BM2011:343d4163do:10.1136bmd4163 Page 2 of 3 ANALYSIS WHO definition becomes counterproductive as it declares people post-traumatic stress disorders. 1 3The sense of coherence with chronic diseases and disabilities definitively ill. It includes the subjective faculties enhancing the minimises the role of the human capacity to cope autonomously comprehensibility, manageability, and meaningfulness of a with lifes ever changing physical, emotional, and social difficult situation. A strengthened capability to adapt and to challenges and to function with fulfilment and a feeling of manage yourself often improves subjective wellbeing and may wellbeing with a chronic disease or disability result in a positive interaction between mind and body--for The third problem is the operationalisation of the definition. example, patients with chronic fatigue syndrome treated with WHO has developed several systems to classify diseases and ognitive behavioural therapy reported positive effects on describe aspects of health, disability, functioning, and quality symptoms and wellbeing. This was accompanied by an of life. Yet because of the reference to a complete state, the in brain grey matter volume, although the causal relation and definition remains"impracticable, because'complete'is neither direction of this association are still unclear operational nor measurable. Need for reformulation Several dimensions of health can be identified in the social domain, including people's capacity to fulfil their potential and Various proposals have been made for adapting the definition obligations, the ability to manage their life with some degree capacity. However, WHO has taken up none of these proposals. participate in social activities including work. Health inthe. emphasises social and personal resources as well as physical of independence despite a medical condition, and the ability domain can be regarded as a dynamic balance between Nevertheless. the limitations of the current definition ar opportunities and limitations, shifting through life and affected increasingly affecting health policy. For example, in prevention by external conditions such as social and environmental programmes and healthcare the definition of health determines challenges By successfully adapting to an illness, people are the outcome measures: health gain in survival years may be less able to work or to participate in social activities and feel healthy relevant than societal participation, and an increase in coping despite limitations. This is shown in evaluations of the Stanford capacity may be more relevant and realistic than complete chronic disease self management programme: extensively recovery monitored patients with chronic illnesses, who learnt to manage Redefining health is an ambitious and complex goal; many their life better and to cope with their disease, reported improved aspects need to be considered, many stakeholders consulted, self rated health, less distress, less fatigue, more energy, and and many cultures reflected, and it must also take into account fewer perceived disabilities and limitations in social activities future scientific and technological advances. The discussion of after the training. Healthcare costs also fell. 15 16 experts at the Dutch conference, however, led to broad support If people are able to develop successful strategies for coping, for moving from the present static formulation towards a more (age related) impaired functioning does not strongly change the dynamic one based on the resilience or capacity to cope and perceived quality of life, a phenomenon known as the disability maintain and restore ones integrity, equilibrium, and sense of paradox. wellbeing. The preferred view on health was"the ability to adapt and to self manage. Measuring health Participants questioned whether a new formulation should be called a definition, because this implied set boundaries and The general concept of health is useful for management and trying to arrive at a precise meaning. They preferred that the policies, and it can also support doctors in their daily definition should be replaced by a concept or conceptual framework of health. A general concept, according to sociologist empowerment of the patient (for example, by changing a Blumer, represents a characterisation of a generally agreed lifestyle), which the doctor can explain instead of just removing direction in which to look, as reference. But operational symptoms by a drug. However, operational definitions are definitions are also needed for practical life such as measurement needed for measurement purposes, research, and evaluating interventions The first step towards using the concept of"health, as the abili Measurement might be helped by constructing health frames to adapt and to self manage " is to identify and characterise it that systematise different operational needs--for example for the three domains of health: physical, mental, and social. differentiating between the health status of individuals and The following examples attempt to illustrate this populations and between objective and subjective indicators o health. The measurement instruments should relate to health as Physical health the ability to adapt and to self manage. Good first operational tools include the existing methods for assessing functional status In the physical domain a healthy organism is capable of and measuring quality of life and sense of wellbeing. WHO has "allostasis"the maintenance of physiological homoeostasis developed several classification systems measuring gradations through changing circumstances When confronted with of health. These assess aspects like disability, functioning, and physiological stress, a healthy organism is able to mount a perceived quality of life and wellbeing an (adapted) equilibrium. If this physiological coping strategy (CooP)Wonca( the world organisation of family doctors) lay finally result in illness. and cultural settings, has been developed to obtain insight into Mental health the perceived health of individuals. The COOP/Wonca Functional Health Assessment Charts present six different In the mental domain Antonovsky describes the""sense of dimensions of health, each supported by cartoon-like coherence"as a factor that contributes to a successful capacity drawings. % Each measures the ability to perform daily life cope, recover from strong psychological stress, and prevent activities on a I to 5 scale REprints:http://journals.bmjcom/cgi/reprintform Subscribehttp:/resources.bmjcom/bmj/subscribers/how-to-subscribeWHO definition becomes counterproductive asit declares people with chronic diseases and disabilities definitively ill. It minimisesthe role of the human capacity to cope autonomously with life’s ever changing physical, emotional, and social challenges and to function with fulfilment and a feeling of wellbeing with a chronic disease or disability. The third problem is the operationalisation of the definition. WHO has developed several systems to classify diseases and describe aspects of health, disability, functioning, and quality of life. Yet because of the reference to a complete state, the definition remains “impracticable, because ‘complete’ is neither operational nor measurable.”3 4 Need for reformulation Various proposals have been made for adapting the definition of health. The best known is the Ottawa Charter,8 which emphasises social and personal resources as well as physical capacity. However, WHO hastaken up none of these proposals. Nevertheless, the limitations of the current definition are increasingly affecting health policy. For example, in prevention programmes and healthcare the definition of health determines the outcome measures: health gain in survival years may be less relevant than societal participation, and an increase in coping capacity may be more relevant and realistic than complete recovery. Redefining health is an ambitious and complex goal; many aspects need to be considered, many stakeholders consulted, and many cultures reflected, and it must also take into account future scientific and technological advances. The discussion of experts at the Dutch conference, however, led to broad support for moving from the present static formulation towards a more dynamic one based on the resilience or capacity to cope and maintain and restore one’s integrity, equilibrium, and sense of wellbeing.6 The preferred view on health was “the ability to adapt and to self manage.” Participants questioned whether a new formulation should be called a definition, because this implied set boundaries and trying to arrive at a precise meaning. They preferred that the definition should be replaced by a concept or conceptual framework of health. A general concept, according to sociologist Blumer,9 represents a characterisation of a generally agreed direction in which to look, as reference. But operational definitions are also needed for practical life such as measurement purposes. The firststep towards using the concept of “health, asthe ability to adapt and to self manage” is to identify and characterise it for the three domains of health: physical, mental, and social. The following examples attempt to illustrate this. Physical health In the physical domain a healthy organism is capable of “allostasis”—the maintenance of physiological homoeostasis through changing circumstances.10 When confronted with physiological stress, a healthy organism is able to mount a protective response, to reduce the potential for harm, and restore an (adapted) equilibrium. If this physiological coping strategy is not successful, damage (or “allostatic load”) remains, which may finally result in illness.11 Mental health In the mental domain Antonovsky describes the “sense of coherence” as a factor that contributes to a successful capacity to cope, recover from strong psychological stress, and prevent post-traumatic stress disorders.12 13 The sense of coherence includes the subjective faculties enhancing the comprehensibility, manageability, and meaningfulness of a difficult situation. A strengthened capability to adapt and to manage yourself often improves subjective wellbeing and may result in a positive interaction between mind and body—for example, patients with chronic fatigue syndrome treated with cognitive behavioural therapy reported positive effects on symptoms and wellbeing. This was accompanied by an increase in brain grey matter volume, although the causal relation and direction of this association are still unclear.14 Social health Several dimensions of health can be identified in the social domain, including people’s capacity to fulfil their potential and obligations, the ability to manage their life with some degree of independence despite a medical condition, and the ability to participate in social activities including work. Health in this domain can be regarded as a dynamic balance between opportunities and limitations, shifting through life and affected by external conditions such as social and environmental challenges. By successfully adapting to an illness, people are able to work or to participate in social activities and feel healthy despite limitations. Thisisshown in evaluations of the Stanford chronic disease self management programme: extensively monitored patients with chronic illnesses, who learnt to manage their life better and to cope with their disease, reported improved self rated health, less distress, less fatigue, more energy, and fewer perceived disabilities and limitations in social activities after the training. Healthcare costs also fell.15 16 If people are able to develop successful strategies for coping, (age related) impaired functioning does not strongly change the perceived quality of life, a phenomenon known asthe disability paradox.17 Measuring health The general concept of health is useful for management and policies, and it can also support doctors in their daily communication with patients because it focuses on empowerment of the patient (for example, by changing a lifestyle), which the doctor can explain instead of just removing symptoms by a drug. However, operational definitions are needed for measurement purposes, research, and evaluating interventions. Measurement might be helped by constructing health frames that systematise different operational needs—for example, differentiating between the health status of individuals and populations and between objective and subjective indicators of health. The measurement instruments should relate to health as the ability to adapt and to self manage. Good first operational toolsinclude the existing methodsfor assessing functionalstatus and measuring quality of life and sense of wellbeing. WHO has developed several classification systems measuring gradations of health.18 These assess aspects like disability, functioning, and perceived quality of life and wellbeing. In primary care, the Dartmouth Cooperative Group (COOP)/Wonca (the world organisation of family doctors) assessment of functional status, validated for different social and cultural settings, has been developed to obtain insight into the perceived health of individuals. The COOP/Wonca Functional Health Assessment Charts present six different dimensions of health, each supported by cartoon-like drawings.19 20 Each measures the ability to perform daily life activities on a 1 to 5 scale. Reprints: http://journals.bmj.com/cgi/reprintform Subscribe: http://resources.bmj.com/bmj/subscribers/how-to-subscribe BMJ 2011;343:d4163 doi: 10.1136/bmj.d4163 Page 2 of 3 ANALYSIS