Introduction
The well-being of people has become one of the main priorities of decision-makers, especially in the creation of primary healthcare models (1). To this end, recognizing the value of the term in the formulation of public policies and programs has been the reason for defining it closely in terms of health to guarantee the best possible health, through attention focused on people's needs and their individual and collective insurance.
From the point of view of the World Health Organization (1) and La Placa and Knight (2), it is necessary to start from an individual biomedical perspective, in which health is understood as "a state of complete physical, mental, and social well-being," and not exclusively "the absence of disease." That said, wellness is defined as an act of caring through a positive state of mind and body, in which the individual feels safe and can cope with a sense of connectedness to people, communities, and the wider environment (2).
In addition, health is also defined comprehensively to contribute as a guide in public health decision-making, so that it reflects, in public policy discussions, and in those of society in general, a distancing of "individual perceptions." It also states that well-being is to guarantee rights for the entire population universally (3), as well as to identify the degree of satisfaction or dissatisfaction of the population regarding their physical health, psychological health, independence traits, social relations, means, and spirituality in light of mortality, morbidity, and other quality of life indicators (4).
These new approaches, which broaden the perspective from the individual to the community level, point out that health promotion and improvement of well-being must respond to a collective effort at the neighborhood, community, local, district, regional, or national level. The case of England stands out, where welfare is understood as the big society, in which the core is small groups of people who surround a person to form a community that supports the individual's welfare, for example, through the practice of physical activity (2,5,6).
In this sense, understanding the term wellness is a central element that can help improve healthcare delivery. Therefore, this article aims to construct and propose a definition of well-being in the context of healthcare, reviewing the literature on the subject and collecting information on the individual perception of citizens and the perspective of the members of the institutions participating in the framework of the Territorial Health Model of Bogotá (Colombia): Salud a mi Barrio, Salud a mi Vereda (Health in my Neighborhood, Health in my Village), under the responsibility of the District Health Secretariat of Bogotá. In this way, it seeks to provide an approximation of the concept for the discussions that surround the formulation of public health policies and their implementation in healthcare models.
Methodology
A multi-method strategy composed of two phases was developed: the first, a literature review, to identify the definitions of well-being in the context of healthcare models, and the second, a qualitative phase, in which the opinions of individuals were collected, based on group interviews using the World Café method, to recognize the perspectives of both the individuals within the institutions and the community. This strategy was developed within the framework of the Special Cooperation Agreement 3028486 of 2021, between the District Health Financial Fund-District Health Secretariat and the Pontificia Universidad Javeriana, Bogotá.
Literature review
A descriptive or mapping review was carried out to identify the concept of well-being through a systematic procedure that included a literature search and classification (7). To this end, a structured research question was posed that allowed the inclusion of documents that mentioned well-being as a definition or related aspects of the term in primary and community healthcare models. In addition, references were included with a publication date after 2000, written in English, Spanish, or Portuguese. No documents were excluded because of their methodological design, type of population, or publication status.
A search strategy was designed, composed of controlled vocabulary (MeSH, Emtree, and DeCS) and free language, considering synonyms, abbreviations, acronyms, acronyms, spelling variations, and plurals. The syntax was complemented with the expansion of controlled terms, field identifiers, truncators, proximity operators and Boolean operators. The terms used are located in the supplementary material of this article. The strategy was adapted according to the thesaurus of each of the databases used. Additional free and indexing terms were identified using the Vosviewer tool (8).
The search was performed on December 23, 2021, in the databases of PubMed, Embase, Virtual Health Library, Web of Science, and ProQuest. Additionally, gray literature was explored through web search engines and web pages of both governmental and private institutions. Finally, we included documents submitted by professionals from the District Health Secretariat of Bogotá.
After eliminating duplicate documents, two reviewers independently selected, based on titles and abstracts, those that met the inclusion criteria, using Rayyan© software (9). The selected articles were read in full text by a single reviewer, who proceeded to extract the pertinent definitions using NVivo 12® (10).
World Café interviews
Then, qualitative data collection was carried out through semi-structured World Café method group interviews to interpret the participants' perspectives regarding the concept of well-being. This methodology aims to "discuss a particular topic in small conversation groups that rotate as the workshop develops" (11), so that, during the interviews, it was possible to deepen the perspectives that contributed to the discussion of the main topic of the debate and to trace opinions and life records around the concept of interest.
Additionally, theoretical sampling was used to collect data that showed relevance to the study, and the sampling strategy was of maximum variation, to analyze the greatest volume of opinions on the concept of well-being from different contexts (12). In this sense, the methodology was not limited to predetermined procedures within each World Café, and the micro public or micro-targeting strategy was used, which allowed the participation of a determined number of demographically diverse citizens (13,14).
As for the participant enrollment strategy, the snowball technique was used, and potential subjects were included in the population with the following characteristics: women and men over 18 years of age who were part of the following groups: women and men at different stages of their life course; victims of the armed conflict; peasants; LGBTIQ+ (lesbian, gay, bisexual, transgender, and queer); people with disabilities and their caregivers; migrants; people belonging to different ethnic groups; and other vulnerable people (recyclers, paid sex workers, and street dwellers). In the case of the representatives of the institutions, the profiles were diverse and were not limited to the area of health, but included officials from different district entities, healthcare promotion companies, healthcare service providers, foundations, and organizations.
Eight interviews of this type were conducted, each with a different population group (LGBTIQ+ people, women, and new masculinities, victims of the armed conflict, migrants, people with disabilities and their caregivers, people belonging to ethnic groups, and other vulnerable people: recyclers, paid sex workers, and street dwellers, and one with people in different life courses to ensure the greatest possible heterogeneity in socio-demographic characteristics, as well as different opinions regarding the proposed topic.
In each interview, two groups were formed: one with officials from institutions and the other with people from the community, to carry out a debate based on a question, and given the flexibility of this specific modality, the construction of the definition of well-being was deepened based on new conversations, combining the discussion groups after a determined period (13,15).
In the group formed by community participants, the questions were oriented around their experiences, perceptions, and expectations about health and well-being, In the group with representatives of the institutions, the questions allowed us to explore the definitions that have been adopted for the term well-being in the health area and also in other sectors. That said, the methodology allowed participants to approach the subject through different questions, ensuring the association of their perceptions and opinions and the joint construction of the concept of well-being between the two groups. The scripts of the interviews were different, to the extent that the particularities of each group of participants were taken into account and allowed to deepen in specific aspects that resulted in the discussion.
Subsequently, the research team analyzed the information collected in each of the interviews and systematized it with the help of a cross-methodology to identify the information related to the concept of well-being according to pre-established categories. After this, a definition of well-being was consolidated according to the concept synthesis strategy proposed by Walker and Avant (16), in which there is an integrative review of the findings of the literature together with the perceptions about the term, identified in the World Café method group interviews.
Ethical considerations
Approval was obtained from the Research and Ethics Committee of the Faculty of Medicine of the Pontificia Universidad Javeriana and the Hospital Universitario San Ignacio for the verbally informed consent process, pertinent to be of minimal risk—according to Colombian regulations (14,17) for the participants, on September 28, 2021, with minute number 34/2021.
To comply, before starting each group interview, the objective, scope, and methodology of the meeting were shared with all participants, ensuring confidentiality, anonymity, voluntariness, and other ethical considerations following and defined in qualitative research methods. In addition, they were allowed to express verbally their voluntary participation in the interview and their consent to record the session and collect the material resulting from the research exercise.
Results
Literature review
A total of 6510 references were consulted according to the search strategy, of which 2099 were eliminated, and in the first moment, the remaining 4411 were reviewed under the title and abstract criteria. In the second stage, 163 references were read in full text, selecting 18 articles related to the topic of well-being and caring for well-being. After the analysis, it was concluded that seven publications referred precisely to definitions or conceptual elements of well-being in the framework of healthcare models, which are referenced in Table 1.
Table 1
Definitions of the concept of well-being extracted from the literature search.
World Café method interviews
Eight group interviews of approximately four hours were conducted between January and February 2022 to saturate the proposed topic. A total of 97 people participated in these sessions, 52.6% of whom represented the community and 47.4% were people from the institutions. Each participant was asked to fill out a survey to characterize them; 93 participants accepted to fill it out (the results of the survey are shown in Table 2).
Table 2
Results of the characterization survey in the World Café method group interviews
The proposed concept of well-being
The findings of the literature regarding the definition of well-being were centered on the elements that guarantee individual balance and the relationship with the environment. One of them is the approach to the term by national entities, where well-being is understood as the set of elements that guarantee a balanced relationship between human beings and their environment (18), a concept that was associated with public policy in Colombia through the well-being state model, which establishes a link between the democratic system, the free market, and state intervention, to lead to opportunities in education, training, employment, and health (19).
In turn, well-being is recognized as a concept linked to improving health not only in the individual but also in areas where the community is the axis that guides policies and is determined by economic, physical, and environmental conditions, to access healthcare resources (6,20). Under this approach, the performers who have the capacity to improve community well-being are the people within each jurisdiction, as well as public sector organizations through shared responsibility. Therefore, well-being also depends on the identification of the conditions that prove to be essential for good and prosperous development, by the individual and his or her community (20).
Likewise, well-being is a component of health that creates new ways of relating and associating, which are an opportunity to use different resources, such as support for the physical health and development of people (21).
Now, the term well-being is closely related to the concept of care for well-being, through the promotion of health, the strengthening of lifestyles and caring habits, the participation of citizens, intersectoral actions, and individual and collective care; in this sense, care is a main way to generate well-being in society, since it refers to the attitude towards people, the population in general, or the environment, and the individual's ability to transmit kindness, compassion, and respect (22).
Regarding the findings of the World Café method group interviews, the representatives of the institutions consider that the concept of well-being is related to the capacity to satisfy vital needs such as feeding, guaranteeing the availability of space, protecting the physical and mental state of the body, enhancing community life, and restoring human dignity.
Another approach of the representatives of the institutions is well-being as an individual subjective state of quality of life, which changes according to the person's life course; furthermore, it is defined based on full rights and beyond the healthcare system's capacity for care. In the words of a representative of the institutions during the World Café method interviews:
each group [...] has its particularities and that [...] influences well-being because [...] it implies [...] how that person is going to be in terms [...] of quality of life [...] society [influences] whether a person is well or not, based on these experiences that occur in the different cycles of life. (Participant Institutionality of World Café life course)
Achieving this wellbeing is not only the responsibility of the healthcare sector; this wellbeing is everyone's responsibility [...]. (Participant in the institutional framework of the World Café life course)
Similarly, in this group they link well-being with a dignified life, access to basic services without barriers and equitable, as well as access to recreation and sports services. In addition, this concept was related to care and self-care, insofar as it implies taking care of one's well-being and that of others, and maintaining healthy relationships with the environment. They agreed that well-being is a holistic concept of being or doing what is considered important for the person, recognizing the difficulties, possibilities, and processes of each person. Furthermore, in terms of a representative of the institutions:
[...] well-being would be [to help people understand when] their rights are being violated, what they can do [...]. The institutions [are] there to be channels of information and [to be able to guarantee] this wellbeing with [...]. (Participant World Café Institutionality, women and new masculinities)
From a territorial approach, the representatives of the institutions understand well-being as an integral concept that includes the sufficiency of some basic elements, such as food, land, and family:
Well-being is the possibility of developing all human capacities through [...] a model of good living that includes adequate social or family support, healthy habits, regular physical activity, healthy living environments [...], and a fundamental element of freedom of thought. (Participant World Café Institutionality, farmers and victims of the armed conflict)
Therefore, well-being for this group is a product of satisfaction with multiple aspects of life, care, and, in turn, timely care. Another element mentioned by the institutional group was the role of the caregiver and his or her well-being:
When [one reads or speaks] of well-being [one refers to] integrality. There are several aspects that make it up and [...] the sum of them as a result [produces] total well-being. [This includes] the family [or] the caregiver, [therefore], seeing also the needs of the caregiver is also part [of] well-being [...]. (Participant institutional framework of the World Café for persons with disabilities)
Regarding the group interviews with the LGBTIQ+ population, from the perspective of the representatives of the institutions, well-being was conceived as the capacity to feel good in an integral way with oneself and with other people. However, officials pointed out that the health system cannot always provide individual solutions that respond to the needs or identities of the population; on the contrary, it offers generalized care according to the sex registered at birth. They also recognize this as a problem, insofar as "if one does not inhabit the body in which one wishes to live but in which the State can take care of," the concept of well-being becomes unsustainable.
In the case of community participants, well-being involves guaranteeing a person's fundamental rights and quality of life, while recognizing and addressing the particular needs of the human being. Therefore, it is having access to healthcare without barriers and providing care. It is also related to democratizing access to information about rights and services that a person can access, training people to have well-being. In the words of a community member during the World Café method interviews:
Well-being is a condition where the individual has [...] satisfaction for the guarantee of his fundamental rights. [The model] seeks [...] to contribute to the well-being of individuals and communities through the competence of the sector. (World Café community participant, migrants)
[...] the healthcare system [...] [trains] in health to achieve well-being [...] [and transforms] this conception of health as illness [...]. (Participant of the World Café community, women, and new masculinities)
This group also addressed well-being from the perspective of care and how the healthcare system should provide it by offering humanized care focused on the different territorial contexts. Regarding the territorial approach, they relate the term to respecting individuals physically and spiritually way, as well as living in balance and harmony with the environment and animals.
On the other hand, the community's perception and experience of the care and well-being offered by the healthcare system were characterized by a feeling of vulnerability due to the treatment received by healthcare professionals. This, as they perceive it, is characterized by being discriminatory and hostile. Similarly, they say they distrust the system because it affects their access and leads people to avoid going to healthcare centers and prefer to go to ancestral doctors:
[…] the concept of well-being for the communities is in fact related to the same concept, [...] well-being is being well for the communities, spiritually, physically, and territorially [...]. (Participant in the World Ethnic Café institutional world ethnic)
In this same sense, in the community group, the people who played the role of caregivers, when talking about well-being, emphasized that their lives would be easier if they had access to a special attention line to request appointments or to go to the emergency service as a priority. Thus, it was pointed out that their improved well-being would, in turn, translate into better patient care:
Not only the health care of the person with disabilities, speaking of the reality of the healthcare sector as such, but also how we favor a person who feels well, whose health feels good, but also [...] that wellbeing goes hand in hand with recreational and sports programs. It is these initiatives that generate well-being, and] they are not from the healthcare sector. (Participant institutional framework of the World Café for people with disabilities)
Regarding the World Café method group interviews with the LGBTIQ+ population, the members of the community state that well-being should be understood as a right, not a privilege, as they consider that the healthcare system should be characterized by providing protection and not, according to their perception, by being costly and difficult to access, discriminatory, and dehumanizing.
For community members who belong to or represent vulnerable populations (recyclers, paid sex workers, and street dwellers), well-being is not only about being well but also about having the basic minimums that guarantee a dignified life. Likewise, from this group's point of view, well-being implies that the entire community has the same opportunities and work tools; for example, all recyclers have access to formalities and vehicles that facilitate the transportation of recyclable objects.
Having said this, and considering the synthesis of what has been identified in the literature and the findings of the World Café method interviews, a definition is proposed that relates care to well-being: Care is an empathetic and protective practice of personal, social, and environmental reality based on recognizing the fragility of humans and their environment. It generates individual and collective development and well-being.
Discussion
As mentioned, to ensure the best possible health for populations and individuals through needs-based care, it is essential to understand how the relationships between the state, individuals, organizations, and society are perceived within the framework of well-being. Taking into account the results of this research, well-being is understood as a concept with implications on both individual and collective levels, instead of focusing on only one of them, and this definition has been integrated with that of care.
Within the definitions found in the literature review, authors such as La Placa and Knight (2) and Chochinov (23) highlight that well-being in healthcare models is frequently associated with the satisfaction of individual needs and attitudes towards others to convey confidence that their interests and individual characteristics will be taken into account at the time of receiving care. It is an idea that is also found in the findings of the World Café method group interviews, from which it is demonstrated that this individual satisfaction is also understood by the members of both the institution and the community, who highlight well-being as the combination of several components through which basic needs are satisfied— such as access to food, a place to live, warm clothing, and even more complex elements such as recreation and sports—as well as healthy coexistence in the different environments of life—home, work, education, community, institutional, family, work, and school.
It is noteworthy that La Placa and Knight (2) suggest that this satisfaction within the concept of well-being is particular; however, this does not mean that it is exclusively individual. On the contrary, they point out that it must take into account the interests and particular characteristics of each population. It is shared in a transversal manner by the participants in the World Café method interviews when they stated that the satisfaction generated by the healthcare system should not only be individual but also group satisfaction.
It was found that, despite the efforts made to have a healthcare system in which all people participate, it sometimes does not take into account the complexity of the set of characteristics that converge (gender, ethnicity, culture, or work activity). This was particularly emphasized by community members and left the perception that the health model is limiting and excludes certain communities from the well-being that it is intended to guarantee under a criterion of equity that does not recognize the particularities of the population groups.
In view of these responses, it is considered fundamental to understand well-being under the criteria of universality and equity, recognizing the particularities and needs of each community and population group throughout life. There, the condition in which they find themselves and the characteristics that define and differentiate them favor the construction of policies in which a collective well-being approach is provided without disregarding individuals.
On the other hand, authors such as Castelli et al. (6) and Vannier et al. (20) analyzed the concept of well-being and associated it with different socioeconomic, cultural, environmental, and political considerations that influence the individual's relationship with his or her community and environment (18). In fact, it is visible that there is a growing interest in associating these conditions to determine the well-being of a person, as well as the attitude that should prevail at all levels of society to facilitate, support, and protect that well-being, through different forms of relationship and association (20,21). Here, the practice of care for well-being plays a fundamental role, as an empathic and protective ability of the personal, social, and environmental realities, based on the recognition of the fragility of humans and their environment, where care is a generator of development and well-being, both individual and collective (23). This was a finding of the literature review that was also validated by finding within the World Café method groups a similar conclusion that points to a care-well-being connection.
Thus, the need to link the concept of care with the individual and his or her environment was also perceived in the narratives and results of the group interviews, as they reflect that care should be humanized, timely, and comprehensive (participant in the institutional framework of the World Café for people with disabilities); that is, it should be able to be reflected outside the healthcare infrastructure to meet the needs of the individual and his or her environment in other scenarios and contexts.
During the group interviews, it was also noticeable the interest of the institutional participants in highlighting the efforts of the District's entities to make care a sustainable and empathetic practice with others, which can be materialized through individual and collective actions, which shows the empirical relationship found from the interviews between well-being and care. In this context, according to their narrative, the provision of services should be oriented to promote comprehensive care and not be limited to social or work activities and should allow for different ways of relating to the community to achieve the state of well-being that they seek to guarantee.
Despite this, it should not be forgotten that well-being is influenced not only by the needs of the individual but also by those of the environments where population groups interact. This means that the provision of services to promote well-being, as perceived in the experiences of the community in the group interviews, cannot be mediated in an isolated manner in the space in which the individual lives and works, but that health plans and interventions must be unified in the different spaces so that the particularities conditioning the citizen are not a barrier to enjoying the well-being sought on a constant basis.
Based on the above, well-being can have an ambivalent connotation, being on an individual level but at the same time collective, according to the concordant findings between the theoretical phase (literature review) and the empirical phase (interviews). On the other hand, it is clear that the idea of well-being is similar to the concept of care, insofar as both seek to improve people's quality of life. Through the two methodological phases used in this research, a coincidence was found in the concept of well-being. It is important to highlight that the community narratives showed that certain aspects seem to be distant from health but are part of that well-being, such as socioeconomic, cultural, and environmental factors. What is interesting here—and perhaps one of the challenges of health models—is to understand these factors to promote well-being that includes interaction with other sectors to achieve the ideal of the citizen in everything that defines and conditions him or her and that would also act independently of the presence or absence of disease, promoting equitable well-being in society.
Finally, the strengths of this study are how the concept of well-being is constructed in a particular way for the context in which the research is conducted: performers including the healthcare system of the city of Bogotá. To analyze and take their feelings in the construction of this concept. However, a review of the literature was made to take more objective aspects into account in the construction of the concept. One of the limitations of this work is not having carried out a systematic review of the literature and not having had the opinion of some other important social performers in the qualitative phase.
Conclusions
In this article, the process of constructing the definition of the concept of well-being that is considered to respond to the dynamics implied by the context, as well as the institutional and community perspective, and the review of the literature, from the individual and collective perspectives, were proposed. A definition of well-being was proposed not only based on what is referred to in the scientific literature on the subject but also on the feelings of people in a specific context. It should be clarified that these are the people who work in the healthcare system and to whom the health actions of this health system in the city of Bogotá are directed.
Well-being is conceived as being influenced by the needs of the individual, in the environments where population groups interact. In the same way. well-being is evidenced closely to the concept of care, to the extent that both seek to improve people's quality of life. In addition, according to the analysis, socioeconomic, cultural. and environmental factors are included in well-being.
Funding
This strategy was developed within the framework of the Special Cooperation Agreement 3028486 of 2021, between the District Health Financial Fund-District Health Secretariat and the Pontificia Universidad Javeriana. Bogotá.
Conflict of interests
The authors of this article want to declare that they have no conflict of interest that could influence the objectivity and integrity of the findings and conclusions presented in this academic publication.
