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How is your health in general? A qualitative study on self-assessed health

J.G. Simon, J.B. De Boer, I.M.A. Joung, H. Bosma, J.P. Mackenbach
DOI: http://dx.doi.org/10.1093/eurpub/cki102 200-208 First published online: 7 June 2005


Background: The single-item measure on self-assessed health has been widely used, as it presents researchers with a summary of an individual's general state of health. A qualitative study was initiated to find out which particular aspects are included in health self-assessments; which aspects do people consider when answering the question ‘How is your health in general?’. Subgroup differences were studied with respect to gender, age, health status and health assessment. Methods: Qualitative study with stratification by background characteristic, health status and health assessment (n=40). Results: Almost 80% of the participants referred to one or more physical aspects (chronic illness, physical problems, medical treatment, age-related complaints, prognosis, bodily mechanics, and resilience). However, when assessing their health, participants also include aspects that go beyond the physical dimension of health. In total, 80 percent of the participants—whether or not in addition to physical aspects—referred to other health dimensions. Besides physical aspects, participants considered the extent to which they are able to perform (functional dimension −28%), the extent to which they adapted to, or their attitude towards an existing illness (coping dimension −28%), and simply the way they feel (wellbeing dimension −20%). In this study, health behaviour or lifestyle factors (behavioural dimension −3%) proved to be relatively unimportant in health selfassessments. Conclusions Self-assessed health proved to be a multidimensional concept. For most part, subgroup differences in self-assessed health could be attributed to experience with ill health: being relatively inexperienced with health problems versus having a history of health problems.

  • qualitative study
  • selfassessed health
  • stratified sample
  • subgroup differences

The single question ‘How is your health in general?’ is a crude and simple measure that has been widely used, as it presents researchers with a summary of an individual's general state of health. It is presumed that in self-assessed health numerous aspects of health are combined within the perceptual framework of the individual respondent.13 This measure proved to be a powerful predictor for mortality; poor self-assessed health increases the mortality risk, even when other (more objective) indicators of health status have been controlled for.4

Many studies have been conducted to find out which particular aspects are included in health self-assessments. In quantitative studies the relationship between a priori defined health measures and self-assessed health has been analysed. In these studies, however, a significant proportion of variance in self-assessed health remains unexplained. This suggests that when assessing their health, participants may include health aspects that have not been routinely included in quantitative analyses. Therefore, some researchers have used a qualitative approach to identify the remaining and unknown aspects of self-assessed health. Briefly summarizing, selfassessed health seems mainly to be associated with physical health problems, functional capacities, health behaviour, and psychological aspects.59 Additionally, some studies found that aspects such as health comparison,5 health transcendence, externally focused, non-reflective,6 social role activities, and social relationships9 were included in health self-assessments. Only two of these qualitative studies attempted to include equal numbers of participants of different sociodemographic backgrounds.5,7 The other studies included convenience samples predominantly consisting of women, elderly, highly educated participants6,8,9 or participants with health problems.8 However, health standards may vary among different subgroups, and probably depend very much upon gender,6 age5,10 and experience with health problems.10 Therefore, it is difficult to decide whether the findings in these studies reflect general health conceptions, or are determined by the most prevalent subgroup. It would be relevant to know whether participants from different subgroups consider entirely different aspects when assessing their health, but with the exception of Krause and Jay's study,5 qualitative studies on self-assessed health rarely examined subgroup differences.

We initiated a qualitative study on self-assessed health in a sample that has been stratified on background characteristics, health status, and health assessment. The present paper focuses on the aspects that people consider when answering the question ‘How is your health in general? Is it very good, good, fair, sometimes good and sometimes poor, or poor?’. We believe that health assessments follow an individual process of ordering and weighing different health aspects. Therefore, we asked participants what went through their minds when answering the question on self-assessed health. The analysis was guided by the following research questions: Which aspects do participants consider when answering the question on self-assessed health? Do participants with different background characteristics (age and gender), and participants with different health status (with and without current chronic conditions) consider the same or different aspects when assessing their health? Do participants with good and less-than-good self-assessed health consider the same or different aspects when assessing their health?

Data and methods

Study population

Our study population consists of participants of the GLOBE study, a longitudinal study designed to describe and explain sociodemographic inequalities in health in the Netherlands. Design and objective of the GLOBEstudy have been described in detail elsewhere.11 At baseline in 1991, participants comprised a cohort of non-institutionalized men and women with Dutch nationality, 15–74 years of age, who were living in the city of Eindhoven or surrounding municipalities. In 1997, a subgroup of respondents to the baseline interview were approached to participate in a follow-up study. For our qualitative study, we drew a stratified sample from the respondents to the 1997 follow-up. The interviews took place in 1998.

The variables for stratification have been chosen because of their supposed relationship with self-assessed health: gender, age, socioeconomic status, and health status. In order to obtain maximum contrast, we included men and women, younger than 40 years of age and older than 60 years of age, with the highest level of education (university degree) and with the lowest level of education (primary or lower vocational education), with a chronic illness (COPD/asthma or chronic back complaints) and without a current illness. Furthermore, we stratified on the most recent available (i.e. 1997) health assessment and thus included participants with (very) good, as well as participants with less-than-good self-assessed health (stratification table is available on request).

Non-response and changes in health assessments

In each stratum, participants were randomly selected. It was, however, not possible to select participants in all strata, due to various reasons. First, some strata did not exist in the population from which we drew our study sample. Second, the number of possible participants that fitted a particular profile (i.e. stratum) could be very low. When these participants all refused to participate in our study, there were no other eligible participants we could approach. Third, some participants changed their health assessment during the 1998 semi-structured interview compared to the followup data (1997) on which we based our initial selection of respondents. All in all, we were able to select participants for 74% of the existing strata.

From May till December 1998, we approached 63 people by mail and telephone. Fourteen persons were unwilling to participate in the study, we were unable to get into contact with six persons, and three persons were unavailable during the study period, although willing to participate. Thus, we interviewed 40 participants, a response of 63%. The distribution of the different stratification variables can be seen in table 1.

Semi-structured interview

All participants were interviewed in their homes by the principal investigator (JS). The semi-structured interviews, lasting approximately 35 minutes, were tape recorded and transcribed verbatim. Following a brief introduction the interviewees were presented with the core question ‘How is your health in general? Is it very good, good, fair, sometimes good and sometimes poor, or poor?’, and were then asked to explain their particular response.

Interview analysis

We started with analysing the verbatim text of the interviews. In each interview, we condensed the answers given to the single-item measure on self-assessed health and the reasons for this health assessment. Parts of the text representing the same theme were summarised with a single phrase, hereby paraphrasing the participant. In this way, each interview could be condensed into personal themes. Next, we categorized the personal themes of all participants into a smaller number of recurrent themes, which we will refer to as health aspects. Finally, on categorization of these health aspects, five conceptually meaningful health dimensions emerged (see Appendix 1 for a flow chart of the coding process). For development of the overall categorization scheme, and for the data analysis that followed, QSR NUD*IST software,12 were used.

To ensure reliability in coding and analysing the interviews four researchers (JS, JB, IJ and HB) independently read and coded eight of the interviews. The results were compared and discussed to come to a reliable method for analysing the interviews. Next, the principal investigator (JS) read and coded all interviews, and designed the final categorization scheme. Finally, one of the other researchers (IJ) independently applied the categorization scheme (on the level of health dimensions) to eight of the interviews. We then calculated Cohen's Kappa, a measure of interrater reliability, and the level of agreement was shown to be good (κ=0.69).13

This paper presents the overall frequency distribution of the different dimensions and health aspects, as well as the distribution of health dimensions by gender, age, health status, and health assessment. Chi-square analyses are used to examine whether referring to a particular dimension varies significantly for different subgroups.


Which health aspects are taken into consideration?

The final categorization scheme consists of 17 health aspects, categorized into five health dimensions. The frequencies with which the different health dimensions and health aspects were mentioned are shown in table 2. In Appendix 2 the description of the health dimensions and health aspects are given and illustrated with quotations. (1) We considered physical references, i.e. any reference to disease, illness, medical treatments, or other ‘bodily'-oriented theme to be an aspect of the physical dimension. (2) Any reference to general functional abilities or limitations we considered to be an aspect of the functional dimension. (3) We considered any reference to a positive attitude towards a current illness or having adapted to its limitations to be an aspect of the coping dimension. (4) Any reference to feeling fit or energetic (‘not feeling tired’) or to feelings without any further justification (simply ‘feeling good’), were considered to be an aspect of the wellbeing dimension. Also, references to the (im)balance between physical and mental health were included in the wellbeing dimension. (5) The behavioural dimension refers to any theme referring to (health) behaviour.

Within each of the overall health dimensions, we have tried to maintain the subtle nuances observed in the interviews by distinghuishing different health aspects. For example, within the physical dimension, we included two related health aspects: ‘bodily mechanics’ and ‘robustness’ (Appendix 2). Both aspects refer to some kind of susceptibility, in which the former refers to the more intrinsic ‘failing bodily mechanics’, the latter refers to the more extrinsic ‘robustness’ i.e. resistance to external agents. In cases where nuances were quite subtle (i.e. statements in which respondents seemed to refer to two or more different health aspects) the context of the whole interview was used to guide decisions on where to classify a statement. However, in the subgroup analyses only the classification in health dimensions was used.

The number of dimensions participants referred to ranged from one to three health dimensions. Almost half of the participants (47%) mentioned aspects from only one dimension, half of the participants (50%) mentioned aspects from two dimension, and one participant mentioned aspects from three health dimensions. In total, 40 participants made 62 references to health dimension, thus on average participants mentioned 1.55 health dimensions.

Differences with respect to background characteristics and health status

Some differences between participants with different background characteristics (gender and age) can be observed (table 3). With regard to gender it can be seen that men do refer to the functional dimension more often than women, 40 versus 15% (not statistically significant), though no differences could be observed with respect to the functional aspects they mention. No gender differences can be observed in the frequency of physical aspects, aspects of wellbeing and aspects of coping.

However, in our study group clear age differences can be observed. Participants in the 60+ age group refer to the physical dimension (92%, p<0.01) and functional dimension (35%, not statistically significant) almost twice as much as 40- participants. Older participants with a chronic illness or a history of illness mention aspects such as ‘prognosis of illness’ or ‘illness-related functional disability’ more frequently than do younger participants. Aspects such as ‘age-related complaints’ or ‘age-related functional abilities’ are only mentioned by older participants, as these aspects do not apply to the young. Another significantly age-related dimension is wellbeing (p < 0.001); ‘feeling fit’, ‘feeling good’, and ‘body/mind equilibrium’ are aspects mentioned almost exclusively by the young. Half of the younger participants mentions aspects of wellbeing, whereas only one elderly participant mentions that he based his health assessment on ‘feeling fit’. With respect to the coping dimension, the age difference is less marked and not statistically significant. Still, almost onethird of the older participants versus onefifth of the younger mentioned aspects of coping.

Participants with and without a current illness differ notably on two dimensions. First, more than half (55%) of the participants with a chronic illness mentions coping with a chronic illness, and, logically, none of the participants with no current illness mentioned it (p<0.001). Second, wellbeing is considered more frequently, although not significantly, by participants with no current illness (30%) compared to chonically ill participants (10%). The functional dimension is mentioned almost equally frequent by participants with no current illness (30%) and chronically ill participants (25%). Although only the former mention functional aspects with a positive connotation: being able to do almost anything, whether or not in relation to (a relatively high) age. Participants with and participants without a chronic illness refer to disability or impaired mobility due to a chronic illness or a history of disease. Nevertheless, for participants with and without a current illness self-assessed health is predominantly associated with the physical dimension. In both groups almost 80% of the participants refer to the presence or absence of physical problems.

The final column in table 3 shows that men, elderly, and chronically ill participants refer to more health dimensions than women, younger participants, and those with no current illness.

Differences between participants with good and less-than-good health assessment

We will refer to participants describing their health as either very good or good as ‘being in good health’, and to participants describing their health as either fair, sometimes good and sometimes poor, or poor as ‘being in less-than-good health’. Table 3 shows that the functional dimension is far more important for a less-than-good health assessment (43%) than for a good health assessment (19%). The gradient from good to poor self-assessed health is very clear, although not statistically significant. When functional aspects are mentioned by participants in good health, it is always with a positive undertone. In addition to positive functional aspects participants in less-than-good health refer to disability and impaired mobility due to disease or illness. The coping dimension is mentioned more frequently, though not significantly, by participants in less-than-good health (36%) than participants in good health (23%). Remarkably, only participants in less-than-good health compare their own health with that of other people who are worse off. In contrast, aspects of wellbeing—such as feeling fit or feeling good—are mentioned predominantly by participants in good health (27%), only one participant with less-than-good health mentions an aspect of wellbeing. Clearly, for good as well as for less-than-good self-assessed health the physical dimension is very important. Still, slightly more participants in less-than-good health (86%) than participants in good health (73%) explain their health assessment in physical terms (not statistically significant). Participants in good health mention the absence of physical problems, only experiencing minor illnesses or age-related symptoms, and a good prognosis. Being in less-than-good health is also associated with the absence of physical problems or only experiencing age-related symptoms. However, participants in less-than-good health also refer to the presence of physical problems. Of those in less-than-good health, particularly participants in poor health mention the severity of their chronic illness and a poor prognosis: their illness has deteriorated.

The final column of table 3 shows that participants with a less favourable health assessment refer to more health dimensions than participants with the most favourable health assessment. A clear gradient can be observed, from an average of 1.4 health dimensions for participants with (very) good selfassessed health up to an average of 2.0 health dimensions for participants with poor self-assessed health.


Summary of the findings

The physical dimension of health has, traditionally, been viewed as being the core of self-assessed health, and in our study too this dimension proved to be a central factor in health self-assessments. Almost 80% of the participants referred to one or more physical aspects. Nevertheless, when assessing their health participants also include aspects that go beyond the physical dimension of health: 80% of the participants—whether or not in addition to physical aspects—referred to one or more of the other health dimensions. Besides physical aspects participants considered the extent to which they are able to perform (functional dimension), the extent to which they adapted to, or their attitude towards an existing illness (coping dimension), and simply the way they feel (wellbeing dimension). Health behaviours proved to be relatively unimportant in health self-assessments. All in all, we may well conclude that self-assessed health is not just a physical but a multidimensional concept.

Methodological issues

When interpreting the results of the present study, some methodological issues should be kept in mind. First, since most qualitative studies apply an inductive procedure to analyse the interviews, our study differs from the other studies on self-assessed health both with respect to the terminology used and the final categorization of these health aspects. Although not all studies describe the contents of the final categories/dimensions in detail, at first glance it seems as if applying our final categorization scheme to the data in other studies would yield different results (table 4). For instance, Krause and Jay (5) categorized references to general energy level as ‘health problems’ which in our study would have been categorized as ‘wellbeing’. Different researchers thus apply a different terminology, but table 4 also shows that, in general, qualitative studies on self-assessed health are quite similar with respect to the health aspects that have been drawn from the interviews.

Second, some studies only included those aspects in the analysis which participants mentioned first (single-reference studies), other studies included all aspects which participants mentioned (multiple-reference studies). Due to both the multiple-reference / single-reference disparity and the differential categorization of health aspects over these dimensions it is quite difficult to compare studies with respect to the average number of health dimensions referred to by participants (e.g. an average of 1.55 dimensions in our study, 1.39 dimensions in a singlereferences study by Krause and Jay5 and 1.19 dimensions in a multiple-reference study by Borawski-Clark.6

Third, even in our small-scale study we were able to identify some statistically significant subgroup differences. In this small study population, it required a difference of over 30% points to become statistically significant. This does not imply that the remaining non-significant subgroup differences of 20 to 25% we identified should be discarded as irrelevant, as these may very well be real differences. When these findings were to be repeated in a larger study population, these subgroup differences would be statistically significant. Therefore, we included these smaller and non-significant subgroup differences in our interpretation of the findings regarding subgroup differences.

Categorization scheme

As noted earlier the physical health dimension was very dominant. On the other hand, virtually no reference was made to mental health. Only one responder did mention mental health, stating that for her own health assessment a balance in physical and mental health was important. Although several psychological mechanisms were mentioned (e.g. categorized within the the coping dimension) or positive health was stressed (e.g. feeling good in the wellbeing dimension), none of the respondents made reference to mental health as such, nor to specific mental diseases or complaints, such as depression or anxiety. This is all the more remarkable since mental health problems are among the most prevalent diseases in the Netherlands and among the diseases with the largest consequences for quality of life.14 However, this finding is in agreement with the findings from other qualitative studies.57,9 Probably, mental health is not consciously taken into account by responders when assessing their health.

Differences with respect to background characteristics and health status

We found that men refer to functional aspects more frequently than women, although this result is only marginally significant. In Western societies men are normally the breadwinner and thus responsible for the main source of income. This may be the reason that men, more than women, have incorporated the functional definition of health as ‘being able to perform the necessary duties’.15,16 We also observed clear and some significant age-differences in our studygroup. Participants in the 60+ age group referred to physical and functional aspects almost twice as much as younger participants. In contrast, half of the younger participants mentioned aspects of wellbeing, whereas this aspect is mentioned only incidentally by elderly participants. Although the distribution of participants with and without a current illness is equal in both age groups, elderly participants more frequently mention a history of illness. Elderly participants probably incorporate these prior episodes of (physical or functional) ill-health in their health assessments. Furthermore, we found some differences between participants with and without a current illness. Aspects of coping are typically mentioned by participants with a chronic illness. On the other hand, aspects of wellbeing are typical aspects of participants with no current illness. Some (predominantly younger) participants are relatively inexperienced with (coping with) physical, functional or age-related health problems. Consequently, these participants do not incorporate these health dimensions in their health assessments, but simply rely on the way they feel. Other (predominantly elderly) participants are more experienced with episodes of ill-health. Yet, for these participants it is not so much the presence of (physical, functional or agerelated) health problems but the extent to which they are capable of coping with these problems which determines their eventual health assessment. The importance of experience with health problems and the ability to cope with them is also reflected in the finding that elderly and chronically ill participants include more health dimensions in their health assessments than do younger participants and those with no current illness.

Differences between participants with good and less-than-good health assessment

There are some differences between participants in good and participants in less-than-good health, though not statistically significant. Again, these differences may be the result of some participants having experienced less health problems than others. For participants in good health two lines of reasoning can be distinguished. Participants with no current illness or other health problems reason: ‘I am not bothered by any physical or functional health problem, I am feeling good’, participants with (a history of) chronic illness or other (e.g. age-related) health complaints reason: ‘I am not bothered by physical or functional complaints, I cope with them’. Participants in less-than-good health seem to experience more physical and functional health problems than participants in better health—as reflected in the larger number of health dimensions they refer to—which they also present as being more severe. On the basis of these interviews we cannot determine whether the participants in less-than-good health truly suffer from more severe problems than participants in better health, or that for some reason these participants are less capable of coping with health problems.

The role of coping

Besides prior or current experience with physical or functional health problems, coping with these problems seems to be important for one's health assessment. It is inherent to our coding process that only explicit statements referring to adapting to illness, attitude towards illness, or comparison were considered to be referring to aspects of coping. However, if we look more close at the data, we find that there are other, more implicit, references which could be considered as a way of coping with health complaints, i.e. referrence to age-related complaints or functioning. It seems as if participants who consider age-related physical complaints or functional decline to be normal, are less bothered by them. And although not all participants mentioning age-related (‘normal’) complaints or age-related functioning assessed their health as good, it may be just the reason why they did not assess their health more poorly.17


We have shown that that self-assessed health is a multidimensional concept. Over the years several qualitative studies on self-assessed health have produced comparable results, even though these studies differed with respect to the subgroups they included and the methodology they applied. The consistency of the findings suggests that we have actually taken a step nearer to identifying which particular aspects are involved in health assessments.

Key points

  • In this qualitative study we studied which particular aspects are included in self-assessed health.

  • Self-assessed health proved to be a multidimensional concept, including primarily physical, functional, coping and wellbeing aspects.

  • Health behaviour or lifestyle factors proved to be relatively unimportant in health self-assessments.

  • Subgroup differences in self-assessed health could primarily be attributed to prior experience with ill-health.

  • The consistancy of these findings with other qualitative studies suggest that we have identified the key dimensions of self-assessed health.

View this table:
Table 1

Distribution of stratification variables in study population

Stratification variablesCategories N
AgeYounger (40−)14
Older (60+)26
Socio-economic statusLow education19
High education21
Health statusNo current illness20
Copd or back complaints20
Self-assessed health (during interview)Gooda26
  • a Includes category ‘very good’ (n=1).

View this table:
Table 2

Frequency of health dimensions and health aspects

Health dimensions Health aspects (n)N (% of total)
Physical 31 (78%)
Chronic illness (15)
Physical problems (11)
Medical treatment (6)
Age-related (‘normal’) complaints (6)
Prognosis of illness (4)
Bodily ‘mechanics’ (1)
Robustness (1)
Functional 11 (28%)
Not being impaired (4)
Illness-related disability (5)
Age-related functional abilities (3)
Coping 11 (28%)
To adapt to illness (5)
A positive attitude (4)
Social comparison (2)
Wellbeing 8 (20%)
Feeling fit (5)
Feeling good (2)
Body/mind equilibrium (1)
Behaviour 1 (3%)
Eating healthy food (1)
View this table:
Table 3

Frequency of different health dimensions, by gender, age, health status and health assessment

SubgroupHealth dimensionsMean no of
Category (n)PhysicalFunctionalCopingWellbeingBehaviourdimensions
    Women (20)15(75)3(15)6(30)4(20)1(5)1.5t-test n.s.a
    Men (20)16(80)8(40)5(25)4(20)0(0)1.7
    60+ (26)24(92)9(35)8(31)1(4)1(4)1.7p <0.10
Health status
    No current illness (20)15(75)6(30)0(0)6(30)1(5)1.4t-test
    Chronically ill (20)16(80)5(25)11(55)2(10)0(0)1.7p <0.10
Health assessment
    Goodb (26)19(73)5(19)6(23)7(27)0(0)1.4
    Fair (6)5(83)2(33)1(17)1(17)1(17)1.7Anova
    Sometimes poorc (5)4(80)2(40)3(60)0(0)0(0)1.8p <0.05
    Poor (3)3(100)2(67)1(33)0(0)0(0)2.0
  • a n.s. Not significant

  • b Includes category ‘Very good’ (n=1)

  • c In full: ‘Sometimes good and sometimes poor’

View this table:
Table 4

Overview of the main dimensions (in italics) of five qualitative studies on selfassessed health

This paperKrause and Jay (5)Borawski-Clark et al. (6)Manderbacka (7)Idler et al. (9)
Physical Health problems Physical health Absence of ill-health Physical health
Presence or absence of health problems and illnessesMedical/health conditionsPresence or absence of diseaseMedical conditions, symptoms, prognosis
Physical functioning Physical symptoms Health as an experience Psychological, emotional health
General physical conditionExperienced symptoms, illnessesAge-related complaints
Reproductive, sensory functions
Functional Physical functioning Physical health Health as a function Physical functioning
Physical functioning, mobilityFunctional capacitiesFunctional restrictionsDaily activities
Social role activities
Social responsibilities
Coping Health comparisons Health transcendence Health as an action Psychological, emotional health
Comparing to other peopleAble to transcend health problemsStrength, copingAttitude
Attitudinal, behavioural Social relationships
PsychologicalSocial comparison
Wellbeing Mental health Non-reflective Health as an experience Physical health
Psychological wellbeingFeeling goodFeeling goodEnergy
Physical functioning Health as an action Psychological, emotional health
Energy levelFitness, vitality, equilibriumPositive emotions, happiness
Behaviour Health behaviour Attitudinal, behavioural Health as an action Health risk behaviours
Positive/ negative behaviourLifestyleLifestyle, health behaviourHealth behaviour
Undefined Externally focused Social relationships
External validation, social support, external causesFamily relations
Psychological, emotional health
Luck, faith
  • Note Van Doorn's paper8 provided little information on the exact contents of the dimensions that were distinguished; this study is not included in the overview.

Appendix 1

Flow chart describing the phases in the qualitative analysis of the interviews


Appendix 2

Description of the health aspects are given illustrated with quotations

Health dimensions

Health aspects

Physical: This dimension refers to the general working of one's body

Chronic illness: presence of a chronic illness or a history of chronic illness

Well, I guess you could say that my health is reasonably okay, only there's no getting away from the fact that I'm, uh, thirty, forty percent asthmatic. That's what I've got, so to speak. Man, 60+, high ses, copd/asthma, ‘fair’

Physical problems: reference to physical complaints, not directly related to any chronic illness, such as never being ill, never needing to stay at home due to illness, or only experiencing minor illnesses

Uh, no problems, no headaches, no stomach aches, no menstrual pains like I used to get. Woman, 60+, high ses, no current illness, ‘good’

Medical treatment: (not) being under medical treatment, or (not) being prescribed medication

I never see the doctor, so, uh, sure, I'm in good shape (…) I mean, well, if you don't need to see the doctor a lot, and you don't have a whole lot of complaints (…) Healthy? Yes, all of us, we're healthy. At least, my husband never has to visit the doctor—knock on wood—up to now, so, well. (…) Never been in hospital for anything, well, only to have a baby, and that's rather a healthy reason, wouldn't you say. Woman, 40-, low ses, no current illness, ‘good’

Age-related (‘normal’) complaints: reference to physical complaints which are considered to be expected, i.e. ‘normal’, considering one's age.

I'd say I'm fine. Yes. Of course there's always some little thing going wrong here and there, but all pretty much to be expected. My arm was giving me problems and the doctor gave me a few shots, I mean, well, it was painful, and after eighty years it's not a surprise my joints weren't working as smoothly as when I was twenty. But actually I'm doing fine. Man, 60+, low ses, copd/asthma, ‘fair’

Prognosis of illness: reference to the course, or prognosis of a chronic illness

Well I don't know whether you read the previous questionnaires? Oh, well two years ago I was operated on for breast cancer, so with that in mind, I'm doing very well (..) Like I said, I may have had an operation but it was localised and I'm fine now. No other complaints. Woman, 60+, high ses, no current illness, ‘good’

Bodily ‘mechanics’: reference to failing ‘mechanics'of the body, as a result of which one may suffer from recurring (minor) physical complaints

The only thing, which is why I was wavering between ‘very good’ and ‘good’, uh, mechanically I'm not in great condition. Right now, for example, I've got a stiff neck, but I've always got a backache. And, uh, that's because well, it's just not strong. Man, 60+, high ses, chronic back complaints, ‘very good’

Robustness: reference to being illness-prone vs. being more robust to illness

I guess it all has to do with constitution, how strong your body is, you know. What I notice in my case is that that's not all that strong, that for the rest I feel perfectly healthy, but I'm very quick to notice when I've been overdoing it. Like when I've had too much to drink. Or forget stuff. That S. I was talking about just now, well, he's a good example. He can eat, say, halfdone chicken legs. If I ate something like that I'd notice right away. My stomach starts acting up or something and he has no problems at all. Man, 40−, low ses, no current illness, ‘good’

Functional: This dimension refers to one's ability to perform certain activities

Not being impaired: reference to general functional abilities or limitations. Referring to being able to do the things one wants to, or needs to do, without any reference to disease, illness or bodily mechanics

Well, because you can do everything, you do everything. But ‘very good’, no, I mean there are also all the days that things don't go very well, so I guess ‘good’ is a happy medium. Woman, 40−, low ses, no current illness, ‘good’

Illness-related disability: reference to some kind of disability or impaired mobility, due to chronic illness or disease

It started with my lungs (…) Yes, (my health) it's poor. I mean, if I could get more air. I mean, right now, and then I'm referring primarily to the past few months, after I've walked for, say, 200 metres, I have to stop and, and catch my breath. Take just yesterday. I wanted to go get a haircut, that's 10 minutes away by bike. Halfway there I had to turn around and go home. So I'm hoping that specialist is right and that if I use oxygen when I exert myself, it'll help. Man, 60+, low ses, copd/asthma, ‘poor’

Age-related functional abilities: relating general functional abilities or limitations to ageing, being able to function well ‘for one's age’

Uhh, if a person's healthy, uhhh, he can do anything he's supposed to be able to do at his age. I mean, look, if you're over sixty, I'm sixty-three, obviously you can't be doing all the crazy things you did when you were twenty or thirty. Man, 60+, high ses, no current illness, ‘good’

Coping: This dimension refers to the psychological mechanism of dealing with an illness

To adapt to illness: reference to having adapted to the chronic illness or having learned to live with its limitations

Because health is extremely complicated. I mean, purely on the physical level, you could check whether every bit of the body is in good working order. And in my case you'd find that there are a great many bits in my body that don't work well. But if you look at the complex, the aggregate and the combination etc. etc., how I function the way I am, well, the answer is good, I would say. (…) So to my mind it has a lot to do with uhh, on the one hand adapting and on the other taking steps to be able to do what you want to do, only in a different way. Woman, 60+, high ses, chronic back complaints, ‘sometimes good and sometimes poor’

A positive attitude: reference to maintaining a positive attitude towards the illness

It's however you look at it, I say. I mean, it's not going at all well to be frank, but I try to take the cheerful view. So, chin up, is what I always say (…) Well, they're not actually very healthy. No, well they always look on the bright side, you see. Yes. And, I mean take someone who has a bug or something else, whatever, that can make you feel really ill, that person knows ‘this'll be over in a couple of days, a few weeks’, and that holds for a lot of things. And that's what I mean by always looking on the bright side. And even when it's like there isn't one, you still always have to find that tiny spark. Woman, 40−, low ses, chronic back complaints, ‘good’

Social comparison: comparing one's own health with the health of peers; comparing one's own health with the health of people who are worse off (downward comparison)

But there are always worse things, aren't there, and that's some consolation. I was just in hospital and I saw a person come out who was bent over nearly double, what a hump! His nose close to scraping the ground, I mean imagine going through life like that? That would really be awful. Man, 60+, low ses, copd/asthma, ‘poor’

Wellbeing: This dimension refers to general feelings and to aspects of mental health

Feeling fit: reference to feelings of fitness or energy, referring to feeling fit, energetic and not tired

Yes, I feel good, I'm never tired and uh especially during the past few years, sure. (…) Yes, physically healthy? I guess, if you're not tired (…) I feel fit, not tired, so I feel healthy. Woman, 40−, low ses, no current illness, ‘good’

Feeling good: reference to general feelings without any objective justification, simply referring to ‘feeling good’

Yes, I feel good, I feel absolutely great. For me, health is ‘feeling good’. And I do. That's how simple it is. (…) Oh, that's, I guess, not feeling bad. Man, 40−, high ses, chronic back complaints, ‘good’

Body/mind equilibrium: reference to the (im)balance of physical and mental problems

If you're ill and out of sorts, you can forget it, you just feel rotten. If you have a psychological problem you feel just as rotten even though physically, there's nothing wrong. But you're not completely healthy if you've got a problem with either. (…) Healthy is when you have no infections of any kind. I guess that's part of it. And that there's no blackness messing up your mind.(…) I mean, you don't have flu, mentally you're okay. And it's like ‘everything's good, I'm doing fine. Woman, 40−, high ses, chronic back complaints, ‘fair’


Eating healthy food: mentioning eating well (all from our own garden) and not eating sweets


The authors would like to thank Dr Ir E. J. de Min for providing the software for calculating kappa coefficients, and Dr H. van de Mheen for participation during the early stages of the research project. We would also like to thank Ms K. Gribling for her careful translation of the excerpts from the interviews. The GLOBE-study is supported by the Dutch Ministry of Public Health, Welfare and Sports, and the Netherlands Health Research and Development Council (ZON).


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