Concepts of health in different contexts: a scoping review

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.

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.

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.

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

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.

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).

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.

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.

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.

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.

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.

Thirteen articles were written from a general population perspective [20‐32]. 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).

Ten articles were written from a care workers perspective [12, 33‐41]. 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).

Eleven articles were written from a patient’s perspective [12, 36, 38, 42‐49]. 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).

Nine articles were written from the perspective of elderly people [18, 43, 47, 49‐54]. 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).

Twenty-three articles were written from a philosophical perspective. We divided the philosophical perspective articles in two groups: social science perspectives (19 articles) [1, 3‐5, 7, 15, 17, 55‐66] and biomedical science perspectives (4 articles) [16, 67‐69]. 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).

Five articles were written with a theological perspective [70‐74]. 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).

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) [75‐78], 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.

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).