Definitions and relationships among terms

The classic understanding of the term health from a biomedical perspective is “absence of disease.” The antonym of health, therefore, is disease. The World Health Organization contributed to the confusion between the terms health and wellness when in 1948 it defined health as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.”¹ Indeed, there are numerous illustrations of the influence of the mind and spirit on the body and thus the importance, from a public health perspective, of considering more than the physical state of the body when formulating solutions to health problems. However, there is also value in differentiating health from more global concepts such as wellness and quality of life, if for no other reason than to explain the phenomenon that an individual can be diseased and well or can experience a high quality of life while simultaneously living with a chronic disease. Considering the catastrophic nature of many neurological diseases that compromise physical health, it is even more important to distinguish between health and wellness to recognize and pursue avenues to enhance overall quality of life and well-being.

H. L. Dunn first conceptualized the term wellness in 1961 and offered the first definition of the term: “an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable.”² Since Dunn’s introduction of the term, numerous researchers and educators have attempted to explain wellness by proposing various models and approaches.^3–11 Although the literature is full of references to and information about wellness, including numerous definitions of the term, a universally accepted definition has failed to emerge. Several conclusions can be drawn, however, from the abundance of literature regarding wellness.

For many people, including the public, health and wellness are synonymous with physical health or physical well-being, which commonly consists of physical activity, efforts to eat nutritiously, and adequate sleep. Research has indicated that when the public is asked to rate their general health, they narrowly focus on their physical health status, choosing not to consider their emotional, social, or spiritual health.¹² Referring to the definition of wellness from Dunn, and consistent with numerous other theorists, it is obvious that wellness, as it is defined, includes more than just physical parameters.

The common themes that emerge from the various models and definitions of wellness suggest that wellness is multidimensional,^2,4–13 salutogenic or health causing,* and consistent with a systems view of persons and their environments.^2,15–17 Each of these characteristics will be explored.

First, as a multidimensional construct, wellness is more than simply physical health, as the more common understanding of the term might suggest. Among the dimensions included in various wellness models are physical, spiritual, intellectual, psychological, social, emotional, occupational, and community or environmental.¹⁸ Adams and colleagues¹⁸ in 1997, toward the aim of devising a wellness measurement tool, proposed six dimensions of wellness on the basis of the strength and quality of the theoretical support in the literature. The six dimensions and their corresponding definitions are shown in Table 2-1.

The second characteristic of wellness is that it has a salutogenic or health-causing focus,¹⁴ in contrast to a pathogenic focus in an illness model. Emphasizing the factors that cause health (e.g., salutogenic) supports Dunn’s² original definition, which implied that wellness involves “maximizing the potential of which the individual is capable.” In other words, wellness is not just preventing illness or injury or maintaining the status quo; rather, it involves choices and behaviors that emphasize optimal health and well-being beyond the status quo. Thus an individual may or may not be well before pathological conditions and health conditions involve the body and similarly may be well during an acute episode or chronic pathology or health condition whether that chronic problem results in static activity limitations or even progressive participation restrictions.

Third, wellness is consistent with a systems perspective. In systems theory each element of a system is independent and contains its own subelements, in addition to being a subelement of a larger system.^12,15,16 Furthermore, the elements in a system are reciprocally interrelated, indicating that a disruption of homeostasis at any level of the system affects the entire system and all its subelements.^15,16 Therefore overall wellness is a reflection of the state of being within each dimension and a result of the interaction among and between the dimensions of wellness. Figure 2-1 illustrates a model of wellness reflecting this concept. Vertical movement in the model occurs between the wellness and illness poles as the magnitude of wellness in each dimension changes. The top of the model represents wellness because it is expanded maximally, whereas the bottom of the model represents illness. Bidirectional horizontal movement occurs within each dimension along the lines extending from the inner circle. As per systems theory, movement in every dimension influences and is influenced by movement in the other dimensions.¹⁸ As an example, an individual who has a knee injury and undergoes surgery to repair the anterior cruciate ligament will probably have at least a short-term decrease in physical wellness. Applying systems theory and according to the model, this individual may also have a decrease in other dimensions such as emotional or social wellness in the postoperative period. The overall effect of these changes in these dimensions will be a decrease in overall wellness, which anecdotally we know occurs when patients have an illness or injury.

A term related to wellness, quality of life, is also used to indicate the subjective experience of an individual in a larger context beyond just physical health. Quality of life has been defined as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. It is a broad ranging concept affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships, and their relationship to salient features of their environment.”¹⁹ Parallel to the issues related to the concept of wellness, there is lack of agreement in the literature on the definition of quality of life and its theoretical components,^20–23 as well as variation in the use of subjective or objective quality-of-life indicators.²¹ Implied by the World Health Organization definition, and supported by several other authors, quality of life is best conceptualized as a subjective construct that is measured through an examination of a client’s perceptions. In other words, quality of life, like wellness, is the subjective experience of health, illness, activity and participation, the environment, social support, and so forth, and it is best measured through an assessment of client perceptions.

A wellness paradigm

The ultimate importance of gaining an understanding of health and wellness is to be able to apply it when interacting with patients/clients. In this sense, the goal would be to improve the health and well-being of the client, in addition to improving movement and participation. A comparison of the traditional “illness” paradigm with both “prevention” and “wellness” paradigms will identify ways in which a physical or occupational therapist can incorporate a wellness paradigm into the treatment of a patient with a neurological condition in the context of rehabilitation. The three approaches or paradigms are contrasted in Table 2-2 on six parameters, including the view of human systems, program orientation, dependent variables, client status, intervention focus, and intervention method.

As stated previously, in a wellness paradigm each dimension or part of the system affects and is affected by every other part, resulting in an integrative view of the human system. In contrast, in a traditional illness or medical model, the systems are independent. There are specialties in medicine by body system (e.g., neurology, orthopedics, gynecology), and in many physical and occupational therapy education programs, courses are arranged by body system (e.g., neurology, orthopedics, cardiopulmonary physical dysfunction, psychosocial), as indicators of the independence of the systems. In a prevention approach, there is recognition that the systems interact, or influence one another, but not in the reciprocal fashion characteristic of wellness.

The program orientation of an illness paradigm is the pathology or disease-causing issue, whereas the orientation of a prevention paradigm is normogenic, meaning efforts are aimed at maintaining a normal state or condition (e.g., normal muscle length, tone). Shifting to a wellness paradigm requires a salutogenic or health-causing approach,¹⁴ with a focus on how to achieve greater well-being, health, or quality of life. This shift emphasizes the capabilities and abilities of the individual rather than the limitations and deficits.

The variables of interest in an illness paradigm are clinical variables, such as blood tests, V.o₂