Beyond the hype of positive health: towards person-centred care
Since 2014, a new concept has been on the rise: positive health. Some see this as the solution to all the problems we currently face in healthcare. It’s not strange. For decades, healthcare has focused only on disease and medical solutions. But along the way we find out that this approach does not always offer sufficient possibilities to fit in with the wishes of the patient regarding treatment and guidance. Especially given the fact that the number of multimorbid patients with complex care needs that are difficult to standardize is increasing. In this blog, we denounce the hype surrounding positive health. We explain what the concept entails. What the beautiful sides of it are, but also the shortcomings. And whether it is indeed the answer to everything.
Positive health is a concept introduced by Machteld Huber. In her 2014 dissertation, Huber turned the WHO definition of health – ‘a state of complete physical, psychological and social well-being and not just the absence of disease and infirmity’ – on its head. Huber argues that this definition is outdated, because then hardly anyone would be healthy. And that it leads to unnecessary and costly medicalization of care. Alternatively, she introduces the definition: ‘the ability to adapt and manage oneself in the light of the physical, emotional and social challenges of life’, which forms the basis for the concept of positive health. In this concept, health is no longer seen as the absence or presence of disease, but as the ability of people to cope with (changing) physical, emotional and social life challenges and to have as much control as possible. Health is then no longer strictly the domain of healthcare professionals, but of everyone. Huber distinguishes six health dimensions to measure ‘health well-being’: 1) body functions, 2) mental functions and mental perception, 3) spiritual dimension, 4) quality of life, 5) social participation and 6) daily functioning, to which she links 32 health aspects.
Huber’s concept receives much praise, but also meets with criticism. She pretends to use a new definition which is not true. Similar health definitions and insights that contain actionable elements have been available in the international scientific literature for many years. Furthermore, the criticism of her work can be roughly divided into three groups: 1) criticism at the conceptual and methodological level, 2) on their practical implementation and application and 3) as a warning of the possible consequences. We explain them briefly.
Huber describes health as ‘the ability to adapt and manage oneself’. In doing so, she (rightly) describes health as a complex and dynamic concept. That is a great gain, but then she reduces positive health to six dimensions. That is confusing. Complexity and reductionism do not go well together. It would be clearer if Huber indicated that reducing health to a number of dimensions is necessary to conduct research, but at the same time also mentioned the limitations of this method. Health as a whole is complex and cannot be reduced to six comprehensive dimensions. This nuance is lacking in Huber’s work.
Huber confuses behaviour with health. For example, according to the definition, very sick people could be seen as healthy as long as they behave constructively. The confusion arises because Huber uses the term ‘health’ for a condition and for dealing with that condition. This double meaning implies that people can deal with their health and their unhealthiness in healthy and unhealthy ways. Thus, depending on the perspective of the evaluator, the same person may be called healthy or unhealthy or even healthy and unhealthy at the same time. Because of this, Huber’s concept leaves many questions unanswered and can lead to peculiar or incorrect inferences.
No implementation strategy
In addition, it lacks a clear implementation strategy and without that the concept will not lead to concrete changes. People apply the ideas as they see fit and a proliferation of (small-scale) initiatives arise that often do not achieve the desired results. The Positive Health Spider Web – a diagram that incorporates the six dimensions of positive health and that care providers can use to map out a patient’s well-being – also provides insufficient direction. It does not indicate which interventions should be used next. Moreover, the focus is only on the individual, while health can also be influenced at the family, neighbourhood, regional and national level.
Health care or disease care?
Should we throw the concept of positive health overboard? That is a little too short, because it is a justified reaction to the medicalisation that has characterised healthcare for years. People have been deprived of their own control in recent years. Huber is right to point out that the focus should not only be on treating illness, but also on promoting health. In addition, the definition fits well with the language and ideas of caregivers. It fills a need and is therefore widely adopted. The concept has woken us up, but we should not adopt it uncritically. Huber says that a new healthcare system should be created based on her definition of health, but the translation of that definition to practice is lacking. The concept of positive health – however beautiful it may seem in theory – has too narrow a basis (only the patient) and is not applicable in practice.
The model of person-centered care offers a better answer to the problems we face. This approach to care, which focuses on personal control, healthy behaviour, preservation of function and the desired quality of life, is more in line with the current demand for care from patients. Person-centered care revolves around the needs and abilities of the patient. It also takes into account a person’s context and differences in personal characteristics. An entirely different approach to the patient-centred (illness) care that dominated for decades (see table below).
But the real issue is that we need to get away from the idea that we have to choose one or the other. It is not either patient-oriented (illness) care or person-oriented (health) care. It should be and-and. You can’t separate one from the other. Both matter, so they must coexist and complement each other.
Focusing only on disease is too limited in the current era. But focusing only on person-centered care also. Healthcare is a complex system. There are factors at all levels that influence each other. What we need to do is approach healthcare as a complex system as well. This means that we have to include all parties concerned: patients, care providers, administrators, health insurers and policy makers. The Rainbow Model offers concrete support in this. It shows at all levels of the system the interventions that can be used to achieve value-driven care. Moreover, these interventions are scientifically underpinned and have proven themselves in several places abroad. So let’s stop chasing all the hype, and instead opt for a broad vision and build on it in practice with a sound, scientifically based implementation strategy. Because if you provide good care at all levels, this translates into quality, patient satisfaction and cost savings. And we are then immediately relieved of all the hypes that would otherwise await us.
Read more about how person-centered care can be implemented using the Rainbow Model in our white paper.