Japanese, there is a word
which means striving to be the best of the best:
dantotsu.
Drawing on the experience of its joint venture,
Fuji Xerox (Kobayashi, 1983), Xerox Corpora-
tion made benchmarking the linchpin of its
approach to TQM. In 1983, the historical market
leader in copiers embarked on a corporate
strategy named Leadership Through Quality.
According to its then CEO Kearns, it was
aimed at fundamentally changing the culture of
Xerox over the next several years. At that time,
the economic warfare against Japanese firms got
coverage in the press, and the battle between
Canon and Xerox hit the headlines. On March
1980, the former targeted the latter in a Forbes
article titled as follows: Xerox, Here We Come.
Five years later, the New York Times announced
that Xerox halts Japanese march. Reported as
a success story, it has become a textbook case
study. It illustrates the turnaround in the way US
companies do business, observed all along the
1980s. Xerox alias the quality company
(Xerox, 1993) was set up as a role model.
In 1986, the Massachusetts Institute of
Technology (MIT) convened a multidisciplinary
commission to address the decline in US indus-
trial productivity and identify emerging patterns
of best practice. The survey, released in 1989,
took Ford and Xerox as examples of successful
companies that strive to be best in their class in
all the main performance categories.
They adopted a series of reforms such as
team-based approaches to product and process
development, increased emphasis on customer
satisfaction, employee involvement in decision
making, a commitment to training and continuous
improvement, and, above all, benchmarking
which was looked on as the keystone of quality
management: A characteristic of all the
best-practice American firms we observed, large
or small, is an emphasis on competitive
Benchmarking
benchmarking: comparing the performance of
their products and work processes with those of
the world leaders in order to achieve improve-
ment and to measure progress (MIT Commission
on Industrial Productivity, 1989).
A far-reaching vehicle for propagating quality
management, particularly benchmarking, has
been the Malcolm Baldrige National Quality
Award. Instituted in 1987 by President Reagan,
it was fashioned after the Japanese Deming Prize
to induce US companies to convert to TQM and,
thereby, improve national competitiveness as
a whole (Mahoney & Thor, 1994). The Baldrige
criteria have provided not only a common
understanding of TQM principles and compo-
nents but also a means to achieve their
implementation. The external intervention
of examiners has proved to help the top manage-
ment to rally the workforce and overcome the
so-called parochial resistance to change or
not-invented-here syndrome. The main purpose
of this performance excellence program is to
get all candidates to assess themselves against
leading organizations. A requirement of Baldrige
Award recipients is indeed to document
their quality journey and open their doors to
interested organizations for 1 full year. Further-
more, benchmarking among contestants is
encouraged as a way of mutual learning.
Paradoxically enough, competitors are at the
same time partners in a sharing process. This
kind of competitive cooperation is neither an
anomaly in a market economy nor a parenthesis
in the neoliberal age, but the actual workings
of competition which will get known as
co-opetition (Brandenburger & Nalebuff,
1996; Mann, Samson, & Wolfram, 1997).
Such quality models and prizes have prolifer-
ated all over the world. For instance, the Euro-
pean Foundation for Quality Management
(EFQM), based in Brussels, established its own
excellence award in 1992. While expanding
throughout space, they also extend their scope
to new categories of applicants. In addition to
small businesses and manufacturing companies,
service firms were entitled to compete from 1990
onward. In 1998, the United States Congress
voted for the creation of two more categories:
367 B
health care and education providers. The sixth
one has included in 2004 all nonprofits, so
that the Baldrige framework now applies to all
types of organizations, from Xerox products or
business services (prizewinner in 1989 and 1997) B
to the City of Coral Springs and the U.S. Army
Armament Research, Development and Engi-
neering Center (2007), via Baptist Hospital
Inc. (2003) or University of Wisconsin-Stout,
the first recipient in higher education (2001).
Wherever benchmarking is implemented to
improve quality and competitiveness, it requires
a sound base of comparable data, a battery of
reliable indicators, and some indisputable targets,
which have proven to be attainable somewhere
else. This management-by-fact tool thus derives
a great deal of its credibility and legitimacy from
the ecumenical language of quantification and
the widespread trust in numbers. As Porter
pointed out, a decision made by the numbers
(or by explicit rules of some other sort) has at
least the appearance of being fair and impersonal.
Scientific objectivity thus provides an answer to
a moral demand for impartiality and fairness.
Quantification is a way of making decisions with-
out seeming to decide (Porter, 1995). Indeed,
benchmarking helps decision-makers be it in
corporations or governments to reach consen-
sus by translating problems of collective action
into statistical issues of quantification. Far from
being policy-neutral (ERT, 1996), it is
a political technology of power, which fosters
quantitative performance rather than quality
of life.
Cross-References
Education
Employee Satisfaction
Employment Commitment
Employment Insecurity
Environment and Health
Health
Performance Indicators
Quality of Life
Service Quality in New Public Management
Sustainability
B 368 Beneficence

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manufactured product. Milwaukee, WI: ASQC.
Anand, G., & Kodali, R. (2008). Benchmarking the Xerox. (1993). A world of quality. The timeless passport.
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tional Journal, 15(3), 257291. XQS Press.
Brandenburger, A. M., & Nalebuff, B. J. (1996).
Co-opetition: A revolutionary mindset that combines
competition and co-operation. New York: Currency
Doubleday.
Bruno, I. (2009). The Indefinite Discipline of Compet- Beneficence
itiveness. Benchmarking as a Neoliberal Technology
of Government. Minerva, 47(3), 261280. Compassion, Happiness, and Self-Esteem
Camp, R. C. (1989). Benchmarking: The search for indus-
try best practices that lead to superior performance.
Milwaukee: ASQC Quality Press.
Camp, R. C. (Ed.). (1998). Global cases in benchmarking:
Best practices from organizations around the world. Benefit of Doubt Approach to
Milwaukee: ASQ Quality Press. Gender Well-Being Assessment
Cochoy, F. (1998). Another discipline for the market econ-
omy: Marketing as a performative knowledge and
know-how for capitalism. In M. Callon (Ed.), The Gender Well-Being Composite Index
laws of the markets (pp. 194221). Oxford: Blackwell.
ERT. (1996). Benchmarking for policy-makers. The way
to competitiveness, growth and job creation. Brussels:
ERT Publication.
European Council. (2000). Presidency conclusions. Benefit-Cost Analysis
Lisbon summit, 2324 March, Nr: 100/1/00.
Foucault, M. (1977). Discipline and punish: The birth of Cost-Benefit Analysis
the prison. New York: Random House.
Guiler, J. K., Rutowski, K. D., & Schimmel, K. E. (2009).
Benchmarking organizational commitment across non-
profit human services organizations in Pennsylvania.
Benchmarking: An International Journal, 16(1), 135150. Benefits of College
Hoyer, R., & Hoyer, B. (2001). What is quality? Learn
how each of eight well-known gurus answers this
question. Quality Progress, 34(7), 5262. Higher Education: Institutional Effects
Kobayashi, Y. (1983). Fuji xerox the first 20 years
19621982. Tokyo: Fuji-Xerox Co.
Mahoney, F., & Thor, C. (1994). The TQM Trilogy. Using
ISO 9000, the Deming Prize, and the Baldrige Award
to establish a system for total quality management. Benevolent Sexism
New York: American Management Association.
Mann, L., Samson, D., & Wolfram, C. J. R. (1997). Gender Inequality and Subjective Well-Being
Benchmarking as a mixed metaphor: Disentangling
assumptions of competition and collaboration. Journal
of Management Studies, 34(2), 285314.
Miranti, P. J. (2005). Corporate learning and quality
control at the bell system, 18771929. The Business Bereavement
History Review, 79, 3972.
MIT Commission on Industrial Productivity. (1989).
Made in America. Regaining the productivity edge. David Schonfeld
Cambridge, MA: The MIT Press. Department of Pediatrics, St. Christophers
Moulier-Boutang, Y. (2012). Cognitive capitalism. Hospital for Children, Philadelphia, PA, USA
Cambridge, UK: Polity Press.
Porter, T. M. (1995). Trust in numbers: The pursuit of
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Princeton University Press.
Synonyms
Rigby, D. K. (2009). Management tools 2009: An execu-
tives guide. Boston, MA: Bain. Death; Death and dying; Grief; Loss; Mourning
Bereavement
Definition
Bereavement refers to the actual experience of
having suffered a loss, whereas grief is the subjec-
tive psychological, social, and somatic reactions
that result from bereavement (Pearlman, DAngelo
Schwalbe, & Cloitre, 2010; Rando, 1984).
Description
Bereavement and grief in children.
Definition and Prevalence
Bereavement refers to the actual experience of
having suffered a loss, whereas grief is the sub-
jective psychological, social, and somatic reac-
tions that result from bereavement (Pearlman
et al., 2010; Rando, 1984). Loss (in general) is
a universal experience even for very young chil-
dren, and bereavement involving a loss due to
death is highly prevalent among children as
well; this entry will focus on bereavement due
to loss related to death. Approximately 1 in 20
children experiences the death of a parent by the
time they reach 16 years of age, and studies have
estimated that approximately 90 % of children
will experience the death of a family member or
friend by the time they graduate from high school
(Ewalt & Perkins, 1979; Harrison & Harrington,
2001; Hoven et al., 2005). Even though bereave-
ment is a normative experience and is not
a disorder per se, the death of a close friend
or family member is nonetheless a profound
experience that has a dramatic impact on the
survivors quality of life in the short term and is
associated with long-term impact as well.
Impact of Bereavement on Intrapersonal
Quality of Life
Children may experience a wide range of reactions
after a significant loss. Sadness and a profound
sense of loss are characteristic and may persist
for an extended period of time. Children may
also experience anger, which may be directed at
individuals felt possibly responsible for the death
(such as the driver of a vehicle after an accidental
death or the treating physician), attributed to God,
369 B
or even directed at the individual who died and left
the survivor with the pain of grief and/or by his/her
absence has impacted their material well-being
such as through the loss of a parents income.
This anger is often accentuated after death by B
suicide but can be seen after any means of death.
Children may avoid previously enjoyed activities
because they no longer, for at least a time period,
bring them pleasure. Or the activities may be asso-
ciated with the individual who died and serve as
a reminder of the loss and trigger a resurgence of
grief. In these ways, grief may impact childrens
sense of happiness, self-satisfaction, and overall
interest in life.
Children who are grieving routinely experi-
ence at least a temporary cognitive impact
they may find it difficult to concentrate and recall
or process information, may experience deterio-
ration in academic performance which may result
in school failure, and may struggle to make even
relatively simple decisions without assistance
(Schonfeld & Quackenbush, 2010). This may
negatively impact childrens sense of personal
competence and autonomy.
Guilt is extremely common and can interfere
with successful adjustment. Children will often
wonder what they did, did not do, could have
done, or should have done that may have
prevented the death, even if there is no logical
reason to believe that they could have done
anything to have prevented the death. Young
childrens incomplete conceptual understanding
of death may accentuate this phenomenon,
but guilt is extremely common among older
children and adolescents as well (Schonfeld &
Quackenbush, 2010). This in turn has implica-
tions for childrens sense of self-satisfaction and
can negatively impact their personal growth.
Childrens health and physical well-being can
also be impacted by bereavement. Fatigue, loss of
appetite, difficulty sleeping or waking,
or physical complaints such as abdominal pain
or headache are common during the acute phases
of grief and may prompt surviving parents to
bring grieving children for medical evaluation.
Death also alters ones life view and disrupts
a sense that life is predictable, orderly, or fair.
Children may become anxious that others close
B 370
to them will die or worry about their personal
mortality. The death of someone close is a threat
to ones assumptive world (Schonfeld &
Gurwitch, 2011). People generally hold certain
assumptions that allow them to function on
a daily basis without feeling overwhelmed by the
possibility of disaster and loss at any moment in
many ways, it is through this mechanism that
children are able to develop a sense of mastery
over their environment, even related to those
aspects over which they in fact have little to no
influence. Children assume that the adults they
love will always be there to care for them and
about them. But a death forces children to
confront the reality that those they love actually
can be killed be lightening, murdered in what
appears to be a random attack, die of an illness
even when they appeared healthy and were taking
reasonable steps to stay well, or be killed in a car
accident even if they are a safe and experienced
driver. This loss of the assumptive world leaves
children feeling shaken, anxious, and vulnerable.
It can cause children to question the fairness of the
world and challenges their emerging sense of mas-
tery of ones environment. This, in turn, can inter-
fere with personal growth.
Impact of Bereavement on Interpersonal
Quality of Life
Children who are grieving may experience devel-
opmental and social regression and thereby become
irritable, demanding, and self-centered. The devel-
opmental regression can impair their sense of per-
sonal competence; the social regression can result
in negative interpersonal interactions. Children who
have experienced the death of a close friend or
family member may become fearful or resistant to
separation from adults and others close to them,
leading to clinginess in young children and school
avoidance in school-age children. Older children,
adolescents, and adults may initiate or increase use
of alcohol, tobacco, or drugs (Brent, Melhem,
Donohoe, & Walker, 2009) and may engage in
other risky behaviors such as reckless driving,
delinquent behavior, and unsafe sexual behavior
(Adams & Deveau, 1987). Peers (and adults) may
not know how to interact with or support grieving
children, and grieving children may avoid
Bereavement
previously enjoyed activities (and thereby the social
interactions with peers related to these activities),
may withdraw from interactions with others, and/or
may feel distant or unable to relate to peers who do
not share a similar life experience. This can
negatively impact social integration, social accep-
tance, positive relations with others, and friendship/
peer satisfaction.
The death of a family member can place strains
on interpersonal relationships among survivors
(Emswiler & Emswiler, 2000). Surviving parents
may be emotionally less available to each other and
their children because of their emotional distress or
if they are engaging in maladaptive attempts at
coping such as increased alcohol or substance use.
Many of the reactions and behaviors seen among
those that are grieving may place significant strain
on a marriage and cause marital discord. Often,
members of the family grieve in a different manner
and along their own timelines one parent may
seek and provide different types of support than the
spouse. For example, one adult may become more
self-absorbed, while the other is seeking physical
intimacy. One may cope through intellectualizing
which may be viewed as emotional detachment or
even denial by the other. Childrens family satis-
faction is thereby compromised, and childrens
inability to predict and manage their family inter-
actions as effectively as they did prior to the death
may lead them to feel less personal competence
and sense of mastery of their environment. The
importance of active communication and appreci-
ation of each others needs and resources becomes
particularly critical as the family works to adjust to
the loss (Schonfeld, 2012).
After the death of a sibling, parents who are
experiencing guilt associated with their perceived
role in the death or anxiety related to fears
of additional losses may alter how they parent
surviving children, which may result in
emotional distancing and/or overprotection
(Krell & Rabkin, 1979). This may disrupt surviv-
ing childrens personal and social growth.
Impact of Bereavement on Environmental
Issues
Death is associated with a number of secondary
losses that independently or incrementally impact
Bereavement
survivors quality of life. The death of a parent
who is a wage earner can result in financial
stressors which, in turn, may require that the
family move in with relatives or to a less expen-
sive home or neighborhood which often requires
that children change schools. The change in
schools may result in the loss of a peer network
(with related impact on interpersonal quality of
life) or pose additional challenges to academic
progress (which in turn negatively impacts
childrens sense of personal competence). Loss
of income may jeopardize plans to attend
a desired college and alter career aspirations;
surviving spouses may find they can no longer
afford vacations or may struggle to provide the
transportation and supervision required to sustain
after-school activities for children, especially
if they need to increase their working hours to
compensate for lost income or expenses incurred
during a lengthy illness. The death of a parent
may impact the quality of the meals served,
the consistency or quality of parenting and
disciplining, the access to advice of a parent of
the same or opposite gender, or the ability to
relive important shared memories. The death of
a sibling may result in a loss of a confidante,
a preferred (or at least readily available)
playmate, or a valued guide to peer relations. In
brief, bereavement involves adjusting not simply
to the loss of a family member or friend but
also the loss of everything associated with that
individual and what they meant to the lives
of survivors (Schonfeld, 2011, 2012; Swick,
Dechant, & Jellinek, 2002) resulting in disrup-
tions to material well-being and interpersonal
quality of life.
Potential Positive Long-Term Impact of
Bereavement on Quality of Life
Children who are grieving may ultimately learn
skills that help them adjust to future losses and
stressors. They may come to appreciate aspects of
life and its experiences that they were less con-
scious of prior to the death, thereby ultimately
increasing their life satisfaction, sense of social
contribution, and social growth. They may dedi-
cate their lives and careers to the attainment of
higher goals, thereby enhancing their personal
371 B
growth. Such posttraumatic growth is most likely
to occur when the loss is not overwhelming and
the individual has sufficient external support and
internal resources for coping and adjustment.
Bereavement generally does not result in mental B
illness or long-term disability, but it almost
always has a significant and long-lasting impact.
The death of a close friend or family member is
nearly always a life-changing event.
Cross-References
Bereavement Phenomenology Questionnaire
Bereavement Response Scale
Mortality
Widowhood
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victims of September 11th: A perspective on the emo-
tional and developmental challenges they face and
how to help meet them. Journal of Developmental
and Behavioral Pediatrics, 23(5), 378384.
Bereavement Phenomenology
Questionnaire
Beverley Raphael1 and Paul Burnett2
1
Disaster Response and Resilience Research
Group, School of Medicine, University of
Western Sydney, Rydalmere, NSW, Australia
2
Division of Research and Commercialisation,
Queensland University of Technology, Kelvin
Grove, QLD, Australia
Synonyms
CBI-17
Definition
Most people experience the loss of a loved one.
How they respond to this loss will have an impact
on their quality of life. In 1944, Lindemann under-
took the first systematic study of bereavement and
noted that uncomplicated bereavement could
include somatic distress, preoccupation with the
image of the deceased, guilt, hostility, loss of usual
patterns of conduct, and imitation of the deceased
behaviors in some people. However, these descrip-
tions were based on the clinical findings of people
who suffered traumatic circumstances of bereave-
ment, and they may not have been an accurate
Bereavement Phenomenology Questionnaire
representation of the normal populous. Raphael
(1983) noted the distinction between bereavement
and grief as follows: bereavement is the reaction to
the loss of a close relationship and grief is the
emotional response (sadness, anger, helplessness,
guilt, and despair) to that loss and is therefore part
of the bereavement process. It is agreed that
bereavement is a process that takes place over
time with initial shock and disbelief progressing
to intense distress, yearning, and progressive adap-
tation. Time taken for these processes varies.
While some studies suggest specific phases, there
is no clear agreement about these. While grief is
a normal human reaction to loss, to the breaking
of affectionate bonds, it is also important to
know and be able to measure when it becomes
problematic, disrupting function, or potentially
a clinically defined disorder, for which interven-
tion may be required. This differs from the fact
that bereavement, as a stressful life event, may
increase risk to health, for instance precipitating
depression and even physical conditions and
premature death.
This entry describes a body of research under-
taken by a team of researchers coordinated by
Professor Beverley Raphael. The research team
investigated bereavement phenomenology using a
variety of approaches, which culminated in the
Core Bereavement Items (CBI) scale being
published in 1997. The journey for measuring
bereavement phenomenology is described below.
Description
Burnett et al. (1994) canvassed the perceptions of
75 significant researchers and writers in the
field of bereavement using the Perceptions
of Bereavement Questionnaire (PBQ), which
consisted of 25 statements designed to measure
perceptions of bereavement phenomena using
a 4-point Likert format. The respondents
rated the perceived frequency of the same 25
items for acute bereavement (first 6 weeks
following a loss) and longer-term bereavement
(beyond the first anniversary). The 25 items were:
1. Intrusive thoughts about the lost person
2. Distressing thoughts concerning the loss
Bereavement Phenomenology Questionnaire
3. Preoccupation with images and thoughts of
the lost person
4. Inability to form clear mental images of the
lost person
5. Hallucinatory experiences of the lost person
6. Sense of presence of the lost person
7. Dreaming of the lost person as if still alive
8. Yearning or pining for the lost person
9. Looking for the lost person in familiar places
10. Distress at reminders of the lost person
11. Attempts to avoid reminders of the lost person
12. Sadness
13. Unreality feelings
14. Anger
15. Guilt
16. Nostalgia
17. Anxiety
18. Depression
19. Crying
20. Acting as if the person is still alive
21. A need to talk about the lost person
22. Searching for the lost person
23. Somatic symptoms
24. Disorganization
25. Special facial features
The findings indicated that 23 of the 25 items
were rated as common to very common in the acute
phase. The two items deemed uncommon in the
acute phase were an inability to form clear mental
images of the lost person (item 4) and attempts to
avoid reminders of the lost person (item 11). The
results for the longer-term phase of normal bereave-
ment indicated that 7 phenomena were common to
very common. These were intrusive thoughts about
the lost person (item 1), preoccupation with images
and thoughts of the lost person (item 3), yearning or
pining for the lost person (item 8), distress at
reminders of the lost person (item 10), sadness
(item 12), nostalgia (item 16), and a need to talk
about lost person (item 21). Eighteen of the 25 items
were rated as uncommon in the longer-term phase
of bereavement.
The same group of significant researchers and
writers in the field of bereavement also completed a
questionnaire relating to different types of grief.
The objective of this exercise was to gain a perspec-
tive on the degree of acceptance for commonly used
terminology being applied to the description of
373 B
atypical forms of grief. Seven terms relating to
grief were identified in the literature (absent,
delayed, chronic, distorted, unresolved, inhibited,
and anticipatory), and respondents were asked
whether or not they thought that this type of grief B
occurred and if it did occur to describe its charac-
teristics and distinguishing features. Middleton,
Moylan, Raphael, Burnett, and Martinek (1993)
reported seven types of grief noting the percentage
of respondents who believed that it occurred
and the phenomenons common features and
characteristics:
1. Delayed grief (77 %) typical grief, just
delayed, grief delayed months or years, grief
subsequently triggered by some event
2. Chronic grief (74 %) chronic depression,
prolonged/unending/unchanging distress,
guilt/self-reproach, marked sadness
3. Anticipatory grief (71 %) a normal grief
reaction which occurs prior to the loss,
thoughts and feelings about a death which
might occur, sadness/sorrow
4. Absent grief (65 %) inhibition or absence of
typical expressions of grief, continue to act as
if nothing has happened, denial of loss or
feelings related to the loss
5. Unresolved grief (57 %) lack of resolving
major grief symptoms
6. Inhibited grief (53 %) cannot talk about,
acknowledge or express the loss; inability to
cry; social/cultural/learnt restraint of expres-
sion of grief
7. Distorted grief (36 %) excessive anger.
Measuring Core Bereavement Phenomena
Burnett, Middleton, Raphael, and Martinek (1997)
described the process followed in developing the
17 item Core Bereavement Items (CBI) scale. An
initial pool of 76 items was derived from reviews
of the bereavement literature and from the clinical
experiences of the research team and were grouped
into 5 areas: 22 items related to thoughts, images,
memories, and dreams of the lost person; seven
items tapped attachment behaviors; 21 items mea-
sured specific emotions and behaviors invoked by
reminders of the lost person; 13 items covered
ongoing behaviors associated with the lost person;
and 13 items related to parameters of resolution.
B 374
Factor analysis results indicated seven subscales
as follows:
1. Images and thoughts (7 items)
2. Sense of presence (4 items)
3. Dreams (3 items)
4. Acute separation (5 items)
5. Grief (5 items)
6. Non-resolution/conflict (6 items)
7. Personal resolution (5 items)
Of the seven subscales, sense of presence,
dreams, and non-resolution/conflict were not
frequently experienced across 4 time periods
(4 weeks, 10 weeks, 7 months, and 13 months)
by 120 bereaved respondents. Additionally it
was noted that subscale 7 (personal resolution)
represented behaviors experienced by someone
recovering from the effects of a major life
event. Consequently, the collection of 17 items
contained in the images and thoughts (7 items),
acute separation (5 items), and grief (5 items)
subscales offers a reliable distillation of items
measuring core bereavement phenomena that
were common to different groups of bereaved
subjects. The items are:
1. Do you experience images of the events
surrounding xs death?
2. Do thoughts of x come into your mind
whether you wish or not?
3. Do thoughts of x make you feel distressed?
4. Do you think about x?
5. Do images of x make you feel distressed?
6. Do you find yourself preoccupied with
images or memories of x?
7. Do you find yourself think of a reunion with x?
8. Do you find yourself missing x?
9. Are you reminded by familiar objects
(photos, possessions, rooms) of x?
10. Do you find yourself pining or yearning for x?
11. Do you find yourself looking for x in familiar
places?
12. Do you feel distress/pain if for any reason
you are confronted with the reality that x is
not present or not coming back?
13. Do reminders of x such as photos, situations,
music, places cause you to feel longing
for x?
14. Do reminders of x such as photos, situations,
music, places cause you to feel loneliness?
Bereavement Phenomenology Questionnaire
15. Do reminders of x such as photos, situations,
music, places cause you to cry about x?
16. Do reminders of x such as photos, situations,
music, places cause you to feel sadness?
17. Do reminders of x such as photos, situations,
music, places cause you to feel loss of
enjoyment?
The CBI-17 can be used as a total scale (alpha
reliability 0.91) or as three separate scales:
images and thoughts (alpha 0.74), acute separa-
tion (alpha 0.77), and grief (alpha 0.86). The
CBI-17 has been used in a number of studies since
being developed. Cluster analysis using the
CBI-17 found that approximately 9 % of commu-
nity-based bereaved subjects experienced chronic
grief, none experienced absent, or delayed
grief and that current estimates of complicated
or pathological bereavement may be inflated
(Middleton, Burnett, Raphael, & Martinek,
1996). Middleton, Raphael, Burnett, and Martinek
(1997) reported that scores on the CBI-17 corre-
lated significantly with depression, state and trait
anxiety, and neuroticism. In another study using
the CBI-17 Middleton, Raphael, Burnett, and
Martinek (1998) found that bereaved parents had
higher scores than bereaved spouses who had
higher scores than bereaved adult children.
The CBI-17 is available at http://eprints.qut.
edu.au/26824/1/c26824.pdf.
Cross-References
Anxiety
Bereavement
Bereavement Phenomenology Questionnaire
Bereavement Response Scale
Cluster Analysis
Factor Analysis
Likert Scale
References
Burnett, P. C., Middleton, W., Raphael, B., Dunne, M.,
Moylan, A., & Martinek, N. (1994). Concepts of nor-
mal bereavement. Journal of Traumatic Stress, 7,
123128.
Bereavement Response Scale
Burnett, P. C., Middleton, W., Raphael, B., & Martinek, N.
(1997). Measuring bereavement phenomena. Psycho-
logical Medicine, 27, 4957.
Lindemann, E. (1944). Symptomatology and management
of acute grief. The American Journal of Psychiatry,
101, 141148.
Middleton, W., Burnett, P. C., Raphael, B., & Martinek, N.
(1996). The bereavement response: A cluster analysis.
The British Journal of Psychiatry, 169, 167171.
Middleton, W., Moylan, A., Raphael, B., Burnett, P. C., &
Martinek, N. (1993). An international perspective on
bereavement related concepts. The Australian and
New Zealand Journal of Psychiatry, 27, 457463.
Middleton, W., Raphael, B., Burnett, P. C., & Martinek, N.
(1997). Psychological distress and bereavement.
Journal of Nervous and Mental Diseases, 185,
447453.
Middleton, W., Raphael, B., Burnett, P. C., & Martinek, N.
(1998). A longitudinal study comparing bereavement
phenomena in recently bereaved spouses, adult
children and parents. The Australian and New Zealand
Journal of Psychiatry, 32, 235241.
Raphael, B. (1983). The anatomy of bereavement.
New York: Basic.
Bereavement Response Scale
T. Anne Richards
Public Health Institute, Oakland, CA, USA
Synonyms
BR-I; BR-II
Definition
The Bereavement Response Scale is an instru-
ment to identify indicators of eventual recovery
from bereavement of the loss of a person with
whom the bereaved had an adult relationship of
emotional attachment.
Description
Comprehensive narrative accounts may be more
easily obtained from bereaved individuals imme-
diately following bereavement than a battery of
measures, thus making the narrative a potentially
375 B
useful tool for assessing indicators of recovery
from grief. The Bereavement Response Scale
(BR) (Weiss & Richards, 1997) was developed
as a tool for using narrative accounts taken in
early bereavement to identify indicators of even- B
tual recovery from loss of a person with whom the
bereaved had an adult relationship of emotional
attachment (Weiss, 1988, 1991; Bowlby, 1980;
Mikulincer & Shaver, 2007).
The findings from the Harvard Bereavement
Study (Parkes & Weiss, 1983) were used to
develop the first iteration of the BR, the BR-I.
Study findings suggested that indicators of recov-
ery could be observed in interviews conducted
46 weeks following bereavement. Further, in
order to regain functioning following bereave-
ment, data indicated that the bereaved person
must (1) achieve cognitive assimilation of the
loss by developing an acceptable account of
how the loss occurred, (2) achieve emotional
assimilation so that memories of the relationship
cease to bring intolerable pain, and (3) develop
a reorganized emotional life that includes
availability of new relationships of attachment,
social life, and adequate ties to community.
The BR-I consists of six categories containing
a total of 21 variables. The categories, with
examples of variables contained within, are
the following:
1. Final stage of illness (caregiving behaviors:
physical and emotional care, acceptance of
responsibility, assurance of love)
2. Death of the partner (attitudes, emotions, and
appraisals: anticipated death, partner had an
easy/peaceful death)
3. Reactions immediately following the death
(effective functioning)
4. Ceremonies (acceptance of service as
satisfactory and appropriate)
5. Process of grieving (emotional state: capacity
to control grieving, absence of guilt or
remorse, not overwhelmed by symbolic
meanings)
6. Indications of movement toward recovery
(experiencing positive well-being)
The BR-1 was applied to a subset of qualita-
tive data from the University of California, San
Francisco (UCSF) Coping Project which was
B 376
a longitudinal study of the effects of caregiving
and bereavement on male partners of men
with AIDS. The subset, called the Rashomon
Project, consisted of narratives from 30 bereaved
caregiving partners interviewed approximately
2 weeks, 4 weeks, and 12 months post-
bereavement.
The 21 variables of the BR-I each had a range
of scores of either 1 to +1 or 2 to +2. Scoring
was based on the theory that caretaking phenom-
ena (Category 1) furthest in temporal sequence
from the death would be weaker indicators of
quality of recovery and that post death indicators
of movement toward recovery (Category 6)
would be stronger indicators of recovery.
Variables could receive positive scores for narra-
tive data that supported the hypotheses for
indicators of recovery or negative scores for
narrative data that countered the hypothesis
for indicators of recovery. Narrative accounts
were coded and scored independently by the
two authors. Coding and scoring were compared
and discrepancies resolved collaboratively
through a reexamination of the coded text.
Reliability of coding was 71 %.
The sum of BR-I scores was correlated
with time-of-bereavement (2 & 4 weeks) scores
and 12-month post-bereavement outcome scores
of four measures: the CES-D (Radloff, 1977);
Positive Morale Subscale of Bradburns
Affect Balance Scale (Bradburn, 1969); Positive
States of Mind Scale (Horowitz, Adler, & Kegeles,
1988); and the Impact of Event Scale (Horowitz,
Wilner, & Alvarez, 1979). The BR-I sum correlated
significantly with all time-of-bereavement
measures: CES-D (r = .49, p = .003); Positive
Morale Subscale of Bradburns Affect Balance
Scale (r = .51, p = .002); Positive States of Mind
Scale (r = .34, p = .03); and the Impact of Event
Scale (r = .43, p = .005). However, with outcome
scores from 12 months post-bereavement, the BR-I
sum only correlated significantly with the Positive
States of Mind Scale (r = .30, p = .05). As a result,
a further investigation was done examining corre-
lations of each item of the BR-I with the Positive
States of Mind Scale to identify items that were
primarily responsible for correlations. Six of the 21
items showed correlations significant at p  .05 as
Bereavement Response Scale
Bereavement Response Scale, Table 1 Significant
correlations of BR-II items with Positive States of Mind
Scale scores at 12 months post-bereavement
Pearson r
BR-II item with PSO p
5. Emotions and attitudes at time of .34 .03
death: ability to anticipate partners
death, partner had an easy death,
perceives self to have been effective
caregiver
10. Acceptance of ceremonies of .29 .05
leave-taking as appropriate and
satisfactory
12. Grieving with capacity to control: .37 .02
absence of guilt and remorse, ability
to deal realistically with the fact of
death and its sequelae
13. There was an acceptable account .34 .03
of how the death occurred and of
events associated with the death,
including belief in an essentially
benign higher power, and an absence
of ambivalence toward the deceased
partner
16. Indicator of movement toward .44 .005
recovery: ability to accept
gratification
21. Indicator of movement toward .39 .01
recovery: display of positive well-
being
Note: Significance tests were one tailed. BR-II Bereave-
ment Response Scale-II, PSOM Positive States of Mind
Scale
seen in Table 1. These six items were formed into
the Bereavement Scale-II (BR-II).
In evaluating the BR-II in comparison with the
BR-I, it may be worth noting that the predictive
value of the BR-I was weakened by its inclusion
of items having to do with quality of caregiving
and with quality of social support that did not
prove to be significantly related to outcomes.
The BR-II, although made up of items chosen
empirically, is conceptually more focused.
It may also be worth noting that the predictive
value of the BR-II was weakened by its reliance on
interviews which did not systematically collect the
information required. Indeed, when the BR-II was
used to predict outcomes for the 19 cases in which
there was adequate data for scores on at least half
its items, its correlation with the 12-month Positive
States of Mind score was .78.
Bernard, Paul
From the analyses of these individual items, it
was concluded that they can be predictive of
a return to effective functioning within 12 months
of bereavement and that further exploration should
take place. The other aspects of the respondents
caregiving and grieving experience which were
measured in the BR-I turned out to be of much
less value as predictors of later recovery. It is
unknown if this occurred because of their lack of
predictive power or because of study design.
The Harvard Bereavement Study was
conducted among widows and widowers. The
UCSF Coping Project was conducted with male
partners of men with AIDS. The findings indicate
that the same bond of emotional attachment
existed in the two kinds of committed partner-
ships and that work done with bereaved widows
and widowers was directly applicable to
situations of bereavement of partners in
a homosexual relationship.
Cross-References
Affect Balance Scale
Attachment
Bereavement
Caregiving
Center for Epidemiologic Studies Depression
(CES-D) Scale
Impact of Event Scale
Reliability
Widowhood
References
Bowlby, J. (1980). Attachment and loss (Loss: Sadness
and depression, Vol. 3). New York: Basic Books.
Bradburn, N. (1969). Psychological well-being. Chicago:
Aldine.
Horowitz, M., Adler, N., & Kegeles, S. (1988). A scale for
measuring the occurrence of positive state of mind:
A preliminary report. Psychosomatic Medicine, 50,
477483.
Horowitz, M., Wilner, N., & Alvarez, W. (1979). Impact
of events scale: A measure of subjective stress.
Psychosomatic Medicine, 41, 208218.
Mikulincer, M., & Shaver, P. R. (2007). Attachment
in adulthood: Structure, dynamics, and change.
New York: The Guilford Press.
377 B
Parkes, C. M., & Weiss, R. S. (1983). Recovery from
bereavement. New York: Basic Books.
Radloff, L. S. (1977). The CES-D scale: A self-report
depression scale for research in the general population.
Journal of Applied Psychological Measurement, 1,
385401. B
Weiss, R. S. (1988). Loss and recovery. Journal of Social
Issues, 44, 3752.
Weiss, R. S. (1991). The attachment bond in childhood
and adulthood. In C.M. Parkes, J. Stevenson-Hinde
& P. Marris (Eds.), Attachment across the life cycle
(pp. 6676). London: Routledge.
Weiss, R. S., & Richards, T. A. (1997). A scale for
predicting quality of recovery following the death of
a partner. Journal of Personality and Social
Psychology, 72(4), 885891.
Bernard, Paul
Celine Le Bourdais
Department of Sociology, McGill University,
Montreal, QC, Canada
Birth, Education, Work History, and
Main Contributions
A committed researcher and sociologist, Paul
Bernard (19452011) dedicated his professional
life to reducing social inequalities and improving
the quality of life for Canadians. Very early in his
career, he became aware of the need to under-
stand the complex interactions between the many
factors affecting individuals throughout their
lives. To achieve this, he believed that it was
necessary to collect detailed information about
individual life pathways, to develop theoretical
and statistical tools to analyze and interpret this
information, and to ensure that public policy inte-
grated the research results by presenting them in
a comprehensible way.
An early advocate of the life course
approach, which aims to analyze the dynamics of
the pathways taken by individuals through time
and space, Paul Bernard pushed for the creation
of a longitudinal household survey in Canada. In
the mid-1980s, he gathered a multidisciplinary
team of researchers from universities across
Canada to work on this ambitious project
B 378
(Bernard et al., 1988, 1992). Their work broadly
directed the content of the Survey of Labor and
Income Dynamics (SLID), a prospective survey
launched by Statistics Canada in 1993. This survey
documented such issues as the growth of income
inequality in Canada. Ten years later, he brought
together a new team of researchers to promote
a similar survey in Quebec (Bernard et al., 2005);
their efforts inspired the development of the Cana-
dian Household Panel Survey Living in Canada.
Paul Bernard was a member of the steering com-
mittee for this survey, tested on a large sample of
households and individuals in 2008 by Statistics
Canada. This in turn had a direct influence on the
content of the Longitudinal and International
Study of Adults (LISA), the type of long-term
household survey Paul Bernard had always
dreamed of. Statistics Canada carried out the first
data collection in 2011.
Determined that these expensive and valuable
data should be of service to society, Paul Bernard
played a crucial role in the creation of a unique
social statistics infrastructure in Canada. He
helped mastermind the Data Liberation Initiative
(DLI) which aimed to make Statistics Canada
survey and census data easily accessible to uni-
versities and colleges for research and teaching
purposes at a minimum cost. He chaired a joint
working group set up by the Social Sciences and
Humanities Research Council of Canada and Sta-
tistics Canada to investigate why the national
longitudinal surveys launched in the mid-1990s
were so little used by researchers. Paul Bernard
played a key role in the creation of the Canadian
Research Data Center Network in 2000, one of
wide range of recommendations put forward by
the working group, and directed this successful
and ever-expanding network during its first 3
years. Over the years, the Network has become
an extraordinary hub of teaching and scientific
activity for a growing number of students and
researchers who carry out cutting-edge research
on key issues for Canadian and Quebec society. It
has become a model for a growing number of
national statistical offices across the world.
Paul Bernard ventured beyond the bounds of
his discipline, sociology, long before the benefits
offered by a multidisciplinary approach to the
Bernard, Paul
study of complex social issues was generally
recognized. Teaming up with researchers in med-
icine, urban planning, and political science, he
produced important publications on questions of
social inequality and health, the revitalization of
poor urban neighborhoods, poverty, and social
participation. Determined that these research
findings influence public policy and improve
population well-being, he initiated and animated
several multi-sectoral partnerships, including the
Population Change and Lifecourse Strategic
Knowledge Cluster, to promote fruitful collabo-
ration between university and government
milieux. Finally, his involvement in numerous
organizations, such as the Canadian Council on
Social Development, the Centre detude sur la
pauvrete et lexclusion of Quebecs Ministere de
lEmploi et de la Solidarite sociale or the chari-
table organization Centraide of Greater Montreal
to name but a few, demonstrates the values of
equality and social justice which inspired him.
Paul Bernard received a masters degree from
Universite de Montreal in 1968 and a doctorate
from Harvard University in 1974. He was profes-
sor of sociology at the Universite de Montreal
from 1975 to 2010. In 2001, he received the
Canadian Sociological Associations Outstand-
ing Contribution Award for his inestimable con-
tribution to the advancement of his discipline. His
premature death in February 2011 interrupted
suddenly a career marked by social commitment
for which the Universite de Montreal awarded
him posthumously the title of professor emeritus.
Cross-References
Canadian Research Data Centre Network
Data Liberation Initiative (DLI)
References
Bernard, P., Beach, C., Curtis, J., Davies, J., Fox, B.,
Lapierre-Adamcyk, E., et al. (1988). A proposal for
a national panel study of the social and economic
dynamics of making a living (144 p.). Report submitted
to the Social Science and Humanities Research Coun-
cil (SSHRC) of Canada, December.
BES (Benessere Equo e Sostenibile) Measuring and Assessing Progress of Italian Society
Bernard, P., Beach, C., Curtis, J., Davies, J., Fox, B.,
Lapierre-Adamcyk, E., et al. (1992). The Canadian
household panel study: Work, income and family life
(144 p.). A Proposal for a Joint Initiative with Statistics
Canada, February.
Bernard, P., Bourdon, S., Charbonneau, J.,
Contandriopoulos, A.-P., Drouin, C., Drapeau, A.,
et al. (2005). Connatre, debattre et decider: la contri-
bution dune Enquete socioeconomique et de sante inte
gree et longitudinale (ESSIL). Institut de la statistique
du Quebec: Quebec. 468 p.
Bernheims ACSA
Anamnestic Comparative Self-Assessment
(ACSA)
BES (Benessere Equo e Sostenibile)
Measuring and Assessing Progress
of Italian Society
Tommaso Rondinella
Presidents Technical-Scientific Secretariat,
Italian National Institute of Statistics Istat,
Rome, Italy
Definition
BES Benessere Equo e Sostenibile. Measuring
and assessing progress of Italian society is
a national initiative launched by Istat and CNEL
for the identification of a set of indicators for
measuring Italian Equitable and Sustainable
Well-being.
Description
The Italian National Institute of Statistics (Istat)
and the Italian National Council for Economics
and Labor (CNEL) launched in December
2010 an inter-institutional initiative to define
a shared set of indicators for measuring progress
of Italian society (Giovannini & Rondinella,
2011, 2012).
379 B
The initiative aims at carrying out a process
which sees the participation of all major repre-
sentatives of Italian civil society in order to define
the dimensions of progress as well as the specific
indicators to represent them. B
The initiative established a Steering Group
coordinated by CNEL and Istat including 20
participants representing different stakeholders
and a Scientific Commission hosted by Istat
and composed by experts and practitioners.
It also foresees the organization of a public
consultation.
The initiatives objectives are to:
Develop a shared definition of progress for
Italian society through the identification of
the most relevant domains
Select a set of high-quality statistical indica-
tors representative of the different domains
Thoroughly communicate the results of the
process. The set of indicators defined is
intended for a broad public audience as well
as for policy use
The process is divided into three phases ful-
filling the objectives:
1. During the first phase the Steering Group
defined the domains to be taken into account.
Meanwhile Italian citizens have been able to
express their priorities both through an ad hoc
open online consultation and through
a specific question included since 2011 in the
Multipurpose survey; the Steering Group
defined also which tools are the most fit-
for-purpose, evaluating which degree of detail
the set of indicators has to reach, as well as
their policy relevance
2. The second phase has been devoted to the
analysis of the available indicators which
could be used to represent the various
domains, stressing their technical features
and opportunity of using them: the number of
indicators in the final set should be small
enough to facilitate their understanding by
non-experts. The Scientific Commission is
responsible for this part of the work.
3. The last phase is dedicated to the drafting
of a final report and the development of
different tools for dissemination and
communication
B 380 BES (Benessere Equo e Sostenibile) Measuring and Assessing Progress of Italian Society

BES (Benessere Equo

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

Legitimacy: CNEL is a council established 1. Environment

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

Cross-References

Beta Weights Correlation Coefficient

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

Partial coefficient; Regression coefficient;

Standardized regression coefficient Better Life Index

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

A coefficient found in multiple regression analy-

sis that represents the unique strength of relation- Synonyms
ship between a predictor and a criterion adjusting
for the effects of all other predictors. BLI; Your Better Life Index
B 382
Definition
The Better Life Index is a set of 11 social indi-
cators, of housing, income, jobs, community,
education, environment, governance, health,
life satisfaction, safety, work-life balance
(Organisation for Economic Co-operation and
Development [OECD], 2011). These indicators
in turn are composed of 20 sub-indicators
through averaging and normalization. By
selecting a set of weights to the sub-indicators,
a user can rank countries according to their
weighted sum.
Description
In recognition of the limitations of Gross Domes-
tic Product (GDP) as an indicator of social pro-
gress, Stiglitz, Sen, and Fitoussi (2009) called for
better measurement through a richer mix of sta-
tistics as basis for decisions about policy. In
response, the Organisation for Economic Co-
operation and Development (OECD) identified
the measurement of well-being and societal pro-
gress as an area of high priority and produced an
extensive database of the 20 sub-indicators for
34 countries available in spreadsheet format
(OECD, 2011).
Recognizing that different peoples ideas
of social progress would call for different
weights to be given to these sub-indicators, the
OECD Better Life Initiative declined to
produce a summary index and has not ranked
the countries as so many other indices do
(e.g., the Human Development Index). In May
2011, it launched instead an interactive online
tool, Your Better Life Index, designed to let any-
one assign weights and compare the factors that
contribute to well-being in countries for which
the requisite statistics are available, such as the
34 OECD countries. The online program shows
the countries relative performance according to
the importance placed on the subindices, all of
which in some way reflect a better life. Your
Better Life Index is user friendly, making it
easy to visualize how a country compares on
each dimension to other countries.
Bias, Statistical
Cross-References
Calibrated Development Index
Human Development Index
Legatum Prosperity Index
Life Quality Index
References
OECD Organisation for Economic Co-operation and
Development. (2011). OECD Better Life Initiative.
Your Better Life Index. Retrieved June 16, 2011,
from http://www.oecdbetterlifeindex.org/
Stiglitz, J. E., Sen, A., & Fitoussi, J. -P. (2009). Report by
the commission on the measurement of economic per-
formance and social progress. Retrieved June 16,
2011, from http://www.stiglitz-sen-fitoussi.fr/docu-
ments/rapport_anglais.pdf
Bias, Statistical
Ralph L. Piedmont
Pastoral Counseling Department, Loyola
University Maryland, Columbia, MD, USA
Synonyms
Nonresponse bias
Definition
Statistical bias is a term that refers to any type of
error or distortion that is found with the use of
statistical analyses.
Description
Bias can arise for a number of reasons including
failure to respect either comparability or consis-
tency, the price collection and measurement
procedures followed, and the calculation and
aggregation formula employed.
The types of statistical biases will be reviewed
here. The first type of statistical bias is found when
Bidirectional Explanation of Satisfaction
a statistic systematically under (or over) estimates
a population parameter. This is the case with the
formula for standard deviation ((S(Xm)2/N)1/2).
When this formula is applied to samples, it will
consistently underestimate the population param-
eter, s. In this instance, the bias can be corrected
by substituting (N1) in the denominator. This
type of bias can be easily corrected mathematically
(Rosenthal & Rosnow, 1984).
The second type of statistical bias occurs when
there is a bias in the subjects selected for analysis.
In this case, a nonrepresentative sample will lead
to population estimates that are skewed. This
situation arises in studies that do not rely on
random sampling or use only a small sample of
subjects.
Finally, statistical bias can be found in many
statistical analyses. Correlational techniques
(e.g., multiple regression, canonical correlation,
and factor analysis) operate by maximally fitting
a set of predictors to an outcome. The use of
a least squares approach insures that sample
specific elements will be used in maximizing
the observed relationships. Thus, the resulting
measures of overall model fit will overestimate
the true population value. It is therefore essential
that these types of findings be replicated in new
samples, where indices of model fit will be lower.
Such distortion can be minimized by employing
samples with large subjects to variables ratios
(Achen, 1982).
Cross-References
Estimator
Response Bias(es)
Test Bias
References
Achen, C. H. (1982). Intepreting and using regression.
Sage University Paper series on Quantitative
Application in the Social Sciences, 097-029. Beverly
Hills, CA: Sage Publications.
Rosenthal, R., & Rosnow, R. L. (1984). Essentials of
behavioral research: Methods and data analysis.
New York, NY: McGraw-Hill.
383 B
Bidirectional Explanation
of Satisfaction
Willem Egbert Saris B
Research and Expertise Centre for Survey
Methodology, Universitat Pompeu Fabra,
Barcelona, Spain
Synonyms
Reciprocal causal relationships
Definition
Bidirectional explanation of satisfaction
means that it is assumed that domain-specific
(DS) satisfactions influence subjective
well-being (SW) but that SW also affects DS
variables.
Description
One of the main issues in social indicator studies
has been the explanation of subjective
well-being (SW). In many older studies, SW
was explained by a linear combination of
domain-specific satisfaction (DS) variables,
such as satisfaction with income, housing, or
social contacts (Andrews & Withey, 1976;
Argyle, 1987; Campbell et al., 1976; Headey,
Holmstrom, & Wearing, 1985). Diener (1984)
was the first to criticize this intuitive approach.
He suggested that the effects could just as well
be reversed, that is, go from SW to DS. He called
his model the top-down model in contrast with
the intuitive bottom-up model that was used till
that moment. This suggestion was based on the
idea that satisfaction might be determined more
by personality characteristics than situational cir-
cumstances. It seems that some people have
a disposition to be satisfied while others do not,
so that satisfaction with life in general (SW) is the
more fundamental variable which spills over onto
domain satisfaction.
B 384
A third possibility, suggested in the literature
by Costa and McCrae (1980, 1984, is that there
are personality traits which cause the SWB
and the DS to covary. In that case, the relation-
ships between SWB and DS variables would be
spurious due to personality characteristics.
The direction of the effects can also vary with
the country studied. In countries with a lower
BNP, the effect of income satisfaction might be
bottom up from DS to SW while in countries with
a higher BNP, the effect might be reversed or not
existing. In the latter countries, the effect of
domain satisfactions of social contacts or mar-
riage on SW might be significant instead because
with respect to income, the people have already
reached a high enough level so that the people are
not too much worried about this domain any-
more. In that case, they are more concerned
about their social relationship as suggested in
Saris, Veenhoven, Scherpenzeel, and Bunting
(1996). Such a difference between countries
would be in line with the theory of Inglehart
(1990 ) that people are nowadays less concerned
about income matters than by environmental
problems, democratic liberties, etc. Also Maslow
(1970) suggested that there is a hierarchy of
values where the higher values become only
important if the lower level values have been
satisfied.
The above arguments suggest that effects of
DS to SW and from SW to DS can be expected.
So in research, it makes sense to start with
a model with bidirectional or reciprocal effects
between DS and SW. However, such models
create difficulties for the estimation of the effects.
Since the paper of Diener (1984), several stud-
ies have been done in order to test the different
models (Headey, Veenhoven, & Wearing, 1991;
Lance, Mallard, & Michalos, 1995). These
studies have not resolved the dispute but rather
complicated it, as they found different effects for
the different domains studied: Lance et al. found
a significant top-down effect of SW for the
domains job satisfaction and satisfaction with
social activities but a bottom-up effect of mar-
riage satisfaction on SW. Headey et al. also found
a top-down effect for job satisfaction and satis-
faction with leisure activities but a reciprocal
Bidirectional Explanation of Satisfaction
relationship for satisfaction with marriage.
Furthermore, they found no significant effects in
either direction for satisfaction with friendship
and health. For the last two topics, the relation-
ships between SW and DS variables turned out to
be spurious due to personality characteristics like
Neuroticism and Extroversion. These studies
make it clear that the direction of the effects
varies with the domain studied. Moeller and
Saris (2001) found that in one country (South
Africa), different directions of effects were
found for racial and income groups. For the rich
blank population, the effect of the DS social
contacts had an effect on SW and SW an effect
on DS with income while for the poor black
population, the DS of the income had
a significant effect on their SW.
In order to be sure that these results are not
artifacts, it is important to have a study design
and an estimation method which provides rather
robust estimates of the reciprocal effects so that
one can decide with a lot of confidence in what
direction the effects go. Scherpenzeel and Saris
(1996) suggested that in general, this is not the
case. They studied the two most commonly used
procedures. The first approach tries to identify the
reciprocal relations at one point in time using
exogenous variables (Lance et al., 1995). The
other procedure uses the same DS and SW vari-
ables at different points in time for identification
of the reciprocal effects (Headey et al., 1991). It
was found that these different approaches for the
same population did not provide the same results.
Saris (2001) suggests that it would be the best to
use panel data as done by Headey et al. (1991) but
with reciprocal, lagged effects and exogenous
variables. It would be attractive to have at least
three waves of the panel. In that case, the model is
rather overidentified, and one can test for possible
instantaneous and lagged effects in both direc-
tions. The model suggested will be described
below.
First of all, it is specified that the DS(t) is
largely determined by the DS(t-1) except when
changes occur in the comparison variables (C).
The comparison variable presents the difference
between the factual situation and the wish they
have for this specific domain (Michalos, 1985).
Bidirectional Explanation of Satisfaction
To this equation, it is added that also a change in
SW might affect the DS variable, as suggested by
Diener (1984), and personality characteristics,
especially neuroticism (N) and extroversion (E)
as suggested by Headey et al. (1991) and Costa
and McCrae (1980, 1984). This can be formu-
lated as follows:
DSt b1 DSt1 b2 CtCt1
b3 SWt SWt1 g1 N
g2 E zt (1)
For SW, we specify a similar process with
respect to its value at time t, but now it is expected
that SW at time t is largely determined by SW
at time t-1 while both are affected by personality
characteristics like neuroticism and extroversion
as suggested by Costa and McCrae (1984) and
Headey et al. (1991). Furthermore, as suggested
by many researchers mentioned above, a
bottom-up effect of changes in DS is introduced.
This leads to the following specification:
SWt b4 SWt1 as an exogenous variable for the DS variables.
b5 DSt DSt1 g3 N This model differs considerably of the model of
g4 E u t (2)
In this model, b3 represents the top-down
effect and b5 the bottom-up effect. The fact that
the personality characteristics appear in both
equations means that these variables generate
spurious relationships between the DS and SW
variables.
The disturbance terms u(t) and z(t) can be
correlated at the same point in time but not at
different points in time. One can also expect that
the effects at different points in time are equal to
each other.
It will be clear that both equations can be rewrit-
ten by writing out the change term as separate level
variables. In that case, the variables at time t and the
lagged variables at time t-1 will become separate
variables, but the effects of these variables will be
the same except for the sign. The effect of
a variable at the same point in time will be positive;
the effect of a lagged variable will be equal but
negative. Using this notation, the model can also be
represented in Fig. 1. For reasons of simplicity, the
385 B
C1 C2 C3
DS1 DS2 DS3
B
SW1 SW2 SW3
N E
Bidirectional Explanation of Satisfaction, Fig. 1 The
presentation of the model of (1) and (2) in a causal dia-
gram. In order to avoid confusion, the arrows from N and
E to DS(t) have been omitted
disturbance terms for the variables have been omit-
ted in the figure as well as the effects of personality
variables on the DS variables.
This model is very much in line with the
model used by Headey et al. (1991) except for
the fact that a comparison variable is introduced
Scherpenzeel and Saris (1995) who used all DS
variables at the same time. It is rather suggested
to follow the approach of Headey et al. who tested
separately the effects of the different DS
variables.
A major difference with the model of Headey
is that effects of lagged variables are specified
next to the effect of variables at the same point in
time. This may lead to a better fit of the model
than they got, specifying these effects to be zero.
If data are available for all variables men-
tioned in three waves of a panel, the model can
be estimated with standard Structural
Equations software, and the model can be
adjusted by omitting nonsignificant effects from
the model. This approach has been used to test
this model on Russian data (Saris, 2001). It turned
out that effects for DS marriage and housing were
top down and for the DS income there are
reciprocal effects in Russia. This illustrates that
it makes sense to study the direction of these
effects because the assumption that all effects of
the DS variables are only bottom up is too simple.
B 386
Cross-References
Subjective Well-Being
References
Andrews, F. M., & Withey, S. B. (1976). Social indicators
of well-being. New York: Plenum Press.
Argyle, M. (1987). The psychology of happiness. London:
Methuen.
Campbell, A., Converse, P. E., & Rogers, W. R. (1976).
The quality of American life. New York: Russel Sage
Foundation.
Costa, P. T., & McCrae, R. R. (1980). Influence of extra-
version and neuroticism on subjective well-being.
Journal of Personality and Social Psychology, 338,
668678.
Costa, P. T., & McCrae, R. R. (1984) Personality as
a lifelong determinant of well being. In C. Malatesta
& C. Izard (Eds.), Affective processes in adult
development and aging. Beverly Hills: Sage.
Diener, E. (1984). Subjective well-being. Psychological
Bulletin, 95, 542575.
Headey, B., Holmstrom, E. L., & Wearing, A. J. (1985).
Models of well-being and ill-being. Social Indicators
Research, 17, 211234.
Headey, B., Veenhoven, R., & Wearing, A. (1991).
Top-down versus bottom-up theories of subjective
well-being. Social Indicators Research, 24,
81100.
Inglehart, R. (1990). Culture shift in advanced industrial
society. Princeton, NJ: Princeton University Press.
Lance, C. E., Mallard, A. G., & Michalos, A. C. (1995).
Tests of the causal directions of global-life facet satis-
faction relationships. Social Indicators Research, 34,
6992.
Maslow, A. (1970). Motivation and personality.
New York: Harper & Row.
Michalos, A. C. (1985). Multiple discrepancies theory.
Social Indicators Research, 16, 347413.
Moeller, V., & Saris, W. E. (2001). The relationship
between subjective well-being and domain satisfac-
tions in South Africa. Social Indicators Research, 55,
97114.
Saris, W. E. (2001). What influences subjective well-
being in Russia. Journal of Happiness studies, 3,
137146.
Saris, W. E., Veenhoven, R., Scherpenzeel, A. C., &
Bunting, B. (Eds.). (1996). A comparative study of
life satisfaction in Europe. Budapest: Eotvos Univer-
sity Press.
Scherpenzeel, A., & Saris, W. E. (1996). Causal
direction in a model of life satisfaction: the top-
down/bottom-up controversy. Social Indicators
Research, 38, 161180.
Bi-factor Analysis
Bi-factor Analysis
Robert Gibbons
Departments of Health Studies, Medicine, and
Psychiatry, University of Chicago, Chicago,
IL, USA
Definition
The bi-factor model is a confirmatory factor ana-
lytic model originally proposed for measurement
data by Holzinger and Swineford in 1937
(Holzinger & Swineford, 1937) and then gener-
alized to the case of discrete item-response data
by Gibbons and Hedeker in 1992 (Gibbons &
Hedeker, 1992). The bi-factor restriction requires
that each item load on a primary dimension of
interest and no more than one secondary
dimension. The secondary dimensions or
subdomains can be nuisance variables such as
positively and negatively worded questions (i.e.,
a methodologic factor) or content domains from
which the items are sampled (e.g., component
dimensions underlying the overall quality of
ones life). When appropriate the bi-factor
model provides numerous advantages over an
unrestricted exploratory item factor analysis
model, including rotational invariance and
unlimited dimensionality. For categorical item
responses, the likelihood of the model can be
evaluated using two-dimensional integration
regardless of the number of subdomains. The
model assumes that all of the intercorrelations
among the items are explained by their joint
association with the primary dimension
and the specific subdomain that they are a part
of. The subdomains are assumed to be
independent.
Description
In quality of life measurement, interest in
bi-factor analysis has increased as the state of
the art for scale development shifted from
Bi-factor Analysis 387 B
classical test theory to item-response theory and the probability that the individual will
(IRT) approaches. Historically, IRT assumed respond incorrectly, indicated by xij 0, is the
unidimensional data, that is, responses to items complement,
could be accounted for by a single attribute or
random effect parameter for each subject. How- Pxij 0jyi 1  Fyi : B
ever, empirical Bayes and marginal maximum
likelihood methods easily extend the theory to Since the multiple factor model implies
item responses that have more than one dimen- conditional independence (i.e., the items are
sion. Such an extension was sketched by Bock uncorrelated conditional on the underlying
and Aitkin (Bock & Aitkin, 1981) and presented factors y), the conditional probability of the
more formally in Bock, Gibbons, and Muraki item score vector xi is
(Bock, Gibbons, & Muraki, 1988). The basic
ideas follow: Px xi j y; g; a
Following Thurstone (1947) assume that an
Y
ni
 1xij
individuals response to a test item j is controlled Fi yi xij 1  Fj yi :
by a latent variable j

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

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

cj gj =sj
the attribute value, or score, of individual i on
factor k, and eij is an independent residual.
According to the conventions of factor analysis, and factor slopes
assume that all variables are standardized and
that scores for different factors are uncorrelated. ajk ajk =sj
Assuming normality, the distributions of these
parameters are yj  N(0,1), yk NID(0,1) and ej rather than threshold and factor loadings.
  Pm In the context of Bayes estimation, the
NID 0; s2j , where s2j 1  a2jk is the
k equation above is the likelihood of yi , and the
uniqueness (i.e., unique item variance). prior, which is multivariate normal, is completely
Individual i is assumed to respond positively specified. However, because of the nature of this
to item j when yij is greater than the item likelihood function, this is an example of a model
threshold gj . Thus, the probability that an individ- outside the exponential family for which no
ual with factor score vector yi will respond closed form of the posterior mean or covariance
positively to item j, as indicated by the item matrix is available. Note, however, that the
score xij 1, is given by the item-response unconditional probability of score pattern xi can
function, be expressed as
Z 1
Fj yij Pxij 1jyij
hxi Px xi j y; g; agydy
Pyij > gj jyi 1
2 !2 3
Z 1 X
m
1 1
exp4 yij  ajk yki =s2j 5dyj As such, the integral in the preceding equation
2psj gj 2 k
 P 
is numerically approximated by m-fold
gj  m k ajk yki Gauss-Hermite product quadrature (Bock &
F 
sj Aitkin, 1981; Bock et al., 1988).
B 388
The Bi-factor IRT Model
The bi-factor restriction for IRT models (Gibbons
& Hedeker, 1992) was the first example of
a confirmatory multidimensional IRT model.
The bi-factor model is based on the idea that in
many cases multidimensionality is produced by
the sampling of items from multiple domains of
an overall psychological construct. For example,
in the measurement of fatigue impact, a measure
could include items that assess cognitive, physi-
cal, and social impact of fatigue. It is quite natural
for responses to such items to appear to be
multidimensional, when in fact, the items mea-
sure a unidimensional construct, that is, fatigue
impact. However, the items within subdomains
are more highly correlated than items between
domains. For example, responses to two items
measuring cognitive fatigue will be more highly
correlated than responses to a pair of items, one
measuring cognitive fatigue and the other
measuring physical fatigue. This leads to viola-
tion of the conditional independence assumption
of a unidimensional IRT model and results in
dimensionality equal to the number of domains
from which the items were sampled. However,
a plausible s-factor solution for many types of
psychological and educational tests is one that
exhibits a general factor and s-1 group- or
method-related factors. The bi-factor solution
constrains each item j to have a nonzero loading
aj1 on the primary dimension and a second load-
ing ajk ; k 2; . . . ; s on not more than one of
the s-1 group factors. For four items, the bi-factor
pattern matrix might be
2 3
a11 a12 0 nal symptom items, making the methodology
6 a21 a22 0 7
a6
4 a31
7
0 a33 5
a41 0 a43
This structure, which Holzinger and
Swineford (1937) termed the bi-factor solution,
also appears in the inter-battery factor analysis of
Tucker (1958) and is one confirmatory factor
analysis model considered by Joreskog (1969).
In these applications, the model is restricted to
test scores assumed to be continuously
distributed. But it is easy to conceive of situations
Bi-factor Analysis
where the bi-factor pattern might also arise at the
item level (Muthen, 1989). It is plausible for
paragraph comprehension tests, for example,
where the primary dimension describes the
targeted process skill and additional factors
describe content area knowledge within para-
graphs. Similarly, in the context of mental health
measurement, symptom items are often selected
from measurement domains and can be related to
the primary dimension of interest (e.g., depres-
sion) and one subdomain (e.g., anxiety). In these
contexts, items would be conditionally indepen-
dent between paragraphs or domains but
conditionally dependent within paragraphs or
domains.
The bi-factor restriction leads to a major sim-
plification of likelihood equations that (a) permits
analysis of models with large numbers of group
factors (e.g., domains), (b) permits conditional
dependence among identified subsets of items,
(c) is rotationally invariant in contrast to the
unrestricted item factor model, (d) always
reduces the likelihood to a two-dimensional
integral that is easily evaluated using traditional
numerical methods, and (e) in many cases pro-
vides a more parsimonious factor solution than an
unrestricted full-information item factor analysis
(Bock & Aitkin, 1981). Furthermore, in the
context of computer adaptive testing (CAT), the
bi-factor model provides a single endpoint (i.e.,
the core dimension) by which to adaptively select
items from a potentially large bank of symptom
items.
Recently, Gibbons and coworkers (2007)
extended the bi-factor model to the case of ordi-
even more useful in the context of psychological
measurement problems (e.g., quality of life)
where Likert-type rating scales are often used.
The bi-factor model can also be used in conjunc-
tion with CAT to measure mental health con-
structs (Gibbons et al., 2008). Cai (2010) has
further generalized the bi-factor model to the
case in which there are multiple intercorrelated
primary domains in addition to subdomains that
nested within each of the multiple primary
domains. There are numerous interesting
applications of this even more general model.
Bi-factor Analysis
The IRTPRO computer program (Cai) can fit
unidimensional and multidimensional IRT
models in addition to the bi-factor model for
binary and ordinal response data.
Recently, there have been several applications
of bi-factor models in the area of personality
research (Patrick, 2007; Reininghaus, McCabe,
Burns, Croudace, & Priebe, 2011; Reise,
Moore, & Haviland, 2010; Rijmen, 2010; Yang,
Tommet, & Jones, 2009). In the area of life
quality assessment, unidimensional IRT models
have been considered (Fryback, Palta,
Cherepanov, Bolt, & Kim, 2010) as well as
IRT-based CAT (Rebollo et al., 2010). Gibbons
and coworkers (2007) have presented a bi-factor
analysis of a quality of life scale, as described in
the following.
Quality of Life Illustration
As an illustration of the bi-factor model for graded
response data, (Gibbons et al., 2007) Gibbons and
colleagues analyzed the Quality of Life Interview
for the Chronically Mentally Ill (Lehman, 1988).
Their analysis was based on item responses of 586
chronically mentally ill patients. Analyses were
performed using the freely available POLYBIF
software (Gibbons & Hedeker, 2007). The scale
consists of seven subdomains (Family, Finance,
Health, Leisure, Living, Safety, and Social), each
with 46 items for a total of 34 items. In addition,
there is one global life satisfaction item, which was
allowed to load on its own subdomain in the event
that it had a unique contribution to the residual
variation above and beyond its contribution to
the primary dimension. Each item is rated on
a 7-point scale with the following response cate-
gories: 1 terrible; 2 unhappy; 3 mostly
dissatisfied; 4 mixed, about equally satisfied
and dissatisfied; 5 mostly satisfied;
6 pleased; and 7 delighted.
Item intercepts, primary factor loadings, and
factor loadings on the eight subdomains are
displayed in Table 1 based on the polytomous
rating scale model (Gibbons et al., 2007). Table 1
shows that all items had substantial loadings on the
primary dimension (factor 1), indicating that the
scale was well designed and that all items were
related to overall life satisfaction. The three most
389 B
discriminating items were global life satisfac-
tion, factor loading (FL) 0.694; satisfaction
with free time, FL 0.611 (subdomain 4);
and emotional well-being, FL 0.609
(subdomain 3). The three least discriminating B
items were satisfaction with people in general,
FL 0.385 (subdomain 7); amount you pay for
basic needs, FL 0.391 (subdomain 2); and
pleasure from TV, FL 0.414 (subdomain 4).
The unique life as a whole item loaded heavily
on the primary dimension, but not at all on the
subdomain, indicating that the primary dimension
is a good measure of overall life satisfaction. The
item intercepts permit items to be positioned rela-
tive to the global life satisfaction item to determine
at what point on the scale a person would report
global life satisfaction. Table 1 shows that the
Health (subdomain 3), Living (subdomain 5), and
Social domains (subdomain 7) were typically
reported at lower levels of satisfaction than the
global item, whereas Financial (subdomain 2)
and Leisure (subdomain 4) items had, on average,
higher intercepts than the global satisfaction item.
The domains of Family (subdomain 1) and Safety
(subdomain 6) items were located at similar levels
to the global item.
In terms of subdomains, items within domains
had a high degree of residual association, with an
average loading of.406.Consistent with this find-
ing was a significant likelihood ratio test for
improvement in fit of the bi-factor model over
the unidimensional graded response model
(w2 2188, df 35, p < .0001). Table 2 displays
the observed and expected (in italics) category
proportions for each item. In general, there is
close agreement between observed and expected
response proportions. The root mean square error
(RMSE) between observed and expected propor-
tions (over all items and categories) was 0.026,
indicating that the model with common category
parameters (Muraki, 1990) fit these data
extremely well. The six category parameters
were as follows:
 1:395  :858  :449 :044 :866 1:793
A model with unique item category parame-
ters (Samejima, 1969) produced a significant
B 390 Bi-factor Analysis

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

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

Bi-factor Analysis, Table 2 (continued)

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

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

Cross-References quality of life indexes using item response theory

Confirmatory Factor Analysis (CFA)
Exploratory Factor Analysis
Factor Analysis
Item Response Theory [IRT]
References
Bock, R. D., & Aitkin, M. (1981). Marginal maximum
likelihood estimation of item parameters: Application
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Bock, R. D., Gibbons, R. D., & Muraki, E. (1988). Full-
information item factor analysis. Applied Psychologi-
cal Measurement, 12, 261280.
Cai, L. (2010). A two-tier full-information item factor
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Kim, J. S. (2010). Comparison of 5 health-related
analysis. Medical Decision Making, 30, 515.
Gibbons, R. D., & Hedeker, D. (1992). Full-information
item bi-factor analysis. Psychometrika, 57, 423436.
Gibbons, R. D., Bock, R. D., Hedeker, D., Weiss, D. J.,
Segawa, E., Bhaumik, D. K., et al. (2007).
Full-information item bifactor analysis of graded
response data. Applied Psychological Measurement,
31, 419.
Gibbons, R. D., & Hedeker, D. (2007). POLYBIF [Com-
puter software]. Chicago: Center for Health Statistics,
University of Chicago. Available from www.
healthstats.org
Gibbons, R. D., Weiss, D. J., Kupfer, D. J., Frank, E.,
Fagiolini, A., Grochocinski, V. J., et al. (2008).
Using computerized adaptive testing to reduce the
burden of mental health assessment. Psychiatric Ser-
vices, 59, 361368.
Gibbons, R. D., Weiss, D. J., Pilkonis, P. A., Frank, E.,
Moore, T., et al. (2012). Development of
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Holzinger, K. J., & Swineford, F. (1937). The bi-factor
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Joreskog, K. G. (1969). A general approach to confirmatory
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B 394 Big Five Model of Personality

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

chronically mentally ill. Evaluation and Program Big Picture Research
Planning, 11, 5162.
Muraki, E. (1990). Fitting a polytomous item response
model to Likert-type data. Applied Psychological Meta-studies
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Muthen, B. O. (1989). Latent variable modeling in het-
erogeneous populations. Psychometrika, 54,
557585. Bigotry and Religion
Patrick, C. J. (2007). A bifactor approach to modeling the
structure of the psychopathy checklist revised. Journal
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Rebollo, P., Castejon, I., Cuervo, J., Villa, G., Garcia-
Cueto, E., Diaz-Cuervo, H., et al. (2010). Validation
of a computer-adaptive test to evaluate generic
health-related quality of life. Health and Quality of Binary Response
Life Outcomes, 8, 18.
Reininghaus, U., McCabe, R., Burns, T., Croudace, T., &
Priebe, S. (2011). Measuring patients views: Eric K. H. Chan
A bifactor model of distinct patient-reported outcomes Department of ECPS, University of British
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Reise, S. P., Moore, T. M., & Haviland, M. G. (2010).
Bifactor models and rotations: Exploring the extent to
which multidimensional data yield univocal scale
scores. Journal of Personality Assessment, 92, 544559. Synonyms
Rijmen, F. (2010). Formal relations and an empirical
comparison among the bi-factor, the testlet, and Dichotomous response format
a second-order multidimensional IRT model. Journal
of Educational Measurement, 47, 361372.
Samejima, F. (1969). Estimation of latent ability using
a response pattern of graded scores. Psychometrika Definition
Monograph Supplement, 17, 168.
Thurstone, L. L. (1947). Multiple factor analysis.
Chicago: University of Chicago Press. Binary response format is defined as a response
Tucker, L. R. (1958). An inter-battery method of factor format in measurement with only two possible
analysis. Psychometrika, 23, 111136. values (e.g., yes or no, true or false).
Weiss, D. J. (1985). Adaptive testing by computer. Journal
of Consulting and Clinical Psychology, 53, 774789.
Yang, F. M., Tommet, D., & Jones, R. N. (2009). Dispar-
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due to sociodemographic differences: An extension
of the bi-factor item response theory model for use in In quality of life measures, a binary or dichoto-
differential item functioning. Journal of Psychiatric
Research, 43, 10251035. mous response format is often used. Many
behavioral, biological, and social variables of
interests have only two possible values, such as
yes or no, true or false. For example, respondents
are asked to answer true or false to a series of
Big Five Model of Personality items on well-being. Multiple choice items on
educational achievement tests can also be viewed
Five Factor Model of Personality as a form of binary response format, as test-takers
answer each of the items either correctly or incor-
rectly. As only two possible values (or outcomes)
are available in a binary variable, logistic
Big Five Personality Traits regression and related dichotomous item
response models are suitable for analyzing these
Five Factor Model of Personality data (see, e.g., Wu & Zumbo, 2007).
Biodiversity Conservation
The advantage of binary response format is that
it is easy for respondents to answer; thus, the
burden placed on respondents is low. Compared
to items with many response options, particularly
items with a midpoint option (e.g., a 9-point Likert
scale with 5 as the neutral option), binary
response formats are cognitively less demanding.
As a result, respondents may be more likely to
complete binary items particularly when the mea-
sure is lengthy. Another advantage of the binary
response format is that relatively smaller sample
sizes are needed to fit measurement models
because fewer parameters need to be estimated
(e.g., more item parameters would have to be
estimated for Likert scales).
Perhaps the major drawback of the binary report
format is that it loses information (forcing people to
choose one of the two options) and that there is less
variability in each item. It is important to note that
variance is needed in psychometric analysis. So,
compared to other response formats (such as Likert
scale), more items may be needed to achieve the
same level of variance if a binary response format
is used. To learn about other response formats
(i.e., ordinal and continuous), please refer to the
Response Formats entry in this volume.
Cross-References
Data Analysis
Logistic Regression
Response Format
References
Wu, A. D., & Zumbo, B. D. (2007). Thinking about item
response theory from a logistic regression perspective:
A focus on polytomous models. In S. S. Sawilowsky
(Ed.), Real data analysis (AERA, educational statisti-
cians book series, pp. 241269). Greenwich, CT:
Information Age.
Binge Eating Disorder
Eating Disorder(s) and Health-Related Quality
of Life
395 B
Biodiversity Conservation
Bill Freedman
Department of Biology, Dalhousie University, B
Halifax, NS, Canada
Synonyms
Biodiversity, species; Biological diversity
Definition
The term biodiversity, or biological diversity, is
a hierarchical concept that refers to the richness
of the living world. At its lowest scale, it includes
the varied genetic information encoded within
the DNA of a population or species. At an inter-
mediate level, it may refer to the number of
species that occurs in a particular ecological
community or geographic area. At an even larger
scale, biodiversity is the variety of habitat types
that is present on a landscape or seascape. For
most people, however, the aspect of biodiversity
that is most easily understood is the number of
species present. This is known as species rich-
ness, and it includes all of the animals, plants, and
microorganisms that may occur. Species richness
may be enumerated in a particular community,
in a politically defined region such as a park or
a country, and ultimately in the entire biosphere.
Description
So far, biologists specialized in the naming of
organisms, or taxonomy, have identified about
1.8 million species. Each is given a binomial
name, such as Homo sapiens for humans. The
groups that are best known and most comprehen-
sively named are relatively large or abundant
animals. In contrast, there are millions of as yet
undiscovered species of smaller organisms that
inhabit poorly documented ecosystems, espe-
cially in tropical forests and deep oceans. Some
estimates of the ultimate species richness of the
biosphere exceed 3050 million.
B 396
About one third of the named species live in
tropical climes and two third in boreal and tem-
perate latitudes. However, at least 90 % of the
unknown biodiversity is thought to exist in the
tropics. The species of tropical rainforest are
especially poorly known, particularly the smaller
invertebrates and microorganisms. Most of this
hidden biodiversity of unnamed tropical spe-
cies is comprised of tiny invertebrates, especially
beetles.
Conservationists value indigenous biodiversity
much more highly than alien elements. Similarly,
ecological communities that are naturally occur-
ring and self-organized are more highly valued
components of natural heritage than are anthropo-
genic habitats created by agriculture or urbaniza-
tion. In fact, when alien species occur in wild
habitats, they are deemed to be a biological pollu-
tion that degrades ecological integrity, and they
may be assigned a derogatory label such as inva-
sive alien. In North America, this is the reason
why the abundant but nonnative dandelion
(Taraxacum officinale) is referred to as a weed
and the alien starling (Sturnus vulgaris) as a pest.
Biodiversity Is Important
To many people, the principal reason to cherish
biodiversity is its intrinsic value, which applies
to anything having unique and irreplaceable qual-
ities. Any entity with intrinsic value has moral
standing and a right to exist, regardless of
whether it is useful to people. The inherent
value of art and other forms of cultural expression
is acknowledged as a reason to hold these human
artifacts in esteem. The same is true of native
species and natural ecological communities, and
so society has a responsibility to ensure that these
elements of biodiversity will survive at viable
levels of abundance.
However, biodiversity also has utilitarian
value, and that is another important reason to
conserve it. Elements of biodiversity are valuable
as sources of food, medicine, materials, and
energy, and they are harvested and manufactured
into many products used by people. In aggregate,
these potentially renewable natural resources
generate a huge economy when traded in domes-
tic and international marketplaces.
Biodiversity Conservation
There are many examples of such bio-
resources. For instance, trees, which are mostly
harvested from wild forests, are used to manufac-
ture lumber, paper, and various wooden products,
or they are burned as renewable biomass energy.
The fruits of many wild plants are collected as
food and medicinals, and waterfowl, deer, and
other wild animals are hunted for meat.
A relatively small number of species has been
domesticated, and they are the basis of most
cultivated agriculture. Collectively, these uses
of biodiversity are responsible for almost all
foods eaten by people and much of the materials
and energy that are used.
In addition to the known commercial benefits
of certain species, there are others whose uses are
not yet discovered, including potential medici-
nals and foods of great value. These potential
benefits are an important reason to conserve all
elements of biodiversity, as is suggested by
a famous quotation of the American ecologist,
Aldo Leopold: To keep every cog and wheel is
the first precaution of intelligent tinkering.
Biodiversity is also economically important
because many people will pay money to experi-
ence its pleasures in nonconsumptive ways, such
as naturalists seeking to observe birds or wild-
flowers in a natural setting. These people expend
considerable leisure time in pursuit of their out-
door sport, and a lot of money may be spent on
travel, accommodations, and field equipment.
Finally, at larger scales, biodiversity provides
vital environmental services that sustain both
people and the natural world. For example, for-
ests store enormous quantities of organic carbon
in biomass and so keep it out of the atmosphere as
carbon dioxide, a key greenhouse gas. Similarly,
well-vegetated landscapes supply predictable
flows of clean water.
Threats to Biodiversity
The natural world has always had to cope with
changes in environmental conditions. Over evo-
lutionary time, which extends through the 3.5-
billion-year history of life, various stressors
have caused many species to become extinct and
have even resulted in the loss of larger taxonomic
units, such as families and orders. In fact, natural
Biodiversity Indices
environmental factors have caused the extinction
of most of the species that have ever lived.
Today, however, there is an unnaturally rapid
rate of extinction that is driven by stressors associ-
ated with the actions of people. This modern biodi-
versity crisis is ruthless. It is mostly caused by
the destruction of natural ecosystems to develop
agricultural and urban land uses, particularly in
low-latitude countries where most biodiversity
exists. Secondary factors are ecological damages
caused by alien species and the overharvesting of
species of economic importance. As bad as it is
today, the biodiversity crisis will become much
worse if effective actions are not quickly taken to
conserve the natural world. Essentially, the fixes to
this awful problem involve the implementation of
economic practices that have softer ecological
effects, coupled with the designation of protected
areas. Those nature reserves are needed to sustain
the critical habitats of biodiversity at risk as well as
wilderness-scale tracts of representative ecosystems.
Conservation of Biodiversity
The conservation of biodiversity is an important
societal goal. Many people are concerned about the
loss of natural values in their local areas, in their
country, and globally. They are demanding that
effective actions be taken to prevent further dam-
ages and to repair some of the ones that have
already been caused. Governments are increasingly
engaged in conservation actions as are private com-
panies and many citizens. Nongovernmental con-
servation organizations have been formed, and they
are helping to deal with issues related to biodiver-
sity. Overall, there is broad-based support for the
vision of conserving biological diversity, and little
opposition to that goal.
At the international level, the conservation of
biodiversity is subject to its own treaty, the Con-
vention on Biological Diversity (1993) of the
United Nations. The objectives of the CBD are
to ensure that biological diversity is conserved
and its products used sustainably, with equitable
sharing of benefits among countries and peoples
of the world. Countries signatory to the CBD are
obliged to develop and implement a national
action plan to conserve biodiversity and to report
on its implementation. Usually, this includes
397 B
endangered-species legislation. Many govern-
mental and private organizations are also setting
aside large tracts as protected areas, whose key
purpose is to conserve the natural habitats of
indigenous biodiversity. B
However, it is also vital to do what is possible
to conserve habitats on lands that are working
to serve the economy by providing food and other
natural resources. Biodiversity can only be
sustained if comprehensive actions are taken to
provide habitats in both working landscapes and
protected areas. The conservation of biodiversity
in this manner is an integral component of the
ecologically sustainable development of the
human economy.
Cross-References
Ecological Well-being
Ecosystem Approach to Human Health
Sustainable Development
United Nations Commission on Sustainable
Development
References
Chivian, E., & Bernstein, A. (2008). Sustaining life. How
human health depends on biodiversity. New York:
Oxford University Press.
Freedman, B. (2010). Environmental Science: A Cana-
dian Perspective. Pearson Education Canada, Toronto,
ON, Canada.
Gaston, K. J., & Spicer, J. I. (2006). Biodiversity. An
introduction. Malden, MA: Blackwell Science.
Lovejoy, T. E., & Hannah, L. (2006). Climate change and
biodiversity. New Haven, CT: Yale University Press.
Naeem, S., Bunker, D. E., Hector, A., & Loreau, M.
(2009). Biodiversity, ecosystem functioning, and
human wellbeing: An ecological and economic per-
spective. New York: Oxford University Press.
Primack, R. B. (2004). A primer on conservation biology
(3rd ed.). Sunderland, MA: Sinauer Associates.
Wilson, E. O. (1999). The diversity of life. New York: W.
W. Norton.
Biodiversity Indices
Indices for Monitoring Biodiversity
B 398
Biodiversity, Species
Biodiversity Conservation
Bioecological Model
Bioecological Theory of Human Development
Bioecological Theory of Human
Development
Matthew Waugh1 and Martin Guhn2
1
Department of Educational and Counselling
Psychology and Special Education, University of
British Columbia, Vancouver, BC, Canada
2
Human Early Learning Partnership, School of
Population and Public Health, University of
British Columbia, Vancouver, BC, Canada
Synonyms
Bioecological model
Definition
The bioecological theory of human development
(Bronfenbrenner, 1986b; Bronfenbrenner &
Ceci, 1993, 1994; Bronfenbrenner & Morris,
2006) is a comprehensive theoretical and
methodological model for the study of human
development. Extending on earlier ecological
models of development (Bronfenbrenner, 1979,
1989, 1986a, 1986b), the bioecological theory
expounds on the biopsychological features of
the developing person and on the capability
for proximal processes to differentiate and
actualize biological potential (Bronfenbrenner
& Ceci, 1993, 1994; Bronfenbrenner & Morris,
2006). The bioecological theory of human devel-
opment has progressed through periodic revi-
sions since its first comprehensive formulation
Biodiversity, Species
in 1970 by one of the twentieth centurys most
prominent developmental psychology theoreti-
cian, and Head Start cofounder, Urie
Bronfenbrenner (19172005). Bronfenbrenner
envisioned that his bioecological theory be rele-
vant for practice, science, and policy, by studying
human development in real or realistic contexts.
This vision is reflected in two axioms
Bronfenbrenner commonly quoted: There is
nothing as practical as a good theory an
expression which Bronfenbrenner credits to his
mentor Kurt Lewin and There is nothing like
the practical to build a good theory
(Bronfenbrenner, 1977a, p. 48). The relevance
of the theoretical model is underpinned by its
utility and practicality in documenting and study-
ing the quality of life. of individuals over their
life course in various ecological contexts, with
the explicit goal to inform practice and public
policy (Bronfenbrenner, 1970, 1974). In fact, it
was from Bronfenbrenners early work that
pioneered Head Start (http://www.acf.hhs.gov/
programs/ohs/), a federally funded, comprehen-
sive early education program that has served
families of low-income children in the USA
since 1964.
Description
Fundamental concepts to the theory follow a set
of systems or nested structures having various
degrees of influence on human development
(Bronfenbrenner, 1979, p. 3). The first level
and innermost system is the microsystem, the
setting which contains the developing person at
any given point in time. Settings may consist of
the persons home, classroom, or work setting,
each having roles which the developing person
fills (e.g., student, teacher, or parent roles).
The interrelations among major settings
containing the developing person at a particular
point in his or her life form the mesosystem
(Bronfenbrenner 1977b, p. 515), and it is with
the proximal processes, or the bidirectional
interactions between organisms or developing
person and the environment, immediate or
distal, that drives human development
Bioecological Theory of Human Development
(Bronfenbrenner & Ceci, 1993, 1994;
Bronfenbrenner & Morris, 2006). Those envi-
ronments in which the individual does not
directly come into contact with, but is nonethe-
less influenced by, including neighborhood and
community systems, local health institutions,
and media, are defined as the exosystem. The
macrosystem is the fourth level, encompassing
the cultural, political, religious, and other
macroinstitutions that influence the developing
person within all other levels over time
(chronosystem).
Bronfenbrenner critiqued his own original for-
mulation of ecological systems theory, due to his
belief that developmental knowledge derived
from examinations of environmental influences
on human development had come at the expense
of defining the fundamental processes that
underlie human development. This led to
a reformulation in the 1990s, when
Bronfenbrenner added two key defining proper-
ties to the ecological model. The first property
maintains that human development is the product
of processes of progressively complex recipro-
cal interactions between an active, evolving
biopsychological human organism and the per-
sons, objects, and symbols in its immediate exter-
nal environment (Bronfenbrenner & Morris,
2006, p. 797). These processes, or proximal
processes, whereby interactions between the
developing person and the immediate environ-
ment are sustained, are seen as the driving force
behind human development (Bronfenbrenner,
2001b). In developmental research, the effects
of such enduring interactions are best mea-
sured when interactions are taking place on
a regular basis over extensive durations. Fur-
thermore, the expansion of the microsystem
incorporated the semiotic system (e.g., sym-
bols and language) as another set of proximal
processes essential for study. Bronfenbrenner
and Morris (2006) advise that objects and
symbols be inviting and promote exploration
and manipulation which can give insight into
the actions, goal setting behaviors, and inten-
tions formed by the developing person. The
second key property of the bioecological
model states:
399 B
The form, power, content, and direction of the
proximal processes producing development vary
systematically as a joint function of the character-
istics of the developing person (including genetic
inheritance); of the environment-both immediate
and remote-in which the processes are taking B
place; of the nature of the developmental outcomes
under consideration; and of the continuities and
changes occurring in the environment over time,
through the life course, and during the historical
period in which the person has lived.
(Bronfenbrenner, 2001/2005, pp. 67)
At the crux of the bioecological theory is its
intent for both the model and subsequent research
designs to be operational (Bronfenbrenner &
Evans, 2000), meaning that the paradigm would
necessarily shift from verifying research towards
discovery. The juxtaposition between a mode of
verification and the discovery mode is the differ-
ence between verification or replication of find-
ings and the more robust mode (i.e., discovery) of
an extended process involving a series of pro-
gressively more differentiated formulations, with
the results at each successive step setting the
stage for the next round (Bronfenbrenner,
2001b, p. 187). This includes the systematic
review and need for devising of alternative
hypotheses prior to the scientific process being
carried out (Bronfenbrenner, 2001a, p. 4), requir-
ing researchers to develop hypotheses of
sufficient explanatory power and precision to
warrant being subjected to empirical test
(Bronfenbrenner & Morris, 2006, p. 801). The
process-person-context-time model (or P-P-C-T )
that has come out of bioecological research meets
this criteria as an operational research design,
holding theory as a critical component and
allowing for the investigation of the properties
previously discussed (effects of proximal pro-
cesses, genetic variability, and environmental
interactions over time):
Process: Central to the P-P-C-T model is the
concept of process, which includes the
proximal processes or particular forms of
interaction between organism and
environment. . .that operate over time and are
posited as the primary mechanisms producing
human development (Bronfenbrenner &
Morris, 2006, p. 795). The form, power,
B 400
content, and direction of these processes, to
a large degree, are dependent on a joint func-
tion of the characteristics of the developing
person (Person), the environmental contexts
(Context), and time periods (Time) in which
processes take place (Bronfenbrenner & Ceci,
1993, p. 178). The properties within proximal
processes are believed to affect the develop-
mental trajectories of the developing person.
Bronfenbrenner cited two categorical path-
ways including dysfunction and competence.
Dysfunction is defined as the inability for an
individual to self-regulate and integrate
behaviors appropriately across situations,
whereas competence, as demonstrated by the
developing person, shows an acquisition and
further development of knowledge and
skills whether intellectual, physical,
socioemotional, or a combination of them
(Bronfenbrenner & Morris, 2006, p. 803).
Person: The power of proximal processes are
regulated and set in motion by three types of
person characteristics (Bronfenbrenner &
Morris, 1998, 2006). The first are dispositions,
which set proximal processes in motion. The
second are an individuals bioecological
resources, including ability and skill sets,
knowledge, and experience necessary for
effective functioning of proximal processes
at a given stage of development
(Bronfenbrenner & Morris, 1998, p. 995). The
final is the demand characteristic that can either
invite or discourage reactions from the social
environment that can foster or disrupt the oper-
ation of proximal processes (Bronfenbrenner
& Morris, 2006, p. 796).
Context: When the microsystem was
expanded, so too was the context of the prox-
imal processes taking place in those environ-
ments that contain the developing person.
Context incorporates all characteristics of the
person (e.g., biopsychological), environments
in which the person is situated, and different
levels of time.
Time: Early concepts of ecological systems
theory only briefly discussed the dimension
of time in relation to molar activities and acts
(Bronfenbrenner, 1979). A molar activity is an
Bioecological Theory of Human Development
activity that is of longer durations and
involves engagement from the developing
person, such as reading a book, participating
in a class discussion, or completing
a homework assignment. Acts constitute an
instant behavior, such as the clapping of the
hands, tapping of the foot, smile, or nod.
A much needed elaboration to the process of
time was provided and represents three levels
of ecology: microtime, mesotime, and
macrotime (Bronfenbrenner & Ceci, 1994).
Microtime refers to continuity versus discon-
tinuity in ongoing episodes of proximal
processes (Bronfenbrenner & Morris, 1998,
p. 995). Mesotime involves the recurrence of
episodes across time (e.g., days, weeks, and
months). Macrotime, unlike the first two
levels, does not directly involve the develop-
ing person, rather it focuses on the larger soci-
ety, across generations, and the events therein
that have the propensity to affect or be
affected by human development over time.
Similar to the imbedding of the property of
time into the three levels of systems, other com-
ponents of the P-P-C-T model can be viewed
within each of the nested structures. For example,
the three properties of person can be imbedded
within the microsystem; disposition, resource,
and demand characteristics of parents, teachers,
students are within the niche of the microsystem.
These components of the P-P-C-T model are
essential for designing studies on human devel-
opment that stand a chance to yield new scientific
knowledge that meets the criteria set forth under
bioecological theory.
Central to the bioecological theory of human
development (Bronfenbrenner & Ceci, 1993,
1994; Bronfenbrenner & Morris, 2006) are the
developmental and behavioral mechanisms
(proximal processes) in a developing persons
environment that drive human development.
The relevance of the bioecological model to
developmental research is in its capacity to
guide exploration and allow investigators
a framework for measuring and organizing envi-
ronmental and biological variables based on its
proximity to the developing person. Structuring
such variables within their respective
Biofeedback
bioecological systems within and around an indi-
vidual provides a tool for evaluating the extent to
which those variables influence the persons
development over time. Bronfenbrenners vision
was to promote applied developmental science
that is both theoretically sound and practically
relevant so as to provide a scientific foothold for
social policy designs and implementation
(Bronfenbrenner, 2001a, p. 4) with the means to
combat the growing chaos in the lives of chil-
dren, youth, and families (Bronfenbrenner,
2001b, p. 186).
Cross-References
Child Development
Development
Human Development
References
Bronfenbrenner, U. (1970). Children and parents
(pp. 241255). Washington, DC: U.S. Government
Printing Office (Report of Forum 15).
Bronfenbrenner, U. (1974). Developmental research, pub-
lic policy, and the ecology of childhood. Child Devel-
opment, 45. Retrieved from http://www.jstor.org.
ezproxy.library.ubc.ca/stable/1127743.
Bronfenbrenner, U. (1977a). Lewinian space and ecolog-
ical substance. In Author (Ed.), Making human beings
human: Biological perspectives on human develop-
ment (pp. 4149). Thousand Oaks, CA: Sage Publica-
tions. Reprinted from Journal of Social Issues, 33,
199212.
Bronfenbrenner, U. (1977b). Toward an experimental
ecology of human development. American Psycholo-
gist, 32, 513531. doi:10.1037/0003-066X.32.7.513.
Bronfenbrenner, U. (1979). The ecology of human devel-
opment: Experiments by nature and design.
Cambridge, MA: Harvard University Press.
Bronfenbrenner, U. (1986a). Recent advances in research
on the ecology of human development. In
R. K. Silbereisen, K. Eyferth, & G. Rudinger (Eds.),
Development as action in context: Problem behavior
and normal youth development (pp. 286309). New
York: Springer Verlag.
Bronfenbrenner, U. (1986b). Ecology of the family as
a context for human development. Developmental
Psychology, 22, 723742.
Bronfenbrenner, U. (1989). Ecological systems theory.
Annals of Child Development, 6, 187249.
Bronfenbrenner, U. (2001a). Growing chaos in the lives of
children, youth, and families: How can we turn it
401 B
around? In Author (Ed.), Making human beings
human: Bioecological perspectives on human devel-
opment (pp. 185197). Thousand Oaks, CA: Sage
Publications (Reprinted from Parenthood in America,
pp. 197210, by J. C. Westman, Ed., Madison:
University of Wisconsin Press). B
Bronfenbrenner, U. (2001b). The bioecological theory of
human development. In Author (Ed.), Making human
beings human: Bioecological perspectives on human
development (pp. 315). Thousand Oaks, CA: Sage
Publications. Reprinted from International encyclope-
dia of the social and behavioral sciences,
pp. 69636970, by N. J. Smelser & P. B. Baltes Eds.,
New York, NY: Elsevier.
Bronfenbrenner, U., & Ceci, S. J. (1993). Heredity, envi-
ronment and the question How?: A first approxima-
tion. In Author (Ed.), Making human beings human:
Bioecological perspectives on human development
(pp. 174184). Thousand Oaks, CA: Sage Publica-
tions. Reprinted from Nature, nurture, and psychol-
ogy, pp. 313323, by R. Plomin & G. E. McClearn,
Eds., 1995, Washington, DC: APA Books.
Bronfenbrenner, U., & Ceci, S. J. (1994). Nature-nurture
reconceptualised: A bio-ecological model. Psycholog-
ical Review, 10(4), 568586. doi:10.1037/0033-
295X.101.4.568.
Bronfenbrenner, U., & Evans, G. W. (2000). Develop-
mental science in the 21st century: Emerging ques-
tions, theoretical models, research designs, and
empirical findings. Social Development, 9, 1525.
doi:10.1111/1467-9507.00114.
Bronfenbrenner, U., & Morris, P. (1998). The ecology of
developmental processes. In W. Damon & R. M. Ler-
ner (Eds.), Handbook of child psychology: Vol. 1 The-
oretical models of human development (5th ed.,
pp. 9931028). New York: Wiley.
Bronfenbrenner, U., & Morris, P. (2006). The
bioecological model of human development. In W.
Damon & R. M. Lerner (Eds.), Handbook of child
psychology: Vol. 1. Theoretical models of human
development (6th ed., pp. 793828). Hoboken, NJ:
Wiley.
Biofeedback
Liana Mattulich1 and David M. Paperny2
1
Inner Key Center, Jefferson, CO, USA
2
University of Hawaii School of Medicine,
Honolulu, HI, USA
Synonyms
Self-regulation
B 402
Definition
Biofeedback is a scientific process where an indi-
vidual usually uses instrumentation to learn to
change physiological activity for the purpose of
improving health and well-being. It is monitoring
and mirroring of signals from the body to
improve health, self-concepts, self-regulation,
and quality of life.
Description
Biofeedback uses scientific instrumentation that
measures physiological activity such as skin tem-
perature, heart and breathing parameters, muscle
activity, and even brainwaves. This information
is presented to the individual, resulting in
changes in thinking, emotions, and behavior
which support positive physiological changes
for a higher quality of life (see BCIA).
Entrainment devices such as those using light
stimulation, binaural sounds, or electrical stimu-
lation are not biofeedback. Biofeedback is as
simple as using a thermometer to measure tem-
perature or a scale to measure weight in order to
use the information so as to allow one to take
action to make a desired change. Biofeedback is
a noninvasive scientific way to see, hear, and
learn the physiology, which enables the training
of self-regulation. This process also can provide
precise psychophysiological measures that allow
the release of unwanted emotional baggage in
order to make better choices in a more aware
state (Dunn et al., 1986).
Two approaches are used in behavioral medi-
cine: Biofeedback helps people recognize how
a physiological system is functioning and learn
self-control of that system, so that it works opti-
mally (e.g., body self-regulation, the analogy of
a tune-up for a car). Self-hypnosis helps people
develop intention and focus on a goal and to think
and act in a more relaxed and deliberate manner.
(e.g., mind self-regulation, the analogy of using
a gas additive for a car).
The biofeedback therapist acts as a coach, not
only by teaching skills but also by providing
Biofeedback
hints for the trainee on how to make internal
self-adjustments to improve performance and
enhance personal success. Biofeedback instru-
mentation is optimally used in conjunction with
psychological procedures specific to the individ-
uals needs, and protocols are tailored to individ-
ual goals and states of well-being or disease
(Gaarder & Montgomery, 1977). Biofeedback
has been proven to be an effective treatment for
migraine and tension-type headaches, urinary
incontinence, high blood pressure, anxiety, and
a number of other conditions. Neurofeedback
(brain wave biofeedback) is an effective treat-
ment for attention deficit hyperactivity
disorder, brain injury, post-traumatic stress,
seizures, and depression. Cost effectiveness,
long-term effects, and existing personal contrain-
dications are considerations for any application
of biofeedback for either personal empowerment
or treatment of specific conditions (Schwartz &
Andrasik, 2003).
Disorders and Treatment Efficacy
The disorders listed below are those most com-
monly evaluated by psychophysiological tech-
nology and treated with biofeedback, which has
been shown to be efficacious to various degrees
based on research studies (see www.aapb.org)
(Hatch et al., 1987).
Efficacious and specific (fifth level):
1. Urinary incontinence in females
Efficacious (fourth level):
1. Anxiety
2. Attention deficit disorder
3. Headache adult
4. Hypertension
5. Temporomandibular disorders
6. Urinary incontinence in males
Probably efficacious (third level):
1. Alcoholism/substance abuse
2. Arthritis
3. Chronic pain
4. Epilepsy
5. Fecal elimination disorders
6. Headache pediatric migraines
7. Insomnia
8. Traumatic brain injury
9. Vulvar vestibulitis
Biofeedback
Possibly efficacious (second level):
1. Asthma
2. Cancer and HIV, effect on immune
function
3. Cerebral palsy
4. Chronic obstructive pulmonary disease
5. Depressive disorders
6. Diabetes mellitus
7. Fibromyalgia
8. Foot ulcers
9. Hand dystonia
10. Irritable bowel syndrome
11. Mechanical ventilation
12. Motion sickness
13. Myocardial infarction
14. Post-traumatic stress disorder
15. Raynauds disease
16. Repetitive strain injury
17. Stroke
18. Tinnitus
19. Urinary incontinence in children
Not empirically supported (first level of
evidence):
1. Autism
2. Eating disorders
3. Multiple sclerosis
4. Spinal cord injury
Biofeedback training improves symptoms,
often allows medication reduction, increases emo-
tional balance, reduces stress, and enhances a sense
of self-control and self-efficacy. In the fields of
education, sports (especially Olympic training),
and among business executives, biofeedback train-
ing commonly provides stress resistance, resil-
iency, enhanced creativity, positive self-esteem,
physical and emotional well-being, leadership
development, conflict resolution, and a capacity
for delay of gratification, as well as receptivity to
learning and greater productivity. Corporate exec-
utives, musicians, artists, and many athletes have
used biofeedback and neurofeedback to reach their
peaks in both competition and performance.
Common modalities of standard biofeedback
(excluding neurofeedback) are as follows, and
the top three are foremost:
TBF (thermal feedback) temperature of the
fingers from warmth produced by increased
circulation of blood
403 B
EDR (electrodermal response) and GSR
(galvanic skin response) variation of electri-
cal conductivity of the skin as related to
emotional states
EMG (electromyography) strength of action B
of sphincters and muscle fibers
OF oxygen flow present in the capillaries as
measured in the fingers
PF pulse variability for training
self-regulation of heart rhythm
HEG (hemo-encephalography) measure-
ment of blood circulation at frontal areas of
the brain
CO2 (capnometry) measures exhalations for
training enhanced respiratory functionality and
efficiency (see Applied Psychophysiology)
HRR (heart rate resonance, HRV) measures
the relationships between the breath and heart
rhythms (see Applied Psychophysiology)
Thermal Feedback (TBF)
Stressful situations cause most people to experi-
ence cold and clammy hands. Such moods and
emotions cause capillaries to contract in response
to hormonal activity and neurotransmitters circu-
lating in the blood. TBF is usually done on one
finger of each hand to identify and retrain the
stress response. It allows the trainee to precisely
sense changes as small as 0.01  F, reflecting the
warmth of blood flow to the fingers. Increasing
the volume of peripheral circulating blood
can be accomplished more effectively by
using adjunct practices and psychological
methods of deep engagement using sensory
integration and visualization of positive
emotional memories.
The trainees first goal is usually to equalize
the temperature of both hands. Bilaterally equal
responses in both may not occur in the presence
of vascular illness in the extremities, neck, or
shoulders. Their second goal is usually the capac-
ity to raise the temperature in both hands to an
average of 95  F in less than 10 min. Raising the
peripheral skin temperature is a powerful tool for
reducing the effects of stress in the entire mind-
body field and helps sustain the skills learned
in training. Certain mindfulness trainings
use 96.8  F as the threshold for optimal
B 404
transformation of the psychophysiology to
exceptional performance states.
Electrodermal Response (EDR) and Galvanic
Skin Response (GSR)
Two reciprocal scales are used to measure the
electrochemistry of the skin. The first is resis-
tance also known as GSR, the resistance of
the skin to conduct electrical current. It measures
dryness increase when sweat is reduced, and it is
measured in mohs. The second measure is
EDR, the conductance the opposite of resis-
tance. EDR reflects electrical activity that
increases with sweat gland activity, which usu-
ally accompanies sympathetic nervous system
arousal. It is also known as skin conductance/
electrodermal response (SC/EDR) and is
measured in ohms.
Stressful situations also cause most people to
experience sweaty hands. EDR, as the measure of
skin conductance (since sweat is a salty conduc-
tive electrolyte), detects both transitory
emotional states and mental events, providing
objective information about the psychophysio-
logical level of arousal. EDR is usually measured
on the palm of the dominant hand or on the
fingertips. Trainees can learn to lower hand
perspiration to 12 of conductance, what is
the threshold of normal. When individuals are
consciously or unconsciously repressing
disturbing thoughts or emotions, feedback will
often show a flat-line dermal response, and the
therapist may utilize cognitive techniques or
other methods to assist self-regulation by releas-
ing an expressive block, reflected by an improved
EDR.
Electromyography (EMG)
EMG measures the electric activity of muscles
(including sphincters) by sensors applied to the
skin over a defined muscle of the body.
Some research centers may insert fine needles into
muscle fibers to measure actual contractions. Para-
plegics with damage to the spinal medulla are better
trained when such electrodes are placed directly
into muscle tissue to facilitate regaining self-regu-
lation. Physical rehabilitation, neuromuscular reed-
ucation, headache, muscle tension, pain, and spasm,
Biofeedback
as well as temporomandibular joint problems, are
some of the medical diagnoses where EMG offers
sustainable, long-term improvements.
Fecal and urinary incontinence (sphincter
failure) are often treatable with only a few EMG
sessions (average 610). Such techniques allow
regaining self-control, yet are least invasive
and very low cost (vs. surgery) for such condi-
tions in the older population. Preceding other
biofeedback techniques, EMG and TBF are
useful preliminary approaches to enhanced
self-regulation in treating many disease states
and particularly in preparation for neurofeedback
training (see www.InnerKeys.info).
Self-Regulation Technology
Precise psychophysiological measures that pro-
vide useful feedback can effect change in a very
short time. Cognitive processing of information
alone cannot produce the required changes in
psychophysiology, body-mind energies, and
behaviors that are required for optimal function-
ing. Biofeedback training using todays technol-
ogy has reached a pinnacle in the ability to
accelerate and sustain over time greater personal
effectiveness, focus, endurance, and emotional
flexibility, which together empower people to
meet the demands of modern living with greater
capacity and facility.
When these technologies are used in combi-
nation with cognitive tools such as introspection,
analogies, storylines, metaphors, sounds, sym-
bols, and sensory integration, then a new level
of well-being and quality of living is created
for daily life which has long-term sustainability:
Introspection is inner silence with
self-observation. (The observer modifies
outcomes recently validated by quantum
physics.)
Analogies enable a literal meaning to be
conveyed in a different form and engage both
hemispheres of the brain simultaneously.
Storylines convey the meaning and signifi-
cance of events, instilling community and
cultural values and identity.
Metaphors represent ideas in another form
with emotional content that evoke specific
psychobiochemistry.
Biofeedback
Sounds focus the mind; modify and restore
mind-body energetic pathways; and have
been used for millennia in music, vocaliza-
tions, mantras, and sacred sounds.
Symbols focus the mind, broadening the
range of perceptions, and induce abstract
thought, giving more clarity meaningful
information.
Sensory integration systematically and rapidly
expands human capacity in unconventional
combinations to significantly develop new,
effective pathways within the mind-body-
energy system.
Biofeedback offers future humanity
self-development and a psychophysiology to
obtain a freedom and inner peace that is sustain-
able during the challenges of daily life and in
personal situations. It is intrinsic learning rather
than external control when people train
self-regulation to reach exceptional performance
levels. The biofeedback-trained condition called
brain plasticity, together with an enhanced
immune response, creates a healthy and efficient
individual, empowered to handle social,
job-related, and daily stresses. It is also possible
to go one step beyond, to create new pathways
that bring the highest potentials of the essence of
that which is human, to enhance creativity
and invention, and to develop an optimal life
experience. Stress reduction, enhanced produc-
tivity, and resiliency in a hostile environment
are all possible with enhanced self-regulation of
the psychophysiology.
Applied psychophysiology has opened
a window for human potential, possibly offering
new, effective solutions to multiple global prob-
lems and needs, including conflicts among the
billions of people living on the planet. The dis-
ease-based paradigm of the past is insufficient for
global well-being, and rational, scientific mea-
sures that demonstrate positive outcomes and
changes are necessary for the well-being of
humanity in so diverse a world today. We are so
at the effect of our physiologic hard wiring and
our biochemical emotions on a daily basis that
both limit our happiness and success. Training to
self-regulate our own individual psychophysiol-
ogy as part of daily education, and also in the
405 B
home, could provide humanity many new options
and choices. Enjoyable methods such as empow-
erment games can build inner joy, self-esteem,
and confidence and create a new generation that
requires no drugs and fewer external controls in B
the face of pressure and stress, since they will
have learned internalized coping mechanisms to
survive and succeed in modern society (Mattulich
& Paperny, 2008).
The highest human potential could be attained
by every trainable person, producing a quality of
life far beyond the narrow horizon so far provided
by our current approaches to health and educa-
tion. It is the responsibility of science and tech-
nology to improve the conditions and well-being
of humanity. We are psychophysiological beings
with a desire to improve ourselves. This
millennium is the moment to allow a new
paradigm, to embrace new options, and to make
self-regulation, enhanced perception, and higher
human potentials part of a future of peace and
prosperity on this planet.
Cross-References
Applied Psychophysiology
Neurotherapy
References
Association of Applied Psychophysiology and Biofeed-
back. (www.aapb.org).
Dunn, T. G., Gillig, S. E., & Ponsor, S. E. (1986). The
learning process in biofeedback: Is it feed-forward or
feed-back? Biofeedback and Self-Regulation, 11(2),
143157.
Gaarder, K. R., & Montgomery, P. S. (1977). Clinical
biofeedback: A procedural manual. Baltimore:
Williams & Wilkins.
Hatch, J. P., Fisher, J. G., & Rugh, J. (1987). Biofeedback:
Studies in clinical efficacy. New York: Plenum Press.
Inner Key International. (www.innerKey.org).
Mattulich, L. M. D., Paperny D. M. D. (2008) Journey to
awareness and beyond with modern technology and
ancient wisdom: Paving your path to empowerment
and transformation with brainwave biofeedback
and your inner keys. Xlibris Corporation. ISBN13
Softcover: 978-1-4363-4464-7. (www.innerkeys.
info).
Schwartz, M., & Andrasik, F. (2003). Biofeedback:
A practitioners guide (3rd ed.). New York: Guilford.
B 406
Biological Diversity
Biodiversity Conservation
Biomedical Model of Qol and Breast
Cancer
Psychological Quality of Life Among Breast
Cancer Patients
Biophilia
Nature and Well-Being
Biophilia Theory
Animal Beauty, Cross-Cultural Perceptions
Biophilic Cities
Sustainable Communities Movement
Biopsychosocial Model
Richard M. Frankel
Department of Medicine, Indiana University
School of Medicine, Indianapolis, IN, USA
Definition
Based on systems theory, the biopsychosocial
model represents the integration of biological,
psychological, and social information gathered
by a clinician in caring for patients. In addition
to disease as a basis for clinical practice, the
biopsychosocial model conceptualizes illness as
Biological Diversity
a social response to disease. One can have an
illness without disease, e.g., grief as a response
to loss, and disease without illness, e.g., asymp-
tomatic hypertension. The biopsychosocial
model extends and elaborates the traditional
biomedical approach by adding the rich human
dimensions of suffering and clinician-patient
relationships both of which can exert powerful
influences on the course, direction, and outcome
of care, including quality of life.
Description
In 1910, Abraham Flexner, published what is
arguably the most influential report on medical
education in the United States (Flexner, 1910).
Flexner argued that medical education should be
based on evidence from the natural sciences and
that all training should come under the umbrella
of universities and other institutions of higher
learning. Until that point, medical education
was largely unregulated, medical schools were
owned by one or several individuals and were in
business to make a profit, and there was no stan-
dard program of learning from school to school
nor was there a licensing body that would
accredit schools and the individuals they turned
out. Flexners focus on the causes and conse-
quences of disease was well warranted. Just
8 years after his report, the flu epidemic of 1918
killed between 20 and 50 million people world-
wide. By contrast the H1N1 flu epidemic of 2009
killed an estimated 18,000 people, underscoring
advances in biomedicines ability to respond to
outbreaks and rapid spread of diseases. In 1977,
some six and a half decades after the Flexner
report exhorted medical schools to focus on the
diagnosis and treatment of disease largely using
evidence from the biological sciences, George
Engel, an internist at the University of Rochester,
with training in psychiatry, published an article in
the journal Science entitled The Need for a New
Medical Model: A Challenge for Biomedicine
(Engel, 1977). In it, Engel argued that the view
espoused by the seventeenth-century philosopher
Rene Descartes that the mind and body are sepa-
rate was false and that biomedicine which is
Biopsychosocial Model
based in this view needed to be replaced. In its
place Engel proposed a biopsychosocial model,
one that synthesized and integrated information
from the biological, psychological, and social
sciences and clinically added the patients expe-
rience of disease and illness as a central task of
doctoring.
The biopsychosocial model has been the basis
for a good deal of basic and applied research. For
example, Robert Ader, who was a close colleague
and disciple of Engels at the University of Roch-
ester, was investigating the effects of classical
conditioning in laboratory rats. Using
a combination of saccharine and Cytoxan which
induces nausea and suppresses the immune sys-
tem, he found that after conditioning just feeding
the rats with saccharine-laced water was suffi-
cient to suppress the immune system of the rats,
demonstrating that the nervous system can affect
the immune system (Frankel, Quill, & Mc Daniel,
2003). Aders research has led to the develop-
ment of an entire field called psychoneuroimmu-
nology. In terms of quality of life, this work is
important because it suggests that conditioning in
humans could eventually be used to alleviate
symptoms and improve quality of life in disorders
such as fibromyalgia and irritable bowel syn-
drome, both of which are known to have
a psychophysiological component to them.
Engels work has remained a strong influence
in medical education where the physicians role
in affecting patients quality of life, not just diag-
nosis and treatment of disease, has been recog-
nized. For example, lifestyle issues such as
tobacco and alcohol use are the leading causes
of preventable deaths. Physicians skills in
counseling patients to make lifestyle changes
has been shown to be effective. It has been
shown, for instance, that 1 min of tobacco cessa-
tion counseling has a measurable effect on patient
quit rates. Almost every medical school in North
America has a course on medical interviewing
that includes skills training in eliciting psychoso-
cial as well as biomedical information. Several
randomized controlled studies have been done
looking at the effects of teaching medical
residents and practicing physicians the
biopsychosocial model (Smith et al., 1998; Fossli
407 B
Jensen et al., 2011), and a systematic review of
the literature on communication interventions in
medical interviewing has shown positive results
in terms of patient satisfaction, functional,
and even biomedical outcomes (Rao, Anderson, B
Inui, & Frankel, 2007). Interpersonal communi-
cation skills are now among six competencies
required by the Accreditation Council for
Graduate Medical Education that all residents
must demonstrate as a condition for licensure.
In 2001, the Institute of Medicine (IOM)
published a heavily cited monograph entitled
Crossing the Quality Chasm: A New Health
System for the 21st Century (Institute of Medi-
cine, 2001). In it, the IOM identified patient-
centered care, as one of six domains of quality.
The term patient-centered care was coined by
Joseph Levenstein and his colleagues at the Uni-
versity of Western Ontario in 1986 (Levenstein,
McCracken, & McWhinney, 1986). It is a direct
descendant of the biopsychosocial model. Today,
patient-centered care is the basis for a number of
research and clinical initiatives that include the
founding of the Patient-Centered Outcomes
Research Institute, instituted as part of the Patient
Protection and Affordable Care Act in 2011 with
yearly funding of 750 million dollars. Models of
care almost always reflect the social, scientific,
and political context in which they emerge.
For Flexner, it was a context in which modern
medicine was unregulated and in its infancy in
terms of curing diseases capable of killing mil-
lions of people in the space of a few years. Today,
the industrialized world enjoys the unprece-
dented benefits of science and technology.
All of these benefits, notwithstanding human
suffering still exists. Engels biopsychosocial
model was an attempt to restore the age-old
promise of the Hippocratic oath to do no harm
and relieve all forms of suffering irrespective of
their origin.
Cross-References
Communication and Personal Well-being
Patient-physician Communication
Quality of Life (QOL)
B 408 Biopsychosocial Model of Quality of Life

References
Bipolar Disorder (BD)
Engel, G. L. (1977). The need for a new medical
model: A challenge for biomedicine. Science, 196,
Heather Armstrong1, Erin Michalak2 and
129136.
Flexner, A. (1910). Medical education in the United States Greg Murray3
1
and Canada. New York: Carnegie Foundation for the University of Ottawa, Ottawa, ON, Canada
Advancement of Teaching. 2
University of British Columbia,
Fossli Jensen, B., Gulbrandsen, P., Dahl, F. A., Krupat, E.,
Vancouver, BC, Canada
Frankel, R. M., & Finset, A. (2011). Effectiveness 3
of a short course in clinical communication Psychological Sciences and Statistics,
skills for hospital doctors: Results of a crossover Swinburne University of Technology,
randomized controlled trial (ISRCTN22153332). Melbourne, VIC, Australia
Patient Education and Counseling, 84(2), 163169.
Frankel, R. M., Quill, T., & Mc Daniel, S. (Eds.) (2003).
The biopsychosoical approach: Past, present,
future. Rochester, New York: University of Rochester Synonyms
Press.
Institute of Medicine. (2001). Crossing the quality chasm:
BD; BD I; BD II; Bipolar affective disorder;
A new health system for the 21st century. Washington,
DC: National Academies Press. Bipolar disorder scale (QoL.BD), quality of life;
Levenstein, J. H., McCracken, E. H., & McWhinney, I. R. Manic depression; Manic depressive disorder;
(1986). The patient centered clinical method I. A Manic depressive illness
model for the doctor patient interaction in family med-
icine. Family Practice, 1, 2430.
Rao, J. K., Anderson, L. A., Inui, T. S., & Frankel, R. M.
(2007). Communication interventions make a differ- Definition
ence in conversations between physicians and patients:
a systematic review of the evidence. Medical Care,
The most widely accepted definition of bipolar
45(4), 340349.
Smith, R. C., Lyles, J. S., Mettler, J., Stoffelmayr, B. E., disorder (BD, previously manic depression or
Van Egeren, L. F., Marshall, A. A., Gardiner, J. C., manic depressive illness) derives from current
Maduschke, K. M., Stanley, J. M., Osborn, G. G., psychiatric taxonomies, which characterize BD
Shebroe, V., & Greenbaum, R. B. (1998). The
as a serious and recurrent mood disorder. People
effectiveness of intensive training for residents
in interviewing. A randomized, controlled study warranting the diagnosis of BD experience mania
[see comments]. Annals of Internal Medicine, 128(2): (pathologically elevated, irritable, or expansive
118126. mood) and depression in various combinations
and intensities.

Description
Biopsychosocial Model of Quality Diagnostic and Definitional Issues
of Life For the current Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV-TR; American
Psychological Quality of Life Among Breast
Psychiatric Association [APA], 2000), the bipo-
Cancer Patients
lar disorders are diagnosed on the basis of manic
symptoms of varying severity. Bipolar I disorder
(BD I), defined by at least one episode of mania
(labeled a mixed episode when a depressive
episode is concurrent), receives most research
Bipolar Affective Disorder and clinical attention. There is growing appreci-
ation that bipolar II disorder (BD II, defined by
Bipolar Disorder (BD) hypomanic episodes and depressive episodes)
Bipolar Disorder (BD)
generates comparable impairment and suicide
risk to BD I. While BD I and BD II are concep-
tualized as episodic disorders, cyclothymic dis-
order is a milder, chronic variant. Contemporary
critiques suggest that BD is best viewed on
a spectrum of severity and more radically that
a fundamental dimensionality (viz., dimensions
of mania- and depression-proneness) underlies
the current categorical diagnostic constructs.
Some features of the current DSM-IV-TR
(APA, 2000) diagnosis of BD are worth
highlighting. First, the serious variants
(BD I and BD II) are conceptualized as episodic
disorders, while cyclothymia is a chronic form.
Second, consistent with the unclear boundary
between hypomania (hypo less than) and
normal mood elevation, a hypomanic episode is
not sufficient for any diagnosis: a diagnosis of BD
II requires a major depressive episode (MDE) in
addition to a hypomanic episode. Third, on the
grounds that manic, hypomanic, and depressive
states often include features characteristic of each
other (e.g., dysphoria in mania, agitation in
depression), it is likely that mixed episodes will
be removed from the upcoming DSM-5 and
a specifier, with mixed features, applying to
any type of episode will be added. Fourth, unlike
the International Statistical Classification of Dis-
eases and Related Health Problems (ICD-10;
World Health Organization, 1993) which
requires both a manic and depressive episode
for the diagnosis of BD, only the former is
required in DSM-IV-TR (unipolar mania does
occur, but is sufficiently rare for this to be
a reasonable position). Finally, DSM-IV-TR rec-
ognizes only one form of MDE, which acts as
a building block toward both unipolar and bipolar
diagnoses. When a patient presents in
a depressive episode, therefore, there is the risk
that BD is misdiagnosed as the more prevalent
major depressive disorder.
As argued in two recent critiques of DSM
(British Psychological Society, 2011; Society
for Humanistic Psychology, 2011), the majority
of psychological syndromes are in fact extreme
variants of normal states, rather than discrete
disease-like entities. Bipolar disorder is a case
in point, as available evidence suggests that
409 B
DSM-IV-TRs categorical diagnoses are rela-
tively arbitrary cut points on a dimension
(or dimensions) of variation in the general popu-
lation. There appear to be two important dimen-
sions underpinning the BD syndrome, namely, B
depression-proneness and mania-proneness.
Consistent with research elsewhere in description
and diagnosis, these two dimensions are com-
monly understood as vulnerability traits.
Although this research throws doubt on DSM-
IV-TRs categorical constructs (bipolar I, bipolar
II, and cyclothymic disorder), the recognized
binary diagnoses have accrued significant
validating information (below) and remain
indispensable tools.
Characteristics of Bipolar Disorder
Bipolar disorder is typically a lifelong, relapsing
condition. Bipolar I disorder affects approxi-
mately 1 % of the population, another 2.9 %
appear to develop bipolar II disorder, and perhaps
4.2 % of the population are affected by cyclothy-
mia. Patients differ widely in terms of the length,
number and type of episodes, severity of symp-
toms, the degree of inter-episode recovery expe-
rienced, and consequent disability. The
average length of each episode is around
36 months, and some type of episode is experi-
enced on average every 2 or 3 years.
Comorbidity with other psychiatric disorders
is the norm: some 56 % of patients with BD
warrant a substance abuse diagnosis, and
80 % an anxiety disorder diagnosis. The bipolar
disorders are associated with significant
morbidity, disability, and mortality. It has been
estimated that a woman who manifests BD at the
age of 25 may lose 9 years in life expectancy,
14 years of productivity, and 12 years of normal
health. Besides costs for the individual patient,
BD symptoms of depressive withdrawal and
hypo/manic recklessness can also place burden
on partners and families. Comorbid medical
problems (especially vascular disease) are very
prevalent. Suicide is a particularly important risk
in BD 2550 % of patients attempt suicide, and
15 % of those not in treatment may complete.
Mania often requires hospitalization, and psy-
chotic symptoms (particularly delusions) are
B 410
common. From a safety viewpoint, a critical
symptom of mania is impaired judgment, which
can lead to risky reward-seeking behaviors.
Impaired judgment is tricky for clinicians
because unlike frank psychosis, the poor
decisions made by patients can be well rational-
ized and consistent with their mood state and
sense of self at the time.
Treatment
Medications are the first-line treatment for the
acute and maintenance phases of BD (see www.
nimh.nih.gov/health/topics/bipolar-disorder), but
outcomes are significantly improved with the
addition of psychological interventions
(Miklowitz & Scott, 2009). Most of what
we know about pharmacological and psychoso-
cial treatments for BD refers to BD I, and
evidence-informed practice for BD II and cyclo-
thymia must rely on extrapolations from relevant
data and theory.
Quality of Life (QoL) in Bipolar Disorder
When exploring QoL in any clinical population,
social, emotional, and occupational well-being
need to be considered in addition to the physical
or health-related concerns that may be present.
Indeed, there is growing recognition that out-
comes in BD should not be limited to the mea-
surement of psychological symptoms, and
pharmacological treatment studies have begun
using QoL measures as secondary outcome
measures (IsHak et al., 2012; Michalak, Yatham,
& Lam, 2005). BD has a significant impact on
psychosocial functioning, defined as a persons
ability to perform activities of daily living and
to engage in meaningful relationships with others
(Michalak & Murray, 2010a). Moreover, symp-
tomatic recovery does not always equate to func-
tional recovery, with a substantial proportion of
people with BD experiencing difficulties with
their psychosocial functioning during states of
remission (Tohen et al., 2000).
Functional outcomes are therefore a crucial
complement to symptom measures (Keck,
2004). Beyond objective functioning, subjec-
tively assessed QoL provides necessary insight
into the persons perceptions of life in relation to
Bipolar Disorder (BD)
their goals, expectations, standards, and concerns
(The WHOQOL Group, 1995). People with BD
often experience lower mental and physical QoL
compared to the general population, and impair-
ment in QoL tends to persist during remission
(Michalak et al., 2005).
Quality of life may also differ depending on
the type of BD experienced and based on the
occurrence of the different mood states. Unsur-
prisingly, QoL is negatively associated with
depression in patients with BD (Michalak, Mur-
ray, Young, & Lam, 2008). In a series of studies
with 68 euthymic patients (Cooke, Robb,
Young, & Joffe, 1996; Robb, Cooke, Devins,
Young, & Joffe, 1997), those with BD II
reported poorer health-related QoL compared
to those with BD I. Another study of 64
euthymic patients with BD I (MacQueen,
Young, Robb, Cooke, & Joffe, 2000) found
that the number of previous depressive episodes
was a stronger predictor of health-related QoL
than the number of previous manic episodes,
such that QoL outcomes decreased significantly
with the first few episodes of depression and
then continued to decrease slightly as number
of episodes increased. This is consistent with
findings that patients experiencing the manic
symptoms of BD report higher QoL outcomes
than those with depressive symptoms (Ritsner,
Kurs, Kostizky, Ponizovsky, & Modai, 2002;
Russo et al., 1997; Votja, Kinosian, Glick,
Altshuler, & Bauer, 2001); however, those
experiencing manic symptoms still reported
impaired health-related QoL functioning com-
pared to euthymic patients (Votja et al., 2001). It
appears that QoL is poorer in BD than in other
mood disorders and anxiety disorders, but that
schizophrenia might compromise QoL more
severely than does BD.
Measurement of QoL in BD
The optimal definition and measurement of QoL
in BD is a work in progress. Reviews of QoL in
BD have identified limitations of assessing QoL
in this population because of the variability in
assessment tools and the lack of a disease specific
measure (IsHak et al., 2012; Michalak et al.,
2005; Namjoshi & Buesching, 2001). To address
Bipolar Disorder (BD)
this need, the first disorder-specific measure of
QoL in BD, the Quality of Life in Bipolar Disor-
der Scale (QoL.BD; Michalak & Murray, 2010b),
was published in both a full 56-item version and
a brief 12-item version. Development occurred
over the course of 4 years and a series of four,
mixed-method empirical studies. Item generation
and reduction included input from individuals
with BD, family members, and field experts in
additional to consultation of the relevant litera-
ture. Initial testing of the QoL.BD shows high
internal reliability, validity, and consistency,
and comparison to existing measures suggests
that the QoL.BD demonstrates greater specificity
resulting in more sensitivity to clinical changes in
patients with BD (Michalak & Murray, 2010b).
The developers of this instrument note that the
structure of QoL in BD is not understood but is
likely that QoL for people with BD is partially
like everyones QoL, partially like the QoL of
people with other disorders and partially unique
to BD.
Cross-References
Mixed Method
Morbidity Measures
Mortality
Physical Well-Being
Productivity
Psychiatric Disorders
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disorders: DSM-IV-TR. Washington, DC: Author.
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American Psychiatric Association: DSM-5 develop-
ment. Leicester, UK: Author.
Cooke, R. G., Robb, J. C., Young, L. T., & Joffe, R. T.
(1996). Well-being and functioning in patients with
bipolar disorder assessed using the MOS 20-ITEM
short form (SF-20). Journal of Affective Disorders,
39, 9397.
IsHak, W. W., Brown, K., Aye, S. S., Kahloon, M.,
Mobaraki, S., & Hanna, R. (2012). Health-related quality
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411 B
Keck, P. E., Jr. (2004). Defining and improving response
to treatment in patients with bipolar disorder. The
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MacQueen, G. M., Young, L. T., Robb, J. C., Cooke,
R. G., & Joffe, R. T. (2000). Effect of number of
episodes on wellbeing and functioning of patients B
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101, 374381.
Michalak, E. E., & Murray, G. (2010a). A clinicians guide
to psychosocial functioning and quality of life in bipo-
lar disorder. In A. Young, N. Ferrier, & E. E. Michalak
(Eds.), Practical management of bipolar disorder.
Cambridge: Cambridge University Press.
Michalak, E. E., & Murray, G. (2010b). Development of
the QoL.BD: A disorder-specific scale to assess quality
of life in bipolar disorder. Bipolar Disorders, 12,
727740.
Michalak, E. E., Murray, G., Young, A. H., & Lam, R. W.
(2008). Burden of bipolar depression: Impact of disor-
der and medications on quality of life. CNS Drugs, 22,
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Michalak, E. E., Yatham, L. N., & Lam, R. W. (2005).
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literature. Health and Quality of Life Outcomes, 3,
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Miklowitz, D. J., & Scott, J. (2009). Psychosocial treat-
ments for bipolar disorder: Cost-effectiveness, medi-
ating mechanisms, and future directions. Bipolar
Disorders, 11, 110122.
Namjoshi, M. A., & Buesching, D. P. (2001). A review of
the health-related quality of life literature in bipolar
disorder. Quality of Life Research, 10, 105115.
Ritsner, M., Kurs, R., Kostizky, H., Ponizovsky, A., &
Modai, I. (2002). Subjective quality of life in severely
mentally ill patients: A comparison of two instru-
ments. Quality of Life Research, 11, 553561.
Robb, J. C., Cooke, R. G., Devins, G. M., Young, L. T., &
Joffe, R. T. (1997). Quality of life and lifestyle disrup-
tion in euthymic bipolar disorder. Journal of Psychi-
atric Research, 31, 509517.
Russo, J., Roy-Byrne, P., Reeder, D., Alexander, M.,
Dwyer-OConner, E., Dagadakis, C., & Patrick, P. D.
(1997). Longitudinal assessment of quality of life in
acute psychiatric inpatients: Reliability and validity.
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Society for Humanistic Psychology. (2011). Open letter to
the DSM-5 task force and the American Psychiatric
Association. Washington, DC: Author.
The WHOQOL Group. (1995). The World Health Orga-
nization Quality of Life Assessment (WHOQOL):
Position paper from the World Health Organization.
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Tohen, M., Hennen, J., Zarate, C. M., Jr., Baldessarini,
R. J., Stakowski, S. M., Stoll, A. L., & Cohen, B. M.
(2000). Two-year syndromal and functional recovery
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B 412
Votja, C., Kinosian, B., Glick, H., Altshuler, L., & Bauer,
M. S. (2001). Self-reported quality of life across mood
states in bipolar disorder. Comprehensive Psychiatry,
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Bipolar Disorder Scale (QoL.BD),
Quality of Life
Bipolar Disorder (BD)
Birth Control
Charles Picavet
Rutgers WPF, Utrecht, UT, The Netherlands
Synonyms
Contraception; Family planning; Planned
parenthood
Definition
Birth control is every method that enables women
and men to influence the timing, number, and
spacing of having children.
Usually, birth control is used as a term that
refers solely to (often hormonal) contraception.
However, the term can refer to a broader spec-
trum of possibilities, including assisted reproduc-
tion for people with fertility problems, postcoital
contraceptive methods, and abortion.
Description
Options for birth control are primarily intended
for enabling women and men to enjoy sexual
intercourse without the need to worry about
having a child. This has considerably increased
the quality of life of particularly women.
Bipolar Disorder Scale (QoL.BD), Quality of Life
Moreover, introduction of modern contraceptives
has had a profound impact on womens lives
and society as a whole (Gianotten, Whipple, &
Fuglsang Owens, 2007; Picavet, Van der Leest, &
Wijsen, 2011).
Historical Development
Hormonal contraception became available in the
early 1960s. Some birth control methods had
been available for a long time before that,
but they did not have the impact of modern
contraceptives. The introduction of reliable
contraception enabled women to control their
fertility, thereby delaying their motherhood,
reducing the number of children they had, and
increasing the time between giving birth to their
children.
This has had more far-reaching consequences
than on reproductive health alone. It opened up
new horizons for many women. For example, an
increasing number of women were able to have
jobs and maintain them after giving birth. Both
motherhood and fatherhood changed, traditional
divisions of labor became a choice instead of
a necessary fact of life.
Impact on Quality of Life
Not much research has been done on quality of life
related to contraception. Mental health-related
quality of life is better for women who use contra-
ception than for women who do not. Women
who use injectables or who have undergone tubal
sterilization are less likely to report at least average
health-related quality of life (Williams, Parisi,
Hess & Schwarz, 2012). Extended use regimens
of short-term hormonal contraception are reported
to have beneficial effects on quality of life of
users, mainly because of reducing menstrual
discomforts and disruptions. The same is probably
true for longer acting hormonal methods
(Nelson, 2006).
Discussion
The focus of this entry is on quality of life
related to contraception. The impact of
fertility problems, assisted reproduction, and
abortion is discussed elsewhere in this
encyclopedia.
Birth Order
Furthermore, the research that is summarized
for this entry is cross-sectional, which makes
causal inferences impossible. Although it is prob-
able that contraceptive use has a positive impact
on womens well-being, there are studies that
suggest it could be the other way around as
well. Women, who are happier and who have
more sense of purpose in their lives, tend to use
contraception more often and also more
consistently.
Finally, most studies on contraception are
done among women. Therefore, little is known
about the impact of contraception on mens qual-
ity of life. Although men have their own needs
when it comes to reproduction, and whether or
not to have children impacts their lives as well,
contraception is primarily seen as a womens
issue. This was probably caused by the pharma-
cological turn in contraception during the 1960s.
There are (still) no pharmaceutical contraceptive
methods for men. However, many women rely on
the male methods, condoms, or vasectomy.
Cross-References
Childlessness
Family Planning
Fertility Plans/intentions
Human Infertility
References
Gianotten, W. L., Whipple, B., & Fuglsang Owens, A.
(2007). Sexual activity is a cornerstone of quality of
life: An update of The health benefits of sexual
expressions. In M. Tepper & A. Fuglsang Owens
(Eds.), Sexual health (Psychological foundations,
Vol. 1). Westport, CT: Praeger.
Nelson, A. M. (2006). Extended-regimen contraception:
Effects on menstrual symptoms and quality of life.
Journal of Family Practice, 55, S1S8.
Picavet, C., Van der Leest, L., & Wijsen, C. (2011).
Contraceptive decision-making: Background and con-
sequences of contraceptive methods. Utrecht, The
Netherlands: Rutgers WPF.
Williams, S. L., Parisi, S. M., Hess, R., & Schwarz, E. B.
(2012). Associations between recent contraceptive use
and quality of life among women. Contraception, 85,
282287.
413 B
Birth Order
Linda Welling
Economics, University of Victoria, B
Victoria, BC, Canada
Synonyms
Order, sibling
Definition
Birth order refers to a persons position in the age
hierarchy of siblings. Later-born children have
higher birth order.
Description
Most individuals are aware of their birth order
and have an opinion about how early interactions
in their family of origin shaped their character.
There are numerous studies, both popular and
academic, relating birth order to individual
characteristics, such as personality and IQ, and
outcomes, such as education, earnings, choice
of profession, and physical and mental health.
In general, the firstborn is seen to be advantaged,
middle borns are disadvantaged, and the results
for later borns are mixed; for a recent summary,
see Sulloway (2007). There are also many studies
showing that birth order effects, if they exist, are
insignificant.
Why position in the sibling age hierarchy
should matter, and how, is still unclear. The con-
fluence theory, first proposed by Zajonc and
Markus (1975), focuses on the home intellectual
environment, based on the cumulative intelli-
gence of the parents and siblings. The firstborn
spends their early childhood at home surrounded
by adults and develops skills to relate to, and
become like, them. The second born enters
a home already inhabited by a child, while later
borns come into homes where the ratio of children
to adults is even higher. The changing intellectual
B 414
environment of the household provides less intel-
lectual stimulation to younger children (at least
when family size is not too large and children are
24 years apart). Firstborns receive additional
benefit from teaching their younger siblings.
The principal alternative theory of resource
dilution (Blake, 1986; Downey, 1995) starts
with the recognition that household resources
financial, intellectual, and emotional are lim-
ited. As the number of children increases, these
resources are spread more and more thinly. Con-
sider financial resources, an important determi-
nant of educational attainments. If births were
perfectly planned and capital markets perfect,
then the effects of resource dilution would
depend solely on family size and income stream,
with no independent role for birth order. How-
ever, if a familys financial situation improves as
the parents age, then financial resources available
to spend on children may differ for early and later
borns, thus generating birth order effects over and
above those due to family size. Parental time is
another important resource; Price (2008) found
that children of higher birth order receive less
quality time with parents at any given age than
do children of lower birth order, at the same age.
Recognizing that income and time with children
are to some extent choice variables for parents,
Gugl and Welling (2010) show that parents who
care equally about both children will provide
different combinations of time and goods to the
two children, because the opportunity cost of
parents time is not the same across time. The
rate of dilution may vary across resources as well:
Downey (1995) provides some evidence for this,
and Steelman, Powell, Werum, and Carter (2002)
provide a broader survey of the interaction of the
resource dilution theory and other aspects of sib-
ling configuration.
The effects of early family interaction are
mediated by the influence of peers in adolescence
and adult life, so the impact of birth order on adult
outcomes depends on how constrained these
early resources are, and the extent to which
later experiences can substitute for early differ-
ences. Given that cognitive skills seem to
become stable at relatively early ages, whereas
noncognitive skills are malleable until much
Birth Order
later in life (see Almlund, Duckworth, Heckman,
and Kautz (2011) for an extensive survey), it is
not surprising that the strongest evidence for
birth order effects is found in studies of IQ.
Mixed results for the existence of birth order
effects on adult outcomes also stem, in part,
from the lack of data sets sufficiently large, and
over a long-enough time period, to derive signif-
icant results.
A number of recent papers have addressed this.
Using various data sets, for different countries,
Ejrns and Portner (2004), Black, Devereux, and
Salvanes (2005), Conley and Glauber (2006), and
Kantarevic and Mechoulan (2006) find that first-
born children have greater educational attainment
and/or higher earnings than later borns, even con-
trolling for family size. Working with Norwegian
data, Black, Devereux, and Salvanes (2011) and
Bjerkedal, Kristensen, Skjeret, and Brevik (2007)
find a strong and significant negative relation
between birth order and IQ, one large enough
between the first- and second born to account for
about 2 % of annual earnings as adults. In a related
paper, Kristensen and Bjerkedal (2007) argued
that since in this data set second-born men whose
older sibling died in infancy had higher IQs than
second borns whose older sibling survived, social
interaction within the family rather than biology is
important for this birth order effect.
These studies control for family income; stud-
ies on some developing countries have shown
that this relationship varies with family income:
Tenikue and Verheyden (2010) find that in poorer
families later-born children achieve higher edu-
cation levels than their older siblings, who spend
more time in child labor. In wealthier families,
firstborns do better.
Of course, educational attainment and earn-
ings are not the sole indicators of well-being. In
a data set of children born in early-twentieth-
century Sweden, Modin (2002) found that later-
born siblings demonstrated a higher mortality
risk than firstborns. For girls/women, this rela-
tionship was significant at each of the four age
intervals studied; for boys/men in the oldest age
range (5580 years), birth order had no indepen-
dent explanatory power once adult social class,
income, and education were introduced into the
Bivariate 415 B
analysis. Modin discusses one of the problems of Kristensen, P., & Bjerkedal, T. (2007). Explaining the
generalizing from long-term studies such as this, relation between birth order and Intelligence. Science,
316(5832), 1717.
when she stresses that the general social and Modin, B. (2002). Birth order and mortality: A life-long
economic conditions in Upsala which the later follow-up of 14,200 boys and girls born in early 20th
borns in this group faced when young might be century Sweden. Social Science and Medicine, 54, B
the source of some of these effects. 10511064.
Price, J. (2008). Parent-child quality time: Does birth
In summary, the existence of birth order order matter? Journal of Human Resources, 43(1),
effects, and their causes, is still an open question. 240265.
As larger, more comparable panel data sets Steelman, L. C., Powell, B., Werum, R., & Carter, S.
become available for more countries, answers (2002). Reconsidering the effects of sibling configura-
tions: Recent advances and challenges. Annual Review
may appear. of Sociology, 28, 243269.
Sulloway, F. (2007). Birth order and sibling competition.
In R. Dunbar, & L. Barrett (Eds.), The Oxford hand-
book of evolutionary psychology (pp. 297311).
Oxford: Oxford University Press.
References Tenikue, M., & Verheyden, B. (2010). Birth order and
schooling: Theory and evidence from twelve Sub-
Almlund, M., Duckworth, A., Heckman, J., & Kautz, T. Saharan countries. Journal of African Economics,
(2011). Personality psychology and economics. In 19(4), 459495.
E. A. Hanushek, S. Machin, & L. Womann (Eds.), Zajonc, R. B., & Markus, G. B. (1975). Birth order and
Handbook of the economics of education. Amsterdam: intellectual development. Psychological Review, 82,
Elsevier. 7488.
Bjerkedal, T., Kristensen, P., Skjeret, G. A., & Brevik, J. I.
(2007). Intelligence test scores and birth order
among young Norwegian men (conscripts) analyzed
within and between families. Intelligence, 35(6),
500515.
Black, S. E., Devereux, P. J., & Salvanes, K. G. (2005). Birth Rate
The more the merrier? The effect of family size and
birth order on childrens education. Quarterly Journal
of Economics, 120(2), 669700. Fertility Rate
Black, S. E., Devereux, P. J., & Salvanes, K. G. (2011).
Older and wiser? Birth order and IQ of young men.
CESifo Economic Studies, 57(1), 103120.
Blake, J. (1986). Number of siblings, family background,
and the process of educational attainment. Social
Biology, 18, 521. Birthrate and US Hispanics
Conley, D., & Glauber, R. (2006). Parental educational
investment and childrens academic risk Estimates of
the impact of sibship size and birth order from exoge-
Fertility and Religion Among US Hispanics
nous variation in fertility. Journal of Human
Resources, 41(4), 722737.
Downey, D. B. (1995). When bigger is not better: Family
size, parental resources, and childrens educational
performance. American Sociological Review, 60,
746761. Bisexual
Ejrns, M., & Portner, C. C. (2004). Birth order and the
intrahousehold allocation of time and education. Sexual Orientation
Review of Economics and Statistics, 86(4),
10081019.
Gugl, E., & Welling, L. (2010). The early bird gets the
worm? Birth order effects in a dynamic model of the
family. Economic Inquiry, 48(3), 690703.
Kantarevic, J., & Mechoulan, S. (2006). Birth order, edu-
cational attainment, and earnings: An investigation
Bivariate
using the PSID. Journal of Human Resources, 41(4),
755777. Zero-Order Relationships
B 416
Bivariate Analysis
Debra (Dallie) Sandilands
Measurement, Evaluation and Research
Methodology, Faculty of Education,
University of British Columbia, Vancouver,
BC, Canada
Definition
Bivariate analysis refers to the analysis of two
variables to determine relationships between
them. Bivariate analyses are often reported in
quality of life research. For an excellent example
of research that utilizes bivariate analyses and
demonstrates how the results of bivariate ana-
lyses can be used to inform further more complex
analyses, please see Michalos, Thommasen,
Read, Anderson, and Zumbo (2005).
Bivariate analysis is contrasted with univar-
iate analysis (analysis of only one variable) and
multivariate analysis (analysis of two or more
variables simultaneously).
Description
Bivariate analyses are conducted to determine
whether a statistical association exists between
two variables, the degree of association if one
does exist, and whether one variable may be
predicted from another. For example, bivariate
analyses could be used to answer the question of
whether there is an association between income
and quality of life, or whether quality of life can
be predicted from income. In limited circum-
stances (discussed below), bivariate analysis can
be used to suggest causation of one variable by
the other.
Two frequently used types of bivariate
analyses are bivariate correlation and bivariate
regression. Each is described below. Please note
that regression is a complex statistical concept
and this entry is intended as an introduction.
More detailed information regarding regression
can be found in Miles and Shevlin (2005),
Bivariate Analysis
Field (2005), Gravetter and Wallnau (2004), and
Glass and Stanley (1970) as well as in other
entries in this encyclopedia to which I have pro-
vided links.
Bivariate Correlation: A bivariate correlation
is a measure of the linear relationship between
two variables. Bivariate correlation is contrasted
with partial correlation (a correlation between
two variables after a third variable has been
taken into account) and with multiple correlation
(correlations between more than two variables).
A bivariate correlation analyzes whether and
how two variables covary linearly, that is,
whether the variance of one changes in a linear
fashion as the variance of the other changes. (For
an explanation of variance, please refer to the
univariate analysis section of this encyclope-
dia). Covariance can be difficult to interpret
across studies because it depends on the scale or
level of measurement used. For this reason,
covariance is standardized by dividing by the
product of the standard deviations of the two
variables to produce the Pearson product
moment correlation coefficient (also referred to
as the Pearson correlation coefficient or simply
as a correlation coefficient) which is usually
denoted by the letter r. Pearsons correlation
coefficient is used when both variables are mea-
sured on an interval or ratio scale. Other correla-
tion coefficients or analyses can be calculated
when variables are not interval or ratio, or
when they are not normally distributed (see
univariate normal distribution). Spearmans
correlation coefficient (Rho) is used for non-
normal or ordinal data, Kendalls tau can be
used for small data sets with many tied ranks,
biserial or point-biserial correlations can be used
when one of the variables is categorical and
dichotomous, and a chi-square analysis is used
to examine the relationship between two nominal
variables (Field, 2005). For more detailed infor-
mation about correlation coefficients, please refer
to the separate entry in this encyclopedia.
It is possible to calculate the amount of vari-
ability in one variable that is explained or
accounted for by the other, known as the coeffi-
cient of determination. The coefficient of determi-
nation is the square of the correlation coefficient.
Bivariate Analysis
Bivariate Analysis,
Fig. 1 Sample scatterplot
showing bivariate
relationship
The statistical significance of a correlation can
be tested (assuming the data meets the assump-
tions for tests of significance such as normal
distribution). A 1-tailed test can be conducted
for a directional hypothesis (such as there will
be a positive correlation between income and
quality of life), and a 2-tailed test can be
conducted for a nondirectional hypothesis (such
as there will be a correlation between income
and quality of life, without specifying whether
the correlation will be positive or negative).
Three important notes should be highlighted
with regard to correlation. First, the presence of
outliers can severely bias the correlation
coefficient. Second, large sample sizes can result
in statistically significant correlations that may
have little or no practical significance. Last, it is
not possible to draw conclusions about causality
based on correlation analyses alone.
Bivariate Regression: Bivariate regression
is a simple linear regression model which is
used to predict one variable (referred to as the
outcome, criterion, or dependent variable) from
one other variable (referred to as the predictor or
independent variable). Bivariate regression is
contrasted with multiple regression in which
one outcome variable is predicted from multiple
417 B
predictor variables. Essentially, a bivariate
regression seeks to find the equation for the best
possible straight line that defines the relationship
between two variables based on a particular
data set. That equation for that line is then used
to predict results for values of the outcome vari-
able that were not found in the original data set.
Statistical (numeric) bivariate analyses are
usually preceded by graphical methods of exam-
ining bivariate relationships, such as scatterplots.
A simple scatterplot is a graph of one variable
plotted against the other variable. The following
scatterplot shows (hypothetical) scores on mea-
sures of happiness and quality of life (Fig. 1).
From the scatterplot, it can be seen that there is
a very high positive correlation (again, hypothet-
ical since the scores are for demonstration
purposes and not based on any real data) between
these two variables, and using the equation for
the line of best fit, one could predict scores on the
quality of life measure based on scores from
the happiness measure, or vice versa.
Bivariate Analyses and Causation: It is
important to note that bivariate relationships can
but do not necessarily imply causation. As noted
in Miles and Shevlin (2005), three conditions
need to be met before causation can be
B 418
established: association, direction of association,
and isolation. Causation necessarily implies cor-
relation in that if one thing causes another then
a change in it produces a change in the other;
therefore, a statistical association is a necessary
but insufficient condition for causation. The
example of the correlation between happiness
and quality of life shown in the scatterplot
above exemplifies the problems of establishing
direction of causation and isolation. Could we
conclude that happiness causes quality of life?
Or that quality of life causes happiness? Or nei-
ther? Typically the cause must precede the effect
in order to establish the direction of causation. In
addition, we must ask ourselves whether one
variable is solely responsible for the other, that
is, whether other variables than those we have
measured may account for the apparent relation-
ship. By definition bivariate analyses cannot sta-
tistically account or control for other variables
(since only two variables are taken into account
in the analyses).
Cross-References
Bivariate Regression
Correlation Coefficient
Levels of Measurement
Linear Regression Model
Multivariate Statistical Analysis
Outliers
Partial Correlations
Standard Deviation(s)
Significance, Statistical
Univariate Analysis
Univariate Normal Distribution
References
Field, A. (2005). Discovering statistics using SPSS.
London: Sage.
Glass, G. V., & Stanley, J. C. (1970). Statistical methods
in education and psychology. Englewood Cliffs, NJ:
Prentice-Hall.
Gravetter, F. J., & Wallnau, L. B. (2004). Statistics for the
behavioral sciences. Belmont, CA: Thomson
Wadsworth.
Bivariate Regression
Michalos, A. C., Thommasen, H. V., Read, R., Anderson,
N., & Zumbo, B. D. (2005). Determinants of health
and the quality of life in the Bella Coola Valley. Social
Indicators Research, 72(1), 150.
Miles, J., & Shevlin, M. (2005). Applying regression and
correlation: A guide for students and researchers.
London: Sage.
Bivariate Regression
Ron Johnston
School of Geographical Sciences, University of
Bristol, Bristol, UK
Definition
Regression involves the estimation of the value of
one variable from that of another, with the rele-
vant coefficients derived from either a complete
set of observations on the two variables or
a sample of them from the total population.
Although no causal link may be intended,
the two variables are usually identified as the
dependent and the independent, respectively,
with the implication that the purpose of the anal-
ysis is to estimate the value of the latter from that
of the former. When presented in graphical form,
the independent variable (usually denoted as the x
variable) is normally placed on the horizontal
axis and the dependent (the y variable) on the
vertical.
The graph illustrates such a regression. The
dependent variable (y) is the percentage share of
the votes received by Plaid Cymru (the Party of
Wales) at the 2010 British general election
campaign in each Welsh constituency; the
independent variable is the percentage of the
population in each constituency who are Welsh
speakers (x). There is a clear upward slope in
the relationship between the two shown by the
regression line; the larger the number of Welsh
speakers the more votes for Plaid Cymru.
Each regression line has two coefficients that
describe its trajectory the constant and the
slope. The constant value (the a value) is
the value of the dependent variable when the
Bivariate Regression 419 B
Bivariate Regression,
Graph 1 Bivariate 50.00
regression between % who
speak Welsh and % who
voted for Plaid Cymru at 40.00
the 2010 UK general B
election

% Voted Plaid Cymru

30.00

20.00

10.00

0.00

0.0000 20.0000 40.0000 60.0000 80.0000

% Who Speak Welsh

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

References perceptual, cognitive, affective, and behavioral

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

Current Cultural Perceptions of Beauty

Body Image Beauty ideals represent culturally prescribed

standards of attractiveness within a culture.
Shayna Rusticus Although cultural perceptions of beauty are sub-
Evaluation Studies Unit, University of British ject to fluctuations over time, in contemporary
Columbia, Vancouver, BC, Canada Western society, the major focus of body image
has come to be on body shape and weight. For
women, the last several decades have seen
Synonyms a cultural ideal emphasizing increasing thinness
and to a lesser degree large breasts (Murnen,
Self-image 2011). More recently, muscle tone is also being
incorporated into current ideals for women in the
twenty-first century with women desiring a full-
breasted firm-looking, toned body (Bordo, 2003;
Definition Grogan, 2010). For men, the male body has
become increasingly more visible in popular cul-
Body image is a multidimensional construct ture, and men too are facing mounting pressures
relating to the image that one forms of their to attend to their appearance and conform to
body and appearance. cultural standards. The male ideal takes the
form of a muscular mesomorphic build with
well-developed muscles on the chest, arms, and
Description shoulders and a slim waist and hips (Grogan;
Pope, Phillips, & Olivardia, 2000). For the major-
Body image is widely believed to be ity of both men and women, these ideals are
a multidimensional construct encompassing impossible to meet, but are still desired because
Body Image
they are associated with self-control, elegance,
social attractiveness, and youth (Bordo, 2003).
Furthermore, individuals who deviate from
these ideals (e.g., obese individuals) can be
highly stigmatized and face multiple forms of
prejudice and discrimination (Puhl & Heuer,
2009).
Body Image and Gender
Gender differences in body image satisfaction
have been widely documented. Women and men
perceive, think, feel, and behave differently in
regard to their bodies and appearance (Calogero
& Thompson, 2010). Perceptually, men tend to
underestimate the size of their bodies and to view
the body as a whole entity with a functional pur-
pose (what the body can do), whereas women tend
to overestimate the size of their bodies and to
perceive the body as a distinct set of parts. Cogni-
tively, men and women also have different beliefs
and attitudes regarding ideal bodies, and they pro-
cess appearance-related information differently.
Men are much more focused on a muscular phy-
sique, while women tend to be more weight con-
scious and desire a thin physique. Although
women had previously been more likely to report
more negative thoughts and beliefs about their
bodies, it appears this difference is declining.
Emotionally, men and women differ in regard to
body dissatisfaction, body shame, and appearance
anxiety, with more women feeling negatively
about their bodies. For body dissatisfaction in par-
ticular, the last several decades have seen increases
in body dissatisfaction among both men and
women, but more so for women. The widespread
weight dissatisfaction reported by women has
become so commonplace that it has been referred
to as a normative discontent; that is, feeling
negatively about ones appearance is thought to
be the norm rather than the exception (Rodin,
Silberstein, & Striegel-Moore, 1984; Tantleff-
Dunn, Barnes, & Larose, 2011). For men, there is
a corresponding normative discontent regarding
their dissatisfaction with their muscularity
(Tiggemann, Martins, & Kirkbride, 2007). Behav-
iorally, men and women engage in different
421 B
activities with respect to their bodies (Calogero
& Thompson, 2010). Women are much more
likely to be susceptible to eating disorders such
as anorexia and bulimia and focus on weight loss.
Although women and men are equally likely to B
suffer from body dysmorphic disorder, for women,
the focus is more often on their hips, weight, and
skin imperfections, whereas for men, the focus is
on muscularity, their genitals, and thinning hair.
Finally, for both genders, the rates of surgical and
nonsurgical cosmetic procedures have dramati-
cally increased and have come to be perceived as
normative behavior although women are nine
times more likely than men to engage in these
procedures (Calogero & Thompson, 2010).
Body Image and Age
Although predominantly studied in adolescent
and young adult female populations, the study
of body image has been applied increasingly
across a broad spectrum of populations: children,
men, middle-aged adults, and older adults. Most
of the research with children has focused on
weight and shape concerns and has found that
children as young as five show concerns that
approximate adolescent and adult concerns; up
to 50 % of 612-year-old boys and girls express
body dissatisfaction (Ricciardelli, McCabe,
Mussap, & Holt, 2009; Smolak, 2011). While
girls generally desire a thinner shape, boys are
mixed in wanting either a smaller (less body fat)
or a larger (more muscular) body size
(Ricciardelli et al., 2009). In adolescence, rates
of body dissatisfaction among girls rise to 70 %
and remain fairly stable over time (Wertheim &
Paxton, 2011). Body image research involving
adolescent boys is limited but does indicate that
they are preoccupied with achieving a lean and
muscular body shape (Ricciardelli & McCabe,
2011). Pubertal development among adolescent
boys has also been associated with a positive
body image experience as their bodies change in
ways that bring them closer to societal ideals for
a man (i.e., they gain in height and muscle mass
(Ricciardelli & McCabe, 2011)), whereas the
body changes and weight gain adolescent girls
B 422
experience during puberty move them away from
the thin ideal (Wertheim & Paxton, 2011).
Moving into adulthood, large percentages of
both men and women continue to experience
their bodies in a negative manner, reflecting the
normative discontent that has become preva-
lent in our society (Grogan, 2011). A growing,
but still limited, body of research in middle-aged
and older adults has found that, although the
physical changes associated with aging (e.g.,
wrinkles, increased body weight, reduction in
muscle tone) take individuals away from cultural
ideals, there is not an associated decline in body
dissatisfaction among men and women. Women
across adulthood report similar levels of body
dissatisfaction regarding their weight and shape;
however, the importance of appearance seems to
decrease with age, and fewer older women report
appearance concerns compared to younger
women (Grogan, 2010; Tiggemann, 2004). It
has been postulated that older women may mod-
ify their appearance standards as they age to
standards that are more age appropriate and real-
istic (Grogan, 2011). Age differences among
adult men have produced inconsistent findings
with some studies suggesting older men are less
satisfied with their body image than younger men
and other studies finding no differences (Grogan).
Overall, most studies suggest that women place
more importance on their appearance than men
across the adult lifespan (Grogan).
Body Image and Quality of Life
A growing body of research in this field has
examined relationships between body image and
various facets of quality of life. Broadly, these
facets can be categorized as psychological factors
(e.g., self-esteem, internalization of the thin/
muscular ideal, social comparison with ideal-
ized models) and behavioral factors (e.g., eating
pathology, muscle building, risky body change
behaviors (Grogan, 2010)). Poor body image
has been linked to multiple negative health out-
comes, such as depression, anxiety, low self-
esteem, body shame, sexual dysfunctions, eating
disorders, body dysmorphic disorder, use of
Body Image
appearance- and performance-enhancing drugs,
and engagement in surgical procedures (Grogan,
2010; Smolak & Cash, 2011; Woertman & van
den Brink, 2012). Furthermore, these negative
outcomes can be compounded when individuals
have internalized societal ideals and are more
prone to making upward and unrealistic social
body comparisons (Grogan, 2010). Because
even minor body image concerns can result in
potentially harmful effects, continued investiga-
tions of correlates of body image and protective
body image factors continue to be important
areas of research.
Cross-References
Anxiety
Beauty
Prejudice
Quality of Life
Self-Esteem
Sexual Dysfunction
Social Comparison
References
Bordo, S. (2003). Unbearable weight: Feminism, Western
cultural, and the body. Berkeley, CA: University of
California Press.
Calogero, R. M., & Thompson, J. K. (2010). Gender and
body image. In J. C. Chrisler & D. R. McCreary (Eds.),
Handbook of gender research in psychology (Gender
research in social and applied psychology, Vol. 2,
pp. 153184). New York: Springer.
Cash, T. F. (2011). Cognitive-behavioral perspective
on body image. In T. F. Cash & L. Smolak (Eds.),
Body image: A handbook of science, practice, and pre-
vention (2nd ed., pp. 3947). New York: Guildford Press.
Grogan, S. (2010). Promoting positive body image in
males and females: Contemporary issues and future
directions. Sex Roles, 63, 757765.
Grogan, S. (2011). Body image development in adulthood.
In T. F. Cash & L. Smolak (Eds.), Body image:
A handbook of science, practice, and prevention
(2nd ed., pp. 93100). New York: Guildford Press.
Murnen, S. K. (2011). Gender and body images. In T. F.
Cash & L. Smolak (Eds.), Body image: A handbook of
science, practice, and prevention (2nd ed., pp. 7379).
New York: Guildford Press.
Pope, H. G., Phillips, K. A., & Olivardia, R. (2000).
Adonis complex: The secret crisis of male body obses-
sion. New York: Free Press.
Bottom-Up Versus Top-Down Theories of Life Satisfaction
Puhl, R. M., & Heuer, C. A. (2009). The stigma of obesity:
A review and update. Obesity, 17, 941964.
Ricciardelli, L. A., & McCabe, M. P. (2011). Body image
development in adolescent boys. In T. F. Cash & L.
Smolak (Eds.), Body image: A handbook of science,
practice, and prevention (2nd ed., pp. 8592). New
York: Guildford Press.
Ricciardelli, L. A., McCabe, M. P., Mussap, A. J., & Holt,
K. E. (2009). Body image in preadolescent boys. In L.
Smolak & K. J. Thompson (Eds.), Body image, eating
disorders, and obesity in youth: Assessment, preven-
tion, and treatment (2nd ed., pp. 7796). Washington,
DC: American Psychological Association.
Rodin, J., Silberstein, L. R., & Striegel-Moore, R. H.
(1984). Women and weight: A normative discontent.
In T. B. Sonderegger (Ed.), Nebraska symposium on
motivation: Psychology and gender (pp. 267307).
Lincoln, NE: University of Nebraska Press.
Smolak, L. (2011). Body image development in child-
hood. In T. F. Cash & L. Smolak (Eds.), Body image:
A handbook of science, practice, and prevention
(2nd ed., pp. 6775). New York: Guildford Press.
Smolak, L., & Cash, T. F. (2011). Future challenges for
body image science, practice, and prevention. In T. F.
Cash & L. Smolak (Eds.), Body image: A handbook of
science, practice, and prevention (2nd ed.,
pp. 471478). New York: Guildford Press.
Tantleff-Dunn, S., Barnes, R. D., & Larose, J. G. (2011).
Its not just a woman thing: The current state of nor-
mative discontent. Eating Disorders, 19, 392402.
Tiggemann, M. (2004). Body image across the life span:
Stability and change. Body Image, 1, 2441.
Tiggemann, M., Martins, Y., & Kirkbride, A. (2007). Oh
to be lean and muscular: Body image ideals in gay and
heterosexual men. Psychology of Men & Masculinity,
8(15), 24.
Wertheim, E. H., & Paxton, S. J. (2011). Body image
development in adolescent girls. In T. F. Cash & L.
Smolak (Eds.), Body image: A handbook of science,
practice, and prevention (2nd ed., pp. 7684). New
York: Guildford Press.
Woertman, L., & van den Brink, F. (2012). Body image
and female sexual functioning and behavior: A review.
Journal of Sex Research, 49, 184211.
Bog
Wetland(s)
Booty Calls
Casual Sex and the Quality of Life
423 B
Botanical Gardens
Museums and Galleries: Their Social Worth
B
Bottom-Up Versus Top-Down
Theories of Life Satisfaction
Bruce Headey
Melbourne Institute of Applied Economic and
Social Research, The University of Melbourne,
Melbourne, VIC, Australia
Definition
Bottom-up theories of life satisfaction (or subjec-
tive well-being, SWB) are based on the idea that
overall life satisfaction is the sum of its parts.
That is, self-reports of life satisfaction represent
a weighted average of satisfaction with different
aspects (domains) of life. By contrast, top-down
theories rest on the premise that satisfaction with
domains of life is mainly a consequence of
overall life satisfaction, which itself primarily
depends on personality traits and other fixed
genetic effects.
Description
The distinction between bottom-up and top-down
theories of life satisfaction was originally made
by Diener (1984). He pointed out that, at time of
writing, most researchers tended to assume that
life satisfaction is a weighted average of satisfac-
tion with different domains of life (working life,
family life, etc.). However, the opposite view was
also tenable. That is, satisfaction with different
domains of life might be a consequence of fixed
(e.g., genetic) or relatively unchanging (e.g.,
personality traits) factors.
Pioneering QOL researchers who adopted
a bottom-up approach included Bradburn (1969)
and the University of Michigan teams of
Andrews and Withey (1976) and Campbell,
B 424
Converse, and Rodgers (1976). Early investiga-
tors whose research could be said to reflect
a top-down approach included those who
believed that SWB nearly always returned to
a baseline after major life events (Brickman &
Campbell, 1971) and also those who viewed
SWB as mainly a function of stable personality
traits (Costa & McCrae, 1980).
In general terms, it may be said that research
which shows that objective conditions, or indi-
vidual preferences and choices, affect SWB
could be regarded as supporting bottom-up the-
ory. Research which shows that fixed traits and
genes affect SWB could be regarded as
supporting top-down theory. An obvious point,
however, is that if all these types of variables
have significant effects on SWB, the debate
loses its point and the key task becomes one
of sorting out main, direct, indirect, and
interaction effects.
Early empirical research on SWB found that
objective conditions (income, housing, etc.) had
surprisingly small effects (Andrews & Withey,
1976; Campbell, Converse, & Rodgers, 1976).
However, a fairly recent review concluded that
about 15 % of the explained variance in SWB is
due to objective conditions (Argyle, 2001). More
interestingly, a study of the 50 American states
found that objective economic and environmental
conditions, which can be viewed as compensated
for by average income differentials between the
states, had an aggregate correlation of 0.6 with
SWB (Oswald & Wu, 2010).
Support for top-down theory, in the form of set-
point theories, reached its apogee in the 1990s
when results from the Minnesota twin study were
interpreted, probably incorrectly (Diener, Suh,
Lucas, & Smith, 1999), as showing that up to
80 % of the variance in long-term life SWB was
genetic (Lykken & Tellegen, 1996). In addition to
twin studies, the strongest support for set-point
theory came from studies which found that most
important-seeming life events have only
short-lived effects on SWB. For example, a recent
comprehensive review claimed that, out of a range
of events (marriage, bereavement, divorce, etc.),
only long-term or repeated unemployment had
Bottom-Up Versus Top-Down Theories of Life Satisfaction
effects on SWB which, on average, lasted more
than a year (Clark, Diener, Georgellis, & Lucas,
2008). In other words, in response to all other
events reviewed, most people soon reverted to
their previous SWB set points.
Set-point theory may still be the most widely
held theory among empirical SWB researchers.
However, it is increasingly coming under attack
in work which claims that SWB is affected by
individual preferences and choices. Several
studies show significant linkages between choice
of life goals and SWB (Kasser & Ryan, 1993;
Diener & Seligman, 2004; Headey, 2008;
Kahneman, Krueger, Schkade, Schwarz, &
Stone, 2006). Prioritizing family-related and
altruistic goals appears to be positively associated
with SWB, whereas prioritizing money and mate-
rial goals appears negatively related.
Volunteering an altruistic activity is associ-
ated with high SWB (Thoits & Hewitt, 2001).
Having the resources needed to pursue life goals
also affects SWB (Diener & Fujita, 1995). SWB
appears to be positively affected by religious
beliefs and behavior (Myers, 2008; Headey,
Schupp, Tucci, & Wagner, 2010). It can be
enhanced or damaged by choice of
marriage partner (Lucas, Clark, Georgellis, &
Diener, 2003; Headey, Muffels, & Wagner,
2010). One of the oldest, most replicated findings
in SWB research is that people who have strong
friendships and active social and community
involvements are happier than average
(Bradburn, 1969; Argyle, 2001). In a recent
study, Headey, Muffels, and Wagner (2010)
showed that the effects of life goals, religion,
choice of marriage partner, and social involve-
ments remain substantial, and not merely
statistically significant, after taking account of
personality traits and other fixed effects.
Empirical investigations intended to provide
direct tests of bottom-up versus top-down
theories face difficult chicken-and-egg issues,
that is, difficult issues in sorting out time
sequences. Suppose one is investigating whether,
in a sample of survey respondents, observed
changes in marriage satisfaction and job satisfac-
tion precede (bottom-up theory) or follow
Bottom-Up Versus Top-Down Theories of Life Satisfaction
(top-down theory) observed changes in life satis-
faction. Clearly, prospective longitudinal data are
needed; investigations based on cross-sectional
evidence or recall data would be futile. But,
even with longitudinal data, it would not nor-
mally be possible to sort out time sequences in
a direct and clear way. In most longitudinal
surveys, respondents are interviewed at annual
intervals. If, as is very likely, the time lag
between the effect of change in a domain
satisfaction on change in life satisfaction, or the
reverse effect, is less than a year, then an annual
longitudinal survey cannot be used to ascertain
directly which change came first.
Despite the difficulties, some attempts have
been made to assess the relative importance of
bottom-up versus top-down explanations of life
satisfaction. Using multiple waves of data from
an Australian longitudinal survey, Headey,
Veenhoven, and Wearing (1991) reported that
changes in marriage satisfaction significantly
affected changes in life satisfaction, as well as
vice versa. In other words, both bottom-up and
top-down explanations had some weight. In other
domains, including work life and leisure, the direc-
tion of causation appeared to be mainly top-down.
Headey, Veenhoven, and Wearing used structural
equation models to estimate their equations. Struc-
tural equation modeling remains controversial in
the social sciences, and the authors conceded that
their results were quite sensitive to assumptions
imposed to identify their models.
It seems possible that that some bottom-up, top-
down issues could be sorted out if data were col-
lected in a longitudinal survey conducted at (say)
monthly intervals or if a long-running survey was
conducted using experience-sampling methods.
However, even without improved data, it seems
clear that both variables associated with bottom-up
explanations, and those associated with top-down
explanations, help to account for differences in
SWB. Top-down variables personality traits
and genetic effects mainly account for stability
in SWB. Bottom-up variables objective condi-
tions, individual preferences, goals, and choices
contribute to accounts of short and long changes
in SWB.
425 B
Cross-References
Experience Sampling
Set-Point Theory
B
References
Andrews, F. M., & Withey, S. B. (1976). Social indicators
of well-being. New York: Plenum.
Argyle, M. (2001). The psychology of happiness (2nd ed.).
London: Taylor & Francis.
Bradburn, N. M. (1969). The structure of psychological
well-being. Chicago: Aldine.
Brickman, P. D., & Campbell, D. T. (1971). Hedonic
relativism and planning the good society. In M. H.
Appley (Ed.), Adaptation-level theory. New York:
Academic Press.
Campbell, A., Converse, P. E., & Rodgers, W. R. (1976).
The quality of American life. New York: Sage.
Clark, A. E., Diener, E., Georgellis, Y., & Lucas, R. E.
(2008). Lags and leads in life satisfaction: A test of the
baseline hypothesis. The Economic Journal, 118,
222243.
Costa, P. T., & McCrae, R. R. (1980). Influences of
extraversion and neuroticism on subjective
well-being. Journal of Personality and Social
Psychology, 38, 668678.
Diener, E. (1984). Subjective well-being. Psychological
Bulletin, 235, 542575.
Diener, E., & Fujita, F. (1995). Resources, personal
strivings and subjective well-being: A nomothetic
and ideographic approach. Journal of Personality
and Social Psychology, 68, 926935.
Diener, E., & Seligman, M. E. P. (2004). Beyond money:
Toward an economy of well-being. Psychological Sci-
ence in the Public Interest, 5, 131.
Diener, E., Suh, E. M., Lucas, R. E., & Smith, H. L.
(1999). Subjective well-being: Three decades of eco-
nomic progress. Psychological Bulletin, 125, 276302.
Headey, B. W. (2008). Life goals matter to happiness:
A revision of set-point theory. Social Indicators
Research, 86, 213231.
Headey, B. W., Muffels, R. J. A., & Wagner, G. G. (2010).
Long-running German panel survey shows that
personal and economic choices, not just genes, matter
for happiness. Proceedings of the National Academy of
Sciences, 107(42), 1792217926.
Headey, B. W., Schupp, J., Tucci, I., & Wagner, G. G.
(2010). Authentic happiness theory supported by
impact of religion on life satisfaction: A longitudinal
analysis with data for Germany. The Journal of
Positive Psychology, 5, 7382.
Headey, B. W., Veenhoven, R., & Wearing, A. J. (1991).
Top-down vs. bottom-up theories of subjective well-
being. Social Indicators Research, 24, 81100.
B 426 Bounded Rationality

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

& Stone, A. A. (2006). Would you be happier if you Brazil, Quality of Life
were richer? A focusing illusion. Science, 312,
19081910.
Kasser, T., & Ryan, R. M. (1993). A dark side of the John H. Salmela
American dream: Correlates of financial success as Human Kinetics, University of Ottawa,
a central aspiration. Journal of Personality and Social Belo Horizonte, Brazil
Psychology, 65, 410421.
Lucas, R. E., Clark, A. E., Georgellis, Y., & Diener, E.
(2003). Reexamining adaptation and the set point
model of happiness: Reactions to change in marital Synonyms
status. Journal of Personality and Social Psychology,
84, 527539.
Lykken, D., & Tellegen, A. (1996). Happiness is a Aged; Poverty; Social class in Brazil; South
stochastic phenomenon. Psychological Science, 7, America; Sports in Brazil
186189.
Myers, D. G. (2008). Religion and human flourishing.
In M. Eid & R. J. Larsen (Eds.), The science of sub-
jective well-being (pp. 323346). New York: Guilford Definition
Press.
Oswald, A. J., & Wu, S. (2010). Objective confirmation of Brazil is located in South America. Its the
subjective measures of economic well-being: biggest country in this continent. Its in the Atlan-
Evidence from the U.S.A. Science, 327, 576579.
comment, 53435. tic Ocean side of the continent and it borders all
Thoits, P. A., & Hewitt, L. N. (2001). Volunteer work the other countries in South America, except for
and well-being. Journal of Health and Social Ecuador and Chile.
Behavior, 42, 115131.

Description

Brazil has the fifth largest land mass in the world,

Bounded Rationality the largest in South America, and is one of the
fastest growing world economies. After becom-
Economic Rationality Assumption
ing an independent country in 1822, slavery only
ended in 1888, the last of all of the Americas. The
population in Brazil in 1900 was about
17,438.434 and grew in 1991 to 147,053,940
Boy Soldier and in 2010 to about 190,000.000.
The socioeconomic classes in the northeastern
Child Soldiers states are still the lowest, with pockets in the
largest developed cities to the south, who live in
favelas, or shanty towns. The disparity between
the rich and the poor is enormous, although this
has been considerably reduced through govern-
Bradburn Scale
mental and food subsidies (cestas familiares) for
the lower classes. Because of their exports of
Affect Balance Scale
lumber, ethanol, and recently discovered,
offshore oil fields, it now has the ninth highest
gross national product (GNP) in the world.
The perceived quality of life (QOL) has been
Brainwave Biofeedback recently assessed with empirical protocols with
the community-dwelling elderly (Teixeira-
Neurotherapy Salmela et al., 2005), chronic stroke victims
Brazil, Quality of Life
(Teixeira-Salmela, Olney, Nadeau, & Brouwer,
1999; Teixeira-Salmela et al.), and Parkinsonians
(Rodrigues-de-Paula, Teixeira-Salmela, Faria,
Morais, Rocha de Brito, & Cardoso, 2006) using
strength and conditioning programs, including
QOL measures. Also QOL has been observed,
assessed, and described in Brazil for wealthy
athletes, coaches, and parents from volleyball,
swimming, and gymnastics, compared to the
less fortunate ones, mainly from soccer (Salmela
& Morais, 2003). This data was compared to
some of the QOL scales reported by Michalos,
Hatch, Hemingway, Lavallee, Hogan, and
Christensen (2007). In addition, published
observations regarding the QOL scales of
successful soccer players, and the life in Brazilian
favelas, as compared to US ghettos are also
reported.
Quality of life and exercise training and
detraining in Brazil. In Canada, research was
conducted on the effects of muscular strength
and aerobic training, including gait speed, stair
climbing, and total peak torques with stroke
victims, along with perceptions of QOL, using
the Nottingham Health Profile (NHP) scales
(Teixeira-Salmela et al., 1999). After a 10-week
program of muscular strengthening and aerobic
conditioning, all variables such as gait speed,
stair climbing, and total peak torque improved,
but the NHP increased by 77.8 %, but there were
no follow-ups after detraining.
Using an identical protocol of subjects with
stroke in Brazil, Teixeira-Salmela et al., (2005)
found similar results for subjects with stroke after
a 10-week strength and conditioning program,
three times a week. After detraining, the physical
benefits plus the perceived QOL persisted. In
a one-year follow-up assessment, the exercise-
induced, as well as some of the NHP variables,
such as energy levels, emotional reactions, and
physical abilities, remained high.
The subjects reported that they were now able
to maintain their social relations, were more
emotionally balanced and confident about doing
simple, normal practical life activities, such as
crossing the street, sitting on their stoops, and
talking to neighbors, and were more confident
getting aboard buses, their main means of
427 B
transportation. Thus, these exercise programs
gave them more social, emotional, and physical
confidence, and a better QOL.
Similar results were obtained with commu-
nity-dwelling Brazilian elderly who were B
assessed and trained with measures of gait
speed, ascending and descending stairs, and the
NHP (Teixeira-Salmela et al., 2005). During
assessments, after 1, 2, and 3 months, their
physical capacities declined after 1 month of
detraining, but their perceptions of their QOL
remained stable. This may have been due to
powerful Hawthorne effects, due to special
and unaccustomed interventions by trained
professionals.
This was also the case with Brazilian individ-
uals with Parkinsons who after 12 weeks of
muscular strengthening, isometric and isotonic
exercises of the trunk and lower limbs,
maintained high levels of perceptions of
QOL, especially for emotional reactions, social
interactions, and physical ability (Rodrigues-de-
Paula Teixeira-Salmela, de Morais Faria, de
Brito, & Cardoso, 2006).
Quality of life and individuals from different
socioeconomic levels in Brazil. Brazil has the
greatest range of socioeconomic classes with the
lowest earnings, about 336 US dollars per month
and the most wealthy earning 12,000 US dollars,
or more, per month. This is especially true for
successful soccer players and corrupt politicians!
Brazil is considered to have the most unequal
distribution of wealth, with the exception of
South Africa. An interesting conundrum is that
wealth is not necessarily associated with
better QOL.
An interesting blog showed the apparently
poor lives of Brazilians, who live in favelas and
have high levels of QOL in the major developed
cities of Sao Paulo, Rio de Janeiro, and Belo
Horizonte (Zezinho, 2010). This is refuted by
the famous American burlesque queen Mae
Wests quotation: I have been rich and poor,
but rich is better. This is an important and con-
tradictory statement regarding the QOL of the
rich and the poor in Brazil and in North America,
regarding life in ghettos in the USA and the
favelas in Brazil reported by Zezinho (2010):
B 428
When I was living in the USA, people would com-
plain about everything. It was as if the stress of
trying to live up to societys expectations were
a burden. I saw many scenes of parents aggres-
sively yelling or even hitting children in
public. I started to see a country and people who
were angry and on the edge about their lives, as if it
was impossible to keep up to expectations. In the
US, they have everything, yet they are still not
happy. I started to question, what is happiness in
the US?
Favelas are called slums or shanty towns,
because of the way the people constructed their
houses. In the beginning, they had no running
water nor electricity, and no infrastructures. So
the government for the longest time turned their
back, while the poor would build their shacks on
the hills. Yet, there was little confrontation
between citizens and the government, because
the favelados represented a large work force for
the middle and upper classes. Who else is going
to clean your house or sweep the streets? As
favelas grew, the state started having concerns.
When you live in conditions where there is no
sanitation, electricity, water, nor anything else,
problems begin to occur. There were we had
problems with garbage removal, and because of
the rats, diseases spread.
But how can people pay taxes when they are
living on less than $700 reais (approximately $400
US) a month? The rich can send their kids to private
schools which ensure them opportunities to get into
universities. This is foreign to the favelados. The
public schools fail to give them these opportunities,
no matter how intelligent you are.
In the favelas, everybody works. There are no
public housing projects, welfare, food stamps,
nor social programs. If you dont work, you
dont live. We care about our community regard-
less of its problems. In the favelas, it is
a community effort for survival and nobody is
better than anybody else. We are all equal; we are
all favelados. Favelas were far from perfect, but
for us, it works.
In Rocinha, the first drug lord Dennis
changed the ways of negative social behaviors
in the favela. The traficantes (drug dealers)
not only sold drugs but acted as internal police
forces for the community. They protected the
community from outside police and rival gang
Brazil, Quality of Life
invasions and established social codes inside
the favela.
Today, the same social codes exist, and unlike
in a US ghetto, one can safely walk through the
favelas anytime, day or night, without fear of
having crimes against them.
Where else can one feel totally free and walk
the streets safely at three in the morning with total
freedom? Where can one walk in a community
where they get greeted 1015 times a day by their
neighborhood people? All one needs to do is walk
out their door and find a party, no need to crash
the party, since there is no such thing. Today, if
they decided they wanted peace, they would stay
inside and relax. In Rocinha, one will never be
lonely.
Our street parties include everyone; nobody is
excluded. We can have a party for any reason,
samba, funk, football, birthday, or just people
who want to get together. If you decide to want
to come for a visit, I am always available to show
people a good time here that you will never
forget. I do not know if the American ghettos
have street parties anymore. In our club, we
can have 3,000 people in there dancing and not
one fight breaks out. Can that be said in any
US ghetto?
QOL and sport in Brazil. While volleyball,
swimming, and tennis are popular sports in
Brazil, soccer, or futebol, is by far the most
popular (Salmela, 1993). Bellos (2002) quotes
Gilberto Freyre in the following manner: The
Brazilians play football as if they were dancing.
This is probably the result of the influence of
those Brazilians who have African blood or are
predominantly African in their culture, for such
Brazilians tend to reduce everything to dance,
work, and play alike. (p.27).
Football was introduced to Brazil in
1894 when Charles Miller, an Englishman,
disembarked in the port of Santos in 1894 with
two footballs in his hands, but has evolved
incredibly since then, resulting in five World
Cup victories, the most in the world. QOL in
Brazil exudes, principally, through football. The
country is totally electric during the Cup, which
has won a record of five times, but between these
events, the bars are completely dominated by
Brazil, Satisfaction with Life Scale Survey Results
discussions about the rankings of the local teams
and their multiple championships. The streets are
full of young players, although the poor do not
have spacious fields, which are only reserved for
the upper class families who are members of
these clubs.
Thus, QOL in Brazil is a complex multiface-
ted concept based upon factors of salaries, health,
social classes, and sport and is constantly chang-
ing. For example, many academics and medical
doctors either cannot speak nor write in English,
although their children can, thanks to early
schooling in specialized schools. Ten years ago,
approximately 60 % of Brazilian women worked
as domestic maids, and their children were taught
these skills of washing floors and dishes, and now
are perpetrating this. Finally, I have seen garbage
men, happily running behind a garbage truck in
orange uniforms, apparently happy, with huge
bags of waste, throwing them into an accelerating
truck, while waving to customers in bars, singing
and waving. Obviously, wealth and QOL are not
directly related in Brazil and require further
study.
Cross-References
Family Relationships
Perceived Quality of Life
Satisfaction with Life as a Whole
References
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New York/London: Bloomsbury.
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Brazil, Satisfaction with Life Scale
Survey Results
Taciano L. Milfont1 and Valdiney V. Gouveia2
1
School of Psychology, Victoria University of
Wellington, Wellington, New Zealand
2
Department of Psychology, Federal University
of Paraba, Joao Pessoa, Brazil
Synonyms
SWLS
Definition
The Satisfaction with Life Scale (SWLS) is
a domain-free measure developed by Diener,
Emmons, Larsen, and Griffin (1985) to access the
cognitive-judgmental component of subjective
well-being (SWB). Its five items are (1) In most
ways my life is close to my ideal, (2) The
conditions of my life are excellent, (3) I am
satisfied with my life, (4) So far I have
gotten the important things I want in life, and
(5) If I could live my life over, I would change
almost nothing. Responses are made on
B 430
a 7-point scale, anchored by 1 (strongly disagree)
and 7 (strongly agree). By answering the
SWLS items, individuals provide their global
judgment of satisfaction with life as a whole.
A score of 20 represents the neutral point on the
scale, and according to the normative data
(Pavot & Diener, 1993), scores on the 59 range
represent being extremely dissatisfied with life,
the 1014 range represent dissatisfied, the 1519
range represent slightly dissatisfied, the 2125
range represent slightly satisfied, the 2630
range represent satisfied, and scores above 31
represent extremely satisfied.
Description
Thousands of international studies have used
the SWLS since its publication, with translations
into several languages. The scale has also been
applied in the Brazilian context. A recent search
of the SciELO shows that this scale has been used
or cited in nine studies between 2002 and 2011
(SciELO stands for Scientific Electronic Library
Online and is a database of electronic scientific
publications in developing countries). A similar
search on Google, using Satisfaction with Life
Scale AND Diener as keywords and narrowing
the search only to pages published in Brazil,
yielded 385 pages citing the SWLS.
The first attempt to validate the SWLS in
the Brazilian context was described in
a conference presentation by Giacomoni and
Hutz (1997), and Gouveia et al. (2003; see also
Gouveia, Barbosa, Andrade, & Carneiro, 2005)
were the first to publish articles explicitly examin-
ing the psychometric properties of the scale.
Drawing from a large sample of 14,405 physicians
from all five regions in Brazil, Gouveia et al.
(2005) confirmed a single-factor solution for the
SWLS in Brazil with both exploratory and confir-
matory factor analyses. Internal consistency
(Cronbachs alpha) was greater than 0.80 for all
regional samples and no gender differences were
observed, but older physicians had higher life sat-
isfaction compared to younger physicians. Scale
score for the overall sample was 23.5 (SD 6.77),
which means physicians were slightly satisfied
Brazil, Satisfaction with Life Scale Survey Results
with life compared to the normative data (Pavot
& Diener, 1993).
A more systematic study examining the
validity of the SWLS in Brazilian samples was
published by Gouveia, Milfont, Fonseca, and
Coelho (2009), who examined the construct and
criterion-related validity of the Portuguese-
Brazilian version of the scale with data from
2,180 participants from five independent and
diverse groups (i.e., undergraduate and high
school students, general population, elementary
school teachers, and physicians).
They first reported the statistics for the five
SWLS items in each sample, including item
means and standard deviations as well as item
factor loadings and corrected item-total correla-
tions. Item 5 (If I could live my life over, I would
change almost nothing) had the weakest psycho-
metric properties, as also observed in other
studies (Pavot & Diener, 1993). Exploratory
factor analysis confirmed a single-factor solution
for each sample as well as the overall sample. All
items showed higher factor loadings (the lowest
was 0.50 for item 5 in the general population
sample), and the single factor accounted for
52 % (high school students) to 68 % (physicians)
of the total variance, explaining 57 % of the
variance for the overall sample.
The unidimensional structure was further
supported by confirmatory factor analyses, with
satisfactory model fit for each of the five sam-
ples as well as for the overall sample. Lower fit
indices were observed for the student sample.
Configural invariance was also supported by
a multigroup confirmatory factor analysis, dem-
onstrating that the single-factor solution is the
same across all five Brazilian samples. The scale
displayed internal reliability ( Cronbachs
Alpha) above the conventional threshold of
0.70 in all samples, with values ranging from
0.77 (for both high school students and general
population) to 0.88 (physicians), with a value of
0.80 for the overall sample. All items also had
strong corrected item-total correlations (the
lowest was 0.44 for item 5 in the general popu-
lation sample).
The general population sample had a lower
scale score (M 23.95), whereas both physicians
Brazil, Satisfaction with Life Scale Survey Results
and high school students had a higher score
(M 24.32 for both), but no statistically signif-
icant differences were observed across samples.
The SWLS score for the overall sample was
24.08 (SD 6.18), which means that these
Brazilian participants were slightly satisfied
with their lives in comparison with the normative
data (Pavot & Diener, 1993).
Gouveia et al. (2009) then examined the
criterion-related validity of the SWLS by exam-
ining associations with positive/negative affect
and psychological distress. Past research has
shown that greater life satisfaction is associ-
ated with high positive affect, while also
associated with low negative affect, general psy-
chological distress, anxiety, and depression
(e.g., Diener, Emmons, Larsen, & Griffin,
1985; Lucas, Diener, & Suh, 1996). A similar
trend was observed across the five Brazilian
samples, with the SWLS positively related to
positive affect (r 0.62) and negatively related
to both negative affect and psychological dis-
tress (r 0.21 and 0.51, respectively).
Besides the Gouveia et al. (2009) study that
publicized the use of the SWLS in Brazil to an
international audience, several other studies have
used the scale and are published in Portuguese.
Table 1 presents a summary of known published
studies. For example, Gouveia, Freires, Araujo,
Santos, and Gouveia (2010) employed the
scale to access life satisfaction among a sample
of 100 prostitutes, who had a scale score below
other Brazilian samples, being slightly dissatis-
fied with life. Other Brazilian samples for which
the SWLS has been used include caregivers with
chronic back pain (Maia, Fialho, Alcantara, &
Morais, 2008), elders living in rural areas
(Albuquerque, Sousa, & Martins, 2010), nurses
(Alves, Vasconcelos, Miranda, Costa, &
Sobreira, 2011), bank workers (Paiva & Borges,
2009), and adults with physical disability
(Resende & Gouveia, 2011).
Associations between the SWLS and broader
constructs have also been examined. The SWLS
has been shown to be negatively associated with
irrational beliefs (Matta, Bizarro, & Reppold,
2009); positively associated with personal
income and negatively associated with intention
431 B
to change profession among physicians, nurses,
and psychologists (Oliveira et al., 2009); and
negatively associated with lower levels of mental
disorders (Goncalves & Kapczinski, 2008).
While some Brazilian studies have found B
women to score higher than men on the SWLS
(e.g., Goncalves & Kapczinski, 2008), others
have found no gender differences (e.g., Ribeiro
& Ruiz, 2009), but more consistently there seems
to be a pattern for older Brazilians to be more
satisfied with their lives (see Table 1). Despite
very good overall psychometric properties of the
SWLS, some studies have shown that item 5 has
the weakest parameters in Brazilian samples
(e.g., Albuquerque et al., 2010; Gouveia et al.,
2009, 2010), just like in other studies (Pavot &
Diener, 1993).
Another noteworthy application of the SWLS
in the Brazilian context is the use of some of its
items in a subjective well-being measure. In
developing their 69-item scale, Albuquerque
and Troccoli (2004) report combining three
items from the SWLS, plus three items from
Lawrence and Liangs Subjective Well-Being
Scale (SWBS), 15 items from Watson et al.s
Positive and Negative Affect Schedule
(PANAS), and newly developed items. While
researchers prefer to measure the affective,
emotional aspects of subjective well-being
(i.e., positive affect and negative affect) inde-
pendently from measures of the cognitive-
judgmental aspects (i.e., life satisfaction), their
Brazilian measure combines all aspects in
a single well-being measure.
Discussion
Future research should consider two main issues
related to the scale, which refers to the weak
psychometric parameters of item 5 and the
overall high scale score across samples. As
discussed by Pavot and Diener (1993) as well
as Gouveia, Millfont, Fonseca, and Coelho
(2009), the poor performance of item 5 may be
related to the fact that the item is wording in
a past orientation. But it could also be related to
 B
432

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

excluded)
Gouveia et al. (2010) Prostitutes 100 17.9 6.41 0.62 26.2 100   Yes 41.9
Resende and Elders acting in 12 5.95b 0.94  68 91.7    
Gouveia (2011) a theater group (29.75)
Alves, Vasconcelos, Nurses 20 4.03b 1.32  34 90.0    
Miranda, Costa, and (20.15)
Sobreira (2011)
Missing information refers to data not reported in the original studies. Responses to the SWLS are made on a 7-point scale, ranging from 1 (strongly disagree) to
7 (strongly agree), unless stated. (a) Data originally reported in Gouveia et al. (2003). (b) Original article reports mean for the SWLS, and sum score was then derived for the
present article. (c) Mean based on a 10-point scale
433
B

B
B 434
the grammatical structure of the statement,
which implies counterfactual thinking that
might hinder its understanding and conse-
quently affect performance and relation to the
other SWLS items (cf. Hershberger, Market, &
Levengood, 1999).
Regarding the second issue, Pavot and Diener
(1993) discuss response artifacts that may influ-
ence the SWLS scores, such as acquiescence
bias and social desirability. There may be
another methodological artifact related to
a self-serving bias. It has been observed that
the scale scores for nonclinical samples are
above the neutral point and this is a widely
replicated finding (Pavot & Diener, 1993, p.
165). In terms of the means given in Table 1,
only two samples (prostitutes and caregivers
with chronic back pain) had a score below the
neutral point of 20. Most groups fall in the range
of slightly satisfied to satisfied, or the 2630
range, which is in line with the normative data.
An optimistic bias underlying the scale, and
well-being constructs more generally (cf.
Sanjuan, Magallares, & Gordillo, 2011), thus
seems to be evident because most individuals
answering the SWLS tend to be satisfied with
their life or fell more satisfied with life than the
average person.
Notwithstanding these general issues, the
available findings support the SWLS as a valid
and reliable measure to the Brazilian context.
Researchers can rely on the Brazilian-Portuguese
version of the SWLS presented by Gouveia et al.
(2009) as an index of life satisfaction.
Cross-References
Life Satisfaction Judgments
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(2010). Validation of the satisfaction with life scale
and affect scales for elders in the countryside
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(1999). Nonevents and adult well-being. Journal of
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Breast Cancer
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Breast Cancer
Nina Rottmann1, Marianne Ewertz2 and
Dorte Gilsa Hansen1
1
National Research Centre for Cancer
Rehabilitation, Research Unit of General
Practice, University of Southern Denmark,
Odense, Denmark
2
Department of Oncology Odense University
Hospital, University of Southern Denmark,
Odense, Denmark
Synonyms
Breast cancer and adaptation; Breast cancer and
body image; Breast cancer and depression; Breast
cancer and emotional sharing; Breast cancer and
fatigue; Breast cancer femininity and sexuality;
Breast cancer and financial stress; Breast cancer
and intimate partner support; Breast cancer and
sexual functioning; Breast cancer and spiritual-
ity; Breast carcinoma; Pain and breast cancer;
Social relationships and roles
Definition
Breast cancer is a disease in which abnormal cells
in the breast grow and divide without control.
435 B
These cells can form a mass of tissue, called
a tumor. Through the blood and lymph system
cancer cells can spread to other parts of the body
and form metastases. Breast cancer is the most
frequent cancer among women worldwide. About B
1.15 million women were diagnosed with breast
cancer in 2002, and approximately 410,000
2008). Due to early detection and modern
treatment, including combinations of surgery,
radiotherapy, chemotherapy, and endocrine
therapy, breast cancer survival has improved.
Still, survival rates vary greatly worldwide.
Five-year relative survival ranges from 80 % or
more in, for example, North America, Sweden,
and Japan to around 60 % in Brazil and Slovakia
and below 40 % in Algeria (Coleman et al.,
2008). Diagnosis and treatment can substantially
affect patients Quality of Life (QoL).
This entry highlights aspects of Health-
Related Quality of Life (HRQol) which women
treated for breast cancer may encounter. HRQoL
is concerned with QoL in relation to health and
impact of the disease. It is a loosely defined term
that can include multiple dimensions such as
physical symptoms, emotional functioning,
social well-being, and existential issues (Fayers
& Machin, 2009).
In this essay, we adopt a broad approach to
HRQoL. We present selected research results in
clusters (Fig. 1), tailored to the experience of
breast cancer. The clusters encompass symptoms,
functioning and broader issues, and are grouped
around the following five overarching aspects of
HRQoL:
Emotional and cognitive issues
Femininity and sexuality
Physical symptoms and late effects
Social relationships and roles
Existential issues
The five clusters are not exhaustive, but
highlight aspects of particular relevance in the
context of breast cancer. The clusters are
described separately in the following. There is,
however, considerable overlap between them,
and they should be seen as highly dynamic and
interrelated. For example, physical late effects
can have social consequences, and changes in
B 436 Breast Cancer

Femininity and sexuality

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

Social relationships Physical symptoms

and roles Intimate partner and late effects
Pain
Family Loneliness

Social support Stigmatization Lymphedema

Participation Work Arm and shoulder

Financial stress function

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

social roles may bring emotional problems.
This entanglement is illustrated through exam-
ples in the text.
We focus on womens subjective perceptions
and patient-reported outcomes (PROs) but
also mention some proxies, where research
including PROs is sparse. For the more specific
effects of surgery and other treatment modalities,
we refer to the essay Breast Cancer Patients,
Surgery, and Quality of Life.
Description
Although breast cancer is not necessarily
immediately life-threatening, the diagnosis and
treatment can be a life-changing experience that
impacts on a womans QoL. Women may have
to deal with physical short- or long-term
consequences of treatment, emotional distress,
and existential concerns, as well as changed
roles in intimate relationships and everyday life.
Emotional and Cognitive Issues
This cluster describes aspects of the breast
cancer experience that have a strong emotional
component. Furthermore, we discuss cognitive
impairments. These issues are all in themselves
burdensome, and they can further interfere with
functioning in everyday life.
A diagnosis of breast cancer may be a shock,
triggering overwhelming feelings of fear,
uncertainty, and loss of control. Women go
through a process of emotional adaptation to
the changed life situation. Many experience
distress (i.e., emotional upset) or depressive
symptoms. Recently, research has pointed to the
heterogeneity in womens experience of distress
throughout the breast cancer trajectory.
Henselmans et al. (2010) identified four different
trajectories over the first year after diagnosis: 36 %
reported no distress, 33 % only experienced dis-
tress in the active treatment phase, 15 % started out
mildly distressed but reported increased distress in
the reentry and survivorship phase, and another
Breast Cancer
15 % experienced chronic distress. Thus, about
two thirds of women experience distress at some
point in the trajectory, and a subgroup of patients
has persistent problems. However, about one third
of women show a resilient pattern with no or only
minimal distress. Women high in mastery, that is,
with a strong sense of control over their lives, were
more likely to show a resilient pattern. Likewise,
psychosocial factors (such as use of avoidant cop-
ing strategies and poor social functioning) have
been identified as probably the strongest predictors
of depressive symptoms in this population.
Pain, physical disability, and further physical
factors also show modest associations (Bower,
2008), and younger women usually report more
or more severe symptoms (Howard-Anderson,
Ganz, Bower, & Stanton, 2012), whereas the
severity of the disease or treatment regimen is
less relevant (Bower, 2008).
Even years after diagnosis, a fear of recurrence
may linger on, that is, the fear that the disease
could recur or progress in the same organ or
a different area of the body. Koch et al. (2013)
suggest that fear of recurrence is experienced in
modest intensity by most survivors. The fear
seems to persist over an extensive period of
time after the initial diagnosis without significant
changes in intensity. However, fear of recurrence
is usually not experienced constantly but
triggered by symptoms or specific situations, for
example, follow-up care appointments.
Although many women experience distress
and symptoms of depression, mood disorders
are not as prevalent. In a large meta-analysis of
patients in oncological and hematological
settings, the prevalence of depression was 16 %,
adjustment disorder 19 %, and anxiety
disorders 10 % using the criteria of the Diagnostic
and Statistical Manual of Mental Disorders
(DSM) or the International Classification of
Diseases (ICD) (Mitchell et al., 2011).
Fatigue, a subjective lack of physical and/or
mental energy, is a common adverse effect of
cancer. Several medical, biological, demo-
graphic, and psychosocial factors are thought to
contribute to fatigue, and it is strongly correlated
with depressive symptoms (Bower, 2008). It can
interfere with usual activities and be a major
437 B
problem. In the majority of studies, 3060 % of
patients report moderate or severe fatigue symp-
toms. Fatigue usually increases among patients
undergoing radiation therapy or chemotherapy,
although it is typically more pronounced during B
chemotherapy. It usually decreases after treat-
ment completion (Bower, 2008) but may remain
a significant problem for a considerable minority
(2030 %). For 534 % posttreatment fatigue is
still a problem up to 5 years after treatment
completion (Minton & Stone, 2008).
A cancer diagnosis can result in the develop-
ment of sleep disturbances, and these may
significantly disrupt the general ability to
function. The prevalence of subjective sleep com-
plaints in women treated for breast cancer ranges
from 20 % to 70 %. However, longitudinal studies
are lacking and controlled studies are required to
determine the degree to which sleep problems in
these women differ from the problems in women
with no cancer history (Bower, 2008).
Cognitive impairments, such as impaired
memory and ability to concentrate, are common
among breast cancer patients. This phenomenon
is popularly known as chemo brain, because
the earliest cross-sectional studies from the
mid-1990s detected cognitive difficulties during
or after chemotherapy. However, later prospec-
tive studies with proper control groups have
shown cognitive deficits in women with breast
cancer already before start of chemotherapy
(Janelsins et al., 2011) indicating that cognitive
problems may be due to other factors, for
example, emotional distress because of the
cancer diagnosis. Studying this issue is complex,
and the literature is not consistent. Patients
subjective ratings of cognitive functions are
typically correlated with fatigue and a depressed
mood, but not with objective cognitive perfor-
mance as measured by neuropsychological tests.
A number of studies using such tests have
indicated impairments in cognitive function in
a subgroup of women that tended to improve
over time. However, the effects seem to be
modest in statistical terms (Bower, 2008).
Cognitive impairments may have a profound
effect on patients lives and interfere with daily
activities.
B 438
Issues Related to Femininity and Sexuality
The breast has been identified as an integral
component of a womans self-concept (Denieffe
& Gooney, 2011). It is related to the areas of
femininity and sexuality. Issues related to these
aspects are described in the following cluster.
The cancer diagnosis and prospect of surgery
that may disfigure or remove a breast can
challenge a womans self-perception. Some no
longer perceive themselves as complete women.
Some fear that they will not be able to attract or
keep a partner. Changed self-perceptions can be
related to treatment side effects such as weight
changes and hair loss (Bertero & Chamberlain
Wilmoth, 2007). For many women, chemother-
apy-induced hair loss ranks among the most
important side effects. It is often considered
unavoidable but transient. Yet, it can be
distressing and even traumatizing. As a visible
reminder of the disease it may also negatively
affect social interactions (Lemieux, Maunsell, &
Provencher, 2008).
The prevalence of problems related to body
image is difficult to determine, as assessment
instruments vary and no cutoff values have been
defined. Falk-Dahl et al. studied disease-free
women 26 years following treatment. They
defined poor body image as scores above the
70th percentile on the body image scale and
found that 31 % had a poor body image. Body
image was relatively stable over the following
3 years. Survivors were slightly more dissatisfied
with their body image than an age-matched
control group from the general population.
However, these differences were small and
not considered clinically significant (Falk Dahl,
Reinertsen, Nesvold, Fossa, & Dahl, 2010).
It is unclear whether a womans age and type
of surgery (breast-conserving surgery versus
mastectomy) are associated with body image
(Falk Dahl et al., 2010; Zimmermann, Scott, &
Heinrichs, 2010). Associations of distress/
depressive symptoms with poorer body image
are more consistent. Characteristics of
a womans partnered relationship also seem to
play a role: In one study women who were
happy in their relationship worried less about
their partners reactions to their appearance after
Breast Cancer
breast cancer. Likewise women whose partners
were happy in their relationship had
a more positive perception of their own appear-
ance (Zimmermann et al., 2010).
The importance of relationship characteristics
has also been pointed out in relation to sexual
functioning. One of the most consistent predic-
tors of sexual functioning following breast cancer
is the quality of the womans partnered relation-
ship (Gilbert, Ussher, & Perz, 2010). Sexuality
can be particularly complex after breast cancer.
Pain during intercourse, vaginal dryness,
decreased sexual interest or desire, decreased
sexual arousal, numbness in a previously sensi-
tive breast, difficulties achieving orgasm, and
lack of sexual pleasure have frequently been
described. Women undergoing chemotherapy
are at higher risk of disturbances in sexual func-
tioning than those not receiving this treatment.
Evidence regarding a possible link between type
of surgical treatment and sexual functioning is
inconsistent (Gilbert et al., 2010). To some extent
breast cancer survivors may attribute changes
typical in middle age to their cancer. In a survey
including 863 breast cancer survivors, one third
of women reported that breast cancer and its
treatment had had a negative impact on their sex
life. Nevertheless, the breast cancer survivors did
not differ from age-matched, healthy control
women on a standard measure of sexuality
(Meyerowitz, Desmond, Rowland, Wyatt, &
Ganz, 1999).
For younger women chemotherapy-induced
menopause, menopausal symptoms, and
infertility are important issues: 3373 % of
women under 50 reported undergoing a meno-
pausal transition with treatment. This was asso-
ciated with bothersome consequences, such as
vasomotor symptoms, sexual problems, and dis-
tress after treatment. Fertility concerns were
prominent for women with a desire to
have children (Howard-Anderson et al., 2012).
Physical Symptoms and Late Effects
This cluster focuses on problems in the breast,
arm, and shoulder area experienced by many
women treated for breast cancer. These problems
Breast Cancer
develop during or after treatment and can persist
for several years.
Pain following surgery and treatment is
common. In different studies prevalence rates
for pain in the arm and shoulder ranged from
9 % to 68 %; prevalence rates for pain in the
breast area ranged from 15 % to 72 % (Lee,
Kilbreath, Refshauge, Herbert, & Beith, 2008).
The symptoms tend to diminish with time after
surgery. However, a recent Danish survey of
3,253 breast cancer patients showed that persis-
tent pain and sensory disturbances remain signif-
icant problems 23 years after surgery (Gartner
et al., 2009): 47 % of patients reported pain, 13 %
of whom had severe and 39 % moderate pain.
Younger women aged less than 40 were 3.6 times
more likely to report pain than women aged
6069 years. Further, axillary lymph node dissec-
tion and radiotherapy were associated with
significantly more pain. There was no difference
in pain according to the surgical procedure
(breast-conserving surgery vs. mastectomy) or
use of chemotherapy.
Another frequent breast cancer-related
symptom is lymphedema, that is, swelling or
heaviness of the arm due to insufficient lymph
drainage. This chronic condition may occur any
time after treatment and can cause disfigurement,
physical discomfort, and functional impairment
(Stamatakos, Stefanaki, & Kontzoglou, 2011).
Gartner et al. (2010) found that the prevalence
of self-reported arm lymphedema varied from 13
to 65 % depending on the treatment received,
with axillary lymph node dissection and
radiotherapy being associated with more
problems. Further, young age was associated
with increased problems.
Related to pain and lymphedema, women may
experience restrictions in arm and shoulder func-
tion. The prevalence ranges from less than 10 %
to almost 70 % in different studies and depends
on method of assessment (measured or self-
reported), time since treatment, and type of treat-
ment: mastectomy leads to greater impairment
than lumpectomy, and radiotherapy likewise
impairs the functioning (Lee et al., 2008). Two
to three years after surgery, 47 % of women
reported light work above shoulder level as
439 B
problematic, and 27 % reported daily activity
with involvement of shoulder rotation as
troublesome (Gartner et al., 2010). These
restrictions can impact on social aspects, such as
participation in activities and work ability. B
Social Relationships and Roles
A diagnosis of breast cancer can influence an
array of social relations and contexts, involving
both a womans intimate relationship and family
roles, but also working life and participation in
other activities. These aspects are outlined here.
A womans experience of breast cancer may
depend heavily on her intimate partner, who often
provides support and participates in treatment-
related decisions. In turn, the patients experience
of cancer can also have a crucial influence on the
partners well-being. In a meta-analysis patients
and partners distress were significantly related
(r 0.29), possibly indicating that a couple reacts
as an emotional system rather than as individuals
(Hagedoorn, Sanderman, Bolks, Tuinstra, &
Coyne, 2008). Relationship processes and cou-
ples common coping with the breast cancer expe-
rience, such as emotional sharing and joint
problem-solving, can be a resource for both part-
ners to draw on. In line with this, it has been found
that in 42 % of couples both the patient and the
partner reported that breast cancer had brought
them closer to their partner (Dorval et al., 2005).
Further, divorce rates have not been found to be
higher for women with breast cancer than in the
general population, despite anecdotal information
about increased marital breakdown (Carlsen, Dal-
ton, Frederiksen, Diderichsen, & Johansen, 2007).
Similarly, social support from the larger
network is important and can have beneficial
effects. Regarding the womans family,
Bertero and Chamberlain Wilmoth (2007) have
described conflicting issues: The wish to protect
ones family from worry can interfere with the
wish to tell them the truth, especially the children.
Women reported the importance of the children
giving them love and treating them as the
mother they had always known. However, some-
times women felt stressed because the family
expected them to continue to manage the same
tasks (e.g., in the household) as they had done
B 440
before diagnosis. Women felt that their family
did not necessarily understand what they were
going through, especially once they seemingly
were back to normal.
The experienced lack of understanding can
also be prominent in other social contexts.
Rosedale (2009) describes it as survivor loneli-
ness, a unique and ongoing experience of isola-
tion. Feelings of loneliness may be triggered
when the women realize that others misunder-
stand how cancer has changed their lives or are
not aware of ongoing aspects of the breast cancer
experience, such as an approaching mammogram
or the anniversary of the diagnosis.
Womens participation in activities of daily
life and social activities may be restricted through
diagnosis and treatment. In the Gartner study
(2010) 24 % of women had to give up everyday
activities after treatment for breast cancer.
Another restraining factor is worry about the
stigma that may be attached to a diagnosis of
breast cancer both regarding the more visible
external signs of cancer such as hair loss and the
very diagnosis (Denieffe & Gooney, 2011;
Lemieux et al., 2008). The stigma attached to
cancer has diminished over the past decades.
Today women with breast cancer generally
receive acceptance and support from the larger
society. However, former negative attitudes still
linger on (Holland, 2002).
Work incapacity during treatment and the
return to work phases can cause concern. Women
are concerned with disclosing the diagnosis to
their employer and to colleagues. Although
a majority has been shown to feel that disclosure
had positive effects, it is an uncomfortable expe-
rience for some women and some even feel
pressured to leave their job. In the weeks before
returning to work, concerns about appearance,
productivity, disappointing the employer, and
job loss are prominent. Most women wish to
regain their normal life after treatment but
may be hindered by concentration and arm prob-
lems or fatigue (Tiedtke, de Rijk, Dierckx de
Casterle, Christiaens, & Donceel, 2010). In the
Gartner study (2010), 36 % of working women
reported that their work had been affected after
the treatment for breast cancer. A supportive
Breast Cancer
work environment can help the women to adapt
to these challenges (Tiedtke et al., 2010). In
a registry-based study, women had an increased
risk for unemployment during the first 3 years
after their cancer diagnosis, but after 3 years the
risk for unemployment was not elevated com-
pared with the non-cancer population (Carlsen,
Dalton, Diderichsen, & Johansen, 2008).
Occupational changes may be some of the
many factors that can cause financial burden
when diagnosed with breast cancer. In a large
Irish study of cancer survivors, primarily
women treated for breast cancer, 49 % reported
financial stress, that is, they stated that the cancer
diagnosis had made it more difficult for them to
make ends meet. A total of 32 % reported finan-
cial strain, that is, concerns about the household
financial situation since the cancer diagnosis.
Those reporting cancer-related financial stress
and strain were at increased risk of anxiety and
depression (Sharp, Carsin, & Timmons, 2012).
Existential Issues
This last section is concerned with the existential
and spiritual aspects that may be triggered by the
experience of breast cancer and its potential
threat to life.
When confronted with a diagnosis of breast
cancer, women become aware of their own
mortality. The threat to life and fear of death
prompts many women to reconsider their lives.
They may feel a need to search and find answers
to existential questions (Bertero & Chamberlain
Wilmoth, 2007; Denieffe & Gooney, 2011).
Bertero and Chamberlain Wilmoth have
described how diagnosis and treatment led many
women to a life review: The women analyzed
accomplishments in life and reordered life
priorities. Certain things were no longer taken
for granted; ordinary events in everyday life
grew in importance, and women chose not to
waste their energy on minor, irritating matters.
Women also tried to make meaning out of the
breast cancer experience. This could give their
lives a sense of purpose and was part of a larger
redefinition of the self, including the experience of
new inner power and growth. For some women this
also involved a spiritual reflection. Some stated
Breast Cancer
that having faith made them realize the value of
their life and that they had the strength to handle
this situation (Bertero & Chamberlain Wilmoth,
2007; Denieffe & Gooney, 2011).
The positive changes that may be part of
a traumatic experience can be summed up
with the term posttraumatic growth. Cancer survi-
vors commonly report changes in three life
domains: changes in the self (e.g., feeling
stronger), changes in interpersonal relationships
(e.g., strengthened ties with other people), and
changes in spirituality or the philosophy of life
(e.g., a greater appreciation of what one has).
Some researchers view posttraumatic growth as
the result of the struggle against the adverse
event. Adverse events shatter ones basic beliefs
and are thus the basis for identity change. Others,
however, consider posttraumatic growth illusory,
arguing that the changes are not real though they
do represent a means of reducing the distress pro-
duced by the threat of cancer. For posttraumatic
growth to occur, the persons subjective perception
of threat and uncertainty seems to be more impor-
tant than objective rates of illness severity.
Sociodemographic factors, such as younger age
at diagnosis, also seem to play a minor role
(Sumalla, Ochoa, & Blanco, 2009).
Concluding Remarks
This essay has surveyed salient aspects of
HRQoL for women treated for breast cancer.
The range of issues has been illustrated by
a model consisting of five broad clusters
(Fig. 1). The five clusters are not exhaustive but
highlight particularly relevant aspects. We left
out interventions to improve HRQoL and aspects
of HRQoL specific to the terminal phase. The
interrelations between the aspects in the model
are complex and indicated through examples.
Our model highlights femininity and sexuality
and existential issues. These aspects are
important in the context of breast cancer, but
less visible in the generic classification into
physical, mental, and social well-being.
The existing literature has some methodologi-
cal limitations. Because of a baseline prevalence
in the general population it is important to include
a control group in order to determine the degree to
441 B
which the breast cancer experience causes certain
problems, such as sexual problems or fatigue.
Some problems may erroneously be attributed to
breast cancer. Recall bias is a challenge in retro-
spective study designs. Further, a wide variety of B
methods of assessment and study designs impedes
comparisons between studies.
We can, however, conclude that women may
encounter many different aspects of HRQoL in the
trajectory of breast cancer. Breast cancer touches
specifically upon issues related to femininity and
sexuality. Women react differently, but some gen-
eral patterns can be identified. Many women expe-
rience distress and related problems at some point,
but most adapt well in the long term. Yet, for
a considerable number of women pain, lymph-
edema or similar physical late effects of treatment
persist for years and may impact on everyday life.
Breast cancer seems to be more disturbing for
younger than for older women, for example,
concerning pain, depression, fertility issues, and
family roles. Strong social relationships, a sense of
mastery over ones life, and other psychosocial
resources seem to foster adaptation. Many
women go through a process of existential
reorientation that may lead to a different outlook
or appreciation of life following the experience of
breast cancer.
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Breast Cancer and Adaptation
Breast Cancer
Breast Cancer Patients, Surgery, and Quality of Life 443 B
Breast Cancer and Body Image Breast Cancer Femininity
and Sexuality
Breast Cancer
Breast Cancer B

Breast Cancer and Depression

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

Brenda den Oudsten1, Jan Anne Roukema2 and

Jolanda De Vries3
1
Breast Cancer and Emotional Department of Medical Psychology, Tilburg
Sharing University, Tilburg, The Netherlands
2
Tilburg University, Tilburg, The Netherlands
Breast Cancer 3
Department of Medical Psychology, Tilburg
University St. Elisabeth Hospital, Tilburg,
The Netherlands

Breast Cancer and Fatigue

Synonyms
Breast Cancer
Breast carcinoma/breast neoplasm; Breast-
conserving therapy/lumpectomy; Mastectomy;
Surgery/ablation/resection/operation
Breast Cancer and Financial Stress

Breast Cancer Definition

Breast cancer or breast neoplasm, or breast

Breast Cancer and Intimate Partner carcinoma is a malignant growth that begins
Support with tissues in the breast, usually the ducts (i.e.,
the tubes that carry milk to the nipple) and lobules
Breast Cancer (i.e., the glands that make milk). Cancer is
a disease in which abnormal cells grow in an
uncontrolled way.
Quality of life (QOL) is often interchange-
Breast Cancer and Sexual ably used with terms, like health status (HS) and
Functioning health-related quality of life (HRQOL). How-
ever, although the concepts overlap, there are
Breast Cancer different features which make them distinct
(Van der Steeg et al., 2008). There is a debate
on how to conceptualize QOL. If one adopts
a critical approach, then a large number of
Breast Cancer and Spirituality published studies actually have not assessed
QOL, but have measured related concepts, such
Breast Cancer as HS and/or HRQOL.
 B
Breast Cancer Patients, Surgery, and Quality of Life, Table 1 Overview of studies on (HR)QOL and HS after surgical treatment of breast cancer (20082012)
Sample
Author Concept Study design size Instruments Findings
444

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

functioning, emotional functioning, sexual functioning, and sexual

enjoyment
Van Esch HRQOL Prospective (assessment before diagnosis, six and 12 n 223 EORTC- Trait anxiety was the only factor that significantly and negatively
et al. months after surgery) QLQ-BR predicted body image, future perspective, and sexual functioning at 6 and
(epub) 23 12 months after surgery, implying that other factors such as disease stage
and treatment have less impact on HS than this personality trait. Type of
surgery had a significant relation with body image: women that had BCT
had a better body image than women that had MTC, during the 12 months
after surgery. Women with BCT had more arm symptoms
Freitas- HS Cross-sectional (assessment at least 6 months after N 70 SF-36 No difference in HS was found between women who received BCT or
Silva et al., completion of oncological treatment and free of MTC and immediate breast reconstruction
2010 disease)
445
B

B
B 446
In general, definitions of QOL emphasize that
it is a multidimensional concept representing
(at least) the physical, psychological, and social
domains. QOL represents subjective evaluations
of oneself, ones social and material world, and
reflects the extent to which the individual is sat-
isfied with them or is bothered by problems in
those areas. In line with this principle, the World
Health Organization Quality of Life Group
(WHOQOL Group, 1995) defined QOL as an
individuals perception of his/her position in life
in the context of the culture and value systems in
which he/she lives and in relation to his/her goals,
expectations, standards, and concerns. It is
a broad-ranging concept incorporating in
a complex way the persons physical health, psy-
chological state, level of independence, social
relationships, personal beliefs, and their relation-
ship to salient features of the environment
(p. 1,405). Thus, this concept is more than just
physical, psychological, and social functioning/
well-being.
Compared to QOL, both HS and HRQOL
focus more exclusively on health aspects
(De Vries, 2001; de Vries & Drent, 2007):
HS reflects solely the functioning in the phys-
ical, psychological, and social domains and
does not focus on the subjective satisfaction
of the individual, whereas QOL revolves
entirely around the contentment with func-
tioning. Patients are asked about their physical
possibilities, state of mind, and social activi-
ties (e.g., Are you able to walk 100 m?).
HS questionnaires usually employ a negative
approach (e.g., ask patients about fatigue),
while (HR)QOL questionnaires also use the
positive approach (e.g., assess patients
energy levels).
HRQOL reflects QOL in relation to the impact
of disease and treatment of patients. Thus,
HRQOL is QOL, but restricted to the physical,
psychological, and social domains of health.
Individual expectations about health, ambi-
tions that one can no longer realize, the capacity
to cope with limitations, the tolerance threshold
for discomfort, and the attitude toward
disease play an important role in QOL. As
a consequence, two persons can have identical
Breast Cancer Patients, Surgery, and Quality of Life
restrictions in functioning (HS), but evaluate
them differently in terms of (HR)QOL. For
instance, not being able to climb stairs does not
mean that the QOL is also impaired.
Description
Breast cancer is the most frequently diagnosed
cancer in women in the developed countries.
When breast cancer is diagnosed in an early
stage, i.e., a tumor smaller than 5 cm in diame-
ter, no metastases beyond the axilla, and a breast
that is large enough in relation to the tumor size,
women can choose between breast-conserving
therapy (BCT) and mastectomy (MTC). BCT
refers to lumpectomy and a staging operation
of the axillary lymph nodes followed by radia-
tion therapy of the remaining breast. In MTC,
all breast tissue, including the nipple, is
removed, and a staging operation is performed
on the axillary lymph nodes. Depending on the
tumor characteristics and the presence of axil-
lary metastases, surgery can be followed by
adjuvant chemotherapy, hormonal therapy,
and/or radiation of the area around the collar
bone. BCT and MTC have proven to be equal
with respect to long-term survival, although
disease-free survival is somewhat less after
BCT. Besides BCT and MTC, it is possible to
undergo MTC with (immediate) breast recon-
struction. In recent years, BCT has become an
alternative to mastectomy. Most women with
early-stage BC have a choice between these
two surgical options, which have equivalent sur-
vival rates (Fisher et al., 2002; Litiere et al.,
2012; Veronesi et al., 2002). However, this deci-
sion is not easy to make. Therefore, concepts
like QOL are important because they can inform
surgeons and patients in the decision-making
process of determining which treatment options
to use.
HRQOL and HS have been studied exten-
sively in breast cancer patients; also, the effects
of surgical treatment on QOL, HRQOL, and HS
have been addressed. The results are inconsistent
(Pockaj et al., 2009). This may be partly due to
differences in conceptualization of QOL and the
Breast Cancer Patients, Surgery, and Quality of Life
subsequent choice of instruments. Other reasons
for inconsistent findings are small sample sizes
from select populations, the lack of baseline char-
acteristics, cross-sectional studies, and
a relatively short follow-up, up to 2 years after
treatment.
Several meta-analyses (e.g., Moyer 1997;
Goodwin et al., 2003) and (systematic) reviews
have been performed on (HR)QOL and HS in BC
(e.g., Chen et al., 2010; Kiebert, de Haes, & van
de Velde, 1991; Pockaj et al., 2009). For these
meta-analyses and systematic reviews, one could
conclude that there is no solid proof of a better
(HR)QOL after BCT compared to MTC. How-
ever, the results with respect to some
subdomains, such as body image and sexual
functioning seemed to favor the use of BCT
(Kiebert et al., 1991; Goodwin et al., 2003).
The present manuscript shows an overview of
the studies comparing BCT and MTC (with breast
reconstruction) on HR(QOL) and HS from 2009
to 2012. Studies before this time period can be
found in the four review articles mentioned.
QOL After Surgical Treatment
In the prospective study of van der Steeg, de Vries
and Roukema (2010), scores on the facet overall
QOL and the separate domains (i.e., Physical
Health, Psychological Health, Social Relation-
ships, and Environment) of the WHOQOL-100
did not show significant differences between the
BCT and MTC (Van der Steeg et al., 2010).
Compared with the reference scores (derived
from the WHOQOL manual), the BCT group
scored higher in the psychological domain
(p < 0.001). There were no other differences
(Van der Steeg et al., 2010). In general, these
findings are in line with two cross-sectional studies
(He et al., 2012; Rabin et al., 2008). Specifically,
these studies also found that women with BCT
scored better on the WHOQOL-Bref domains
Physical Health and Psychological Health (Rabin
et al., 2008), as well as the FACT-C subscale
Social Adjustment (He et al., 2012).
HRQOL and HS After Surgical Treatment
Three studies examined the role of surgical
treatment with EORTC-QLQ C30 and the
447 B
cancer-specific module EORTC-QLQ-BR 23,
which measures mainly symptoms but also con-
tains one general item on QOL. The findings are
somewhat inconsistent. Van Esch et al. (2011)
showed that women with BCT had a better body B
image than women that had MTC, during the
12 months after surgery. Arm symptoms were
more often reported by women with BCT. Shi
et al. (2011) found that women treated with
BCT score better on role functioning, emotional
functioning, cognitive functioning, and body
image during a two-year follow-up period.
Arndt, Stegmaier, Ziegler and Brenner (2008)
found that the differences between BCT and
MTC on global health/QOL and social function-
ing gradually increased overtime. These differ-
ences became statistically significant at 5 years
after diagnosis/treatment. Women treated with
MTC showed a greater decline in global health/
QOL scores than women treated with BCT.
After controlling for potential confounders,
women with BCT reported better physical and
role functioning, were sexually more active, and
were more satisfied with their body image com-
pared with women treated with MTC already at
one year after diagnosis. No difference in HS,
assessed with the SF-36, was found between
BCT and MTC in women who completed
their cancer treatment at least 6 months (Freitas-
Silva, Conde, de Freitas-Junior, & Martinez,
2010).
Breast Reconstruction and (HR)QOL/HS
One prospective study evaluated the impact of
breast reconstruction using a single-stage,
microsurgically transferred, muscle-sparing
transverse rectus abdominis myocutaneous (MS-
TRAM) flap or a deep inferior epigastric artery
(DIEP) flap on QOL (Zhong et al., 2012). Com-
pared to preoperative scores, the BREAST-Q
subscale scores breast, sexual well-being, and
psychosocial well-being improved significantly
postoperatively. However, the physical well-
being of the chest and abdomen deteriorated
significantly 3 weeks after reconstruction. At
3 months after reconstruction, both subscale
scores improved significantly. The effectiveness
of immediate versus delayed reconstruction
B 448
following surgery for BC is still unclear
(DSouza, Darmanin, & Fedorowicz, 2011).
Other Factors that Affect (HR)QOL/HS
Several prospective studies have now shown the
influence of trait anxiety on overall QOL, espe-
cially in women treated with BCT (Van der Steeg
et al., 2011; Van der Steeg et al., 2010). When
women were divided into four groups based on
their scores on trait anxiety (high versus low) and
surgical treatment (BCT versus MTC), trait
anxiety turned out to have more impact on
QOL than surgical treatment. For the women
treated with MTC, the personality trait neuroti-
cism significantly influenced the overall QOL,
and, again, this influence exceeded the influence
of surgical treatment. However, the effect of neu-
roticism on overall QOL was not as strong as the
effect of trait anxiety.
The role of lymphedema secondary to axillary
dissection, chronic pain, impaired range of motion,
and decreased muscle strength occurs quite fre-
quently (i.e., up to 51 %; Pockaj et al., 2009).
The extent to which such complications play
a significant role in (HR)QOL is not well
documented (Pockaj et al., 2009). One study
examined the QOL in patients after axillary
lymph node dissection and sentinel lymph node
biopsy and found that patients who had an axillary
lymph node dissection experienced more shoulder
symptoms, limitations in daily life, and imposed
more restrictions on themselves than patients with
sentinel lymph node biopsy. However, no signifi-
cant differences during physical examination were
found. A decreased range of motion and a higher
score on trait anxiety resulted in a lower QOL
(Aerts et al., 2011).
Conclusion
Numerous studies have been performed to eval-
uate (HR)QOL and HS; however, pure QOL is,
compared to the other concepts, less often stud-
ied. Although the available studies often are lim-
ited by methodological concerns, it seems that
BCT does not outperform MTC in providing
a better QOL. Also, immediate breast reconstruc-
tion after MTC does not demonstrate an improve-
ment in HRQOL.
Breast Cancer Patients, Surgery, and Quality of Life
Cross-References
Anxiety
Body Image
Breast Cancer
Cognitive Function
Meta-analysis
Oncology
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B 450
BR-I
Bereavement Response Scale
Bribe Payers Index (BPI)
Corruption
Brief Derogatis Psychiatric Rating
Scale (BDPRS)
Derogatis Psychiatric Rating Scale (DPRS)
Brief Symptom Inventory (BSI)
Methadone Treatment for Opiate-Dependent
Persons
BR-II
Bereavement Response Scale
Brundtland Commission (World
Commission on Environment and
Development)
Noriko Kono
Padeco Co., Ltd, Minato-ku, Tokyo, Japan
Address
The Brundtland Commission, also known as the
World Commission on Environment and Devel-
opment (WCED), disbanded in 1987. In the
United Nations, it is also called the UN Special
Commission on the Environment.
BR-I
Brief History
The aim of the Brundtland Commission was to help
direct the nations of the world towards the goal of
sustainable development. The commission is also
known as the World Commission on Environment
and Development (WCED). It operated from
1984 to 1987. The commission published its results
in the Brundtland report in 1987. Thereafter,
sustainable development became an important
concept in the vocabulary of politicians, practi-
tioners, and planners (WCED, 1987; Burton,
1987).
The report by the Brundtland Commission
developed the most widely used definition of
sustainable development as development
which meets the needs of current generations
without compromising the ability of future gen-
erations to meet their own needs (WCED, 1987).
The idea of sustainable development emphasized
lifting those at the base of the economic pyramid
to higher standards of living. Simultaneously, it
promoted decoupling environmental degradation
and economic prosperity.
After the commission presented the idea of
sustainable development, the phrase often
was discussed alongside the idea of quality of
life. For example, the UK government
published A Better Quality of Life:
A Strategy for Sustainable Development for
the United Kingdom in 1999 (DETR, 2000)
and claimed that the core of sustainable devel-
opment is the simple idea of ensuring a better
quality of life for everyone, now and for gener-
ations to come. Similarly, the sustainable
development act of the government of Quebec
stipulated quality of life in its first principles
(PoQ, 2002). It declared that human health and
improved quality of life are at the center of
sustainable development concerns.
The foreword of the Brundtland report
declared that What is needed now is a new era
of economic growth- growth that is forceful
and at the same time socially and environmen-
tally sustainable. It emphasized the importance
of economic growth, which is coexistent with
social and environmental sustainability.
A famous report by Max-Neef (1995) asserts
Brundtland Commission (World Commission on Environment and Development)
that when a certain level of economic growth
is increasing, there exists a great level of thresh-
old which the quality of life is declining. There-
fore, careful attention should be paid to attain
both sustainable development and quality
of life.
Activities/Major Accomplishments/
Contributions
Led by Madam Gro Harlem Brundtland, the com-
mission initiated international discussions on
how to reconcile the environmental and social
justice challenges created by uneven economic
development. It held hearings and made site visits
to diverse locations such as Canada, Japan, and
the Soviet Union. Its initiatives to consult widely
were considered a notable contribution during the
time of the Cold War. Its work made contribu-
tions to introducing inclusive discussion styles
open to all nations in considering environmental
problems (Encyclopedia Britannica, 2012).
The widespread publicity around and interest in
the commission helped to make the phrase sustain-
able development an important vocabulary addi-
tion for politicians, administrators, and planners.
In defining sustainable development as develop-
ment which meets the needs of current generations
without compromising the ability of future gener-
ations to meet their own needs, the commission
changed the terms of the development debate by
making economics compatible with environmen-
tal concerns (UNECE, 2012). It stated that eco-
nomics and environment were closely linked and
that economic development and reduction of
poverty were essential to protecting the environ-
ment. Where previous approaches to economic
growth expected environmental and social costs,
the concept of sustainable development promoted
the idea of a three-legged school where elements
were balanced (Venkataraman, 2009).
The commission led to the United Nations Con-
ference on Environment and Development
(UNCED), a 2-year series of preparatory meetings
culminating in the Earth Summit in Rio de Janeiro,
June 1992. The meeting followed up on the Stock-
holm Conference in 1972, an earlier event where
451 B
world leaders discussed environmental and devel-
opment issues (The Regeneration Project, 2012).
The Brundtland report and the United Nations
concomitant events made governments world-
wide begin to examine their programs and poli- B
cies to find ways to promote sustainable
development. In this process of focusing on sus-
tainable development, consumers were encour-
aged to redefine the meaning of quality of life
and separate it from the economic concept of
standard of living.
Cross-References
Sustainability
Sustainable Development
Sustainable Development Indicators
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B 452
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Brunswikian Model
Self-Confidence
Building Adaptive Capacity
Community Adaptation, Arctic
Building Organizational Capacity
with Community Collaboratives
Anne M. Izod1, Zheng Yang2 and Mary C. Hano2
1
Department of Public Administrtation, North
Carolina State University, Raleigh, NC, USA
2
North Carolina State University, Raleigh,
NC, USA
Definition
Organizational capacity as described in this con-
text by Nowell and Foster-Fishman (2011) refers
to an organizations knowledge and awareness of
systems, issues, and information; the organiza-
tions social capital; and the organizations
opportunity and impact.
Description
Despite academic interest in understanding the
impact of community collaboration on organiza-
tional capacity, there are few studies present in the
literature that present a method for analyzing these
benefits as the targeted intermediate outcome.
Nowell and Foster-Fishman (2011) offer one of
Brunswikian Model
the first empirically validated frameworks for con-
ceptualizing dimensions of organizational capac-
ity that can be enhanced as an outcome of
collaborative membership. The Nowell and
Foster-Fishman (2011) framework was developed
based on a mixed methods study of 51 multi-sector
midwestern collaboratives formed to improve
their communities responses to domestic vio-
lence. Through asking key informants to describe
the different ways in which involvement in
a collaborative enhances or reduces the capacity
of involved organizations, three types of mutually
reinforcing outcomes were identified:
(1) increased knowledge and awareness, des-
cribed as an enriched awareness of the complex
dynamics of problem domain, increased staff
understanding of their organizations role within
that system, and better access to general informa-
tion and feedback related with their work;
(2) expanded social capital, described as
improvements in an organizations reputation
among other participating organizations as well
as other organizations becoming more accessible
and responsive to their needs; (3) enhanced orga-
nizational opportunity and impact, an organiza-
tions enhanced ability to attain resources, resolve
problems, fulfill missions, utilize services, and
increase influence in important decision-making
processes. The original three-dimension frame-
work was modified in the second phase of the
empirical study to include resource acquisition
as a separate dimension after confirmatory factor
analysis was used to test the fitness of the model,
and the overall pattern of fit statistics for the four
factor model suggests adequate fit.
Nowell and Foster-Fishman (2011) also inves-
tigated potential negative impacts to organiza-
tional capacity in both phases of their study
but found these impacts to be infrequent and
described as minor. Informants in phase
one mainly mentioned the potential downside
of strengthened relationships, including
a heightened level of accountability to other
stakeholders, the potential for lines of confiden-
tiality to be crossed, and the potential for the
work of the collaborative to compete for grants
with service providers. In phase two, negative
impacts mentioned were a perceived lack of
Building Organizational Capacity with Community Collaboratives
respect within the collaborative for ones organi-
zation and having ones organization more
exposed to scrutiny by other organizations.
In examining the relationship of organizational
characteristics and their representatives to each
outcome, the study found that there were no sig-
nificant differences between public, for profit, non-
profit, and community-based groups for building
organizational capacities. However, management
level, depth of involvement, and representative
experience and expertise are significant predictors
in one or more categories of capacity building for
collaboratives member organizations. Executive
directors were found to report significantly greater
outcomes related to social capital and knowledge
and awareness relative to program staff. Also,
when organizations had been with the collabora-
tive longer and when representatives held leader-
ship positions and attended meetings more
frequently, participants reported greater outcomes
related to expanded knowledge and awareness,
increased social capital, and enhanced opportuni-
ties and impact. In addition, when representatives
perceived their collaboratives leadership and
decision-making practices as effective, they also
reported greater positive impact to their organiza-
tion as a result of their participation in the collab-
orative. Thus, in addition to identifying what kinds
of organizational capacity outcomes and negative
impacts may result from involvement in collabo-
ratives, findings from this study help to show some
characteristics that may be associated with receiv-
ing the greatest benefit out of ones membership.
Discussion
There have been a few other studies published
since 2010 that have also examined the impacts
on an organizations capacity as a result of its
participation in a community collaborative.
While Nowell and Foster-Fishmans
(2011) framework was developed in the context
of study domestic violence collaboratives,
these findings support the benefits since
discussed elsewhere. A study published in 2011,
which is based on a survey between 2008 and
2010 on 131 Communities Empowering Youth
(CEY) grants and over 500 associated partner
organizations, found that through working
453 B
together, organizations participating in CEY
achieved or improved within the four organiza-
tional capacity domains that the study measured:
(1) leadership development, (2) organizational
development, (3) program development, and B
(4) community engagement. Partner organiza-
tions reported some statistically significant
increases in all four capacity domains, and lead
organizations reported some increases in three
domains (Francis et al., 2011). In addition, Fetsch
and DeBasio introduced a study examining how
a unique model of collaborative partnership
between two major nursing organizations, the
Greater Kansas City Area Collegiate Nurse
Educators and the Kansas City Area Nurse Exec-
utives, has enhanced organizational efficiency
and efficacy between the groups, which has
directly benefited the organizational members
(Fetsch & DeBasio, 2011). Lastly, Anderson-
Butcher et al. introduced the Ohio Community
Collaboration Model for School Improvement
(OCCMSI) which is a new genus of district and
school improvement models that connects part-
nerships with other organizations and new work-
ing relationships with families, community
leaders, and youths. Their study found that key
capacities were developed by six schools and six
districts piloting the OCCMSI based on
a qualitative research, the changes including
leveraging family and community resources for
learning, healthy development, and overall
success in school (Anderson-Bucher et al., 2010).
The development of a framework for under-
standing and measuring these intermediate out-
comes is a key addition to both practice and
future research. Furthermore, the finding that
collaboratives in this study were able to promote
both issue and system awareness has particularly
significant implications for practice.
Cross-References
Community-Based Planning
Community Capacity Building
Community Planning
Community-University Partnership(s)
B 454
National Neighborhood Indicator Partnership
Pornography and Mens Attitudes Supporting
Violence Against Women
Public Attitudes Toward Partner Violence
Against Women
Violence Against Women
References
Anderson-Butcher, D., Lawson, H., Iachini, A., Bean, G.,
Flaspohler, P., & Zullig, K. (2010). Capacity-related
innovations resulting from the implementation of
a community collaboration model for school improve-
ment. Journal of Educational and Psychological
Consultation, 20(4), 257287.
Fetsch, S. H., & DeBasio, N. O. (2011). Academic service
partnerships: Organizational efficiency and efficacy
between organizations. Journal of Professional
Nursing, 27(6), e82e89.
Francis, K., Minzner, A., Fisman, L., Fox, L., &
Fink, B. (2011). Building non-profit capacity and com-
munity partnerships: Findings from the Communities
Empowering Youth (CEY) evaluation Final Report,
OPRE Report # 201135. Washington, DC: Office of
Planning, Research and Evaluation, Administration for
Children and Families, U.S. Department of Health and
Human Services.
Nowell, B., & Foster-Fishman, P. (2011). Examining
multi-sector community collaboratives as vehicles for
building organizational capacity. American Journal of
Community Psychology, 48(34), 193207.
Built Environment
Adriana Araujo Portella
Faculty of Architecture and Planning, Federal
University of Pelotas, Brazil
The Bartlett School of Planning at University
College London, London, UK
Joint Centre for Urban Design at Oxford Brookes
University, Oxford, UK
Synonyms
Built form; City environment; Physical environ-
ment; Streetscape; Urban environment
Built Environment
Definition
Built environment is a general concept that can
be related with all the structures built by man to
support human activity. This term comprises
everything that is physically part of a city,
a town, or village, such as buildings, roads,
squares, parks, sidewalks, commercial signage,
street furniture, and so on (see Fig. 1). We need
to take into account that, in most cases, we eval-
uate the built environment in terms of its visual
quality, and it is the aspect that makes better cities
and urban spaces. In this sense, the built environ-
ment can contribute to making peoples life
a pleasure or a pain. This entry attempts to focus
on the visual quality to understand the impor-
tance and the impact of the built environment in
peoples quality of life in order to help further
discussion in the fields of architecture, planning,
urban design, and environment psychology.
Description
The process of user evaluation of the built envi-
ronment involves two principles: perception and
cognition. Perception is related to the process
by which users get visual information of places
through stimuli. In city centers, for example,
these stimuli are physical elements of public
spaces, such as commercial signs, shapes and
colors of buildings, street furniture, and so on.
Cognition does not need to be related directly to
visual stimuli linked to physical characteristics of
places. The cognition process concerns symbolic
meanings associated with places and can be
influenced by the users urban context, values,
culture, and individual experiences. This defini-
tion agrees with the statement by Meader, Uzzell,
and Gatersleben (2006, p. 61): people do not
perceive the environment through clear eyes,
but through perceptual lenses coloured by their
world view.
An approach suggested by Lang (1987, p. 191)
says that the process of perception and cognition
of the built environment involves three
interlinked factors: (1) multisensorial perception,
(2) symbolic meanings, and (3) the relationship
Built Environment
Built Environment,
Fig. 1 The diversity of the
built environment of the
City of York in England
(Source: Author)
between these symbolic meanings and the phys-
ical characteristics of the built environment. In
this way, user perception involves more than
a mere intellectual association related to an
observed object; this is also linked with the cog-
nitive process from the first stage. The result of
the processes of perception and cognition consti-
tutes the mental representation of the built envi-
ronment, and this representation is what people
evaluate as positive or negative when the built
environment is analyzed. In other words, we do
not see the built environment itself but the image
that it has in our minds (see Fig. 2). This image
can be positive or negative depending on how the
parts that form the built environment are
organized.
Formal and symbolic factors influence judg-
ments of the built environment. In this case, the
character of city can be built by physical charac-
teristics of building facades and symbolic mean-
ings attributed to these by users. For example, the
character of the city centers of New York and Las
Vegas in the United States is formed by physical
and nonphysical elements of the urban space
related to shopfronts, advertisements, buildings,
landscape, and so on. According to Kelly and
Kelly (2003, p. 16), New York can be described
455 B
B
in the following way: it is the quiet and the
noise; the street signs and the street art; the orga-
nized trip and the unexpected discovery; the sky-
scrapers and the green space.
Taking an architectural approach, formal fac-
tors refer to the physical characteristics of ele-
ments that compose the built environment; they
concern appreciation of shapes, rhythms, com-
plexities, and sequences of the visual world,
although they can also be extended to a sonic,
olfactory, and haptic dimension (Lang in Nasar,
1988, p. 11). As defended by Lang (2005,
pp. 9798) and Curran (1983, p. 125), the per-
ceived quality of a city is very much dependent
on the visual quality of its streets, which depends
on formal factors such as lengths of blocks, cross
sections, widths of roadbeds and sidewalks,
building setbacks and heights, frequencies of
entrances to buildings, presence or absence of
shop windows and shopfronts, and so on. Sym-
bolic factors are related to the cognition process
and involve connotative meanings that users
associate with places (Nasar, 1988, p. 3; Lang,
1987, pp. 188215). They are constituted by dif-
ferent, but overlapping, images and interpreta-
tions, which can vary among individuals (Rogers,
1992, p. 245). Kong and Yeoh (2004, p. 2) argue
B 456
Built Environment, Fig. 2 The process of mental representation of the built environment (Source: Author)
that people are active participants in the process
of making places and meanings attributed to the
built environment.
Visual Quality in the Built Environment
The concept of visual quality in the built environ-
ment is related to the level of order among the
physical elements of built space such as the fea-
tures of buildings, roads, sidewalks, and commer-
cial signs. Weber (1995, p. 113) describes the
following relationship: the more orderly
a configuration, the higher its aesthetic
value (see Fig. 3). According to Gestalt psychol-
ogy principles, high visual quality of public
places consists in the good form or pragnanz
of the city. Good in this case concerns how
elements in an aesthetic composition are related
to each other such as regularity, orderliness, sim-
plicity, symmetry, and so on, which then refer to
specific Gestalt laws. Places where there is no
aesthetic conflict between their physical elements
are recognized as having high visual quality or
high order. On the other hand, low visual quality
is linked to disordered places. According to Lang
(1987, p. 189): a disordered environment is one
where the relationship of components to each
other is purely haphazard and not governed by
some overall principle.
Weber (1995, p. 109) and Arnheim (1977,
p. 162) argue that order is an indispensable aspect
in all kinds of configuration (physical and
mental). According to these authors, ordered
compositions cause positive reactions on user
Built Environment
perception and evaluation of the built environ-
ment. Although user evaluation can be influenced
by particular experiences, preferences, and feel-
ings, the perception of order is evaluated as pos-
itive by almost all people. Nasar (1998, p. 260)
defends that an ordered built environment will
always be evaluated positively by people who
live in different cultures and physical environ-
ments. On the other hand, disordered public
spaces will always be evaluated negatively
because, when people are exposed to a series of
disconnected aesthetic elements (such as com-
mercial signs, buildings, and urban furniture), it
provokes user saturation. This saturation experi-
ence means that people lose the enjoyment of
variety, and their senses become insensitive to
the succession of visual stimulus without order
(Lozano quoted in Nasar, 1988, p. 405).
The importance of high visual quality in the
built environment is analyzed in several studies
(Herzog, 1992; Nasar, 1988; Russell & Ward,
1981; Stamps, 2000; Weber, 1995). These studies
support the argument that built environment
influences human behavior, and they also identify
aesthetic compositions of buildings evaluated
positively and negatively by users. According to
Kelly and Kelly (2003, p. 9), the importance of
high visual quality is also emphasized because it
promotes safe, better behavior from users and can
create interaction between people and local
authorities in order to get a better sense of com-
munity. Lang (2005, p. 75) says that the visual
quality of built environment is essential to
Built Environment
Built Environment,
Fig. 3 An example of
a well-ordered built
environment: City of Ouro
Preto in Brazil (Source:
Author)
experiencing cities and the perceptions of their
quality; the high visual quality of places built by
street morphology, squares, parks, and buildings
that face public areas forms the international
images of global cities such as London, Paris,
and Singapore. In addition, Gehl (2001) argues
that the extent and character of outdoor life can be
influenced by physical planning, stating that there
is a relationship between outdoor visual quality
and outdoor activity. In this regard, the visual
quality of built environment influences the
users evaluation of the functions of cities (such
as places of leisure, work, or for passing through)
and affects how people use the city, how long
individual activities last, and which activity types
may develop (Hass-Klau, Crampton, Dowland, &
Nold, 1999, pp. 2527).
Urban design principles can help to increase
the visual quality of built environment. Sherlock
(1991) suggests that cities need to have decent
environments, without which people and their
activities will eventually melt away. According
to him, the expression decent environment
does not simply mean pleasant buildings. This
term has to mean that users feel pleased and
interested with the appearance of streetscapes
(Sherlock, 1991, pp. 164165). For example,
Sherlock demonstrates that people like shopping
457 B
B
in ordered areas, and treatment of public spaces
helps to determine pleasurable and interesting
shopping experiences. Users will prefer cities
with qualities that make them stand out from
other cities in terms of the level of order.
Since 1960 we know what can help people
prefer one city instead another one. The concepts
come from a well-known study developed by
Kevin Lynch in three American cities Boston,
Jersey City, and Los Angeles. His theory states
that two elements are fundamental in the under-
standing of built environment legibility and
imageability. The concepts of legibility and
imageability concern an exploration of how peo-
ple use and visualize the built environment.
Legibility can be related to the term
wayfinding. Wayfinding can be applied in the
built environment context as the user experience
of orientation and choosing a path within a place,
with regard to a set of architectural and design
elements that may influence orientation (Passini,
1992, p. 66; Trulove, 2000, pp. 116117). In
other words, this term concerns the users capac-
ity to form cognitive maps and involves two
abilities cognitive and behavioral applied to
get to a destination (Golledge, 1999; Herzog &
Leverich, 2003). In this case, legibility embraces
character and sense of place with clarity and
B 458
Built Environment, Fig. 4 City center of Bath in England as an example of a place with high legibility (Source:
Author)
helps wayfinding (Butina & Bentley, 2007,
pp. 242243; Urban Design for Retail Environ-
ments, 2002, p. 40). In this regard, legibility is
related to the ease with which people understand
the layout of places. On the other hand,
imageability is the quality in a physical object
which gives it a high probability of evoking
a strong image in any given observer. Physical
characteristics of built environment, such as
shapes of buildings and colors, are elements that
compose mental images of the built environment
and help people remember a place as unique
(Lynch, 1960, 2007). A highly imageable city
would be well formed, contain very distinct
parts, and be instantly recognizable by people
(Nasar, 1998, pp. 89). In this sense, legibility
and imageability increase user perception of per-
sonal safety and make people become more
familiar with their surroundings.
Passini (1992) suggests that post-Kevin Lynch
studies have confirmed that the importance of
legibility and imageability in built environment
is valid in other cities outside the United States.
In many cases, there are minor differences in the
relative importance of different elements over
different cultures. Consequently, Lynchs find-
ings (1960) have been implemented in city plan-
ning operations in several places in recent years.
As a result, people are benefiting from the use of
more legible and imaginable city elements and
clearer forms. Strategies applied by local
Built Environment
authorities to improve legibility and imageability
of public areas can be seen in Bristol, England.
One of the aims of the Development Plan adopted
in Bristol is to create a comprehensible image of
the city by means of signs, routes, street furniture
design, public art, publicity, and marketing
(Kelly & Kelly, 2003). Similarly, practices in
development controls in Bath emphasize the
importance of legibility in terms of landmarks
and the relationship to existing and past urban
form (see Fig. 4).
Order, Complexity, and Chaos in the Built
Environment
Even though user evaluation of the built environ-
ment can be influenced by user background, user
evaluation of order is the result of an environment
in which parts form the whole in such a way that
redundancy, self-contradiction, and conflict are
avoided (Lang, 1987, p. 189). According to
Weber (1995, p. 110), perceptual order is
a consequence of physiological processes that
are based on innate biological principles, each
individuals sense of cognitive order will, to
some degree, be intersubjective. The segrega-
tion and unification of visual stimuli from the
built environment, which result in the perception
of order, are determined by the principles of
Gestalt Theory related to the psychological orga-
nization of visual compositions. The principles of
Gestalt explain why a determined place is
Built Environment
perceived as orderly, pleasant, and interesting by
users from different backgrounds despite the
complexity of stimulation this place presents.
These principles indicate how human beings
tend to organize their perceptions so as to give
preference to more regular configurations. One of
the most sustained analyses of the content of
architecture based on the Gestalt Theory of per-
ception was conducted by Arnheim (1977). The
approach adopted in his work can be summarized
by his following words: Shapes can be analysed
in detail by describing their forms in terms of
geometry, size, quantity and location, also there
are visual forces which expand and contract, push
and pull, rise and fall, advance and recede
which determine meaning and expression in art
(Arnheim, 1977, p. 10).
The principle of good Gestalt or law of
pragnanz is defined as a tendency of users to
take on as much regularity as possible, and this
is focused on pattern perception. Seven Gestalt
laws form the factors that influence user evalua-
tion of the built environment: proximity, similar-
ity, closure, good continuance, closeness, area,
and symmetry. A study conducted in Brazil and
England (Portella, 2007) shows that the principle
of complexity, related to the Gestalt laws, has the
highest influence on user evaluation of the built
environment. The relevance of complexity has
been highlighted by early studies such as the
one of Birkhoff (1933) which indicated that
visual quality depends on two factors: order and
complexity.
Complexity refers to a variety of elements and
relationships in an ordered aesthetic configura-
tion, which is structured according to some over-
all principle based on Gestalt Theory. This
concept is related to the level of order of elements
that form the built environment; places where
order does not exist are perceived and evaluated
as chaotic and irregular, and not as complex.
Salingaros (2000, pp. 292293) argues that: In
a general complex system (. . .) certain rules of
assembly are followed so that the parts cooperate
and the whole functions well. Most streetscapes
lie between disorder and order in which the ones
in this last group can reflect different levels of
complexity. In this regard, a complex built
459 B
environment is characterized by an ordered aes-
thetic composition formed by many visual points
of attention and different aesthetic relationships
between them (Kaplan in Nasar, 1988, p. 48;
Stamps, 1998, pp. 14071417; Weber, 1995, B
p. 125).
There is agreement in the literature that com-
plexity is a necessary condition for user satisfac-
tion with the built environment. Venturis (1977)
and Berlynes (1960) early studies were the first
to explore the principle of complexity in urban
streetscapes. Venturi confronted ideas related to
modernist architecture which promoted places
with low complexity, while Berlyne addressed
the same propositions as Venturi, but in an
approach which attempted to identify variables
that may result in places being perceived posi-
tively. Kaplans work (1976b) identified negative
implications of environments perceived as too
complex or too monotonous on user behavior,
such as difficult wayfinding due to too high or
too low visual stimulations and lack of interest. In
addition, other studies show that complex street-
scapes are evaluated more positively than simple
streetscapes because they provide more informa-
tion (Elsheshtawy, 1997, p. 303; Lang, 1987,
p. 196; Weber, 1995, p. 124). At the same time,
studies show that user preferences are associated
with moderate levels of complexity; the
extremes low and high complexities are not
evaluated positively by observers (Portella, 2003,
2007; Nasar & Hong, 1999; Nasar, 1988, 1998,
1983). At the same time, people who live in
different places can have different levels of tol-
erance to the variation of physical characteristics
of the built environment.
Weber (1995, p. 123) and Lang (1987, p. 196)
suggest that, according to user perception and
evaluation, there is a relationship between the
affective dimensions of pleasure and interest
with complexity. In terms of the dimension of
pleasure, this relationship is directly propor-
tional until an optimum is reached; when this
limit is exceeded, the relationship becomes
inversely proportional. There have been several
attempts to define this optimum level, but the
number of factors that influence user perception
and evaluation of the physical environment is so
B 460
Built Environment, Fig. 5 Relationship between plea-
sure, interest, and order regarding user evaluation of the
built environment (Source: Lang, 1987, p. 196)
high that no clear definition can be made. On the
other hand, in terms of the dimension of inter-
est, the relationship with complexity is always
directly proportional (see Fig. 5).
Points for Consideration
It is unclear why people from different cultures
tend to have a similar sense of satisfaction when
visiting global cities as Paris, London, and Rome,
for example. Even people who have never been to
these places would state that they like them. In
this way, it is assumed that users preference
and satisfaction for the built environment go
beyond personal experiences and are more
related to concepts of order, visual quality, com-
plexity, and contrast than we think. If this is
the case, it is possible to help to define general
guidelines principles to enhance the built envi-
ronment and, consequently, improve peoples
quality of life.
Cross-References
Aesthetic Value
Cognition
Housing and Quality of Life
Restorative Natural Environments
Sense of Place
Urban Design
Built Environment
References
Arnheim, R. (1977). Dynamic of architectural form.
Berkeley, CA: University of California Press.
Berlyne, D. E. (1960). Conflict, arousal and curiosity.
New York: MacGraw-Hill. Birkhoff 1933.
Birkhoff, G. D. (1933). Aesthetic measure. Cambridge:
Harvard University Press.
Butina, G. W., & Bentley, I. (2007). Identity by design.
London: Architectural Press.
Curran, R. (1983). Architecture and the urban experience.
New York: Van Nostrand Reinhold Company.
Elsheshtawy, Y. (1997). Urban complexity: Toward the
measurement of the physical complexity of street-
scapes. Journal of Architecture and Planning
Research, 14(4), 301328.
Gehl, J. (2001). Life between buildings. Copenhagen: The
Danish Architectural Press.
Golledge, R. (1999). Wayfinding behaviour: Cognitive
mapping and other spatial processes. Baltimore: The
John Hopkins University Press.
Hass-Klau, C., Crampton, G., Dowland, C., & Nold, I.
(1999). Streets as living space. Helping public places
play their proper role. London: Landor Publishing.
Herzog, T. R. (1992). A cognitive analysis of preference
for urban spaces. Journal of Environmental Psychol-
ogy, 12(3), 237248.
Herzog, T. R., & Leverich, O. L. (2003). Searching for
legibility. Environment and Behavior, 35(4), 459477.
Kaplan, R. (1976). Wayfinding in the natural environ-
ment. In G. T. Moore & R. G. Golledge (Eds.), Envi-
ronmental knowing: Theories, perspectives and
methods (pp. 324). Stroudsburg: Dowden, Hutchin-
son and Ross.
Kelly, A., & Kelly, M. (2003). Building legible cities 2.
Bristol: Bristol Cultural Development Partnership.
Kong, L., & Yeoh, B. (2004). The meaning and making of
place: Exploring history, community and identity.
Retrieved April 26, 2004, from http://www.fas.nus.
edu.sg.
Lang, J. (1987). Creating architectural theory, the role of
the behavioral sciences in environmental design. New
York: Van Nostrand Reinhold.
Lang, J. (2005). Urban design, a typology of procedures
and products. London: Architectural Press.
Lynch, K. (1960). The image of the city. Cambridge: MIT
Press.
Lynch, K. (2007). The image of the environment and
the city image and its elements. In M. Larice & E.
Macdonald (Eds.), The urban design reader
(pp. 153166). New York: Routledge.
Meader, N., Uzzell, D., & Gatersleben, B. (2006). Cultural
theory and quality of life. European Review of Applied
Psychology, 56(1), 6169.
Nasar, J. L. (1988). Environmental aesthetics: Theory,
research and applications. Cambridge: University
Press.
Nasar, J. L. (1998). The evaluative image of the city.
London: Sage.
Bullying
Nasar, J., & Hong, X. (1999). Visual preferences in urban
signscapes. Environment and Behavior, 31(5), 671691.
Passini, R. (1992). Wayfinding in architecture. New York:
Van Nostrand Reinhold.
Portella, A. A. (2003). A Qualidade Visual dos Centros de
Comercio e a Legibilidade dos Anuncios Comerciais
(Visual Quality of Commercial City Centres and Leg-
ibility of Commercial signs), Master Dissertation in
Regional and Urban Planning, Federal University of
Rio Grande do Sul, Porto Alegre. Dissertation
unpublished.
Portella, A. A. (2007). Evaluating commercial signs in
historic streetscapes: The effects of the control of adver-
tising and signage on users sense of environmental
quality., Ph.D. Thesis concluded at Oxford Brookes
University in the Joint Centre for Urban Design.
Rogers, A. (1992). Key themes and debates. In A. Rogers,
H. Viles, & A. Goudie (Eds.), A Students companion
to geography (p. 245). Oxford: Blackwell.
Russell, J. A., & Ward, L. M. (1981). The psychological
representation of molar physical environments. Jour-
nal of Experimental Psychology, 110(2), 121152.
Salingaros, N. A. (2000). Complexity and urban coher-
ence. Journal of Urban Design, 5(3), 291316.
Sherlock, H. (1991). Cities are good for us. London:
Paladin.
Stamps, A. E. (1998). Complexity of architectural facades:
From vague impression to define design features.
Perceptual and Motor Skills, 87(2), 14071417. 3.
Stamps, A. E. (2000). Psychology and the aesthetics of the
built environment. San Francisco: Kluwe Academic
Publisher.
Trulove, J. G. (2000). This way, signage design for public
spaces. New York: Rockport Publishers.
Urban Design for Retail Environments. (2002). Produced
by the building design partnership with support from
CABE and English heritage for the British Council of
Shopping Centres (BCSC). London: BCSC.
Venturi, R. (1977). Complexity and contradiction in
architecture. London: Architectural Press.
Weber, R. (1995). On the aesthetic of architecture, a
psychological approach to the structure and the
order of perceived architectural space. San Francisco:
Ashgate.
Built Form
Built Environment
Bulimia Nervosa
Eating Disorder(s) and Health-Related Quality
of Life
461 B
Bulimia Nervosa and Caregivers
Caregivers of Patients with Eating Disorders,
Quality of Life B
Bullying
Susan Limber and Weijun Wang
Institute on Family & Neighborhood Life,
Clemson University, Clemson, SC, USA
Definition
Bullying is unwanted aggressive behavior
that involves an imbalance of power between
two or more individuals (Nansel et al., 2001;
Olweus, 1993, 2010). This imbalance of power
may be characterized by differences in size or
strength, popularity, abilities, or numbers,
among other characteristics. Typically, bullying
is repeated over time. Bullying may include
direct actions (such as hitting, taking or damaging
possessions, taunting, or name-calling) or
indirect actions (such as social exclusion,
rumor-spreading or manipulation of friendships).
Relational and social bullying are terms used
to describe behaviors that are meant to damage
a childs social standing or reputation with peers
or that use the threat of the loss of a relationship
to manipulate others. Cyber bullying, or elec-
tronic bullying, is a form of bullying that involves
the use of electronic or cyber communications
to bully (Hinduja & Patchin, 2009; Kowlaski,
Limber, & Agatston, 2012).
Description
National estimates of the rates of bullying vary
considerably depending on the definitions of
bullying that are used, measurement strategies,
and the ages of participants. However, studies
consistently show that bullying is a relatively
common experience for children and youth.
B 462
According to the School Crime Supplement to the
National Crime Victimization Survey, 28 % of
students aged 1218 had been bullied at school
during the 2009 school year and 6 % reported
having been cyber bullied anywhere (Robers,
Zhang, Truman, & Snyder, 2012). Another
national survey, the 2009 Youth Risk Behavior
Survey published by the Centers for Disease
Control and Prevention reported that 20 % of
high school students were bullied on school
property at least once in the previous 12
months and 16 % had been electronically bul-
lied (Eaton et al., 2012). The most common
forms of bullying that children and youth expe-
rience are verbal (e.g., being made fun of,
called names, insulted, being the subject of
rumors) (Robers et al., 2012).
Not only are students involved in bullying
as victims, but they also may bully others, or
they may bully others and also be bullied them-
selves. This latter group is often referred to as
bully-victims. In a recent study of more than
520,000 3rd12th grade students in the USA,
researchers found that 20 % of girls and 25 % of
boys had been involved in bullying on a regular
basis (23 times/month or more often) as victim
only (14 % of girls and 13 % of boys), bully
only (4 % of girls and 8 % of boys), or
bully-victim (3 % of girls and 4 % of boys)
(Olweus & Limber, 2010).
The frequency and forms of bullying that
children experience and engage in vary
depending upon their age and gender. Children
are most likely to be bullied during elementary
school grades (Finkelhor, Ormrod, Turner, &
Hamby, 2005; Olweus & Limber, 2010), and
their likelihood of being bullied decreases through-
out middle and high school years (Nansel et al.,
2001; Robers et al., 2012). On the other hand,
children and youth are most likely to bully others
during early to middle adolescence (Espelage &
Swearer, 2010). Children are involved in different
forms of bullying at different ages, depending on
their verbal, cognitive, and social development
(Rubin, Ceah, & Menzer, 2010). For example,
while physical bullying is more common among
elementary school children, it is less frequent
among middle or high school students. Electronic
Bullying
bullying, on the other hand, typically emerges in
the middle school years (Kowlaski, Limber, &
Agatston, 2012).
Although both boys and girls are involved in
bullying, most studies have found that boys are
somewhat more likely than girls to bully or to
be characterized as bully-victims (Cook,
Williams, Guerra, Kim, & Sadek, 2010; Craig
et al., 2009). Most studies show small differences
between boys and girls in their likelihood of
being bullied (Cook et al., 2010; Robers et al.,
2012), but there are fairly consistent gender dif-
ferences in the types of bullying that boys and
girls experience. For example, boys are more
likely than girls to be physically bullied by
peers, while girls are more likely to be bullied
through rumor-spreading and social exclusion
(Robers et al., 2012). Although boys are usually
bullied by other boys, girls are bullied by
boys and girls (Finkelhor et al., 2005; Nansel
et al., 2001).
There is no single cause of bullying. Rather,
individual, peer, family, and environmental
factors may make it more or less likely
that a child will be involved in bullying
(Swearer, Espelage, Koenig, Berry, Collins, &
Lembeck, 2012). For example, an individuals
temperament may play a role. Children and
youth who are bullied are more likely to have
quiet, passive personalities, lack social skills,
and have internalizing problems (such as depres-
sion). Those who bully are more likely to have
impulsive temperaments, have negative attitudes
about themselves and others, and have problems
resolving problems with others (Cook et al.,
2010; Olweus, 1993). Peer factors also play
a role. Children and youth are more likely to
bully if they have friends who bully or who
have positive attitudes toward violence (Cook
et al., 2010; Olweus, 1993). Bullied children
tend to be socially isolated and report having
few friends (Cook et al., 2010; Swearer et al.,
2012). Family factors are also related to
a childs likelihood of being involved in bullying.
Children are more likely to bully if there is a lack
of parental warmth and engagement, a lack of
parental supervision, inconsistent discipline, and
harsh physical punishment within their families
Bullying
(Cook et al., 2010; Olweus, 1993). Exposure to
parental conflict and domestic violence and the
experience of child abuse have been found to be
related to greater likelihood of bullying others
and being bullied (Baldry, 2003; Bowes et al.,
2009; Shields & Cicchetti, 2001). Aspects of the
school and broader environment may also affect
childrens likelihood of involvement in bullying.
For example, students who have a sense of
belonging to the school and perceive they are
treated with respect and fair treatment are less
likely to be involved in bullying (Cook et al.,
2010). Bullying is also particularly prevalent
where there are indifferent or accepting attitudes
about bullying by school staff and students and
where there is poor adult supervision (Olweus,
1993; Pellegrini & Barini, 2000).
Although any child may be bullied, some
groups of children and youth are at higher risk
for being bullied than others, including children
with learning disabilities (Mepham, 2010;
Mishna, 2003), children with attention-deficit
hyperactivity disorder (ADHD; Twyman et al.,
2010; Weiner & Mak, 2009), children and youth
with autism spectrum disorder (ASD; Twyman
et al., 2010), those with special health-care needs
or chronic diseases (Dawkins, 1996; Magin,
Adams, Heading, Pond, & Smith, 2008; Storch
et al., 2004; Hamiwka et al., 2009), those who are
obese (Fox & Farrow, 2009; Gray, Kahhan, &
Janicke, 2009), and those who are underweight
(Wang, Iannotti, & Luk, 2010). Adolescents who
identify themselves as lesbian, gay, bisexual, or
transgender (LGBT); those who are questioning
their sexual identity; and those who are perceived
to be gay or lesbian also are at greater risk of
being bullied (Eisenberg, Neumark-Sztainer,
Story, & Perry, 2005; Harris Interactive &
GLSEN, 2005).
The experience of bullying may have negative
effects on the health, mental health, and academic
work of bullied children and youth. They are
more likely than non-bullied peers to be anxious,
have low self-esteem, be depressed, think about
suicide, and attempt suicide (Craig, 1998;
Hinduja & Patchin, 2010; Juvonen, Graham, &
Shuster, 2003; Klomek, Marrocco, Kleinman,
Schonfeld, & Gould, 2008; Kumpulainen,
463 B
Raasnen, & Puura, 2001). Bullied children are
also more likely than non-bullied children to
experience psychosomatic problems such as
headaches, stomach aches, sleep problems, poor
appetite, and bed wetting (Fekkes, Pijpers, & B
Verloove-Vanhorick, 2004; Gini & Pozzoli,
2009). They are more likely than peers to want
to avoid school (Kochenderfer & Ladd, 1996)
and to have lower academic achievement
(Aresneault et al., 2006; Buhs, Ladd, & Herald,
2006; Nakamoto & Schwartz, 2010). Conse-
quences of bullying may last years after the
bullying has ended. In adulthood, individuals
who were bullied as children have higher rates
of depression and anxiety and lower self-
esteem than peers who were not bullied as
children (Olweus, 1993; Roth, Coles, &
Heimberg, 2002).
There is also reason to be concerned about
children who bully others. They are more likely
than their peers to be involved in other antisocial,
violent, or troubling behavior, including fighting,
vandalism, stealing, weapon-carrying, school
dropout, poor school achievement, drinking
alcohol, and smoking, and thinking about and
attempting suicide (Byrne, 1994; Cook et al.,
2010; Gini & Pozzoli, 2009; Haynie et al.,
2001; Nansel et al., 2001).
Although adults often view bullying as
a problem between two children, it is more
accurate to understand it as a group phenome-
non, in which children may play a variety of
roles, including active or passive supporters of
the bullying, disengaged onlookers, and
defenders (Olweus, 1993). These roles may
change from one situation to the next. Large
percentages of children indicate that they have
witnessed bullying (Trach, Hymel,
Waterhouse, & Neale, 2010). Most have nega-
tive reactions to bullying and feel sympathy
for bullied children (Baldry, 2004; Olweus &
Limber, 2010).
In recent years, the prevention of bullying in
schools has received considerable attention
from the federal government, state legislators
(Alley & Limber, 2009), and researchers
(Jimerson, Swearer, & Espelage, 2010; Ttofi &
Farrington, 2009).
B 464 Bullying

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Burden of Illness
Duke Severity of Illness Checklist
Burden to Others
Self-Perceived Burden to Others
Bureaucratic Politics
Democracy and Bureaucracy
Burnout
Arturo Juarez-Garcia1, Aldo Vera-Calzaretta2,3
and Cinthya A. Flores-Jimenez4
1
Universidad Autonoma del Estado de Morelos,
Cuernavaca, Mexico
2
Escuela de Salud Publica, Universidad de Chile,
Santiago, Chile
3
Fellow Program ITREOH, Mount Sinai
University, New York, NY, USA
4
Unidad de Investigaciones y Servicios
Psicologicos, Universidad Autonoma del Estado
de Morelos, Cuernavaca, Mexico
Synonyms
Burnout syndrome; Chronic stress; Psychosocial
stress
Burden of Illness
Definition
What Is Burnout?
In general, burnout (BO) is conceived as
a response mechanism to chronic stress.
A person is subject to chronic stress when the
dose of stress accumulated surpasses the optimal
threshold for adaptation, and his (or her) organ-
ism begins to show signs of exhaustion such as
ulcers, allergies, and migraine, among others. The
moment when this exhaustion manifests itself is
variable and depends both in the psychological
profile of the person and the amount and
frequency of experienced adjustments.
BO manifests regularly in human services
professions. It is a subjective experience that
has a negative connotation for the individual
who suffers from it, since it involves emotional
disturbances, interaction problems with other
people, psychophysiological alterations, and neg-
ative repercussions that affect not only for the
individual, but the organization where he works
(Sandoval, 2000).
Maybe the more widely accepted definition is
the one by Maslach and Jackson (1981), where
BO is defined as a response to chronic work
stress characterized by negative attitudes and
feelings toward co-workers and the professional
role itself, as well as the experience of being
emotionally exhausted. In this definition,
according to the authors, three dimensions that
constitute BO can be identified:
Emotional exhaustion: It refers to the lack of
ones own emotional resources and the feeling
that nothing can be offered to the other person,
that one can give no more from oneself at the
affective level. It is an experience of being
emotionally tired due to daily and continuous
contact with people who are the subject of the
work.
Depersonalization: It is the development of
negative feelings and attitudes, cynical and
insensitive, toward the recipients of the ser-
vices given, who are seen by the professionals
in a dehumanized way due to emotional
hardening.
Lack of personal accomplishment: It is
a perception that possibilities for personal
Burnout
achievement at work have disappeared, which
diminishes personal expectations and com-
prises a negative self-evaluation, including
rejection of oneself and of ones personal
achievements, as well as feelings of failure
and low self-esteem.
In the beginning, since this problem came
from the social work, it was minimized
and taken lightly by popular psychology.
Nonetheless, today there are substantial works
and theoretical models that rest upon the first
questions about scholarly research on this field.
But, according to the definition by Maslach and
Jackson (1981), a person with burnout claims to
be exhausted and emotionally empty; in other
words, the person feels that he cannot offer
anything psychologically to others and, in many
cases, chooses to act coldly, distantly, and even
negatively, toward people whom he is servicing.
On top of that, he has a negative perception
of himself, where his accomplishments and job
performance are not valued as something positive
but as a failure or somewhat lacking, which
increases his low self-esteem and poor perception
of himself and those around him.
It is important to mention that attempts at
translating the term burnout to other languages
have failed in the sense that a general convention
in its use and/or definitive adoption within each
country. Maybe the only way to maintain the
convention when referring to this phenomenon
is to keep naming it in English, as it is the case
of a global construct.
Description
Background
The term burnout (BO) was first used in 1974
by the American psychoanalyst Herbert
Freudenberger (Freudenberger & Richelson,
1981), to indicate a state of physical and
emotional tiredness that results in certain work
environments. This author introduced the term
referring to a phenomenon that he had observed
in himself and his colleagues when they worked
at a free clinic for drug addicts. The type of work
that these people performed was characterized by
467 B
lack of a fixed work-schedule, very high number
of working hours, scarce payment, and very
demanding social context, which was usually
tense and difficult. Another element was the
common lack of systematic preparation of B
workers, who tried to replace their lack
of professional preparation with enthusiasm.
Freudenberger took a word that was commonly
used during the 1960s to refer to the effects of
chronic drug abuse and began utilizing it in order
to characterize the state of exhaustion experi-
enced by himself and some of his colleagues
when they started to look tired, depressed, apa-
thetic, and with signs of guilt, paranoia, and
omnipotence that interfered with their capacity
to reduce their activity level. At the same time, he
found a particular susceptibility among young,
idealist students who wanted to be productive to
human kind by becoming doctors, nurses, or
teachers. Later, he defined BO as a state of
fatigue or frustration caused by the devotion
to a cause, lifestyle, or relationship that failed to
grant the expected gratification.
Meanwhile, Christina Maslach (1982),
a social psychologist, studied the ways in which
people faced emotional stress, particularly cogni-
tive strategies such as detached concern and
dehumanization in self-defense. Soon she
discovered that both techniques play a relevant
role in peoples identity and behavior at their
work place. Incidentally, she commented on
these results with a poverty lawyer who pointed
out that they referred to this phenomenon as
burnout. Once Maslach and her colleagues
adopted this term, they realized that this phenom-
enon was recognized by their interviewees, so
a new colloquial expression was born: Burnout
syndrome.
Freudenberger, together with University of
California at Berkeley psychologists Christina
Maslach and Ayala Pines, made this concept
popular during the 1970s, and began studies that
legitimized its status as a social issue (Pines &
Aronson, 1988). Nonetheless, while the two last
authors, as social psychologists, focused their
BO studies on psychosocial factors directing
their research toward the relation between
environmental and individual determinants,
B 468
Freudenberger, a psychoanalyst, contemplated
a BO model that emphasized the psychology of
the individual and focused on the capabilities and
vulnerabilities of the individual in stressful
situations.
BO presented as the description to
a generalized problem in multiple fields, which
affected job satisfaction, professional involve-
ment, and job efficacy and quality. The novelty
of the concept was that, unlike many others, it did
not originate as a result of laboratory research,
but as the finding of a real problem experienced
within the wide core of professional occupations.
The colloquial term burnout (BO), and
its underlying theoretical model, became like
rubbing salt into the open wound of many profes-
sional workers. The phenomenon described
corresponded, not to an intellectual or academic
problem, but to a felt concern within different
professional groups. From then on a true
proliferation of papers has occurred; they are
mostly descriptive in nature, presenting the
misfortunes that go along with BO.
Measurement of Burnout
The gold-standard measurement for Burnout
evaluation is the self-report. Different evaluation
questionnaires have been developed in the last
decades, many of which are within the frame-
work of methodological requirements and have
been tested for validity and reliability. Among
them are:
The Maslach Burnout Inventory (MBI),
created by Maslach and Jackson in 1981, is
the most widely used instrument to measure
this syndrome, and the one instrument that
the largest number studies have used to
demonstrate their validity and reliability. It
comprises 22 items that measure three compo-
nents: emotional fatigue, low sense of
achievement, and depersonalization. Also,
Maslach has developed a new version to eval-
uate the Burnout syndrome in occupational
sectors where human service is not necessarily
present and, therefore, is applicable to a wider
range of existing work sectors. It is called
MBI-General Survey (GS), and it comprises
16 items.
Burnout
The Teacher Burnout Scales (TBS), built by
Seidman and Zager (19861987). It has 21
items that show four factors: professional
satisfaction, perceived administrative support,
coping with job-related stress, and attitudes
toward students.
Teacher Attitude Scales (TAS), which is
a modified version of MBI that has 25 items
of the MBI and are extended by author with 40
items specific to teachers. These additional
items describe situations of satisfaction
or work-related stress designed by Farber
(1984).
The Staff Burnout Scales for Health Profes-
sionals (SBS-HP), elaborated by Jones in
1982, is used to measure burnout in healthcare
professionals. It has 30 items in a 6-degree
scale, and it measures 4 factors: dissatisfaction
or job stress, psychological or interpersonal
stress, illness and stress, and lack of profes-
sional relationships toward patients.
The Tedium Measure (TM) of Pines and
Aronson (1988), the TM is used in profes-
sionals of any occupational sector to measure
tedium and, in human services professionals,
to calculate burnout, where it is called BM. It
is made up of 21 questions that are arranged
in three subscales: physical exhaustion,
emotional exhaustion, and mental exhaustion.
Spanish Burnout Inventory (Cuestionario para
la Evaluacion del Sndrome de Quemarse por
el Trabajo-CESQT). Developed by Gil-Monte
(2003), it suggests the components of psychic
wear and tear, sloth, and lack of enthusiasm
for the work (Gil-Monte et al., 2006). Also, it
tries to identify two profiles in the process of
burnout, one that progresses without feelings
of guilt, and the other where feelings of guilt
are present (the latter one being more severe).
Today, this is the second most used instrument
(after MBI) for the Spanish-speaking
population.
In addition to the instruments briefly described
here, there is a wide array of instruments that one
can find in the literature. Nevertheless, informa-
tion related to validity reported reliability uses
and limits of such instruments should be
explicitly.
Burnout
Causes of Burnout
More than causes, one can talk about predicting
variables or, in the words of some authors,
trigger/facilitating variables for Burnout.
Professionals vulnerable to presenting
Burnout syndrome have various characteristics
in common, which represent the variables that
have been majorly associated with the occurrence
or worsening of the syndrome. These variables
can present themselves singly or in combined, but
it has been found that they are important predic-
tors that can lead to think that the worker will
develop Burnout syndrome at some point during
his work activities.
The variables can be grouped mainly into
characteristics of the worker and characteristics
of the organization or of the work environment.
Regarding the first ones one can find the
following:
Sex. Maslach (1982) pointed out that women
experience more emotional exhaustion, and
less personal realization than men (Maslach
& Jackson, 1981). The double role of women
at work and home is also a source of stress.
Age. Different studies have found a significant
relation between age and Burnout syndrome
(Seltzer & Numerof, 1988). It is possible that
the relationship between the two is associated
to experience inside the profession.
Marital status. According to Maslach, having
children can be a protective factor against
Burnout syndrome. Authors such as Cooke
and Rousseau (1984) point out that this
situation also contributes something positive,
for having the possibility of sharing work
issues with the family can be an opportunity
to receive support, advice, or simply to vent.
Personality. Dispositional variables that are
more or less stable in the personality of
an individual, such as self-esteem, type-A
behavior pattern, or introversion, have been
associated to components of burnout. Also,
an association has been found between low
emotional control, low self-efficacy, and
burnout (Juarez-Garca, 2005). order to determine the appropriate work methods,
Regarding the organizational or work environ-
ment characteristics, recently Leiter and Maslach
(1999) proposed the model The Six Areas of
469 B
Work life (SAW), in order to frame the research
of preceding conditions that could lead to the
development of Burnout syndrome. Within this
frame, Leiter and Maslach introduced six areas
which suggest that there be equilibrium between B
employees and employers inside organizations;
the areas are: workload, control, reward, commu-
nity, fairness, and values. These will be described
in the following subsections.
Workload
According to Leiter and Maslach (1999), work-
load is defined as the amount of work that has to
be done at a certain time. It has a predictable and
consistent relationship, particularly with
emotional exhaustion. One of the problems of
the workload is the continuous or regular intensi-
fication of work which exceeds the human limits
of what one person can do.
Sonnentag and Kruel (2006) presented
findings regarding the impact of workload on
the health of employees. They explain that,
when employees have to take work home in
order to finish it, the opportunities of detaching
from work and recovering are hindered because
people preserve the emotions caused by their
work, feeling physically tired.
Leiter and Maslach (1999) emphasized that
a maladjustment or role conflict occurred when
there was a mismatch between the characteristics
of the job and an elevated work volume that
originated without any control. There is evidence
that suggests the impact of workload and its
potential effect in the mental health of workers,
but this can be alleviated through other resources
such as social support, recognition of skills, and
control (Bakker, Demerouti, & Euwema, 2005).
Control
According to Ashforth and Saks (2000), control is
a combination of work autonomy and the
capability of the workers to participate in the
decisions that affect them. Control provides
workers with the liberty, or task domain, in
schedules, and objectives, by themselves.
From the point of view of the employee, sat-
isfactory control of the workplace allows for
B 470
ideas and creativity to flow consistently with the
demands of work (Schaufeli & Bakker, 2003);
the results are then better for organizations.
When there is conflict over control, it usually
reflected in hierarchical organizations, and
individuals caught up in such hierarchies are
incapable of exercising control over their work.
According to Leiter and Maslach (1999), malad-
justment in the workers control makes it, so they
are obligated to act in a manner that is at odds
with their own values and principles; workers,
therefore, have a lack of autonomy.
According to Jimenez and Moyano (2008),
more personal control at work simultaneously
renders with organizational benefits, reduces
absenteeism, and increases productivity. Organi-
zational cultures with high degrees of formality
and hierarchy, and less self-determination
and intimacy, show less well-being and more
difficulties to integrate work and family.
Reward
Leiter (2010) indicates that reward can be finan-
cial or social, and that it is received by a person
for his contribution to work. Within an organiza-
tion, the reward creates a reason for significant
contributions to work. Nonetheless, when people
experience lack of recognition, they perceive
a devaluation of their work and of themselves,
experiencing feelings such as not being worthy of
an increase in pay for the work they do, dissatis-
faction toward work, or feeling unchallenged.
Paid work gives more than only income to
support the standard of living. In modern society,
work covers personal needs at psychological
levels, such as giving a sense of personal worth
and individual welfare (Gill, 1999).
Effort at work is recognized as part of a process
of socially organized exchange that favors
rewards, which can be distributed in three subsys-
tems: economic, esteem, and promotion opportu-
nities. Nonetheless, the lack of reciprocity between
the costs of effort and the received rewards causes
reactions of sustained tension at the emotional and
psychological levels (Siegrist, 1996). According to
Leiter and Maslach (1999), maladjustments in
reward increase the vulnerability of workers to
suffer from Burnout syndrome.
Burnout
Community
According to Leiter and Maslach (2004),
community is the quality of the social interaction
at work, which includes matters such as conflicts,
mutual support, proximity, and ability to work
together. People grow through the community,
and community is the social support that
reaffirms the membership of the person to
a group that shares his values. Unfortunately,
some jobs isolate people from one another or
promote impersonal social contact, creating
conflicts with other peoples work. Constant
conflicts give way to negative feelings of frustra-
tion and hostility, and reduce the possibility of
social support (Leiter & Maslach, 2004).
Community has an important role in the health
of workers. Leiter and Maslach (1999, 2004) iden-
tified community as an aspect of work life that
could have influence in exhaustion, but they con-
cluded that social support within organizations,
from both supervisors and coworkers, helped face
the demands of work and Burnout syndrome. Gill
(1999) saw work as a creative effort of workers,
which allowed them to escape social isolation.
Fairness
Fairness makes reference to administrative
leadership of the organizations, which should be
considered, same as all of its staff members, with
clear procedures of promotion and awards
without discrimination or favoritism (Maslach
& Leiter, 2005).
Fairness shares some qualities with commu-
nity and reward. Justice is a clear quality of
communion, especially related to the distribution
of recognition, rewards, and opportunities. The
main focus of fairness is the spirit of mutual trust
between people in the organization. Fairness is
the quality that all people who have authority
within the organization and who have
a responsibility to be fair and to make decisions
that affect the work and the environment of the
personnel in the organization. Fair decisions are
those that give a certain amount of consideration
to various staff conditions, and designate
resources and opportunities according to the
objectives of the organization and not to personal
advantage of privileged individuals or groups.
Burnout
A fair decision is one in which people have an
opportunity to present their arguments, and in
which they feel treated with courtesy and respect
(Maslach & Leiter, 1999).
Hasty and unfair decisions alienate people
from their community. Research ascertains that
the fact of personnel perceiving their supervisors
as being fair and supportive contributes to better
acceptance of organizational change by
staff members of the organization, and reduces
susceptibility to Burnout syndrome (Leiter &
Maslach, 1999).
If workers consider that they are being
treated unfairly, their perception will generate
tensions, perception of unfairness at work,
absenteeism, (De Boer, Bakker, Syroit, &
Schaufeli, 2002), feelings of dissatisfaction and
demotivation, lack of productivity, and decrease
of the quality of the work (Wayne, Shore,
Bommer, & Tetrick, 2002).
Values
According to Maslach and Leiter (1999) the values
area of worklife is at the heart of staff members
relationships with their work, and encompasses the
ideals and motivations that originally attracted
them to the organization. Values go beyond the
utilitarian exchange of time for money; in this
sense, the mismatch between personal values
with those of the organization has the potential to
alter relations between people and their work.
Some types of work require full participation of
the staff members of the organization. Thus, the
decision to make a commitment of this depth to an
organization calls for a thorough personal consid-
eration. When the balance is mutually favorable,
the process may result in a productive psycholog-
ical contract that serves as a basis for an enduring
work relationship for both parts (Maslach &
Leiter, 1999).
Due to their deeply personal character,
mismatch of values has the potential to disrupt
the relationship between individuals and their
work. So, when people have values which are
different from those adopted by the organization
for which they work, the job becomes irrelevant,
exhausting, and is associated to risk of experienc-
ing Burnout syndrome (Leiter & Maslach, 1999).
471 B
These are some of the environmental
work factors that Maslach and Leiter (1999)
have considered as the most important
predictors (or precursors) the apparition of burn-
out. Nonetheless, research continues to identify B
other potential stressors that could vary according
to context, occupational sector, specific
duties, etc.
Consequences of Burnout
The concept of Burnout syndrome brings
together a number of symptoms that occur
together for the disease to develop. These
symptoms represent a manifestation of workers
exposure to a chronic form of stress according to
the literature, a series of alterations have been
described as consequence to this exposure and
as direct manifestation of the syndrome (Ortega &
Lopez, 2004). They are divided in three groups:
Consequences that have direct incidence in
physical health (physical alterations). Cardio-
vascular system alterations (hypertension,
coronary disease, sudden heart attacks)
(Selye, 1979), chronic fatigue, headache and
migraine (International Labour Organization,
2012), gastrointestinal alterations (abdominal
pain, irritable bowel syndrome, duodenal and
gastric ulcers), respiratory disorders (asthma)
(Henry et al., 1991), sleep disturbances, and
alterations of the muscular-skeletal system,
such as muscle and joint pain (Ortega &
Lopez, 2004).
Consequences that affect mental health
(emotional alterations). Anxiety, depression
(Gil-Monte, 1994), low self-esteem and lack
of motivation (Maslach & Jackson, 1981),
emotional detachment (Schaufeli & Enzmann,
1998), feelings of professional frustration and
desire to quit their job (Shirom, 2009).
Consequences related to the work environ-
ment. Aggressive behaviors toward coworkers
and the recipients of services given (patients,
students, etc.) (Gil-Monte & Peiro, 1997),
absenteeism (Maslach, 1982), increased
violent behavior, decreased productivity, lack
of competition, and deterioration of the
quality of work (Ortega & Lopez, 2004;
Shirom, 2009).
B 472
Even today, it is difficult to establish what all
the specific effects of burnout are. However,
research still continues in hopes that it will
continue to have clarity regarding the impact
and scope of this phenomenon.
Cross-References
Distress
Emotional Well-being
Main and Buffering Effect of Social Support
Occupational Attitudes
Occupational Stress in a Multicultural
Workplace
Psychosocial Adjustment (Includes
Psychosocial Functioning and Well-Being)
Psychological Stress and Employee
Engagement
Stress Reactivity
Work Stress
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Business Ethics
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Burnout Scale
Emergency Workers Quality of Life
Burnout Syndrome
Burnout
473 B
Business Ethics
Alex C. Michalos
University of Northern British Columbia, Prince B
George, BC, Canada
(residence) Brandon, MB, Canada
Synonyms
Corporate responsibility; Corporate social
responsibility
Definition
Business here refers to all systems and activi-
ties involved in the commercial exchange of
goods and services. Ethics refers to all human
action aimed at securing a good quality of life.
So business ethics refers to all activities and
systems concerned with the commercial
exchange of goods and services with respect to
their impact on the quality of peoples lives.
Description
The connection between business ethics and the
quality of life may be regarded as very close and
direct if one is a moral consequentialist, in partic-
ular if one is some kind of an act utilitarian.
Generally speaking, moral philosophers may be
divided into two very broad groups, deontologists
and consequentialists. Deontologists hold that
some human actions are inherently morally good
or evil; for example, murder is inherently bad, and
telling the truth is inherently good. Consequen-
tialists hold that no human actions are inherently
morally good or evil, but all human actions are
subject to evaluation from a moral point of view.
The moral point of view may be based on one of
the following two principles.
1. Principle of Beneficence: One ought to try to
act so that ones actions tend to impartially
improve the quality of life of those affected
by the actions.
B 474
2. No Harm Principle: One ought to try to act so
that ones actions tend not to harm anyone
affected by the actions.
Depending on how one regards ones
basic moral principles, there may not be
much difference between a deontologist and a
consequentialist. If, for example, a consequen-
tialist believes that either the Principle of Benef-
icence or the No Harm Principle specifies a kind
of action that is inherently moral, then at that
level the consequentialist is also a deontologist.
If, on the other hand, a consequentialist believes
that the institution of morality is constructed by
human beings, for whatever reason, then that sort
of consequentialist is not a deontologist. The
present essay is written from the point of view
of the latter sort of consequentialist.
Assuming that one is going to try to act in
accordance with the Principle of Beneficence,
again broadly speaking, there are two ways to
go. One can:
1. Try to improve relatively objective circum-
stances that are measured by objective
social indicators, e.g., things like ensuring
that people have access to freshwater and
clean air, to full employment with fair
wages, cleaner and safer workplaces,
longer lives free of disability and disease,
elimination of poverty and homelessness,
and the reduction of crime.
2. Try to improve relatively subjective circum-
stances that are measured by subjective social
indicators, for example, such things as peoples
reported peace of mind, contentment, hap-
piness, and satisfaction.
Clearly, if ones relatively objective and
subjective circumstances are improved, then the
quality of ones life is improved. It is evidently
trivially true that if ones total circumstances are
improved, one is better off and the quality of
ones life has improved. So, generally speaking,
ones moral obligation is to try to act so that the
quality of peoples lives is improved objectively
and subjectively.
Since actions performed by business people
are species of human actions, morally speaking,
one ought to conduct ones business activities in
accordance with the Principle of Beneficence,
Business Ethics
i.e., business people, through their business
activities, ought to try to improve the quality of
peoples lives.
When people use the phrase quality of life,
they sometimes intend to contrast it with quanti-
ties or numbers of something. There are, then,
two quite different sorts of things that one might
want to refer to when using the phrase quality of
life. In the first place, one might want to refer to
sorts, types, or kinds of things rather than to mere
numbers of things; for example, one might want
to know not merely how many people were
admitted to a hospital last year and for how
long, but also what sorts of people they were,
male or female, young or old, rich or poor, and
so on. When the term quality in the phrase quality
of life is used in this sense, one may say that it and
the phrase in which it occurs is intended to be
primarily descriptive. In the second place,
however, one might want to refer to the value or
worth of things by using the term quality in the
phrase quality of life. For example, one
frequently hears of people making a trade-off
between, say, a high salary on the one hand and
better working or living conditions on the other.
Presumably the exchange here involves monetary
and some other value. That is, one exchanges the
value of a certain amount of money for the value
of a certain set of working or living conditions.
When the term quality in the phrase quality of life
is used in this sense, one may say that it and the
phrase in which it occurs is intended to be
primarily evaluative. Both senses of the phrase
quality of life are important. It is important to be
able to describe human existence in a fairly
reliable and valid fashion, and it is important
to be able to evaluate human existence in the
same way.
There is a long historical tradition of moral
consequentialists that may be traced very far back
in time to Platos Protagoras or somewhat less
farther back to Jeremy Benthams ideas about
a felicific calculus that would allow decision
makers to calculate the net pleasure or pain
connected to every action for everyone affected
by that action, with public policy choices made to
get the greatest net pleasure or least net pain for
the greatest number of people (Bentham, 1789).
Business Ethics
Since pleasure and pain are relatively transient
experiences, something more durable would have
better suited Benthams purpose. If happiness is
regarded as a relatively long-lasting positive
experience and/or attitude (Veenhoven, 1984),
then that would distinguish it from transient plea-
surable mood states and would justify moving
from Benthams greatest pleasure principle to
Mills utilitarian principle of the greatest happi-
ness for the greatest number (Mill, 1861). For
economists, utility theory is the apparent heir of
Bentham and Mill (Mitchell, 1918). Utility
theory is formally elegant and has been an
enormously fruitful source of research programs
in individual and group decision making related
to commercial markets, social and political
relations, bargaining, conflict resolution, gaming,
and scarce resource allocation in practically all
areas. It is the heart of microeconomics. Unfor-
tunately, utility theory (as many other theories) is
much better on paper and in classroom exercises
than it is in practice, especially in public policy
making. What is worse, utility theory begins with
revealed preferences which are the mere tips of
socially, psychologically, and pragmatically
constructed icebergs of more or less coherent
systems of knowledge, opinions, attitudes,
desires, and needs (Michalos, 1967, 1978, 1985;
Schwarz & Strack, 1999). However, for present
purposes, the defect of utility theory as
a psychosocial theory of perceived well-being is
not its biggest problem. Its biggest problem is that
it merely provides information about the
subjective states of people, although we know
that peoples objectively measurable circum-
stances are also important features of the quality
of their lives. Because, morally speaking, our
commitment ought to be not merely to improve
peoples (subjective) feelings and attitudes about
their lives but as well to improve the very
(objective) conditions in which they live their
lives, defining our basic Principle of Beneficence
in terms of the quality of life seems to be most
appropriate.
An ideal consequentialist assessment of the
quality of life of an individual or group would
have to satisfactorily address the following criti-
cal issues:
475 B
1. Affected population: Who will be affected by
the action, from the actor alone to everyone
else?
2. Spatial coordinates: Across what amount of
space should one look, from ones own home B
to the whole world?
3. Temporal coordinates: Across what length of
time should one look how far into the future?
4. Population composition: How should the
affected individuals be characterized, if at
all, in terms of sex, age, education, ethnic
background, income, etc.?
5. Domains of life composition: What domains
of life should be examined, for example,
health, job, family life, and housing?
6. Objective versus subjective indicators:
Supposing one grants that both kinds of
indicators are important, how should one
decide exactly which kind to use for which
domains?
7. Positive versus negative indicators: Negative
indicators seem to be easier to craft for some
domains, which may create a biased assess-
ment; for example, in the health domain
measures of morbidity and mortality may
crowd out positive measures of well-being.
8. Input versus output indicators: Should one
measure only what one invests, what comes
of the investment, or both?
9. Benefits and costs: What particular benefits
and costs should be counted, for which
individuals and groups?
10. Discount rates: How much should one dis-
count costs and benefits delivered sometime
in the future, compared to those delivered
today?
11. Measurement scales: There are usually dif-
ferent ways to measure the same and differ-
ent things. How should one choose the best
sort of scale or measuring device?
12. Distributions: How should central tendencies
and variation be measured in diverse fields?
13. Interaction effects: Prior to taking action, one
ought to have some idea of what causes what
and what might be jointly interacting with
what, which requires some sort of common
sense and perhaps some relatively main-
stream scientific research.
B 476
14. Confidence levels: Since one often lacks
complete certainty regarding the truth of
claims, what level of confidence should one
require to accept any particular claim?
15. Research procedures: Since ones data are as
good as ones search and research proce-
dures, what adequacy criteria should be
used to assess procedures?
16. Research personnel: The procedures one
uses are likely to be as reliable as the people
doing the research. How should one identify
generally acceptable experts, if indeed
experts are to be chosen at all?
17. Aggregation function: How should all the
diverse elements of the assessment be
aggregated?
18. Assessment assessor: Supposing one believes
such overall life assessment is possible,
a reasonable person might ask: Who should
decide (audit) if the assessment is adequate
or appropriate?
19. Assessment criteria: Supposing we were able
to settle on some suitably able and willing
auditor, what criteria should be used to audit
the adequacy of the assessment?
In the presence of so many questions to be
answered, it is not surprising that even people
who share the same general approach to moral
appraisal might reach different conclusions about
the same cases. In such cases, those who answer
different questions in different ways will have to
negotiate a common approach, which of course
may or may not work depending on the cases and
the appraisers. In any event, for moral consequen-
tialists the connection between business ethics
and the quality of life is very close and direct.
While moral consequentialism certainly has
its disadvantages, they are probably not more
troublesome than the disadvantages of other
theories.
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well-being: Judgmental processes and their methodo-
logical implications. In D. Kahneman, E. Diener, &
N. Schwarz (Eds.), Well-being: The foundations of
hedonic psychology (pp. 6184). New York: Russell
Sage.
Veenhoven, R. (1984). Conditions of happiness.
Dordrecht: D Reidel.
Business for Social Responsibility
Anete Farina1 and Maria Jose Chambel2
1
Department of Social Psychology, University of
S. Paulo, Sao Paulo, Brazil
2
Department of Social and Organizational
Psychology, University of Lisbon, Lisbon,
Portugal
Definition
Social responsibility in business is a broad con-
cept that has been applied to the entire production
chain. It is intrinsically linked to both factors that
define the essence of organizations practices:
ethics and transparency in business management.
These factors should be reflected in the daily
decisions that impact on society, on the environ-
ment, and on the future of business (Ethos, 2003).
Description
Social responsibility is the moral principle that
guides the individual and social actions that
express the principles and values adopted in the
business behavior. Ethics and social responsibil-
ity have aroused the interest of organizations as
an important variable in their relations with their
stakeholders who participate directly or indi-
rectly in the business (Frazao, Costa, & Neves,
2007).
Business for Social Responsibility
The European Commission defines corporate
social responsibility as the organizations com-
mitment in analyzing and preventing the negative
impacts of their actions on society and their
respect for laws and collective agreements
(European Commission, 2011).
This theme of corporate social responsibility
has evolved from charity and altruism to
a relationship with the business strategy (Smith,
1994). In other words, now we should consider
that if an organization acts as a social responsible
institution, it acquires a source of competitive
advantage (Serpa & Fourneau, 2007). In fact,
from the 1960s to the 1990s, the movement
of social responsibility in business gained
a high projection in the USA and Europe,
and the development of the organizations
culture of social responsibility became almost
an imperative for management if the compa-
nies hoped to remain competitive in their
respective markets.
The starting point of this trend was the trans-
formation of the globalized production system,
which weakened considerably the regulation by
governments. The priority on employment and
the imposition of production standards in order
to reduce the social costs generated the depen-
dence of governments on large companies
(Chandler & Mazilish, 2005). These companies
have been given unprecedented trading power
that allowed them to transfer responsibilities to
the stakeholders. However, complaints about
the processes of dehumanization in employ-
ment mobilized the public opinion to demand
the adoption of an approach of corporate social
responsibility that involved an ethical practice
of production: the elimination of child labor,
subcontracting, and other forms of exploitation
of human labor (Thiery, 2005). Moreover, the
adoption of this practice promotes the advan-
tage in domestic and international markets
because it increases the companys positive
image, which in turn drives the consumers
preference.
However, the adoption of socially responsible
practices needs an organizational paradigm in its
current business strategy that can support those
practices. Therefore, the appropriateness of the
477 B
strategy of adopting a socially responsible atti-
tude is a process that must be incorporated into
the companys culture (Coutinho, & Soares,
2002). In fact, the fulfillment of social responsi-
bility requires that the organizations integrate the B
respect for employees, consumers, and environ-
ment rights in their values. In addition, it is nec-
essary that organizations establish a closer
collaboration with stakeholders, in order to max-
imize the creation of shared value among their
owners/shareholders and the society in general.
The complexity of this process will depend on
factors related to company size and nature of its
operations (Catalin & Carmen, 2008).
Nowadays, organizations are encouraged to
adopt strategies for social responsibility and to
cultivate opportunities for developing innovative
products, services, and business models that con-
tribute to the social welfare and lead to higher
quality life on the planet (European Commission,
2011). Thus, the social responsibility of business
comprises a broad set of actions that should ben-
efit the society, namely, the economy, the educa-
tion, the environment, the health, the local
activity, and the government. The actions should
improve social programs aimed at improving the
quality of life (Oliveira, 2005).
This standpoint implies multiple require-
ments, such as respect for the citizens rights;
good relationships with partners, customers, and
suppliers; promotion of quality in production,
employee participation in decision-making, and
investments in safety at the workplace; and pro-
fessional development, user satisfaction assur-
ance, contributions to community development,
and investments in technological research and
environmental conservation (Carroll, 1999).
Thus, it is necessary to adopt an attitude of trans-
parency in business management that implies
policies, practices, activities, and behaviors usu-
ally expected by any members of the society and
the adherence of a set of rules and standards that
meet the expectations of various audiences
(Veloso, 2002). The contemporary world
demands for transparency and requires the sub-
mission of an environmental performance and
measures for accident prevention (Montana &
Charnov, 1999).
B 478
Transparency in business supports the ethical
action and exists to meet social expectations,
ensuring consistency between discourse and
practice in the communication of important
information about products and services (Rico,
2004). One tool that encourages this transparent
communication with the public is the Social
Responsibility Report. This annual document
presents a set of information on economic, envi-
ronmental, and social activities developed by
the company and its main commitments and
public goals for the future. This is an instru-
ment by the company that discloses investment
in projects and/or actions from the perspective
of social responsibility (Menegasso, 2002). In
fact, the involvement with social responsibility
calls for economic planning to achieve the
desired goals and relies on a multidimensional
approach to ensure civil, political, economic,
social, cultural, and environmental rights
(Stoner & Freeman, 1994).
Social responsibility in business, therefore,
concerns the criteria used by the organization
for making decisions, the values that define its
priorities, and the relationships with all the
stakeholders it interacts with. Thus, investing
in social responsibility means investing in an
image crucial to add more value to products
and services and attract new customers. How-
ever, social responsibility in business depends
on its representation as an organization with
a culture of values (Ghemawat, 2000). The
emergence of such kind of company, able to
achieve an economic growth sustained in social
concern, has been increasingly demanded by
society. Investments in social responsibility
add to the society, by considering the interests
of society, the company, and the business
itself.
However, corporate social responsibility
also requires focus on the legislation in the
field of social rights or environmental stan-
dards. In countries where such regulations do
not exist, efforts should be made to establish
such an appropriate legal and regulatory
framework that allows the developing of
socially responsible practices (Livro Verde,
2001).
Business for Social Responsibility
Cross-References
Business Ethics
Perspectives of Social Agents
Social Inclusion
Social Institutions
Social Integration
Social Justice
Social Marketing
Social Sustainability
References
Carroll, A. B. (1999). Corporate social responsibility:
Evolution of a definitional construct. Business & Soci-
ety, 38, 268295.
Catalin, D. R., & Carmen, C. N. (2008). The growth of
organizations competitiveness through the development
of social responsibility investments projects. Accessed
Mars 02, 2012, from http://steconomice.uoradea.ro/
anale/volume/2008/v4-management-marketing/039.pdf
Chandler, A., & Mazlish, B. (2005). Leviathans: Multina-
tional corporations and the new global history. Cam-
bridge: Cambridge University Press.
Coutinho, R. B. G., & Soares, D. M. T. (2002). Gestao
estrategica com responsabilidade social: Arcabouco
analtico para auxiliar sua implementacao em
empresas no Brasil [Strategic management and social
responsibility: Analytic framework to assist its imple-
mentation in companies in Brazil]. Revista
Administracao Contemporanea, 6(3), 7596.
Ethos, Instituto Ethos. (2003). Accessed Febrary 16, 2012,
from www.ethos.org.br
European Commission. (25, October 2011). A renewed
EU strategy for 201114 for corporate social respon-
sibility, Brussels. COM(2011) 681 final.
Frazao, M. F., Costa, S. S., Neves, F. N. O. (2007). A
Dimensao Etica da Responsabilidade Social nas
Organizacoes. Maieutica Digital, 1, 196210.
Ghemawat, P. A. (2000). Estrategia e o Cenario de
Negocios [Strategy and scenario of business]. Porto
Alegre: Bookman.
Livro Verde. (18/07/2001). Promover um quadro europeu
para a responsabilidade social das empresas
[Promoting a European framework for corporate
social responsibility]. Bruxels: European Community
Commission. Accessed Februry 16, 2012, from www.
europart.eu.int
Menegasso, M. E. (2001). Responsabilidade social das
empresas: Um desafio para o Servico Social [Social
responsibility of companies: A challenge for social
service] (Vol. 1(5), pp. 6371). Florianopolis: Revista
Katalysis.
Menegasso, M. E. Responsabilidade social das empresas:
um desafio para o Servico Social. Revista Katalysis,
Business Well-Being
num. 5, julio-diciembre (pp. 6371). Universidade
Federal de Santa Catarina.
Montana, P. J., & Charnov, B. H. (1999). Administracao
[Management]. Sao Paulo: Editora Saraiva.
Oliveira, J. A. (2005). Uma avaliacao dos balancos sociais
das 500 maiores [An assessment of the social respon-
sibility report of the 500 largest companies]. Revista de
Administracao de Empresas, 4(1, Art. 2).
Rico, E. M. (2004). A responsabilidade social empresarial
e o estado: Uma alianca para o desenvolvimento
sustentavel. Perspectiva, 18, 4.
Serpa, D. A. F., & Fourneau, L. F. (2007).
Responsabilidade social corporativa: Uma
investigacao sobre a percepcao do consumidor [Social
responsibility of business: A research about consumer
perception] RAC-eletronica. Revista Administracao.
Contemporanea, 11(3), 83103.
Smith, C. (1994). The new corporate philanthropy (pp.
105116). Boston: Harvard Business School Publication.
Stoner, J., & Freeman, R. (1994). Administracao
[Management]. Rio de Janeiro: LTC.
Thiery, P. (2005). Ethique Marketing et responsabilite
societale de lentreprise: Entre civisme et cynisme.
Decisions Marketing, 38, 5969.
Veloso, L. H. M. (2002) Etica, valores e cultura:
especificidades do conceito de responsabilidade social
corporativa. In: ASHLEY, Patrcia Almeida. (Coord).
Etica e Responsabilidade Social nos Negocios. Sao
Paulo: Saraiva.
Business Regulation Measure
Ease of Doing Business Index
Business Well-Being
Joanne Lyubovnikova1, Reena Govindji2 and
Michael West1
1
Aston Business School, Aston University,
Birmingham, UK
2
Centre for Applied Positive Psychology,
Coventry, UK
Definition
Business well-being encompasses a number of
factors concerned with an individuals psycho-
logical responses to their job and workplace.
479 B
Description
There are two theoretical perspectives which
explain how individual well-being and
performance at work are shaped by organiza- B
tional factors. The first draws on the job
demands-resources model (Demerouti, Bakker,
Nachreiner, & Schaufeli, 2001) and proposes
that psychological well-being and job perfor-
mance will be negatively affected if a job or
work environment imposes too much challenge
(leading to strain) or too little challenge (leading
to boredom). Organizations which promote busi-
ness well-being therefore provide the right
job design (e.g., social support, feedback,
decision-making latitude) to promote positive
job challenges without overwhelming individuals
in terms of demands. The second perspective
draws on literature from the positive psychology
field to argue that positive emotional states, rela-
tionships, and appraisals accentuate psychologi-
cal well-being and build an organizational
climate characterized by motivating, meaningful,
and engaging work experiences. The integration
of these two perspectives allows to highlight
the four most crucial factors for creating
effective work communities and enabling busi-
ness well-being: authentic leadership, effective
people management, positive emotional environ-
ments, and work engagement.
Authentic Leadership
As a result of advancing technology, financial
pressures, global competition, governmental
initiatives, and an evolving economic and ethical
climate, leaders are facing a high degree of com-
plexity in their environment. These demands
require extraordinary leadership skills where
leaders have the capacity to both enable profound
change and sustain the well-being of their
employees. Naumann and Bennett (2000)
described leaders as being climate engineers;
what they convey through their personality,
values, beliefs, preferences, and behaviors leaves
an imprint on the character and well-being of those
they lead. Recent research shows that leaders are
most at their best when they are being authentic.
Authentic leadership has been defined as leaders
B 480
who are deeply aware of how they think and
behave and are perceived by others as being
aware of their own and others values/moral per-
spectives, knowledge and strengths (Avolio,
Griffith, Wernsing, & Walumbwa, 2010).
Through increased self-awareness, self-
regulation, and positive modeling, authentic
leaders develop authentic followers, who demon-
strate parallel qualities of their leaders and who
together develop an engaged, positive, and ethical
organizational climate in which leaders and fol-
lowers sustain their well-being (Gardner, Avolio,
Luthans, May, & Walumbwa, 2005).
Authentic leaders also seek to understand the
unique strengths of their employees and create
opportunities to build upon these towards achiev-
ing organizational goals (Kaplan & Kaiser,
2010). Together with this, individuals who use
their strengths have better well-being and vitality
(Govindji & Linley, 2007). Leaders therefore
have a significant role to play in cultivating
business well-being.
Effective People Management
Key to the well-being of people at work are that
they are clear about what it is they are required to
do and that they feel valued, respected, and
supported. Ensuring that this is true for all staff
is a first step in creating a work community char-
acterized by well-being and effectiveness. This
means ensuring that all staff are set clear objec-
tives relevant to organizational goals. Objectives
should be clear and challenging (in order to be
motivating), and, ideally, their achievement
should be measurable, so the individual has
clear feedback on their performance (Locke &
Latham, 1990). Second, employees in organiza-
tions are likely to report well-being and commit-
ment when they are treated with respect by
supervisors and employers and are given the nec-
essary support and resources they need to do their
jobs effectively. The person who is generally
most influential for better or worse in translating
organizational policies into practices that affect
employee well-being is the individuals line man-
ager. To the extent that she or he gives guidance,
support, positive feedback, and respect and cre-
ates a positive working environment for the
Business Well-Being
employee, well-being and good performance are
likely to be fostered.
Individuals at work are also more likely to
have high levels of commitment and satisfaction
when they find appropriate opportunities for
growth and development in their work.
Well-being at work is therefore also dependent
on good job design. Research demonstrates the
importance of five dimensions of job design
(Hackman & Oldham, 1976). Task identity refers
to the need for a job to be whole piece of work,
giving the satisfaction of tangible achievement.
Skill variety refers to the value to the individual of
doing a job that demands a range of skills, thus
enhancing their feelings of competence and
ensuring skill development. Task significance
describes the importance of doing a job that
makes a difference to the performance of the
team, the organization, to customers, or to soci-
ety. Autonomy gives the individual a sense of
control and competence, contributing to well-
being and effectiveness. Finally, feedback gives
employees clarity about their work performance,
contributing to feelings of accomplishment and
satisfaction while enabling targets to be set for
skill development and improved performance.
Learning and development opportunities are
also helpful for human health and well-being,
and people generally respond positively to the
opportunity to acquire new skills at work. When
employees are learning, either through formal
training or informally through team member or
supervisor coaching, their individual well-being
and that of the organization as a learning entity
are enhanced.
Positive Emotional Relationships
Research evidence shows convincingly how
important positive emotions, such as hope, plea-
sure, happiness, humor, excitement, joy, pride,
and involvement, are as a source of human
strength (Fredrickson, 2001). When individuals
feel positive emotions, they think in a more flex-
ible, open-minded way and consider a much
wider range of possibilities than if they feel anx-
ious, depressed, or angry. This enables them to
accomplish tasks and make the most of the situ-
ations they find themselves in. They are also more
Business Well-Being
likely to see challenges as opportunities rather
than threats. When they feel positive, they exer-
cise greater self-control, cope more effectively,
and are less likely to react defensively in work-
place situations. The benefits do not stop there.
They spill over too into what is called pro-social
behavior cooperation and altruism. When they
feel positive emotion, they are more likely to be
helpful, generous, and to exercise a sense of
social responsibility (Fredrickson, 2001). The
implications for the workplace are that by devel-
oping an environment where people feel positive,
organizational citizenship can be encouraged, or
the tendency of people at work to help each other
and those in other departments, to do that bit extra
which is not part of their job. Increasingly,
researchers suggest that organizational citizenship
is what probably makes the difference between the
most profitable organizations and most of the rest
(Podsakoff, MacKenzie, Paine, & Bachrach,
2000).
There is a strategic role for human resource
management leaders to encourage a culture of
positive emotion given the links to stronger orga-
nizational performance, lower employee turn-
over, and better health (Fredrickson, 2001).
This means encouraging good humor, positive
feedback, confidence, and enthusiasm through
socialization of new employees, through the mes-
sages given by the leaders in the organization and
through the modeling of relationships across the
organization. Discouraging the use of aggressive
emails is one small step. Encouraging celebra-
tions of success and appreciation of contributions
is vital. Moreover, organizations that practice
corporate social responsibility by contributing
to their communities, practicing ethical
business principles, and taking vigorous steps to
preserve the environment have higher levels of
commitment from employees and customers
(Collier & Esteban, 2007).
Work Engagement
Work engagement is a distinct and powerful
kind of employee well-being and is often consid-
ered to be the direct antipode of employee
unwell-being or burnout (Schaufeli, Taris, &
Van Rhenen, 2008). Although many everyday
481 B
connotations and definitions exist, work engage-
ment is most frequently conceptualized in the
literature as . . .a positive, fulfilling, work-
related state of mind that is characterized by
vigor, dedication, and absorption (Schaufeli, B
Salanova, Gonzalez-Roma, & Bakker, 2002,
p. 74). Vigor refers to an individuals willing-
ness to exert high levels of effort, energy, and
mental resilience when executing tasks. Dedica-
tion is characterized by experiences of meaning-
fulness, inspiration, involvement, and pride in
ones work. Absorption describes the high
levels of concentration, engrossment, and attach-
ment experienced while carrying out tasks,
whereby time flies by and one finds it difficult
to detach from work. Overall, work engagement
is a persistent and pervasive affective-cognitive
state in which employees feel compelled to strive
towards a challenging goal, applying all of their
energy and resources, and becoming intensely
involved in their work. This heightened sense of
excitement is what demarcates work engagement
from the construct of job satisfaction, whereby
employees are simply contented with their expe-
rience in the workplace.
So why is this unique form of well-being so
important for creating effective work communi-
ties? Work engagement has been shown to pre-
dict a number of bottom line organizational
outcomes including increased job performance,
financial returns, and client satisfaction (e.g.,
Bakker & Bal, 2010). Work engagement is also
associated with heightened organizational com-
mitment, lower turnover intentions, and
increased organizational citizenship behavior.
As a result, there has been a sharp increase in
scientific research exploring the key drivers of
work engagement.
So what can organizations do to facilitate
experiences of vigor, dedication, and absorption?
A recent meta-analysis found that autonomy,
feedback, social support, and organizational cli-
mate are consistently associated with work
engagement (cf. Halbesleben, 2010). Therefore,
supporting and empowering employees to take
more control over their work is likely to facilitate
experiences of work engagement. Personal
resources such as optimism and self-efficacy
B 482
have also been shown to be particularly impor-
tant, reiterating the importance of a positive
emotional climate in the workplace to stimulate
such individual strengths and attributes.
Conclusion
What is known about well-being at work contra-
dicts that can create effective organizations,
focusing only on performance. It is possible to
work with and not against human needs, capabil-
ities, and potential and create effective working
communities that have successfully and at the
same time promote the health and well-being of
those who work within them. The four key prin-
ciples that have been proposed here represent
powerful ways to facilitate such results in todays
workplace.
Cross-References
Business Ethics
Confidence
Corporate Social Responsibility
Decision Making
Emotions, Sociology of
Health
Motivation
Personality, an Overview
Psychological Well-Being
Social Support
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Customer Satisfaction