APPLIED PSYCHOLOGY: HEALTH AND WELL-BEING, 2009, 1 (1), 46–61

doi:10.1111/j.1758-0854.2008.01002.x

The Observational Evaluation of Subjective

Well-Being in Patients with Rheumatoid Arthritis
Afton L. Hassett*
University of Medicine and Dentistry of New Jersey-Robert Wood Johnson
Medical School, New Brunswick, NJ, USA

Ross Maclean
Bristol-Myers Squibb, Plainsboro, NJ, USA

Christopher Peterson
University of Michigan, USA

Marian R. Stuart
University of Medicine and Dentistry of New Jersey-Robert Wood Johnson
Medical School, New Brunswick, NJ, USA

Steven Buyske
Rutgers University, USA

Nansook Park
University of Rhode Island, USA

Shantal V. Savage
University of Medicine and Dentistry of New Jersey-Robert Wood Johnson
Medical School, New Brunswick, NJ, USA

Tracy Li
Bristol-Myers Squibb, Lawrenceville, NJ, USA

Martin E.P. Seligman

University of Pennsylvania, USA

* Address for correspondence: Afton L. Hassett, UMDNJ-Robert Wood Johnson Medical

School, Division of Rheumatology and Connective Tissue Research, 1 Robert Wood Johnson
Place, MEB-484, New Brunswick, NJ 08903-0019, USA. Email: a.hassett@umdnj.edu

© 2009 The Authors. Journal compilation © 2009 International Association of Applied

Psychology. Published by Blackwell Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ,
UK and 350 Main Street, Malden, MA 02148, USA.
 OBSERVED SUBJECTIVE WELL-BEING 47
An important aspect of general health is subjective well-being (SWB), which is
defined as happiness and overall satisfaction with life. Herein we examined the
reliability and validity of observation-based ratings of SWB in patients with
rheumatoid arthritis (RA). Ten RA patients experiencing a disease flare (period
of increased symptoms) completed two semi-structured interviews (baseline and
4 weeks later) that were digitally recorded. Twelve healthcare professionals
watched the 20 brief videos in random order and scored them using the Well-
Being Coding System (WBCS) for observer-reported SWB. Patient-reported
SWB scores and scores from the Medical Outcomes Study: 36-Item Short Form
Survey (SF-36) were compared to observer-reported scores for SWB. We found
inter-rater reliability to be extremely high and a significant relationship between
observer SWB composite scores and patient SWB composite scores. Observer
SWB composite scores and other scores associated with SWB from the SF-36
were also related significantly. There was also some evidence supporting the
ability of observers to detect change in SWB. Taken together, we found prelimi-
nary evidence suggesting that when using information gleaned from brief patient
interviews clinicians can make reliable and valid evaluations of patients’ SWB.

Keywords: observational research, outcome measures, quality of life, rheuma-

toid arthritis, subjective well-being

INTRODUCTON
The medical profession has long focused on identifying, treating, and reduc-
ing symptoms associated with disease states. These are of course urgent and
important goals. Yet, just as important is helping patients live well and be
healthy. Few would disagree with the assertion of the World Health Organi-
zation (1946) more than 60 years ago that, “Health is a state of complete
physical, mental, and social well-being and not merely the absence of disease
or infirmity”, but this statement too often remains a mere slogan. In the
absence of concepts and measures that make positive health outcomes like
“well-being” more concrete, it is not surprising that medicine has continued
to focus almost exclusively on disease.
Fortunately, the new field of positive psychology provides an approach to
operationalising well-being. Concerned with what makes life most worth
living, positive psychologists have articulated a vision of the psychological
good life and—just as importantly—provided ways to ascertain its compo-
nents. One important aspect of the good life as studied by positive psycholo-
gists is subjective well-being (SWB), also known as happiness, which is
defined as high levels of positive affect, low levels of negative affect, and the
judgment that one’s life has been lived well (Diener, 1984). Well-being has
also been studied with a focus on positive psychological functioning or psy-
chological well-being (PWB) (Ryff & Singer, 1996). PWB comprises more
aspirational domains such as self-acceptance, autonomy, and purpose in life
(Ryff & Singer, 1996). Although both theories have their merits, we will assess
well-being from the SWB perspective.

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48 HASSETT ET AL.

SWB is typically measured with self-report questionnaires. Although these

methods have demonstrated reliability and validity (Diener, Emmons,
Larsen, & Griffin, 1985; Diener, Lucas, & Oishi, 2002; Pavot, Diener, Colvin,
& Sandvik, 1991), they may present logistical challenges for some clinical
settings or populations. Yet, even if questionnaires were convenient and
routinely used, experts have highlighted the importance of multi-modal
assessment of complex affective/cognitive constructs, such as SWB (Diener
et al., 2002). In lieu of questionnaires, in the clinical setting SWB is informally
evaluated by the clinician who looks for affective signs and listens to patient
reports regarding quality of life. Accordingly, the present research examined
the reliability and validity of clinician ratings of SWB for use as another
method of assessment for SWB. We explored the accuracy of clinician obser-
vations of SWB, like those typically made in everyday practice, by having
clinicians watch brief videos taken during interviews of patients with rheu-
matoid arthritis.
Rheumatoid arthritis can be a devastating disease characterised by joint
inflammation, chronic pain, and fatigue (Harris, 2005a) frequently resulting
in functional impairment, work disability, and depression (Kvien, 2004). Yet,
recent research in rheumatoid arthritis has begun to focus on protective
factors like self-esteem, optimism, and good adjustment to illness and the role
these factors play in promoting well-being (Nagyova, Stewart, Macejova, van
Dijk, & van den Heuvel, 2005). However, much of the well-being research in
the medical literature, including that for rheumatoid arthritis, is not guided
by theoretically based and empirically supported concepts of well-being like
SWB and PWB. Instead, too often a positive variable is simply labeled
“well-being”; however, there are findings that can serve as the substrate for
understanding general well-being in rheumatoid arthritis. For example, one
such study using the Life Satisfaction Index as a proxy for “psychological
well-being” reported that when compared to healthy controls, well-being, or
perhaps more appropriately life satisfaction, was diminished in rheumatoid
arthritis (Borman et al., 2007). Others have described in rheumatoid arthritis
an inverse relationship between well-being and important medical outcomes
such as pain (Schleicher et al., 2005), swollen and tender joint count (Bartlett,
Piedmont, Bilderback, Matsumoto, & Bathon, 2003), disease activity and
disability (Mangelli, Gribbin, Büchi, Allard, & Sensky, 2002), and depression
(Bartlett et al., 2003; Mangelli et al., 2002).
The goal of the present research was to assess whether observers could
determine patients’ general subjective sense of well-being or SWB based
solely on watching brief patient interviews. In addition to providing another
way to assess SWB, observer-reported well-being could demonstrate validity
for what many healthcare clinicians do routinely and intuitively—assess
health-related quality of life and treatment efficacy simply by listening to and
observing their patients.

© 2009 The Authors. Journal compilation © 2009 International Association of Applied

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 OBSERVED SUBJECTIVE WELL-BEING 49
METHODS

Participants
Two sets of participants were recruited for this study: patients and healthcare
clinicians (observers). The first set of participants consisted of 10 patients
with rheumatoid arthritis from the rheumatology clinic at the University of
Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical
School (UMDNJ-RWJMS). Rheumatologists identified patients with a
confirmed diagnosis of rheumatoid arthritis (Arnett et al., 1988), increased
signs and symptoms indicative of a disease flare, and a planned change in
medication. Other inclusion criteria were being between the ages of 25 and 80,
fluency in English, and willingness to complete questionnaires and participate
in recorded interviews.
The second set of participants was observers: 12 healthcare clinicians
recruited from UMDNJ-RWJMS and the community (four physicians, four
nurses, and four psychologists). A representative sample of equal genders was
recruited to include a wide range of ages and levels of clinical experience and
experience working with rheumatoid arthritis patients. All observers agreed
to uphold patient confidentiality. If an observer discovered that he/she knew
a patient well, e.g. former patient, the observer would be excluded. The
Institutional Review Board of UMDNJ-RWJMS approved this study.

Measures
Theoretically Based Assessment of Well-Being and Questionnaires. Diener
and colleagues (Diener, 1984; Diener, Oishi, & Lucas, 2003; Lucas, Diener, &
Suh, 1996) conceptualised SWB as consisting of two components: emotional
(both negative and positive affect) and judgmental (evaluations of one’s life).
The emotional component can be assessed with the Positive and Negative
Affect Scale (Watson, Clark, & Tellegen, 1988). The judgmental component
can be operationalised with the Satisfaction with Life Scale (Pavot et al., 1991).

Positive and Negative Affect Scale (PANAS). The PANAS consists of

two mood scales with 10 items each for the assessment of positive and
negative affect. Each mood scale has a range from 5 to 50 points, with higher
scores indicating greater levels of affect. The mood scales are internally
consistent, uncorrelated, and stable over a 2-month period with good con-
vergent and discriminant validity (Watson et al., 1988).

Satisfaction with Life Scale (SWLS). The SWLS is a self-report

measure consisting of five items that produces scores that range from 5 to 35,
with higher scores indicating greater life satisfaction (Diener et al., 1985). The

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50 HASSETT ET AL.

SWLS is valid, reliable, and appropriate for a wide age range (Diener et al.,
1985; Pavot et al., 1991). Assessing well-being using these instruments has
demonstrated good discriminant validity (Lucas et al., 1996).

Medical Outcomes Study: 36-Item Short Form Survey (SF-36). The

SF-36 was used to measure physical and emotional changes. The SF-36 is a
well-validated 36-item questionnaire developed for the assessment of health-
related quality of life in many medical populations including rheumatoid
arthritis (Brazier et al., 1992; McHorney, Ware, & Raczek, 1993; Tugwell,
Idzerda, & Wells, 2007; Ware & Sherbourne, 1992). The SF-36 provides eight
subscale scores and two composite scores all with a mean of 50 and a stan-
dard deviation of 10, with higher scores indicative of better quality of life. We
used the two component scores, Physical Component Summary (PCS) and
Mental Component Summary (MCS), and only the two subscale scores that
are associated with general well-being—Vitality and Mental Health (Ware &
Sherbourne, 1992).

Patient Procedures
Patients meeting study criteria had a baseline assessment within 7 days of
physician referral. Patients gave informed consent and then completed the
PANAS, SWLS, and SF-36. Next, patients participated in the first of two 5-
to 10-minute semi-structured recorded interviews. The interviews were con-
ducted by either ALH or MRS and took place in a private room. The
interview addressed: (1) initial symptoms, rheumatoid arthritis diagnosis, and
disease progression; (2) current symptoms and physical functioning; (3) role
functioning; (4) mood and current concerns; and (5) view of the future. The
interviews were recorded with a digital video camcorder. A neutral back-
ground was used and only patients appeared in the shot. They appeared from
the waist up, allowing hand gestures to be recorded. Patients returned 4
weeks later to complete the same three questionnaires and a second recorded
interview using questions similar to those used in the first interview. Initial
symptoms and rheumatoid arthritis diagnosis were not queried, although
early rheumatoid arthritis was frequently discussed anyway. Patients received
r50 at each assessment session.

Digital Video Editing

Videos were recorded with a Panasonic PV-GS250 digital video camcorder.
Digital footage was edited by ALH using Microsoft’s Digital Image
Suite Plus. Editing followed a strict set of rules to minimise bias. First, all
interviewer comments were removed as were references to patient names or
other identifying information. Next, temporal references and highly personal

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 OBSERVED SUBJECTIVE WELL-BEING 51
information, e.g. details of a marital conflict, were removed. Inaudible mate-
rial, long pauses, and repetitions were omitted. Finally, lengthy stories were
condensed to achieve the objective of creating 3-minute video vignettes rep-
resentative of the full interviews in terms of content and emotional tone.

Development of the Well-Being Coding System (WBCS)

Observational research typically relies on a pencil and paper instrument on
which the observers can “code” their impressions. The WBCS was created
to capture the affective and life satisfaction components associated with
SWB.
The WBCS was based on adapted versions of the SWLS and PANAS.
First, instructions for both instruments were rewritten to instruct the
observer to respond to each item as it pertained to the patient. For example,
the revised instructions for the SWLS read, “Below are five statements that
may or may not pertain to the patient. Using the 1–7 scale below, indicate
your agreement with each item as it pertains to the patient by placing the
appropriate number on the line preceding that item.” Next, items on the
SWLS were rewritten where, “In most ways my life is close to my ideal”
became “In most ways the patient’s life is close to ideal”. The items on the
PANAS which are single item affective states required no such modification
although as previously mentioned the instructions required modification.
Next, we conducted a small pilot trial to test the readability, clarity, and
initial performance of the WBCS. Six research assistant “observers” watched
two videos of mock-up patient interviews and used the WBCS to code their
impressions. None of the observers reported difficulty understanding the
directions or content of the items. Scoring is based on a mean of 50 and a
standard deviation of 10 and is described in detail in the statistical analysis
section. Our pilot trial showed that the WBCS was easy to use, required
minimal training, and demonstrated good agreement (alpha = .95).

Healthcare Clinician Rating of Patient SWB

Observers received approximately 15 minutes of training. Video vignettes
were viewed on a desktop computer using Microsoft Windows Media Player.
Observers were oriented to Media Player then received instruction regarding
the WBCS. Next, observers were allowed to practice using the media appli-
cation and the WBCS by watching and scoring the same two mock-up videos
used during the pilot. Observers were told, “We are interested in your general
impressions of the individuals observed in the videos. You will most likely not
receive enough information to make perfect judgments. You may rewind and
review a video vignette, but you may not return to it after proceeding to the
next video.” Most observers were trained individually, and they received

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52 HASSETT ET AL.

limited feedback during training. After scoring the mock-up videos, observers
were told whether they tended to score the videos more favorably, less favor-
ably, or similarly to others. The source for comparisons was mean scores
from the pilot trial that used the same two videos.
After training, observers scored the 20 video vignettes (10 baseline and 10
follow-up) alone in a comfortable room with study personnel intermittently
present or nearby. To reduce expectancy effects, video files were randomised
using Media Player’s shuffle feature. An observer was just as likely to see a
follow-up interview before the baseline interview as they were to see the
videos in proper temporal order. Corresponding number coded WBCS forms
were provided for each vignette. Completed WBCS forms were collected
frequently and thus were not available to observers for later reference.
Observers were blind to the results of patient-completed questionnaires.
Observers were paid r300 for approximately two hours of their time.

Statistical Analysis
Separate composite scores were created for patient data (i.e. questionnaires)
and observer data (i.e. coding). These composite scores reflected the combi-
nation of both affective (e.g. positive and negative affect) and cognitive (i.e.
satisfaction with life) components of SWB. Typically, composite scores for
SWB using these instruments are calculated by subtracting negative affect
from positive affect and then adding satisfaction with life. To improve gen-
eralisability, positive affect, negative affect, and satisfaction with life scores
were transformed to reflect population norms. Then they were combined by
subtracting negative affect from positive affect and then adding satisfaction
with life. Finally, the composite scores were scaled and translated to achieve a
sample mean of 50 and a standard deviation of 10. Using the norms from
other studies (Watson et al., 1988; Yoshioka, 2002), the exact formula we used
simplifies to: well-being = (SWLS/1.77) + (Positive affect/1.47) - (Negative
affect/1.36) + 27.6.
Next, the observer and patient scores on the global well-being score and
three domains of well-being were correlated. Inter-rater reliability (IRR) was
estimated using an explicit model. Individual video scores were modeled as a
linear combination of an overall mean, a session effect, a research participant
effect, an observer effect, a research participant by session effect, an observer
by session effect, and a normal random term. All but the session effect were
treated as random effects, with distinct variances. IRR for this setting was
then defined as the estimate of:

σ Subj
2
+ σ Subj
2
× Session
ρ=
σ 2
Subj +σ 2
+ σ Rater + σ Rater
Subj × Session
2 2
r × Session + σ Error
2

© 2009 The Authors. Journal compilation © 2009 International Association of Applied

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 OBSERVED SUBJECTIVE WELL-BEING 53
with each variance replaced by its estimate. The denominator is the total
variance of the scores while the numerator is the component of variance due
to participant-to-participant variability. A high value indicates that most of
the score variability is due to patient participant variability rather than
observer variability or the variability inherent in the scoring system. As the
asymptotic confidence interval for the IRR is known to perform poorly, BCa
bootstrap confidence intervals were constructed instead (Efron & Tibshirani,
1993). IRR for means of more than one observer were obtained using the
Spearman Brown prophecy formula. IRR was also calculated for the differ-
ence from session to session (using the standard formula).
Correlations among observer SWB composite scores (means across all
observers) and patient SWB composite scores were examined as a measure of
validity. Other measures of validity would be significant relationships
between observer SWB composite scores and patient-reported mental and
physical health scores on the SF-36: MCS, PCS, Mental Health subscale, and
Vitality subscale. In addition, sensitivity to change in patient presentation
was calculated by comparing change within patient between the SF-36 MCS
and PCS, the two SF-36 subscales “Vitality” and “Mental Health” and
observer SWB composite scores (means across all observers) from the WBCS.
The study was designed to give a 95 per cent confidence width of .3 for an
IRR of .8. Except for a Holm correction for multiple testing applied in
Table 1, all significance levels are nominal. A power estimate determined the
number of patients and clinicians required to provide an adequate number of
observations.

RESULTS

Patient Participants
Table 1 presents the demographic data and patient-reported scores from
questionnaires and observer-reported scores from the WBCS. All but one
patient had a significant change in medication. At baseline, patient mean
scores on the SF-36 were as follows: MCS = 52.8 (18.6), PCS = 40.2 (14.8),
Vitality 46.0 (22.6), and Mental Health 65.2 (18.6), while the patient SWB
composite score was 49.6 (10.0). After the intervention period, the mean
scores for the SF-36 were MCS = 59.9 (19.2), PCS = 50.6 (22.6), Vitality
subscale 49.0 (16.3), and Mental Health subscale 63.2 (17.5), while the
follow-up patient SWB composite score was 49.5 (11.0). None of the self-
reported change scores were statistically significant.

Healthcare Clinician Participants

Table 1 also depicts the observer SWB composite scores from the healthcare
clinicians. Of those recruited, nine were affiliated with the UMDNJ-RWJMS,

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54 HASSETT ET AL.

TABLE 1
Demographic Characteristics and Scores

Patient demographics (n = 10) Mean (Standard Deviation)

Age 58.1
Sex, female:male 7:3
Ethnicity
White 8
Hispanic/Latino 2
Duration of Illness (years) 7.92 (8.29)

Patient reported scores Pre Post Change CI

Satisfaction with Life Scale 23.2 (7.5) 23.7 (8.3) 0.5 (3.2) (-1.8, 2.8)
Positive Affect 35.7 (5.5) 35.6 (6.5) 0.1 (3.7) (-2.7, 2.5)
Negative Affect 20.9 (8.6) 21.3 (7.0) 0.4 (8.2) (-5.5, 6.3)
SWB Composite 49.6 (10.0) 49.5 (11.0) -0.1 (6.1) (-4.4, 4.3)
MCS 52.8 (18.6) 59.9 (19.2) 7.1 (15.1) (-3.7, 17.9)
PCS 40.2 (14.8) 50.6 (22.6) 10.5 (15.6) (-0.7, 21.6)
SF-36 Vitality 46.0 (22.6) 49.0 (16.3) 3.0 (10.9) (-4.8, 10.8)
SF-36 Mental Health 65.2 (18.6) 63.2 (17.5) -2.0 (11.2) (-10.0, 6.0)

Observer reported scores

(n = 11) Pre Post Change CI

Satisfaction with Life Scale 13.4 (3.1) 17.3 (4.9) 3.8 (4.2) (0.9, 6.8)
Positive Affect 29.2 (4.1) 33.3 (6.3) 4.1 (5.2) (0.4, 7.8)
Negative Affect 20.2 (3.5) 16.2 (5.1) -4.1 (4.4) (-7.2, -0.9)
Well-Being 40.2 (5.9) 48.1 (10.4) 7.9 (8.4) (1.9, 14.0)

CI = Nominal 95% Confidence Interval for Change. No Change Score was significant after a Holm correction
for multiple testing.

while three came from the community. Four observers were physicians (three
rheumatologists and one family practice physician), four were nurses and
four were psychologists. One observer, a rheumatologist, was excluded due to
knowing several patients well. There were no differences between occupations
regarding ability to accurately assess SWB. Mean scores for observer SWB
composite scores from baseline (40.2 [5.9]) to follow up (48.1 [10.4]) changed
significantly at a nominal significance level of .05; however, when the p-values
in Table 1 were corrected for multiple testing using the Holm method, none
of the results were statistically significant.

Inter-rater Reliability
The reliability for the observer SWB composite scores estimated by modeling
produced an initial estimate of .65 (one observer) with a 95 per cent confi-

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 OBSERVED SUBJECTIVE WELL-BEING 55
TABLE 2
Inter-Rater Reliability (IRR)

Well-being

IRR Estimate 0.65

B—A 0.52
Lower Confidence Limit 0.39
Upper Confidence Limit 0.79
IRR 2 Observers 0.79
IRR 3 Observers 0.85
IRR 4 Observers 0.88
IRR 5 Observers 0.90
IRR 6 Observers 0.92

IRR = inter-rater reliability. B—A = Difference from session A to session B. Lower CL and upper CL are the
BCa 95% bootstrap confidence intervals for the IRR estimate. IRR 2 observers and so on are the IRR using
the mean of two observers and so on.

dence interval of (.39, .79). Based on this estimate, IRR for the 11 observers
was 0.95. Complete estimates are shown in Table 2. IRR was also calculated
for each session individually (not shown) with results consistent with those in
the table. Observer type—psychologist, physician, or nurse—did not have a
significant effect (not shown).

Validity
The dataset had complete results for 10 patient participants and 11 observers.
Correlations among observer SWB composite scores (means across all
observers) and patient SWB composite scores are shown in Table 3. Patient
SWB composite scores correlated significantly with observer SWB composite
scores (r = .66). Further, there are significant relationships between observer
SWB composite scores and patient-reported mental and physical health
scores: SF-36 MCS (r = .77), SF-36 PCS (r = .63), Mental Health subscale
(r = .70), and Vitality subscale (r = .65). Notably, SF-36 MCS and PCS scores
have higher correlations with observer SWB composite scores (r = .77 and
.63, respectively) than with patient SWB composite scores (r = .65 and .54,
respectively), although all are significant.
Table 4 shows correlations of the change in observer SWB composite
scores with the change in SF-36 MCS and PCS, as well as Mental Health and
Vitality subscales. The table also shows partial correlations after controlling
for the sex of the participants. Duration of illness was assessed and found not
to be a significant covariate. One patient participant, number 3, had very
large increases in observer SWB composite scores (23.3) and Vitality (20.0),
resulting in a high influence point that may give misleading estimates. After

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Psychology.
TABLE 3
Correlations of Patient-Reported Scores and Observer Means
HASSETT ET AL.

Pt WB Obs WB Pt SWLS Obs SWLS Pt PA Obs PA Pt NA Obs NA MCS PCS MH V

Patient WB 0.66** 0.84** 0.61** 0.60** 0.64** -0.75** -0.60** 0.65** 0.54* 0.62** 0.60**
Observer WB 0.54* 0.96** 0.53* 0.93** -0.41 -0.93** 0.77** 0.63** 0.70** 0.65**
Patient SWLS 0.51* 0.44* 0.50* -0.43 -0.49* 0.51* 0.37 0.48* 0.54*
Observer SWLS 0.50* 0.85** -0.35 -0.88** 0.73** 0.70** 0.65** 0.64**
Patient PA 0.62** -0.03 -0.35 0.44 0.39 0.49* 0.32
Observer PA -0.33 -0.73** 0.63** 0.44 0.69** 0.44*
Patient NA 0.47* -0.47* -0.42 -0.39* -0.44*
Observer NA -0.80** -0.68** -0.62** -0.76**
MCS 0.80** 0.82** 0.81**
PCS 0.54* 0.74**
MH 0.66**

Note: * Correlations with absolute value greater than .44 are significant at a = .05;** Correlations with absolute value greater than .55 are significant at a = .01;
Pt: Patient; Obs: Observer; WB: Well-Being; SWLS: Satisfaction With Life Scale; PA: Positive Affect; NA: Negative Affect; MCS: Mental Component Summary; PCS:
Physical Component Summary; MH: SF-36 Mental Health Scale; V: SF-36 Vitality Scale.

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 OBSERVED SUBJECTIVE WELL-BEING 57
TABLE 4
Correlations and Partial Correlations (Conditional on Sex of Patient) for
Changes from Baseline on the SF-36. Correlations of the Change in Observer
SWB Composite Scores with the Change in SF-36 MCS, PCS, and Mental
Health and Vitality Subscales

MCS PCS MH V
(conditional (conditional (conditional (conditional
Model MCS on sex) PCS on sex) MH on sex) V on sex)

Differences .55 .79** .38 .46 .36 .60 .54 .65*

(including
Patient 3)
Differences .82** .89** .60 .68* .32 .55 .29 .45
(without
Patient 3)

Note: * = significant at a = .05; ** = significant at a = .01; MCS: Mental Component Summary; PCS: Physi-
cal Component Summary; MH: SF-36 Mental Health Scale; V: SF-36 Vitality Scale.

conditioning on the sex of the participants, the change in SF-36 MCS is

highly correlated with the change in observer SWB composite scores, whether
or not patient participant 3 is included, while the change in SF-36 PCS is
correlated only when patient 3 is omitted.

DISCUSSION
Intuitive deductions about a patient’s affect and psychosocial functioning are
central to the art of medicine, yet there is little empirical evidence to support
the validity of these judgments. We demonstrated that SWB composite scores
based on patient self-report agreed substantially with those generated by a
group of healthcare clinicians who watched and listened to short digitally
recorded vignettes of the same patients discussing their symptoms and func-
tioning. Both observed SWB and that reported by patient participants were
closely related to component and well-being-related subscale scores from the
most commonly utilised quality of life instrument, the SF-36.
Our patients as a group did not experience significant improvement after a
medication change. This was not a clinical drug trial, thus patients received
treatment as usual and were followed over 1 month which likely did not
provide adequate time to assess full response. Interestingly, there was a trend
toward improvement that was reflected in mental health component and
observer SWB composite scores, but not in the patient SWB composite
scores. Again after corrections for multiple testing, change scores were not
significant, thus no conclusions can be drawn. Of note, our sample had
satisfaction with life scores similar to those in healthy populations (Diener

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58 HASSETT ET AL.

et al., 1985), yet observer scores for satisfaction with life were uniformly
lower than those reported by the patients, suggesting that our observers
assumed rheumatoid arthritis would have a more profound impact on SWB
than was actually experienced by patients. The observers, however, were in
agreement regarding which patients had better SWB (ordering of patients)
and how SWB changed over time as reported by the patients.
Our findings suggesting that SWB is related to both physical and mental
health scores in rheumatoid arthritis are in accordance with those of others
(Bartlett et al., 2003; Mangelli et al., 2002; Schleicher et al., 2005). Overall,
the growing interest in the assessment of well-being in general is likely related
to the bi-directional relationship between well-being and physical health
(Rozanski & Kubzansky, 2005). For example, greater feelings of well-being
have been associated with fewer clinical colds (Cohen, Alper, Doyle, Treanor,
& Turner, 2006) and survival in coronary artery disease (Barefoot et al.,
2000) and lung transplantation (Squier et al., 1995), while chronic illness in
general has been found to adversely affect well-being (Mangelli et al., 2002).
Others have explored mechanisms and reported that there are distinctive
biological correlates for well-being and negative affects such as depression,
anxiety, and anger (Ryff et al., 2006). While the WBCS will likely have little
clinical utility, we hope that providing another method for the assessment of
SWB will encourage increased and more comprehensive research related to
SWB in medical populations.
There are limitations to this study predominantly due to the number and
nature of our participants. Although a power estimate guided the number of
patient participants recruited, we focused on a relatively small, nonrandom
group of patients with rheumatoid arthritis. Our results may not generalise to
patients with other medical diagnoses especially since rheumatoid arthritis
patients tend to be largely female (Harris, 2005b). We found important
differences between the genders on SWB which could be attributed to gender-
specific differences in affective style. Results in studies using a balanced
sample could vary from our findings. Personality factors could also play a
role. For example, several patients who were invited to participate declined,
expressing discomfort with a recorded interview. Those who did agree to
participate may have been more gregarious and thus easier to read than more
introverted patients. Our results could also be skewed by research participant
response bias due to videotaping which might have caused patients to
respond less candidly or to present themselves more positively at follow-up
which could account for the trend toward healthcare clinicians detecting
SWB improvement that patients did not themselves report. It will also be
important for future studies to use structured interviews using the exact same
questions for all interviews. As for the healthcare professional observers, we
attempted to identify individuals presumed by study personnel to have
varying levels of patient empathy. Because empathy was not formally mea-

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Psychology.
 OBSERVED SUBJECTIVE WELL-BEING 59
sured, it is not known whether our healthcare professionals are representative
of others in terms of possessing a quality likely to enhance performance
related to rating SWB, empathy. Finally, video editing bias may exist as
the observers did not have access to all of the video footage and what
was shown was edited by study personnel. Nonetheless, every effort was
made to produce a vignette that was true in content and mood to the unedited
footage.
In conclusion, we have demonstrated good preliminary evidence that the
SWB of patients with rheumatoid arthritis can be observed by healthcare
clinicians. Our findings indicate that the subjective experience of SWB may
not be an entirely internal and private process. Thus, observed SWB assessed
in this manner also has the potential to be an objective outcome measure
and/or one confirming patient report, thus addressing Diener et al.’s (2002)
call for a multi-method battery for the assessment of SWB. We have begun to
demonstrate that healthcare clinicians can indeed accurately assess a patient’s
general well-being through their judgments related to affect and life satisfac-
tion. This information may inform treatment decisions, and could even
enhance the clinician–patient relationship by encouraging healthcare clini-
cians to more confidently engage patients in discussions regarding mood and
psychosocial functioning.

ACKNOWLEDGEMENTS
This study was supported by Bristol-Myers Squibb (BMS), where Dr Hassett
also acts as a consultant. Drs Ross Maclean and Tracy Li are employees of
BMS in Outcomes Research. No outside editing or writing assistance was
used. We thank our participants including our clinic patients who shared
their compelling stories in front of a camera and our healthcare workers who
while watching the videos appeared quite moved by the words of the patients.

REFERENCES
Arnett, F.C., Edworthy, S.M., Bloch, D.A., McShane, D.J., Fries, J.F., Cooper, N.S.
et al. (1988). The American Rheumatism Association 1987 revised criteria for the
classification of rheumatoid arthritis. Arthritis and Rheumatism, 31, 315–324.
Barefoot, J.C., Brummett, B.H., Helms, M.J., Mark, D.B., Siegler, I.C., & Williams,
R.B. (2000). Depressive symptoms and survival of patients with coronary artery
disease. Psychosomatic Medicine, 62, 790–795.
Bartlett, S.J., Piedmont, R., Bilderback, A., Matsumoto, A.K., & Bathon, J.M.
(2003). Spirituality, well-being and quality of life in people with rheumatoid arthri-
tis. Arthritis and Rheumatism, 49, 778–783.
Borman, P., Toy, G.G., Babaoglu, S., Bodur, H., Ciliz, D., & Alli, N. (2007). A
comparative evaluation of quality of life and life satisfaction in patients with
psoriatic and rheumatoid arthritis. Clinical Rheumatology, 26, 330–334.

© 2009 The Authors. Journal compilation © 2009 International Association of Applied

Psychology.
60 HASSETT ET AL.

Brazier, J.E., Harper, R., Jones, N.M., O’Cathain, A., Thomas, K.J., Usherwood, T.
et al. (1992). Validating the SF-36 health survey questionnaire: New outcome
measure for primary care. British Medical Journal, 305, 160–164.
Cohen, S., Alper, C.M., Doyle, W.J., Treanor, J.J., & Turner, R.B. (2006).
Positive emotional style predicts resistance to illness after experimental
exposure to Rhinovirus or Influenza A virus. Psychosomatic Medicine, 68, 809–
815.
Diener, E. (1984). Subjective well-being. Psychological Bulletin, 95, 542–575.
Diener, E., Emmons, R.A., Larsen, R.J., & Griffin, S. (1985). The Satisfaction With
Life Scale. Journal of Personality Assessment, 49, 71–75.
Diener, E., Lucas, R.E., & Oishi, S. (2002). Subjective well-being: The science of
happiness and life satisfaction. In C.R. Snyder & S.J. Lopez (Eds.), Handbook of
positive psychology (pp. 63–73). New York: Oxford University Press.
Diener, E., Oishi, S., & Lucas, R.E. (2003). Personality, culture, and subjective well-
being: Emotional and cognitive evaluations of life. Annual Review of Psychology,
54, 403–425.
Efron, B., & Tibshirani, R. (1993). An introduction to the bootstrap. New York:
Chapman and Hall.
Harris, E.D., Jr. (2005a). Clinical features of rheumatoid arthritis. In E.D. Harris Jr.,
R.C. Budd, M.C. Genovese, G.S. Firestein, J.S. Sargent, & C.B. Sledge (Eds.),
Kelley’s textbook of rheumatology (Vol. 2, 7th edn., pp. 1043–1078). Philadelphia,
PA: Elsevier Saunders.
Harris, E.D., Jr. (2005b). Etiology and pathogenesis of rheumatoid arthritis. In E.D.
Harris Jr., R.C. Budd, M.C. Genovese, G.S. Firestein, J.S. Sargent, & C.B. Sledge
(Eds.), Kelley’s textbook of rheumatology (Vol. 2, 7th edn., pp. 1028–1042). Phila-
delphia, PA: Elsevier Saunders.
Kvien, T.K. (2004). Epidemiology and burden of illness of rheumatoid arthritis.
Pharmacoeconomics, 22, 1–12.
Lucas, R.E., Diener, E., & Suh, E. (1996). Discriminant validity of well-being mea-
sures. Journal of Personality and Social Psychology, 71, 616–628.
McHorney, C.A., Ware, J.E. Jr., & Raczek, A.E. (1993). The MOS 36-item Short
Form Survey (SF-36): II. Psychometric and clinical tests of validity in measuring
physical and mental health constructs. Medical Care, 31, 247–263.
Mangelli, L., Gribbin, N., Büchi, S., Allard, S., & Sensky, T. (2002). Psychological
well-being in rheumatoid arthritis: Relationship to “disease” variables and affec-
tive disturbance. Psychotherapy and Psychosomatics, 71, 112–116.
Nagyova, I., Stewart, R.E., Macejova, Z., van Dijk, J.P., & van den Heuvel, W.J.A.
(2005). The impact of pain on psychological well-being in rheumatoid arthritis:
The mediating effects of self-esteem and adjustment to disease. Patient Education
and Counseling, 58, 55–62.
Pavot, W., Diener, E., Colvin, C.R., & Sandvik, E. (1991). Further validation of
the Satisfaction with Life Scale: Evidence for the cross-method convergence of
well-being measures. Journal of Personality Assessment, 57, 149–161.
Rozanski, A., & Kubzansky, L.D. (2005). Psychologic functioning and physical
health: A paradigm of flexibility. Psychosomatic Medicine, 67(Suppl. 1), S47–
S53.

© 2009 The Authors. Journal compilation © 2009 International Association of Applied

Psychology.
 OBSERVED SUBJECTIVE WELL-BEING 61
Ryff, C.D., Deinberg Love G., Urry, H.L., Muller, D., Rosenkranz, M.A., Friedman,
E.M. et al. (2006). Psychological well-being and ill-being: Do they have distinct or
mirrored biological correlates? Psychotherapy and Psychosomatics, 75, 85–95.
Ryff, C.D., & Singer B. (1996). Psychological well-being: Meaning, measurement, and
implications for psychotherapy research. Psychotherapy and Psychosomatics, 65,
14–23.
Schleicher, H., Alonso, C., Shirtcliff, E.A., Muller, D., Loevinger, B.L., & Coe, C.L.
(2005). In the face of pain: The relationship between psychological well-being and
disability in women with fibromyalgia. Psychotherapy and Psychosomatics, 74,
231–239.
Squier, H.C., Ries, A.L., Kaplan, R.M., Prewitt, L.M., Smith, C.M., Kriett, J.M.
et al. (1995). Quality of well-being predicts survival in lung transplantation candi-
dates. American Journal of Respiratory and Critical Care Medicine, 152, 2032–
2036.
Tugwell, P., Idzerda L., & Wells, G.A. (2007). Generic quality-of-life assessment in
rheumatoid arthritis. American Journal of Managed Care, 13(Suppl. 9), S224–
S236.
Ware, J.E. Jr., & Sherbourne, C.D. (1992). The MOS 36-item short-form health
survey (SF-36). I. Conceptual framework and item selection. Medical Care, 30,
473–483.
Watson, D., Clark, L.A., & Tellegen, A. (1988). Development and validation of brief
measures of positive and negative affect: The PANAS scales. Journal of Personality
and Social Psychology, 54, 1063–1070.
World Health Organization (1946). Preamble to the Constitution of the World Health
Organization as adopted by the International Health Conference, New York,
19–22 June 1946. Official Records of the World Health Organization. Geneva,
Switzerland: author.
Yoshioka, M.R. (2002). Psychosocial measures for Asian-American populations:
Tools for direct practice and research [homepage on the Internet]. New York:
Columbia University School of Social Work; c1995–2002 [cited 2006 Sept 18].
Adults: Satisfaction with Life Scale (Yoshioka); [2 screens]. Available from: http://
www.columbia.edu/cu/ssw/projects/pmap/docs/yoshiokaswls.pdf

© 2009 The Authors. Journal compilation © 2009 International Association of Applied

Psychology.