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Towards a patient-centred
operationalisation of the new dynamic
concept of health: a mixed methods
study
M Huber,1 M van Vliet,1,2 M Giezenberg,3 B Winkens,4 Y Heerkens,5
P C Dagnelie,6 J A Knottnerus7
Open Access
much more prevalent. Moreover, the old denition data (different forms of interviews analysed with a mani-
described an unattainable utopian and static state, fest content analysis). The second step (B) was a verica-
according to which almost everybody to some extent tion phase that used quantitative methodology (a
could be considered ill, and which unintentionally could cross-sectional survey). The rationale for using a mixed
enhance the risk of medicalisation.37 For example, with methods approach was that two steps of data generation
modern diagnostic techniques and steadily lowered and verication were necessary to support the process of
cut-off points for laboratory values, borderline abnormal making the health concept more operational.5
values can often be measured, also in the absence of
disease, thus evoking unnecessary treatment just to be Participants
on the safe side. Over time, the need for a dynamic Participants were stakeholders from seven main domains
description of health that highlights the human capacity within healthcare: healthcare providers ( physicians,
for resilience and for coping with new situationsas we nurses, physiotherapists), patients with a chronic condi-
are repeatedly required to do in lifewas increasingly tion, policymakers, insurers, public health professionals,
being felt.8 Thus, the new general concept of health, citizens (as a representative reection of society) and
as provided above, was developed at an international researchers from different professional backgrounds. In
invitational conference for experts held in the the recruitment of participants, the aim was to have a
Netherlands in 2009. A concept was preferred over a broad, representative spectrum of stakeholders in the
denition that implies having set boundaries and Netherlands. The selection of people and organisations
precise, dened meanings. However, a general concept was based on the advice of healthcare opinion leaders
also needs further operationalisation into denitive con- and the authors knowledge about the eld.
cepts, for use in daily practice and for monitoring pur-
poses.9 The research project described here is intended Ethical considerations
as a rst step towards such operationalisation. This study is exempt from ethical approval in the
The study considered three research questions: Netherlands. The participants from the interview and
1. What do the various stakeholders consider to be posi- survey study were informed of the studys purpose, mode
tive and negative elements of the new general of participation and condentiality. Participation was
concept of health, and which elements should be entirely voluntary, and data were handled condentially.
specied in more detail?
2. What do different stakeholders consider to be indica- The first explorative step: a qualitative approach
tors of health? MethodsA
3. Do these indicators represent the new concept of Participants and data collection
health? During this explorative phase, 37 qualitative (semistruc-
This approach allows the expressed indicators to be tured) interviews and 13 focus group sessions were held,
broad, which is in line with the discussions about a new involving a total of 140 people from seven stakeholder
broad concept of health in 2009, which nally con- domains (see table 1). During the meetings, rst a pre-
densed into the new dynamic concept. Question 3 was paratory introduction to the WHO denition and the
chosen to assess the relationship between the expressed new concept of health was provided, and subsequently
indicators and the new concept. the three research questions were posed to guide the
interviews and focus group sessions. The questions
framed the interviews, where the interviewer encouraged
METHODS AND RESULTSA TWO-STEP APPROACH participants to elaborate, specify and discuss their
Study design opinions.
The study was performed using a mixed methods Individual and minigroup interviews (two or three
approach10 where the rst step (A) was made with quali- persons) were conducted by the rst author face to face,
tative methodology in order to explore and generate except from two interviews by phone call. Focus group
Open Access
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Health literacy
Ability to work
Daily functioning
about this new concept. The questionnaire presented
Instrumental
Basic ADL
the main positive and negative opinions, as expressed in
the interviews. Respondents could agree or disagree
ADL
with an unrestricted number of the opinions. They were
also invited to make additional positive or negative
comments.
Thirty-two statements covering all health domains that
Social and societal participation
Experiencing to be accepted
were derived from the interviews were presented, and
Social and communicative
Meaningful relationships
Community involvement
respondents were asked if they considered the state-
ments to apply to health. Each statement generally cor-
Meaningful work responded to a specic aspect of health. Respondents
Social contacts
Balance
the respondents.
Esteem/self-respect
observations
Energy
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questionnaire were included in newsletters, posted on from 1.13 to 1.99 (see online supplementary le 2).
certain websites and distributed via social media. Composite scores based on the mean of corresponding
Data collection took place during October to health-aspect subscores were calculated and checked for
November 2012. No empty elds were allowed during internal consistency by determining Cronbachs . This
the completion of the questionnaire to avoid missing showed strong correlations between the aspects scores
data. within the dimensions and thereby supported the selec-
tion of each set of aspects to represent the dimensions.
Data analysis
General characteristics of responders and the responses Importance of health dimensions as perceived by
regarding the positive and negative aspects of the new stakeholders
health concept are presented by meanSD for numer- 1. General
ical variables and number (N) and/or percentages for Mean composite scores about the importance of each
categorical variables. In addition, mean scores for each dimension as being part of health are represented on a
health aspect were calculated and used to construct nine-point scale in gure 1, per stakeholder group.
composite scores reecting their importance. This gure shows marked variation in mean composite
Subsequently, general linear models (GLM) were tted, scores between stakeholder groups for all health dimen-
both uncontrolled and controlled, for age, gender, level sions, except from bodily functions. Uncontrolled GLM
of education and chronic disease to test for differences conrms no signicant difference in mean composite
between stakeholder groups. GLM models were also scores for bodily functions between stakeholder groups
tted, both uncontrolled and controlled, for age, ( p=0.583), in contrast to signicant differences between
gender and chronic disease for subgroup analyses stakeholder groups for all other dimensions (all p values
among the group of healthcare providers. Data were 0.001). Corrected GLM showed that these differences
analysed using SPSS V.21.0 (IBM, New York, USA). A were still signicant after controlling for age, gender,
two-sided p Value 0.05 was considered statistically level of education (academic vs non-academic), and
signicant. having (had) a chronic disease (yes or no) ( p=0.628 for
bodily functions, p=0.040 for daily functioning, and
ResultsB p<0.001 for all other dimensions).
Response rate and demographics 2. Patients and healthcare providers (see online supple-
In total, 1938 respondents from seven stakeholder mentary le 3)
groups completed the survey. Different response rates Figure 2 shows the mean composite scores on the
were obtained from the panels. The response rates were importance assigned to each dimension as part of
30% for physicians (n=317), 35% for physiotherapists health by various healthcare providers and patients.
(n=216), 71% for patients (n=455), and 62% for citizens Among the healthcare providers, the mean composite
(n=430). Further, 170 responders from a convenience scores of nurses were generally the highest and most
sample among eight patient associations were included congruent with those of patients ( p0.105), except for
in the group of patients, resulting in 575 patients with daily functioning ( p=0.002). Uncontrolled GLM demon-
diverse chronic diseases. Response rates for other stake- strated that all mean composite scores showed signi-
holder groups cannot be provided, as it is unknown how cant differences between patients and physicians (all p
many individuals in total were reached. values 0.042). After controlling for age, gender and
The demographic characteristics of the respondents chronic disease, all differences in dimension composite
are outlined in table 3. More than half of all respon- scores between physicians and patients remained statis-
dents (55.3%, n=1071) had experienced at least one tically signicant (all p values 0.034), except for the
chronic condition in his/her life. Cardiovascular disease dimension bodily functions ( p=0.136).
(15.7%, n=305), neck and/or backache (13.6%, n=264), 3. Healthcare providers according to whether they have
diabetes (11.3%, n=219), chronic joint problems experienced a chronic disease (see online supplemen-
(10.7%, n=207), respiratory disease (10.3%, n=200), and tary le 4)
cancer (5.7%, n=110) were the most common chronic Uncontrolled GLM demonstrated that mean compos-
conditions ( per respondent more than one answer ite scores for physicians who had experienced a chronic
possible). disease were signicantly higher for the spiritual/exist-
ential dimension, social and societal participation and
Positive and negative aspects of the new concept daily functioning (all p values 0.050), compared to
The 1938 respondents scored 4514 positive and 3443 nega- physicians without experience of chronic disease.
tive aspects, plus an additional four positive and ve nega- Uncontrolled GLM showed no differences between
tive aspects in the category other (see tables 4 and 5). nurses and physiotherapists with or without experience
of chronic disease, except for the spiritual/existential
Mean scores and composite scores per health aspect dimension, which was signicantly higher among nurses
The mean scores for each of the 32 statements varied with a chronic disease ( p=0.042). Controlling for age
from 6.58 to 7.80 on a nine-point scale with SDs ranging and gender ( physicians and physiotherapists) and age
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Gender (%)
Male 42.5 43.3 41.2 51.2 31.3 73.3 19.1 33.0
Female 57.5 56.6 58.8 48.8 68.8 26.7 80.9 67.0
Age (yearsSD) 51.613.4 50.39.5 56.6 52.5 44.610.9 42.6 45.111.5 40.611.3
12.7 16.6 10.1
Type of employment (%)
Independent 16.9 41.8 5.6 5.3 0 0 1.1 2.8
Salaried employee 50.0 52.9 28.3 44.7 98.8 100.0 95.5 89.6
Flexible/on call 2.0 0.6 2.4 4.9 0 0 0 0
Huber M, et al. BMJ Open 2016;5:e010091. doi:10.1136/bmjopen-2015-010091
Open Access
(nurses) by GLM revealed that physicians with a chronic questionnaires on ability to cope, resilience and self-
disease considered the spiritual/existential dimension management as a starting point, to make the concept
( p=0.007) and the dimension social and societal partici- measurable, but preferred an open enquiry for indica-
pation ( p=0.002) signicantly more important than phy- tors of health. This approach is connected to the broad
sicians without a chronic disease. and open discussions which led in 2009 to the new
Overall GLM analysis revealed that having a chronic dynamic concept of health and enabled us to integrate
disease, for the whole research population, was inde- the perceptions of all stakeholders in the elaboration of
pendently related to lower scores for the dimension the concept.
bodily functions and higher scores for the spiritual/ The concept received considerable support from all
existential dimension (see online supplementary le 5). stakeholder groups. What most respondents generally
appreciated about the new concept was that a person is
described as more than his illness, and that the focus is
DISCUSSION on a persons strength rather than his weakness. A point
In this exploratory study, with qualitative and quantita- of attention was the notion that the concept requires
tive elements, we evaluated the support for the new substantial personal input, something not everyone
dynamic concept of health as the ability to adapt and to would be capable of.
self-manage, in the face of social, physical and emotional A broad range of health indicators was mentioned,
challenges and elaborated indicators of health, per- which we categorised into six dimensions: bodily func-
ceived to connect to the concept, in order to make the tions, mental functions and perception, spiritual/exist-
concept measurable and by that take a rst step towards ential dimension, quality of life, social and societal
operationalisation. We could have chosen existing participation, and daily functioning, with underlying
Open Access
Figure 1 Mean scores per stakeholder group on a nine-point scale, indicating the importance assigned by respondents to a
dimension as being part of health.
aspects. Seventy-eight per cent of respondents in the but clear differences in perceptions as an interesting
qualitative study felt that their indicators tted in with result of the survey. Another strength is the large
the new concept, thus amply supporting a match number of survey respondents.
between the concept and the indicators of individual sta- A limitation of the study is that question 3 (Do your
keholders. Different stakeholder groups mentioned dif- indicators of health represent the new concept?) was not
ferent types of health indicators, yet many of the included in the online questionnaire. In this question-
stakeholders found their indicators to reect the naire, all 32 indicators were presented to the respon-
concept. dents and it would have required a different way of
The survey conrmed the support for the concept and questioning to nd the match between the concept and
the positive and negative elements connected to the the indicators. Therefore, the answer to question 3 was
concept. Concerning the different health indicators, the solely based on the results of the qualitative phase.
survey showed that all stakeholder groups considered Further research to study the relation between the
bodily functions to represent health, whereas judgements health indicators put forward by stakeholders and the
about the other dimensions differed signicantly between new health concept, as proposed by the invitational con-
groups. Patients considered all six dimensions as almost ference of 2009, is recommended.
equally important, thus preferring a broad concept of Another limitation is that response rates varied in the
health, whereas policymakers as well as healthcare provi- quantitative phase, for patients being 71%, for citizens
ders (and among the latter especially physicians) assessed 62%, whereas the response rate for physicians was only
health in a more narrow and biomedical way. 30%. This lack of motivation of physicians, to consider
A strength of the study is the evaluation of the new the content of the concept of health, seems concord-
concept of health among a broad representation of sta- ant with the main outcome of our study, namely the
keholders in healthcare and the exploration of health apparent differences in perceptions of health between
indicators among these stakeholders, resulting in a 78% physicians and patients, where health interests are con-
match between the expressed indicators and the cerned. Furthermore, a potential for response bias
concept during the qualitative phase. The exploration of exists, because people in favour of the newly posed
health indicators followed a bottom-up inductive health concept might have been more willing to com-
approach, resulting in a categorisation of six main plete the survey. However, if this would be the case, it
dimensions and 32 aspects of health, with unexpected seems plausible that differences between patients and
Open Access
Figure 2 Mean scores per healthcare provider group and patients on a nine-point scale, indicating the importance assigned by
respondents to a dimension as being part of health.
other stakeholder groups would be even larger. Owing interpreted and more research is needed to generalise
to practical limitations, it was not feasible to generate the results to the whole population. Finally, the study
representative and stratied samples for participation in was conducted in the Netherlands and its generalisabil-
this study, except from physicians, physiotherapists, ity to other, especially non-western, populations will
patients and citizens. Instead, the relatively uncontrolled need to be studied too.
method of snowball sampling was used for other stake- The existing literature about health indicators and
holder groups. Therefore, results should be cautiously patient reported outcome measures was studied during
the categorisation process of the statements in the quali-
tative phase. This showed that the statements obtained
in the present study covered a broader area of life than
most generic measures of perceived health and
health-related quality of life. The fact that we found
such broadness might be considered a weakness, as we
cannot connect the results to an existing measurement
instrument. However, it might be considered a strength
that our results have a broad empirical basis. We found
most congruence of our ndings with the dimensions
and aspects reported in a study by Stewart et al16 on the
quality of life of dying persons, and as described by
Willemstein et al17 for outcome measures in the care
sector. We compared our ndings to the International
Classication of Functioning, Disability and Health
(ICF),18 the WHOs present terminology on health,
functioning and health-related domains with multidi-
Figure 3 The six dimensions on a subjective scale, mensional concepts, but were not able to categorise or
visualised for practical use, indicating a fictional estimation of code many of the statements using the ICF. One import-
a persons state of positive health. ant reason for this is that the ICF lacks a classication of
Open Access
personal factors, and many of our aspects seemed to We propose the concept of positive health and the
best suit this category. The rst and fth authors, who web diagram as a rst denitive concept as referred to
are ICF-specialists, elaborated together the 32 aspects by Blumer,9 elaborated from Health as the ability to
of positive health, linking them to the most appropriate adapt and self manage in the face of social, physical,
ICF categories, using the linking rules of Cieza.19 Of the and emotional challenges.1
32 aspects, 18 were coded as personal factors. We con-
cluded that the personal factors we uncovered in our Author affiliations
1
study could be used as input for attempts to formulate a Department of Healthcare and Nutrition, Louis Bolk Institute, Driebergen, The
Netherlands
list of ICF Personal Factors. 2
Department of Health Sciences, Mid Sweden University, Sundsvall, Sweden
Physicians assessed health signicantly more narrowly 3
Policy-Analysis and Entrepreneurship in Health and Life Sciences at VU
(main emphasis on bodily functions and quality of life) University Amsterdam, Amsterdam, The Netherlands
4
than did patients, whereas for physicians who had Department of Methodology and Statistics, Faculty of Health, Medicine and
Life Sciences, Maastricht University, Maastricht, The Netherlands
experienced a chronic disease, the spiritual/existential 5
Dutch Institute of Allied Health Care, Amersfoort & HAN University of Applied
dimension and social and societal participation became Sciences, Research Group Occupation & Health, Nijmegen, The Netherlands
more important. 6
Department of Epidemiology, Faculty of Health, Medicine and Life Sciences,
Overall, having a chronic disease was itself independ- Maastricht University, Maastricht, The Netherlands
7
ently related to a decrease in the value placed on bodily Department of General Practice & Scientific Council of Government Policy,
functions and an increase in the value awarded to the Maastricht University, The Hague, The Netherlands
spiritual/existential dimension. Acknowledgements The authors thank all participants from the different
This phenomenona change in perception after stakeholder groups for their input in the interviews and focus groups, and the
experiencing a major life event such as facing a chronic larger groups of stakeholders for contributing to the questionnaire. They also
diseaseconnects with what is described as a response thank the researchers of the NIVEL Institute for their input in the process of
shift; a change in experienced quality of life and categorising the indicators of health.
health-related quality of life when facing a serious Contributors MH conceptualised and designed the study in cooperation with
illness. This has been described in other studies, both in MvV and MH was involved as project leader and researcher in the whole
general and for specic diseases.2023 study. MH performed interviews, MH, MvV and MG performed focus groups
and analysed the qualitative results. MH and MvV designed the questionnaire,
The discrepancy between the broader perception of MH recruited participants and MvV statistically analysed the outcomes. BW
health of patients and the mainly narrower perception supervised statistics, YH and MH related the Positive health concept and ICF,
of health held by other stakeholders requires attention, PCD and JAK supervised the study. MH drafted the manuscript with input
if the prevailing policy trend of patient-centred care is from MvV on methodology, statistics, tables and figures, from YH on ICF. All
co-authors contributed to the discussion and critically revised the manuscript.
to be taken seriously. To emphasise the difference to the
JAK is guarantor.
narrow interpretation of health as the absence of
disease, we propose for the broad perception of health Funding The study was funded by the Netherlands Organisation for Health
Research and Development (grant number 20005095404) and by the Optimix
the concept of positive health and to illustrate this with Foundation.
the web diagram shown in gure 3.
Patients broad perception of health, or positive Competing interests None declared.
health, should receive attention, as this may prevent Provenance and peer review Not commissioned; externally peer reviewed.
misunderstandings and improve communication in Data sharing statement No additional data are available.
medical practice, especially when shared decision Open Access This is an Open Access article distributed in accordance with
making is also practised and the question is posed on the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which aspect of the web diagram the patient has the which permits others to distribute, remix, adapt, build upon this work non-
wish to improve his/her situation. This could very well commercially, and license their derivative works on different terms, provided
be a different area than the medical domain and the original work is properly cited and the use is non-commercial. See: http://
creativecommons.org/licenses/by-nc/4.0/
another professional than a physician might rst be
needed. This approach might empower patients and by
that connect to the new concept of health.
Future research should explore whether actions or REFERENCES
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Towards a 'patient-centred'
operationalisation of the new dynamic
concept of health: a mixed methods study
M Huber, M van Vliet, M Giezenberg, B Winkens, Y Heerkens, P C
Dagnelie and J A Knottnerus
These include:
Notes