Meaning of well-being among Iranian women: A phenomenological descriptive approach.

BACKGROUND: Well-being is a subjective concept and means different things to various people. Most of the research investigating the experience has concentrated on its problematic and pathological aspects. The aim of this research was to enhance the understanding of the contextual meaning of well-being based on personal life experiences of the participants. This will be of help to experts in the field of health for monitoring, diagnosis, nursing, treatment, and rehabilitation.
MATERIALS AND METHODS: This research was conducted by utilizing the Husserlian approach which involves direct exploration analysis and the description of a particular phenomenon. Data were collected by conducting unstructured, in-depth interviews of 20 Iranian young and middle-aged women. Analysis was conducted using the Colaizzi's methodology.
RESULTS: The general meaning of the phenomenon, well-being, is understood as having the feeling of peace in life by the participants in this study. Well-being was identified by six major themes, including enjoying and being satisfied with life, the feeling of belonging together (or relating to others), the feeling of being healthy, the feeling of a relationship with God, to be able to afford what one needs to buy, and life as a whole (interconnection between different aspects of a person's life).
CONCLUSIONS: Well-being as a feeling of peace in life can originate from both hedonic and eudemonic perspectives. A person's state of satisfaction in different aspects of her life can lead to the experience of well-being. All these aspects should be taken into account when health practitioners plan to promote the state of well-being among people.

INTRODUCTION

Women's health is the keystone of family and society's health. Women's problems could adversely affect physical health and, in particular, mental health of the family, society, and future generations.[1] In most countries, women live longer than men; they constitute half of the world's population, but they are generally less healthy. The American Academic of Nursing's 1996 Expert Panel on Women's Health says that women's health includes their entire life span and involves health promotion, maintenance, and restoration, and is related to biological, social, and cultural dimensions of women's lives as well.[2] Well-being is gaining increasing attention, both in the scientific literature literature and policy-oriented analysis.[3] Well-being is the most commonly used word in philosophy, usually related to health. In the nursing discipline, well-being is an important phenomenon for concern.[4] Well-being means different things to different people. For some, financial well-being is most important; for others, physically being well, and still others desire well-being in relationships and family affairs. Various kinds of freedom are important for well-being, such as freedom from fear, worry, and anger, as well as freedom to pursue one's dreams and mission in life.[5] Well-being, as defined by Naess and colleagues, includes the ability to be active, have good interpersonal relationships together with self-esteem as well as rich and intense aesthetic experiences.[6] Being active means having a zest for life, being involved in something outside one's own world, and having control over one's actions. The meaning of good relationships is closeness, friendship, and feelings of identity with a group. Self-esteem emphasizes the ability to cope and feel satisfied with one's own efforts, while the aesthetic aspects are associated with being open and receptive.[6]

Well-being has been defined as “the state of being comfortable, healthy, or happy.”[7] The absence of anxiety, restlessness, and depression, as well as having a basic mood of happiness are also indicative of well-being.[6] This brief explanation indicates that well-being is complex and includes various aspects of human life. The concept of well-being has been discussed and defined from different perspectives. It has commonly been defined as both health and Quality of Life (QoL).[8] The effort to understand well-being and its causes is not new, but it is an issue that has attracted attention throughout history.[9] Literature on well-being is relatively scant when compared with the wealth of literature on disease, disability, and disorders, and a considerable body of these studies has focused on empirical methodology of research to capture subjective well-being.[10] Two major problems found in the research on well-being were the lack of a clear definition of the term at the start and the lack of consistency in the methods used for measuring the phenomenon.[4] In view of the difficulty involved in capturing its substantial content, the existence of the concept of well-being in health care promotion has been questioned.[11] However, according to Sarvimaki, the concept of well-being may be perceived as both a unifying concept and characteristic of health and QoL.[8] In the same article, the author argued that although well-being is a holistic concept, it can still be conceptualized in empirical research as, for example, physical, psychological, social, and spiritual, but it must be viewed as a whole on a philosophical level in order to achieve a deeper understanding.[8] Contemporary research on well-being has increasingly recognized the importance of differentiating between hedonic and eudaimonic perspectives on well-being. From a hedonic perspective, well-being is equated with pleasure. Alternatively, the eudaimonic perspective views well-being as the cultivation of personal strengths, living virtuously, and contributing to the greater good.[12] Research on well-being is classified into three perspectives including objective, subjective, and mixed approaches, of which the subjective approach provides an in-depth study of the phenomenon.[13] In Iran, the majority of studies on women's well-being have applied quantitative methodology that have discussed some of the contributing factors such as health condition, demographic variables,[14] and fertility.[15] There are limited qualitative researches focusing on women's well-being as a unique phenomenon in the country. Research structured by the insights of phenomenology is a significant venture for theory and practice.[16] Therefore, the aim of the present study was to enhance understanding of the contextual meaning of well-being based on personal life experiences of the participants with a phenomenological approach. This will be of help to experts in the field of health for monitoring, diagnosis, nursing, treatment, and rehabilitation of the persons who of persons who of persons who need to be promoted in their state of well-being.

MATERIALS AND METHODS

The research was conducted by the Husserlian approach which involves the “direct exploration, analysis, and description of a particular phenomenon.” With descriptive phenomenology (i.e. Husserlian inspired), researchers aim to reveal the essential general meaning structures of a phenomenon.[17] This descriptive phenomenology study used in-depth interviews to examine Iranian women's experiences.

Participants

Twenty Iranian Muslim women from Tehran city were recruited into the study by purposive sampling. The inclusion criteria were: Being able to converse fluently in Persian language, and women aged 20 years or older who lived with their parents. The study participants were selected from those women who referred to the House Health Regions 1 and 5 of Tehran Municipality.

Data collection

Phenomenological interviews were conducted with Iranian women who were 20 years or older, on separate occasions between May 2009 and July 2009. The researchers tried to approach the informants in an open and sensitive manner, took nothing for granted, and sought clarification by posing additional questions. The interviews began with an overall question about the informants’ experiences of their present life situation. In phenomenology, the present time includes both the past and the future, thus the informants could tell their unique stories in the way they wanted and remember things with the help of open-ended and broad questions.

Participants engaged in phenomenological interviews, lasting between 60 and 120 min, focusing on their lived experience of good health and well-being. A range of specific techniques were used to elicit information, including use of initial open-ended and trigger questions, followed by probing, specific, and interpreting questions. These interviews were audio-taped and transcribed verbatim.

Data analysis

Data analysis was undertaken using Colaizzi's seven-step approach[18] that was modified by Moustakas.[19] The outline of the seven-step approach to analyze the phenomenon of well-being is as follows: transcribe all the participants’ descriptions, extract significant statements or phrases, create formulated meanings or meaning units, aggregate formulated meanings into theme(s), write and incorporate the result into rich and exhaustive descriptions, identify the fundamental structure of the concept, and return to subjects for validation.[18]

Ethical considerations

All ethical considerations were addressed to the satisfaction of the relevant Human Research Ethics Committee of University of Social Welfare and Rehabilitation Sciences in Tehran, including informed consent and confidentiality. All participants were provided with full explanation about the research and its aims. Written informed consent was obtained from the participants before they participated in this study. The code numbers are being used to protect participants’ identities.

Validity and rigor

Credibility and transferability were confirmed by five women participants and the first three authors of this study. They validated interpretation of the findings and verified the accuracy of the interview transcriptions, and derived themes. Trustworthiness was established with an experienced qualitative researcher by auditability and random check of the interviews for similar codes, meaning units, and themes.

RESULTS

The number of women who were recruited by purposive sampling in the study was 20 with an age range from 20 to 45 years. The demographic characteristics of the participants are presented in Table 1.

Table 1

Demographic characteristics of the participants (N=20)

The general meaning of well-being is stated as “the feeling of peace,” a state or situation in which a person can feel having a peaceful life. This means a situation or state in which the person feels happy, pleasant, and peaceful without being anxious. As participant number 1 said:

“The general meaning of well-being is peace. If you have this peaceful situation, you can claim that you have well-being. When you are fine in all aspects of your life, you are relaxed in all aspects, then you can claim that you are OK.”

Six major themes were identified from the interviews. These included enjoying and being satisfied with life, the feeling of belonging together (or relating to others), the feeling of being healthy, the feeling of a relationship with God, to be able to afford what one needs to buy, and life as a whole (interconnection between different aspects of a person's life).

Theme 1: Enjoying and being satisfied with life

One of the most important themes describing the participants’ well-being is having the feeling of enjoying and being satisfied with all aspects of their lives. According to the participants, one's experiences of having these kinds of feelings are vital to the experience of well-being. As it has been mentioned by them, health (physical, social, and psychological), different crises in life, peace, and security in the society can make people feel whether or not they enjoy well-being in their lives. Therefore, being qualified and satisfied in these aspects, as they mentioned, can lead them to enjoy their lives, which, in turn, can result in having the feeling of well-being. The reason why a person cannot enjoy or be satisfied might be different. So many reasons can lead to that, but whatever the reason would be, it is not our focus to understand the meaning of well-being. The important thing is that whenever a person enjoys his/her life, this feeling brings a sense of well-being and happiness together for him/her, as participant number 2 stated:

“… Then if I can’t enjoy my life for any reason, I will lose my well-being, health and happiness.

…As mentioned before, there are many reasons that make persons not enjoy their lives, for example, getting ill and physical problems”

When a person feels being satisfied with all aspects of his/her life, then he/she feels happy and this feeling can bring along well-being for him/her, as participant number 3 perceived and described this life satisfaction so clearly as below:

“When you are fine in all aspects of your life, you are relaxed in all aspects, then you can claim that you are OK.”

The participants concluded that this satisfaction should be felt and fulfilled in all aspects of a person's life including physical and psychological health, partner relationships, familial relationships, social relationships, work, financial status, and life as a whole. Therefore, when a person feels satisfied in different aspects of his/her life, he/she feels relaxed, happy, and pleasant so that the person feels he/she is having a peaceful life, which can certainly bring along the feeling of well-being.

Theme 2: Feeling of belonging together

Participants perceived an important experience as they pointed out, which is “contact with other people” or “being together with other people” that gives one a “feeling of belonging together.” They emphasized that their well-being has a close connection to their relationships with others such as spouse, children, family, the people who are close to them, and also the people at their work place (such as clients, colleagues, etc.).

It can be concluded that a person lives in a social network system which can affect his/her well-being. So, this person–environment interaction can determine how the person feels having well-being effectively, as participant numbers 4 (P. 4) and 8 (P. 8) mentioned:

(P. 4): “For being healthy, one's spouse can certainly be a determining factor in having a peaceful life. I have an intimate and warm relationship with my husband, his family and my family. This can make me feel confident, secure and relaxed so that there are people who help and support us intimately and eagerly when we need their help.”

(P. 8): “This is an undeniable fact that the people live in relation to each other and their society.”

It is apparent that one's well-being can influence the whole family's well-being, as it is quite clear in this sentence that was expressed by participant number 5:

“When I am happy, I have a good communication with my family, the family outcome improves and finally my kids do their tasks efficiently.”

Sometimes this can be extended to a larger group of people such as clients or colleagues at the work place and they can have an effect on how he/she feels psychologically; for instance, participant number 6 remarked:

“I do feel happy when my clients (patients) feel happy, and I do feel sad when they feel sad.”

It can be understood how deeply this social network system can influence on a person's well-being and everyone has his/her own role in this interconnected system, as participant number 7 describes this interrelated social network system as follows:

“The important issues are my family's health (my family's health including mother, father, sister, brother, spouse,…), having good relationships among them all, having warm relationships among them all and between me and my husband's family as well as my husband and my family. The important thing here is having warm relationships.”

Therefore, it can certainly be meaningful for participants to have a feeling of well-being when they are in good relationship with others and feel a sense of belonging to each other.

Theme 3: Feeling of being healthy

It is understood from the participants’ statements that having problems with their health and their special experiences in this case can make them not having a feeling of well-being. However, it is not the only reason to feel like this. Physical and psychological disorders affect a person's health negatively. It was mentioned by the participants that good health can effectively make them have a feeling of well-being and all aspects of health are important, such as physical, psychological, and social. This health is not just limited to them (participants). It means that not only their health is very important to have a feeling of well-being, but also their family's health would be absolutely essential for them to feel like that and, in some cases, the latter seems to be more important to them rather than their own health to have a feeling of well-being. It is evident in the following statements made by participant number 9:

“The most important factor affecting my well-being is to be healthy and my family's health is prior to mine to feel having well-being.

I feel having well-being when I’m fine; that means I am OK in physical, spiritual, and psychological aspects of my life.”

Body has been considered as an important focal point by the participants. So, illnesses and physical problems are given high priority. They found “physical health” as the most important factor influencing the well-being, as it was declared by participant number 11 as follows:

“Physical health is the first and the most important effective factor on well-being.

In my experience, I suppose physical illness is worse than psychological illness.”

They also found a mutual relationship between physical and psychological health that affects a person's well-being, which was apparent in the expression of participant number 11:

“Disorders and physical problems can affect a person's health both physically and psychologically. This can lead to decrease of pleasure in a person's life.”

Although it cannot be claimed that well-being can be limited to a person's health in different aspects, it (well-being) can be certainly influenced by health, since being healthy is a very important state to have a feeling of well-being (according to the participants’ expressions). When a person is ill, he/she cannot enjoy and feel satisfied physically, emotionally, psychologically, and generally. So, his/her peaceful life can be affected and the person might consequently lose his/her well-being because of this dissatisfaction.

Theme 4: Feeling of a relationship with God

Spiritual and religious beliefs, as it has been called here as “the feeling of a relationship with God,” seem to be a powerful means to have a feeling of well-being among the participants. On reading the interviews it is clear that this feeling (relationship with God) can help a person feel more relaxed and comfortable, and be able to continue life, have a meaningful life, have good feelings, being protected from hazards and being safe. It can finally empower him/her with the ability to live. In that process, the person can re-establish a good relationship with their world by which they can feel relaxed and peaceful. The following sentence was said by participant number 12 in this issue:

“The feeling of connection to God as a higher power makes me feel relaxed and having well-being.”

As it has been understood, this kind of belief can help the person cope with stress and problems in order to adjust to her/his world. According to the statements of participant numbers 13 (P. 13) and 14 (P. 14), spiritual beliefs can be helpful to improve their well-being:

(P. 13): “The feeling of a relationship with God makes my life meaningful.”

(P. 14): “Spiritual beliefs can help the person improve his/her well-being.”

The “sense of relationship with God” helps them feel more satisfied of their own lives since they find their satisfaction in God. The relationship with God as a higher being gives a special meaning to their lives and relates them to beyond the world. Participant number 15 said:

“I hope the Lord helps and blesses me; this (situation that I have now) is also an exam for me.”

Theme 5: To be able to afford

Financial welfare, as has been mentioned by the participants, is another quality that describes their well-being since it can help them fulfill their reasonable needs. Although higher financial status cannot sometimes make the individual feel satisfied completely in his/her whole life, it can provide a situation in which their needs can be fulfilled. However, people's economical needs are totally different since it is absolutely a relative item among different groups of people. On the other hand, when a person feels that he/she has a good financial status, this can lead them to have better social welfare in which not only the person's needs can be fulfilled, but also he/she can have more joy and satisfaction compared with those who cannot afford their daily living expenses. Therefore, social welfare can help them both meet their needs and enjoy their lives; in these two ways, they seem to experience a feeling of well-being, as participant number 16 stated:

“Financial welfare is very important. It is important so that can meet reasonable needs not unreasonable ones. That means if one could not have leisure, travel or do shopping what he/she likes, the person would feel unpleasant and would lose her/his psychological health.”

Theme 6: Life as a whole (interconnection between different aspects of the person's life)

It has been pointed out by the participants that there is an interconnection between different aspects of a person's life, so that they all are very important to have a feeling of well-being. The important point here is that all these aspects can influence each other because they are interrelated and can influence each other effectively. As a result, what can make a person to have a feeling of well-being might be “to feel satisfied with all of these aspects” or in other words in their “life as a whole.” It has been perceived and described by participant numbers 17-20 (P. 17-P. 20) clearly:

(P. 17): “When you are fine in all aspects of your life, you are relaxed in all aspects, then you can claim that you are OK.”

(P. 18): “All these mentioned aspects are interrelated. There is interconnection between them all. All of them are pre-requisites and essential to have your health; that means these factors have to be fine to provide your health.”

(P. 19): “All effective factors to make me satisfied and pleasant in my life are interrelated and should be considered together.”

(P. 20): “All these factors (person's own health, her family's health, familial relationships, partner relationships, social relationships, work) can determine a person's physical and psychological health and finally her/his peaceful life.”

DISCUSSION

The purpose of this study was to improve the understanding of the contextual meaning of well-being based on the life experiences of participants. The results of the present study showed that enjoying and being satisfied with life is the participants’ most important aspect of their well-being. Some investigators measure well-being as simply feeling of being satisfied in life.[20] Satisfaction in life is subjective, overall assessment of feelings about life as a whole.[21] From a subjective perspective, well-being has two components; the first perspective which is called hedonism defines well-being as the presence of positive effect with the net pleasures and absence of negative affect. From this perspective, subjective well-being usually includes two elements, namely, affective balance and, secondly, perceived life satisfaction, which is more stable and has greater cognitive component with a global judgment on life itself.[9] Congruent with our findings, Khupantavee and colleagues in their phenomenological study reported that participants in their study stated that being satisfied with their condition is important to their personal attitude in order to achieve well-being.[4]

Feeling of belonging together was another component of well-being which was expressed by the participants. The desire for social bonds and connections with others has a long history in psychological research. It has been referred to as the need for affection between people, the need for positive regard from others, belongingness, affiliation motivation, and the need for relatedness.[22] The sense of belonging assists in improving self-worth and to move toward autonomy.[20] Parvizi and her colleagues’ qualitative research finding suggests that having a successful marital relationship is an antecedent for women's health.[23] Young and her colleagues in their longitudinal study suggested that there was an association between better sense of belonging to a neighborhood and improved physical and mental health, lower stress, better social support, and being physically active.[24]

The participants stated that the feeling of being healthy is essential to the well-being. According to Merleau-Ponty, “The body defines one's world. Therefore, problems perceived by people regarding their body and health can certainly be meaningful to experience their lived world.”[25] But the ethical theory, eudemonistic health or self-actualization and the attainment of one's greatest human potential, maintains that eudaimonia or happiness is reached through virtue.[2] The classic definition of health given by the World Health Organization as “a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity” reflects a holistic perspective.[23] In the field of QoL, health is identified “as being physically fit, not sick, and without pain and disability.” The people may be in poor health, but are still able to adapt to their conditions and find happiness and satisfaction in life.[26] In order to reach a state of complete physical, mental, and social well-being, an individual or a group should able to identify and realize the aspirations, satisfy their needs, and change or cope with their environment. Health is, therefore, seen as a resource for everyday life, not the objective of living.[9]

Feeling a relationship with God was another articulated element by the participants. After decades of empirical research, there is substantial evidence that religion and spirituality are strongly associated with mental health and psychological well-being. It is widely assumed that relationship with God plays a positive role in providing a sense of identity, a network of social support, and a coherent framework for responding to existential questions. It can help cope with negative life events or chronic illnesses, and leads to a sense of shared understanding of a loss or a trauma.[27] Relationship with God and spiritual beliefs assist the individuals achieve a sense of well-being which has been described as spiritual well-being in the literature. Spiritual well-being is a multidimensional factor which includes a vertical and a horizontal dimension. The vertical dimension refers to the relation with God and the horizontal dimension refers to the feeling of having a goal in life and life satisfaction without considering a special religion. Spiritual well-being also includes a social (existential well-being) and a religious (religious well-being) element. Religious well-being indicates having relation with a superior power, i.e. God. Existential well-being indicates a person's feeling of who is he/she, what does he/she do, and why and where does he/she depend on. Both religious well-being and existential well-being make a person move beyond his/her self and find harmony in life. Individuals having an active spiritual life are healthy people mentally. These people are inclined to see themselves lovely, skillful, and competent, and can find God, so that it guides them in their lives, makes them happy, and supports them when they need it.[28] One approach to increase the well-being is to pay more attention to spiritual development and healing.[29] The findings indicate that there is also a positive correlation between spiritual well-being and general QoL.[30]

Being able to buy what is needed was found to contribute to the feeling of well-being, as remarked by the participants. According to Maslow's Hierarchy of Needs, this is quite understandable since when the person's needs can be met in different levels, he/she can feel relaxed and secure enough to pursue his/her desires in higher levels.[31] Although higher financial status cannot sometimes make the individual feel satisfied completely in his/her whole life, it can provide a situation in which the individual's needs can be fulfilled. However, people's economical needs are totally different since it is absolutely a relative item among different groups of people. A substantial body of research suggests that women living in poor socio-economic circumstances have more health problems than those living in better conditions. In addition, studies show that a poor socio-economic situation is not only responsible for the occurrence of ill health, but also determines how severe it will become.[32] Compatible with our findings, Khupantavee and colleagues in their phenomenological study described a person's ability to take financial care, particularly in having an occupation and/or enough money to support certain basic needs such as food, clothing, housing, transportation, and supporting the family (livelihood), influenced the meaning of the well-being experienced by the research participants.[4] In another qualitative research, the Iranian women stated that economical problems and inappropriate occupation are the main barriers for their health and well-being.[1]

Life as a whole was notified by the women participants as another feature of well-being. It can be concluded that if a person can feel satisfaction in different aspects of her/his life such as personal, social, economical, familial, spiritual, health (physical and psychological), and finally life as a whole (whole life), she/he might have a feeling of well-being in the broad context of QoL. A holistic construct that views human health and well-being within the contexts of proximal and distal environments is QoL. It combines the elements of broad societal indicators with the actual lived experience of people.[33] The World Health Organization defines QoL as “the individuals’ 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.”[34]

As it has been understood, well-being can be defined as a state of having the feeling of peace in life. This feeling can originate from both hedonic and eudemonic perspectives. The basic idea in hedonic perspective in which the objective of life is to experience the greatest possible amount of pleasure (also oriented toward enjoyment and noble activities). Happiness would be, in some sense, the sum of pleasurable moments,[9] which means that a situation or state (well-being) in which the person feels happy, pleasant, and peaceful without being anxious. On the other hand, eudemonic perspective represents a perspective in which well-being lies in the performance of action coherent with deep values that imply a full commitment with which people feel alive and real.[9] Defined as a fundamental cognitive representation of the nature of well-being, participants’ conceptions of well-being have been found to include both hedonic and eudemonic dimensions. There are stable differences between individuals in the degree to which hedonic and eudemonic dimensions are emphasized in the persons’ conceptions of well-being.[12]

CONCLUSION

This final result seems to be important and applicable for experts in the field of health for monitoring, diagnosis, nursing, treatment, and rehabilitation. They should look at “individuals’ well-being” as a holistic and comprehensive concept, which can be influenced by so many aspects of a person's life, not just one special clear angle. Therefore, all these aspects should be taken into account when they plan to promote the state of well-being among people. However, this whole concept, including all the constituents, i.e. enjoying and being satisfied with life, the feeling of belonging together, the feeling of being healthy, the feeling of a relationship with God, to be able to afford what one needs to buy, and life as a whole, can make just one essential meaning which is characterized by having the feeling of peace in life – a state or situation in which the person feels happy, pleasant, and having a peaceful life.