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Concepts of health in different contexts: a scoping review

Abstract

The rationale of our study was that the World Health Organization’s (WHO) definition of health from 1947 which includes “… complete physical, mental and social wellbeing…” does not fit the current societal viewpoints anymore. The WHO’s definition of health implies that many people with chronic illnesses or disabilities would be considered unhealthy and complete wellbeing would be utopian and unfeasible for them. This is no longer uniformly accepted. Many alternative concepts of health have been discussed in the last decades such as ‘positive health’, which focusses on someone’s capability rather than incapability,. However, the question remains whether a general health concept can guide all healthcare practices. More likely, health concepts need to be specified for professions or settings. The objective of our study was to create a structured overview of published concepts of health from different perspectives by conducting a scoping review using the PRISMA-ScR guideline. A literature search was conducted in Pubmed and Cinahl. Articles eligible for inclusion focussed on the discussion or the conceptualisation of health or health-related concepts in different contexts (such as the perspective of care workers’ or patients’) published since 2009 (the Dutch Health Council raised the discussion about moving towards a more dynamic perspective on health in that year). Seventy-five articles could be included for thematic analyses. The results showed that most articles described a concept of health consisting of multiple subthemes; no consensus was found on one overall concept of health. This implies that healthcare consumers act based on different health concepts when seeking care than care workers when providing care. Having different understandings of the concepts of health can lead to misunderstandings in practice. In conclusion, from every perspective, and even for every individual, health may mean something different. This finding stresses the importance that care workers’ and healthcare consumers’ meaning of ‘health’ has to be clear to all actors involved. Our review supports a more uniform tuning of healthcare between healthcare providers (the organisations), care workers (the professionals) and healthcare consumers (the patients), by creating more awareness of the differences among these actors, which can be a guide in their communication.

Peer Review reports

Introduction

The World Health Organisation’s (WHO) definition of health does not fit the current societal viewpoints anymore [1]. The WHO definition of health is formulated as “Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” [2]. Due to the word ‘complete’ in this definition, many people would not be considered healthy, because of their chronic illnesses or disabilities [1, 3]. For them, complete wellbeing would be utopian and unfeasible [4]. This is no longer uniformly accepted. Perspectives on people with physical disabilities are changing; they are no longer seen as ‘unhealthy’. On the other hand, the focus has shifted to the fact that people, when they get a chronic illness or disability, do need to adapt to their new situation; being able to do this is part of the recently developed paradigm of ‘positive health’ [5].

Many alternative concepts of health have been discussed in the last decades in philosophical and policy-oriented health and medicine debates, changing from health as being free from disease to health as someone’s capabilities. Prominent concepts of health which have been widely discussed and criticized by philosophers were developed by Boorse, Nordenfelt, and Nussbaum, respectively. Boorse’s biostatistical theory of health is a purely descriptive quality of an organism [6], which focusses on the functioning of body parts and on physiological systems being free from disease [7]. Nordenfelt discharged Boorse’s biostatistical theory and focussed on the ‘second-order ability to achieve vital goals’ in which actions are oriented to achieve minimal happiness, being a condition that the person prefers [8]. Like Nordenfelt, also Nussbaum’s capability approach is about achieving a set of capabilities in things that are important in a person’s life [9]. However, Nordenfelt focusses on a person’s health relating to human flourishing and achieving vital goals, while Nussbaum focusses on defining components of a person’s life that equally reflect human dignity as well as being able to be and to do certain things [10]. More recently, the International Classification of Functioning, Disability and Health (ICF) focussed on performance as well as capacities taking a broader set of aspects into account: body functions, activity and participation, environmental and personal factors, and body structures [11, 12].

These broader views on health were further extended since the positive health concept was postulated by Huber et al. in 2011 [5, 12]. Positive health focusses on someone’s capability rather than incapability, which means that people with chronic diseases or disabilities are no longer automatically seen as ‘not healthy’. Besides, there is a clear focus on resilience and self-management in social, physical and emotional challenges [5, 12]. To further operationalise the concept of positive health, Huber et al. conducted survey research among several stakeholders, asking what they considered important aspects of health. This resulted in the identification of 32 aspects categorized into six dimensions: 1) bodily functions, 2) mental functions and perception, 3) spiritual/existential dimension, 4) quality of life, 5) social and societal participation, and 6) daily functioning [12]. This concept has had a strong influence on healthcare policy in the Netherlands. Furthermore, since 2020 the Eastern Institute of Health (HSA) in Iceland has also started the implementation of positive health [13].

Reactions to the concept of positive health in the literature are mixed. The dimensions are seen as meaningful, however, the terms ‘adapt’ and ‘self-manage’ are being questioned. Jambroes et al. [14] discussed that several groups of people like frail elderly or people with mental disorders may not have the capacity to adapt or to manage their own health. Furthermore, giving people the responsibility for their own health management can cause people to feel guilty when health problems occur [14]. Prinsen and Terwee [15] tried to develop an instrument for measuring positive health. The results showed that the aspects of the ‘positive health’ concept had not yet been worked out clearly. The experts involved questioned whether the operationalisation of the conceptual model is a reflection of health or a reflection of aspects of life that influence health (i.e., are determinants of health) [15]. Also, Hafen [16] sees the ‘ability to adapt and self-manage’ as a determinant instead of part of the concept of ‘health’ itself. Motives for including aspects in the six dimensions were unclear, nor was it always clear to which dimension certain aspects belonged. Overlap was seen across aspects within dimensions [16].

It can be concluded that a clear alternative concept of health to replace the WHO definition has not yet been found. To our knowledge, no reviews have been conducted on this topic yet. However, it is important to have a clear and understandable general health concept for management, designing and redesigning policy, research and healthcare practices [5, 17]. It may help policymakers to establish and implement effective health policies to improve health status, quality of life, morbidity and mortality [18]. Clear understanding of the meaning of health by healthcare professionals and patients will foster active participation and will increase patient empowerment [18]. However, it is questionable whether a general health concept can guide all practices. More likely, health concepts need to be specified for specific professions or settings [1]. To answer this question, we conducted a scoping review, to create a structured overview of published concepts of health from different perspectives that can support a more uniform tuning of healthcare between healthcare providers and healthcare consumers. The research question was: How is the concept of health defined in different contexts and from different perspectives? (For example, from the perspective of healthcare providers and healthcare consumers).

Method

Design

This scoping review was conducted using the PRISMA-ScR guideline, which follows a systematic approach to map evidence and identify main concepts and theories on a topic [19]. This design was used because our research question was broad. In line with the design of a scoping review, our review did not have the intention to perform a structured evaluation of the research quality, but focussed on all publications available about our topic.

Eligibility criteria

Articles eligible for inclusion focussed on the discussion or conceptualisation of health or health-related concepts. We included original research articles (interview or focus group discussions in qualitative design studies, surveys and concept mappings, quantitative or mixed methods studies exploring the concept), but also literature reviews, books, and letters to the editor. We excluded intervention studies using health or wellbeing related terms as one of their outcome measures. These studies do not focus primarily on discussing the concept of health. Validation studies of questionnaires or instruments evaluating health or wellbeing related terms not primarily focussing on the concept or definition of health were also excluded. Articles needed to be published in English between 2009 (the Dutch Health Council raised the discussion about moving towards a more dynamic perspective on health [5, 12] in that year) and May 2020.

Information sources

The search was conducted in two databases: Pubmed and Cinahl, on May 25, 2020. The search was conducted by the first author (VvD) and was peer reviewed within the research team. These databases were chosen because of their focus on social behaviour and medical sciences. A snowball method was conducted on the references of the collected articles. Finally, four experts in the field were asked for additional papers that might have been missed.

Search

The exact search string for PubMed is shown in Table 1 and for Cinahl in Table 2.

Table 1 The search string as conducted in PubMed
Table 2 The search string as conducted in Cinahl

Selection of sources of evidence

Results of the search were uploaded in Rayyan, a free web application for independent selection of articles by multiple researchers. Two researchers (VvD and EB) independently screened all titles, abstracts and full-text articles for in- or exclusion. In addition, they discussed the articles on which there was disagreement. If no agreement was reached after discussion, a third researcher (LN-vV) was asked. Simultaneously, three senior researchers (LN-vV, EdV, DvdM) independently screened 10 % of the articles for in- or exclusion in the first two phases, the title and abstract selection, in order to validate the process.

Data items

Preceding the coding process, a list of themes of interest was developed in consensus by the research team based on the aim of the scoping review and research question consisting of: 1) concept of health (a description of a health (−related) concept or definition, or what a health (−related) concept or definition should contain); 2) dimensions of health (category of health indicators for operationalisation in healthcare); 3) perspective (the perspective from which the concept of health was explored or the article written).

Data charting process

For data extraction and synthesis, a thematic analysis was conducted to identify patterns within the data. First, a form including characteristics of the article and the list of themes was developed. The characteristics consisted of: country, article type/study design and perspective population/theoretical approach. The list of themes of interest was pilot tested on three articles by the first (VvD) and the last author (LN-vV). Second, the first author (VvD) started data extraction. Third, within the themes of interest, an open coding process was started using a bottom-up approach by the first author (VvD). The program ATLAS.ti (version 8) was used when coding the data. Codes were extracted from the data using the exact words from the original article. After coding all articles, the codes were categorised into potential subthemes, which fit into the overarching themes (i.e. concept of health, dimensions of health, perspective). We introduced a minimum level of appearance for subthemes in at least three articles as threshold for relevance. In case a subtheme was represented in at least 3 articles a description in detail of the subtheme was given. This threshold was based on consensus within the research team with the aim to keep our focus on the most relevant results. During the entire process, four researchers (EB, LN-vV, EdV, DvdM) were repeatedly consulted to discuss the analytic process and the development of the results.

Synthesis of results

The articles were first divided into the retrieved subthemes for theme 3 (perspective), resulting in an overview of the results of theme 1 (concept of health) and theme 2 (dimensions of health) per subtheme of perspective (theme 3). In Fig. 1, the process for synthesis of results is shown.

Fig. 1
figure 1

Diagram for synthesis of results

Results

Selection of sources of evidence

In Fig. 2, the flowchart with the number of retrieved articles in Pubmed and Cinahl and in−/exclusion per selection step is shown. Articles that did not fulfil the inclusion criteria after screening title, abstract or full text, respectively were not included for the next step. In the first step (title screening), there was an initial agreement of 94% between the authors VvD and EB. Simultaneously, the initial agreement with the senior researchers (LN-vV, EdV, DvdM) was 94%. In the second step (abstract screening), the initial agreement was 77% between the authors VvD and EB. In addition, the initial agreement with the senior researchers (LN-vV, EdV, DvdM) was 82%. In the third step (full-text screening), the initial agreement was 87% between the authors VvD and EB. In total, 75 articles were included for thematic analysis. Fifty-six articles were excluded in full-text screening, because they did not meet the inclusion criteria: 29 articles were not focussing on the concept or definition of health, 12 articles were intervention studies using health or wellbeing related terms as one of their outcome measures, 4 articles focussed on validation studies of questionnaires or instruments evaluating health or wellbeing related terms, for 8 articles no full texts were available, 2 articles were excluded because they were duplicates and 1 article was in Spanish.

Fig. 2
figure 2

Flowchart for inclusion process

Characteristics of sources of evidence

For theme 1 (concept of health) 159 codes (210 quotes) were created during the analysis process. For theme 2 (dimensions of health) 72 codes (148 quotes) were created. For theme 3 (perspective) 68 codes (92 quotes) were created. Table 3 shows the coding scheme with the identified subthemes and codes of theme 1 concept of health. Table 4 shows the coding scheme with the identified subthemes and codes of theme 2 dimensions of health. To see details of Table 3 the supplementary Table 1 shows the same coding scheme, but includes also all related quotations from the 75 articles.

Table 3 The coding scheme; identified subthemes and codes for theme 1, the concept of health
Table 4 The coding scheme; identified subthemes and codes for theme 2, dimensions of health

Themes 1 and 2: concepts of health and dimensions of health

From the data for theme 1 (concepts of health) 159 codes were extracted and categorised. Nine subthemes arose by categorising the codes: multi-sided, adapting to change, complete wellbeing or functioning, participation, daily functioning, wellbeing, satisfying life, self-management, and subjective (see Table 3). Most articles (58/75) described a concept of health consisting of multiple subthemes. From the data for theme 2 (dimensions of health) 72 codes were extracted and categorised. Eight subthemes arose by categorising the codes for this theme: physical, mental, social, spiritual, individual, environmental, functional, and other dimensions (see Table 4). Almost half of the articles (36/75) described multiple dimensions of health. Similarities and differences in subthemes between theme 1 (concepts of health) and theme 2 (dimensions of health) were seen, represented by the related subthemes (see Tables 5, 6, 7, 8, 9, 10 and 11). An overview of the presented concepts and dimensions of health in more detail can be found in Supplementary Tables 2A to 2G (S2A-S2G). An overview table of the numbers of articles representing subthemes identified in the articles for theme 1 and theme 2, respectively, grouped per subtheme of perspective (theme 3), can be found in Supplementary Tables 3A and 3B.

Table 5 Included articles discussing health from a general population perspective
Table 6 Included articles discussing health from a care workers perspective
Table 7 Included articles discussing health from a patient’s perspective
Table 8 Included articles discussing health from the perspective of elderly people
Table 9 Included articles discussing health from a philosophical perspective
Table 10 Included articles discussing health from a theological perspective
Table 11 Included articles discussing health from a context specific perspective

Theme 3: concept of health from different perspectives

From the data for theme 3 (perspective) 68 codes were extracted and categorised. Seven subthemes arose by categorising the codes: general population (articles which do not specify a specific perspective in their study), care workers, patients, older people, philosophical, theological, and context specific (articles which define a specific context or viewpoint such as ‘Māori spiritual healers’). In the next paragraphs the similarities and differences between theme 1 (concepts of health) and theme 2 (dimensions of health) are outlined per perspective, in line with Tables 5, 6, 7, 8, 9, 10 and 11. We reviewed every subtheme mentioned in the included articles. We did not take into account the importance or weighting of a certain subtheme in our analyses although it was considered of higher importance in that specific article.

Health from a general population perspective

Thirteen articles were written from a general population perspective [20,21,22,23,24,25,26,27,28,29,30,31,32]. These articles were mostly literature studies, discussion articles or commentaries in which health concepts were discussed. Detailed characteristics of the included articles are shown in Table 5.

In the next paragraph, illustrative quotes are given for the subthemes of theme 1 (concept of health) which were identified in at least three different articles. Examples of quotes are also given of associations seen between the results of theme 2 (dimensions of health) and theme 1 (concept of health). For more detailed information and all quotes see supplementary Table S2A.

Content belonging to four subthemes were identified in at least three articles written from the general population perspective: multi-sided, self-management, participation, and subjective. The subtheme multi-sided view on health, i.e., health not only related to the physical dimension, was identified in five articles (5/13) written from a general population perspective. For example, Amzat and Razum [21] wrote: “the concept of health presents a form of ambiguity because it is multidimensional, complex, and sometimes elusive”. The multi-sided view on health from this perspective was also identified by the multiple dimensions of health (theme 2) being reported in six articles (6/13). For example, Lipworth et al. [27] wrote: “… balance among the physical, spiritual, cognitive, emotional, and/or social domains of life”. The subtheme self-management as part of a health concept was identified in three articles (3/13) written from a general population perspective. For example, Makoul et al. [28] wrote about the concept of health: “Health is the result of an individual’s behaviors, and is embodied in the self-control it takes to enact the behaviors”. The subtheme participation, i.e., being active and participating in life, as part of a health concept was identified in three articles (3/13) written from a general population perspective. For example, Makoul et al. [28] wrote: “Health is the means to living an active life”. Participation as part of a health concept was also identified in the dimension social (theme 2). For example, Makoul et al. [28] wrote: “… the biopsychosocial model encompasses mental, emotional, social, and spiritual elements as well”. The subtheme subjective view on health as part of a health concept was identified in three articles (3/13) written from a general population perspective. For example, Kaldjian [25] wrote: “… we can endorse a concept of health that incorporates … subjective features of human valuing”. The other subthemes for the concepts of health were not identified in three articles or more and thus not further described here (see S2A).

Health from a care worker’s perspective

Ten articles were written from a care workers perspective [12, 33,34,35,36,37,38,39,40,41]. The care workers in these articles were for example general practitioners, social workers, and staff in mental health. Characteristics of the included articles are shown in Table 6.

Content belonging to six subthemes were identified in at least three articles written from a care worker’s perspective: multi-sided, subjective, adapting to change, satisfying life, wellbeing and complete wellbeing and functioning. The subtheme multi-sided view on health was identified in six articles (6/10) written from a care worker’s perspective. For example, Hunter et al. [36] wrote; “health is more multidimensional” and Merry [40] wrote; “health is viewed from a holistic perspective”. The multi-sided view on health from this perspective was also identified by multiple dimensions of health (theme 2) being reported in six articles (6/10). For example, Ashcroft and Van Katwijk [34] wrote; “… health is physical, mental and emotional well-being—as determined by relationships with others and with the constructed and natural environments …”. The second subtheme, health is subjective, i.e., the concept of health depends on personal perceptions and experiences, was identified in four articles (4/10) written from a care worker’s perspective. For example, Merry [40] wrote; “… each person is unique and that how health is defined by a person, group, or community is subjective”. The subtheme adapting to change, i.e., being able to adapt to personal or environmental health-related changes and circumstances, as part of a health concept was identified in three articles (3/10) written from a care worker’s perspective. For example, Huber et al. [5] wrote; “… health as ‘the ability to adapt and to self-manage …”. The subtheme satisfying life, i.e., values that contribute satisfaction in life, as part of a health concept was identified in three articles (3/10) written from a care worker’s perspective. For example, Jormfeldt [38] wrote; “feeling harmony and meaningfulness in life”. The subthemes wellbeing and complete wellbeing or functioning as part of a health concept were both identified in three articles (3/10) written from the perspective ofcare workers. For example, Hunter et al. [36] wrote; “… the most advanced conception of ‘health that is more than the absence of disease’ was a liberating and expansive way of being…”. However, they also referred to health as “… health being understood only as the absence of disease”, which relates to complete wellbeing. Notably, the subtheme complete wellbeing or functioning was never used as a concept of health on its own by care workers but always in combination with other subthemes for the concept of health. The other subthemes for the concepts of health were not identified in at least three articles and are not further described here (see S2B).

Health from a patient’s perspective

Eleven articles were written from a patient’s perspective [12, 36, 38, 42,43,44,45,46,47,48,49]. The patients in these articles were for example patients with chronic illnesses, patients in mental health services, patients with psychosis, and patients with pressure ulcers. Characteristics of the included articles are shown in Table 7.

Content belonging to six subthemes were identified in three articles or more from a patient’s perspective: subjective, daily functioning, self-management, satisfying life, adapting to change, and multi-sided. The first subtheme health as subjective as part of the health concept was identified in five articles (5/11) written from a patient’s perspective. For example, Post [45] wrote: “… conceptualization of health encompassed … personal evaluations of well- being” and Ebrahimi et al. [43] wrote: “… health is a subjective and dynamic phenomenon”. The subjective view on health from this perspective was also seen by the dimension individual (theme 2). For example, Schrank et al. [46] wrote: “… the domain of individual well-being represents the subjective part of the concept”. The second subtheme daily functioning, i.e., daily functioning in life, as part of the health concept was identified in four articles (4/11) written from a patient’s perspective. For example, Warsop [48] wrote: “Health is always in the background, letting us do what we always do” and Post [45] wrote: “… health encompassed how well people function in everyday life …”. Daily functioning as part of a health concept was also identified in the dimension functional (theme 2) by Post [45]: “Functional health, including both physical functioning in terms of self-care, mobility, and physical activity level and social role functioning in relation to family and work”. The subtheme self-management as part of a health concept was identified in four articles (4/11) written from a patient’s perspective. For example, Jormfeldt [38] wrote: “… to be able to manage ones daily tasks”. The subtheme satisfying life as part of a health concept was identified in three articles (3/11) written from a patient’s perspective. For example, Jormfeldt [38] wrote about the attitudes towards health: “… to experience meaningfulness in life…” and “… to have a peaceful and positive feeling inside…”. The subtheme adapting to change as part of a health concept was identified in three articles (3/11) written from a patient’s perspective. For example, Shearer et al. [47] wrote: “Health was characterized by a rhythmic pattern of living with the paradox of chronic illness; that is, constructing meanings about one’s health that enhance personal strengths while acknowledging the losses and changes brought on by their illness”. The subtheme multi-sided view on health was identified in three articles (3/11) written from a patient’s perspective. For example, Hunter et al. [36] wrote: “… health that is more than the absence of disease …”. The multi-sided view on health from this perspective was also identified by multiple dimensions of health (theme 2) being reported in four articles (4/11). For example, Gorecki et al. [44] wrote: “We developed a conceptual framework of HRQL [Health-Related Quality of Life] in PUs that includes four domains: PU-specific symptoms, physical functioning, psychological well-being and social functioning”. The other subthemes for the concepts of health were not identified in at least three articles and are not further described here (see S2C).

Health from the perspective of elderly people

Nine articles were written from the perspective of elderly people [18, 43, 47, 49,50,51,52,53,54]. The elderly people in these articles were for example elderly people with chronic illnesses. Characteristics of the included articles are shown in Table 8.

Content belonging to five subthemes were identified in at least three articles written from the perspective of elderly people: adapting to change, self-management, subjective, satisfying life, and participation. The subtheme adapting to change as part of a health concept was identified in six articles (6/9) written from the perspective of elderly people. For example, Goins et al. [53] wrote: “… defining health as a value indicates it can be fleeting, both lost and regained” and Cresswell-Smith et al. [51] wrote about the concept of health: “… older adults have been seen to adapt and accept limitations as part of the ageing process”. The second subtheme self-management as part of a health concept was identified in six articles (6/9) written from the perspective of elderly people b. For example, Song and Kong [18] wrote: “… older adults experience health when they have the ability to do something independently…”. That health is subjective was identified in four articles (4/9) written from the perspective of elderly people. For example, Ebrahimi et al. [43] wrote: “The state of being in harmony and balance is highly individualized …”. That health is subjective was also identified by the dimension individual (theme 2). For example, Ebrahimi et al. [43] wrote: “… characterized as the individual’s experience and perception of being in harmony and balance…”. The subtheme satisfying life as part of a health concept was identified in four articles (4/9) written from the perspective of elderly people. For example, Song and Kong [18] wrote: “… older adults experience health when they have … connectedness with others …”. Satisfying life as part of a health concept was also identified in the dimension social and spiritual (theme 2) by Song and Kong [18]: “In addition, social, familial, and spiritual domains resonated with the theme of “connectedness with others”” [18]. The subtheme participation as part of a health concept was identified in four articles (4/9) written from the perspective of elderly people. For example, Fänge and Ivanoff [52] wrote: “Health was very much related to the possibility of being active and participating in social life …, and it was always evaluated in relation to their age and what they perceived could be expected in this context”. Although it was not frequently identified in the subthemes of theme 1 (concept of health) the multi-sided view on health from the perspective of elderly people was identified by multiple dimensions of health (theme 2) being reported in five articles (5/9). For example, Goins et al. [53] wrote: “… holistic nature of health, cut across more than 1 dimension … health cannot be compartmentalised but includes elements of physical, behavioral, psychological, and spiritual well-being”. The other subthemes for the concepts of health were not identified in at least three articles and are not further described here (see S2D).

Health from a philosophical perspective

Twenty-three articles were written from a philosophical perspective. We divided the philosophical perspective articles in two groups: social science perspectives (19 articles) [1, 3,4,5, 7, 15, 17, 55,56,57,58,59,60,61,62,63,64,65,66] and biomedical science perspectives (4 articles) [16, 67,68,69]. The social science perspectives were for example holistic, phenomenological, epistemological, and philosophical anthropology (see Table 9). The biomedical science perspectives were for example naturalist and health/health impairment-continuum (see Table 9). Characteristics of the included articles are shown in Table 9.

In the articles written from a social science perspectives content belonging to four subthemes were identified in at least three articles: adapting to change, multi-sided, subjective, and satisfying life. The subtheme adapting to change as part of a health concept was identified in ten articles (10/19) written from a social science perspective. For example, Cloninger et al. [56] wrote about the concept of health as: “… a person as s/he adapts to an ever-changing internal and external environment”. The subtheme multi-sided view on health was identified in seven articles (7/19) written from a social science perspective. For example, Bircher and Kuruvilla [3] and Cloninger et al. [56] both wrote about the concept of health as: “… a complex adaptive system …”. The multi-sided view on health was also identified by multiple dimensions of health (theme 2) being reported in six articles (6/19) with a social science perspective. For example, Misselbrook [61] wrote: “But if we truly believe in a multi-sided model of health, which includes the biomedical, social, psychological, anthropological and spiritual dimensions, then we are swimming against the stream”. That health is subjective was identified in five articles (5/19) written from a social science perspective. For example, Sturmberg et al. [17] wrote: “The perception of being healthy is an emergent phenomenon based on individual and collective understandings of everyday realities”. The subtheme satisfying life as part of a health concept was identified in five articles (5/19) with a social science perspective. For example, Misselbrook [60, 61] wrote: “… health can be seen as the ability to flourish …”. In the articles from a biomedical science perspective content belonging to only one subtheme was identified in at least three articles: complete wellbeing or functioning. For example, Boorse [67] wrote about the concept of health as: “… each internal part to perform all its normal functions …”. The other subthemes for the concepts of health were not identified at least three times in the articles with a biomedical science perspective and are not further described here (see S2E).

Health from a theological perspective

Five articles were written with a theological perspective [70,71,72,73,74]. The perspectives in these articles were for example United Methodist church clergy and Islamic philosophy. Characteristics of the included articles are shown in Table 10.

Content belonging to onesubtheme was identified in at least three articles: multi-sided. The subtheme multi-sided view on health was identified in four articles (4/5) written from a theological perspective. For example, Proeschold-Bell et al. [71] wrote: “… we define our final health outcome holistically to indicate that health is not merely the absence of problems but is, rather, the presence of multiple life satisfactions”. The multi-sided view on health from this perspective was also identified by multiple dimensions of health (theme 2) being reported in four articles (4/5). For example, Proeschold-Bell et al. [71] wrote: “… spiritual, emotional, physical, mental well-being”. The spiritual dimension was identified in a theological perspective in four articles (4/5). For example, Proeschold-Bell et al. [71] wrote: “Although spiritual well-being may not have the rigorous definition and tradition of physical and mental health, participants considered it essential …”. The other subthemes for the concepts of health were not identified at least three times and are not further described here (see S2F).

Health from a context specific perspective

Eleven articles were written from a context specific perspective. We divided these articles with a context specific perspective in four groups: cultural perspectives (4 articles) [75,76,77,78], immigrant perspectives (3 articles) [73, 79, 80], educational level perspectives (2 articles) [81, 82], and other perspectives (2 articles) [83, 84] (see Table 11). These contexts are diverse and cannot be seen as one similar group. Because of heterogeneity, this subtheme was not included in supplementary Tables 3A and 3B. For characteristics of the included articles and more detailed information about these concepts of health related to their specific contexts see supplementary Table 2G.

Discussion

We posited the research question whether a general health concept can guide all healthcare practices. It seems more likely that specific health concepts are needed for different professions or settings instead. In this scoping review, we provide an overview of articles discussing various concepts and dimensions of health, which were either general or specified to a particular context. We observed relevant differences but also similarities in the concepts and dimensions of health per context.

The variety of concepts of health already suggests that no consensus can be made on one overall concept to replace the WHO definition of health. First of all, our analysis shows that the best fitting health concept depends on the context. Besides, healthcare consumers act based on different health concepts when seeking care than care workers when providing it. This could mean that there is a misfit in the aims of healthcare consumers, compared to care workers. It is remarkable that complete wellbeing or functioning is mentioned by care workers, while healthcare consumers barely mentioned this biomedical viewpoint. Healthcare consumers value self-management, while care workers do not focus on self-management in their health concepts. Furthermore, individual health experiences can change over the course of life, due to diverse life circumstances and events [55]. It was seen that patients in general tend to focus on daily functioning while elderly people specifically focus on participation. This shows that one health concept does not automatically fit all age groups. On the other hand, there were interesting similarities regarding the concepts of health. In the majority of the articles, health was conceptualised as multi-sided and subjective, and not merely as complete wellbeing or functioning as suggested in the biomedical model. Furthermore, in the majority of the contexts other prerequisites for health were adapting to change and satisfying life. Indeed, no consensus can be made on one general health concept; all health concepts capture aspects that seem relevant [7].

Nevertheless, it is important to be clear about which health concept is used as a basis for development and implementations in health management, for (re)designing health policy and for research. Health concepts developed in one context do not hold automatically in other contexts. As a result, the expectations of healthcare consumers and care workers might not align in care provision. Having different understandings of the concepts of health can lead to misunderstandings in practice. Our overview of health concepts gives insight in the variety of experiences with health concepts of people with diverse health, life, community and other environmental circumstances. Policy officers or healthcare providers can check the similarities and differences of their health concept with health concepts in other contexts included in this overview. Even better, the overview we provide can be used by care workers preparing their conversation about what health means for the healthcare consumer. However, it should be emphasized that health could mean something different for each individual; no concepts are intrinsically incorrect. As Haverkamp et al. [7] described, health concepts share different features or assumptions and should be understood as a member of a family of concepts. By exploring the health concept in dialogue, important purposes of health provision can be defined by the care worker and the healthcare consumer together. Through such conversation between actors, health provision can be customised for each individual. Tools such as the positive health dialogue tool [12] might be of use in these conversations. This dialogue tool consists of six dimensions of health which correspond to the dimensions found in our study. However, the environmental dimension was not included in the positive health dialogue tool and might be of additional value to the conversation about what health means to an individual.

Many perspectives shared a similar multi-sided approach as Huber’s positive health [12]. Taking a closer look, we noticed that ‘the ability to adapt and to self-manage’, the main issues of the concept of positive health, were also recognised in other health concepts, independently of perspective. The concepts of health described the ‘ability to adapt’ for example as adapting to changing physical conditions, such as ageing, illness or disability, and also as emotional balance and as health being a dynamic state in which adaptation to circumstances is necessary. ‘The ability to self-manage’ was described for example as autonomy or independence. However, care workers had barely focussed on this. This indicates that for care workers, patient self-management has less priority. Furthermore, we noticed that subjectivity was not explicitly mentioned in Huber’s concept, while this was frequently mentioned in the articles included in our review. However, Huber et al. did explain that positive health focuses on people’s strengths rather than weaknesses. As Huber argues, people’s strengths are based on their perception of and experiences with health [12], which is subjective. Notably, as mentioned by Prinsen and Terwee [15], it is not entirely clear whether the positive health concept refers to patients’ experiences or to their satisfaction with their health, and overlap between dimensions and aspects of Positive Health exist; this was also seen in our results.

Methodological considerations

A few methodological considerations are worth mentioning. A limitation of the search strategy was that the keyword ‘health’ by itself led to too many results. To solve this, we used the keyword ‘health’ in combination with ‘concept’ and ‘definition’ and used more specific keywords such as ‘health perception’ and ‘perceived health’ to broaden the search strategy and capture all relevlant articles for our research. Most research we found was conducted in Europe and North America. Fewer research articles from Central/South America, Australia, Africa and Asia were found. Their views on health may be underrepresented. To decrease the chance that articles were missed in the search, a snowball method was conducted on the results of the primary search. Four experts from the field were asked to check whether they missed any articles in the selection. Moreover, we did not include the weighting (importance) of a specific subtheme as was described in some articles. To compensate, we only incorporated a subtheme in our analyses by introducing a minimum level of appearance in multiple articles (> 3) as threshold. Strengths of the research were the thoroughly structured process of article selection, the inductive method of analysis, and the repeated consultation of four researchers (EB, LN-vV, EdV, DvdM) to discuss the process and the results by the first author (VvD).

Conclusion

We performed a scoping review to explore if one general health concept can guide all different care practice situations. Based on of the variety of health concepts from different perspectives, we conclude that for every perspective, and even for every individual, health can mean something different. Thus, it seems impossible to choose or define one health concept appropriate for all contexts. However, in the interaction between care workers and healthcare consumers (and also in health policy) it is important that the meaning of ‘health’ is clear to all actors involved to avoid misunderstandings. Our overview supports a more uniform tuning of healthcare between healthcare providers (the organisations), care workers (the professionals) and healthcare consumers (the patients), by creating more awareness of the differences among these actors, which can be a guide in their communication.

Availability of data and materials

The dataset (list of included articles) supporting the conclusions of this article is included within the tables in this article and in the supplementary files.

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VvD conducted the research and wrote the main manuscript. EB assisted with the screening of all titles, abstracts and full-text articles for in- or exclusion. EB, EdV, DvdM and LN-vV were repeatedly consulted to discuss the analytic process and the development of the results. Authors EB, EdV, DvdM, AK and LN-vV reviewed the manuscript. All authors read and approved the final manuscript.

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Correspondence to V. P. van Druten.

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Supplementary Information

Additional file 1: Supplementary Table 1.

The coding scheme; identified subthemes and codes for theme 1, the concept of health.

Additional file 2: Supplementary Table 2A.

Included articles discussing health from a general population perspective. Supplementary Table 2B. Included articles discussing health from a care workers perspective. Supplementary Table 2C. Included articles discussing health from a patient’s perspective. Supplementary Table 2D. Included articles discussing health from the perspective of elderly people. Supplementary Table 2E. Included articles discussing health from a philosophical perspective. Supplementary Table 2F. Included articles discussing health from a theological perspective. Supplementary Table 2G. Included articles discussing health from a context specific perspective.

Additional file 3: Supplementary Table 3A.

Overview of number of articles per subtheme for theme 1 (concept of health) for different perspectives. Supplementary Table 3B. Overview of number of articles per subtheme for theme 2 (dimensions of health) for different perspectives.

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van Druten, V.P., Bartels, E.A., van de Mheen, D. et al. Concepts of health in different contexts: a scoping review. BMC Health Serv Res 22, 389 (2022). https://doi.org/10.1186/s12913-022-07702-2

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Keywords

  • Health
  • Health concept
  • Health definition
  • Positive health
  • Health-related concepts
  • Health perception
  • Perceived health
  • Scoping review