Adolescents' Interpretation of the Concept of Wellness: A Qualitative Study.

Introduction: This study sought to explore and describe the interpretation which adolescents ascribe to the term wellness at a selected high school in the Western Cape Province of South Africa.
Methods: A qualitative research design was utilized. Nine focus-group discussions were conducted among 58 adolescents. Sample was selected purposefully and collected data was analyzed using open coding.
Results: Findings reflected adolescents' interpretations of the term wellness in the realm of holistic well-being transcending the nonexistence of illness or sickness in the body. The interpretations given include: healthy living which embrace eating enough nutritious foods, exercising regularly and being actively involved in physical activities; practicing self-care habits such as personal hygiene and grooming; well-being of the mind (psychological, emotional); having a balanced personality and interpersonal processes; being focused and goal directed and spiritual well-being.
Conclusion: It is imperative to consider adolescents' understandings of wellness when planning, designing, implementing and evaluating adolescent wellness programs.

Introduction

Wellness is a concept which emanated from the concept of holistic health and over the years, it has been conceptualized to mean different things by different authors. For instance, it has been described as an individual’s advancement towards enhancing the quality of his or her life, health, as well as psychological and social well-being in practical and positive ways.[1] Also wellness has been defined as involving the concurrent achievement of three categories of needs which are personal, collective and relational needs.

Personal needs have to do with the pursuance of meaning, self-determination, spirituality, and opportunities for growth. Collective needs include access to adequate health care, environmental protection, welfare policies and economic equality while relational needs entails maintaining strong relationships between persons and groups.[2] Likewise, the National Wellness institute defines wellness as: ‘an active process through which people become aware of and make choices toward, a more successful existence’.[3] A common denominator in all the above definitions presumes that wellness involves positive thought processes, social and environmental receptiveness as well as lifestyle behaviors.

While the terms wellness and health have sometimes been used as synonyms by some authors,[4,5] it is important to mention that wellness is a concept that is distinct from yet related to health which usually lays emphases on the presence or absence of illness in an individual.[6] This is evident in a frequently cited definition of health from the 1946 Constitution of the World Health Organization which declares that ‘health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’.[7] Even though wellness may be characterized by physical as well as psychological and social well-being,[8] it is clear that wellness is far from being a ‘state’ and rather involves the practice of specific constructive activities, habits or lifestyle.

Hence, wellness is not static but a dynamic process aimed at promoting overall well-being.[9] For example, a person may be practicing wellness even though the person may be exhibiting signs and symptoms of a chronic illness such as hypertension if the person eats healthy foods, exercises regularly and avoids unhealthy habits like excessive cigarette smoking and alcohol intake.

The majority of wellness models[10-13] describe the concept as a holistic and multidimensional concept encompassing the following dimensions: physical, social, mind (emotional, psychological) and spiritual parts which are interrelated and interacts in a synergistic and dynamic manner. Each of these dimensions is viewed as important and not a single dimension operates independently. In other words, the sum of these dimensions is neither greater nor smaller than but equal to the whole.

Adolescent wellness is an increasingly important area of concern for research. However, close analysis of existing literature yields very little information on the definition of wellness from the perspectives of adolescents; given the unique characteristics of the adolescent group. Furthermore, no previous qualitative study has explored the understanding of the concept of wellness among adolescents. The majority of the literature[6,14,15] focused on the measurement of wellness among adolescents.

Nevertheless, it is of necessity to know how the adolescent group understand and interpret wellness because their understanding of the concept during this period of their lives may affect their lifestyle choices which may later be carried on into adulthood. Importantly, a nuanced understanding of this term among adolescents is needed to apprise adolescent research, policy, and programmatic interventions that can improve the strategies and resources which adolescents make use of.

We base our exploration on the premise that adolescents are persons with abilities to contribute in a diversity of ways to their development and to society. Their views must be appreciated and they should be regarded as active and not passive members in the creation and determination of matters concerning their personal lives and of the societies in which they reside.[16] Hence, attention has to be given to adolescent’s own views about wellness.

Therefore, this study wanted to find out how adolescent learners at a high school interpret the concept of wellness in order to provide a holistic understanding and a more grounded direction for practice and policy in this area.

Materials and methods

This research study employed a qualitative and exploratory design. Qualitative design uses a flexible approach to understand and give meaning to the understandings of research participants. It also permits a thorough examination of a phenomenon through the gathering of rich narrative data,[17] while an exploratory research design is largely used in establishing new facts and gathering new information or ideas.[18]

The sample which consisted of fifty-eight (N=58) adolescents between the ages of 15 and 19 years attending a high school were selected through purposive sampling. Purposive sampling refers to the selection of respondents who will generate the necessary data to meet the objective of a study.[17] The high school is a co-educational public school for boys and girls.

Focus Group Discussions was used to collect data from the adolescents. A focus group discussion allows participants to freely express themselves and to clarify their own views. It also assists a researcher to get a broad range of views about a topic from the participants in a comfortable, permissive and non-threatening way. It is recommended that they should last no longer than 60 to 90 minutes.[19] Each FGD conducted in this research study consisted of 6 to 8 participants and did not last more than an hour per session.

Data was collected to the point of saturation, leading up to the total of Nine (9) FGDs that was conducted. Data saturation was detected during the interviewing process at the point that no new information was provided by participants.[20] Open coding technique was used in the analysis of the collected data after a transcription of the voice recordings and writing up of field notes was done.

The researcher was assisted by school staff (teachers) in identifying and contacting suitable potential participants in grade levels nine, ten and eleven. All the potential participants were invited to participate in the focus group discussions and were given an information sheet containing the purpose of the study, assurance of anonymity and confidentiality and an option to withdraw at any stage. Participants above the age of 18 years were required to sign a consent form while those below the age of 18 who were interested in participating were given letters seeking consent from either their parent(s) or guardian(s). They were requested to bring along a signed copy of the permission letter when attending a focus group discussion. In addition, they signed an assent form before they were allowed to participate in the discussions. Two focus group discussions were first conducted as a pilot test to assess whether the questions that were put to the participants were clear and well understood and to ensure that the questions generated the information that was required.[19] The discussions were facilitated by the corresponding author in a private room free from distraction on the school premises. The time scheduled for each of the focus group discussions did not interfere with the school activities of the participants.

The participants were grouped based on their grade level because it was anticipated that they would be more relaxed discussing issues with those in the same grade as they were. The researcher informed the participants that a voice recorder would be used to capture information shared and that field notes would be taken during the discussion. On the whole, three focus group were conducted in each of the grade levels (nine, ten and eleven) amounting to the total of nine focus groups conducted. The discussion guide used contained questions focused on their understanding or the meaning of the term wellness and their wellness experiences.

The research ethics committee of the University in the Western Cape, South Africa granted approval for the study. (Ethics committee No=13/9/39)

Results

Of the fifty-eight adolescents, twenty-nine of them were seventeen years old, twenty-one were sixteen years old, four were fifteen years old, three were eighteen years old and only one of them was nineteen years old. The average age of the participants was 16.6 years. Thirty-five were females and the remaining twenty-three were males. Twenty-one of the participants were grade eleven learners, followed by nineteen grade nine learners and eighteen grade ten learners.

The adolescents gave their various interpretations of the term to encompass healthy living, not necessarily a lack of sickness / illness, caring for oneself physically, mind (psychological, emotional) and spiritual well-being and possessing a healthy personality.

1. Healthy living

In this study, the adolescents were of the view that wellness required the participation of an individual in a healthy lifestyle. For instance, one 16-year-old female participant stated that in her opinion, wellness meant living a well-adjusted life that included eating healthy food, exercising and avoiding a stressful life:

‘I think that wellness is having a balanced life. Like maybe doing exercises, eating healthy and relaxing. Not stressing. It does not matter if things do not go your way (pause). That is wellness’.

Similarly, another participant (17-year-old male) stated that wellness entailed a lifestyle that was not associated with drug and alcohol abuse:

‘Not to use drugs and … alcohol. These things destroy your body and can kill you. You got to live right and you will be healthy, you see’.

2. Not necessarily a lack of sickness / illness

In their discussions, some of the adolescents affirmed that wellness further included the absence of disease or illness in the body and the ability of the human body to fight diseases through a properly functioning immune system, some believed that it transcended the presence of illness in the body. As an illustration, one 17-year-old female participant stated:

‘It is when you do not have any sicknesses and you are living a healthy life and you have got a strong immune system. It is when you are healthy’.

Nonetheless, some adolescents accurately identified that wellness did not only imply the mere absence of disease and infirmities in the body, as one 15-year-old female participant said:

‘I think that it does not only mean when you do not have illness, because you can be sick and you still have wellness because you look good, you feel good and stuffs [sic] like that… you know, it is when you have [a] focus in life’.

Similarly, another adolescent participant (16-year-old male) stated:

‘It is not just about having no sickness in your body because it is also about respecting other people and appreciating that other people have something you don’t have and not being jealous of what the other person has’.

3.Caring for oneself physically

There was a general agreement among the participants that wellness also included the practice of self-care activities; such as bathing, feeding, wearing clean apparels and generally caring for the physical appearance. A female participant who was 17 years old emphasized (‘was adamant’ from field notes) that wellness involved a person practicing personal hygiene:

‘It is also about how you look and care for yourself. How you wash yourself, the clothes that you wear. To be well, you do not have to wear dirty clothes and shoes. You have to take care of your body every day’.

Likewise, a 17-year-old male participant reflected that wellness generally meant taking care of one’s body (smiling and making gestures with his hands):

‘It is how you look after your body; TLC [tender loving care]. How you eat healthy and how you exercise’.

They also indicated that in assessing an individual’s state of wellness, they would consider the outward physical appearance of the person in order to make up their minds about the state of that person’s wellness. For instance, a 17-year-old male participant specified that the initial thing he would do while assessing an individual’s state of wellness would be for him to assess the individual’s physical appearance:

‘For me, if I want to judge wellness, I will first of all look at the physical appearance to see if the person is clean or otherwise [sic]. That is what I will first look at. Your clothes that you put on and your shoes must be okay and you have to be neat and tidy’.

A 17-year-old female participant also revealed:

‘It means you look after your body and you are clean and neat. You take care of your body and you do not wear dirty clothes. People will look at you when you are not clean and they will say that you are not alright’.

4. Mind (emotional, psychological) and spiritual well-being

The participants in this study conceptualized emotional, psychological and spiritual well-being as an essential part of wellness. A 16-year-old female participant said that wellness had to do with an individual who is resilient and optimistic about whatever situation he or she was in:

‘You got to be strong and positive and think right things in your head and not stress about a thing’.

Another 17-year-old female commented that spiritual well-being was part of endurance and even when a person was going through difficulties, one still needed to remain positive and spiritual (prayerful) in order for one to handle the difficult situation:

‘Like when you are going through a tough time, you must be able to withstand the situation, to be strong, to give yourself encouragement. Like when you are going through tough situations and knowing that you are going to be okay. Being spiritually strong is necessary because I know with God, things happen for a reason and with God you can handle it. You can always bow down on your knees and talk to him and he will give you help.’

Furthermore, the participants in this study perceived wellness as displaying a balance between the physical, emotional (mind) and spiritual spheres of life. This perspective was evident when one 17-year-old female said that the physical and the emotional aspects were inseparable:

‘I personally think wellness is your physical health, your emotional health, because it all binds in one. That is what I think’.

These assertions are noteworthy because it shows that the adolescent participants have a holistic view of wellness.

5. Healthy personality

It was clear that the adolescents in this study understood the dimensions of a healthy personality and they related it to wellness.

They reflected that wellness was expressed as an understanding, acceptance and respect of oneself and the ability to relate well with other people. For instance, a 16-year-old male participant indicated:

‘…Wellness means that you know yourself, you respect yourself and you are proud of the things that you can do’.

For the adolescents who participated in this study, maintaining healthy, nonthreatening relationships with their peers was seen to be important and bullying was regarded as an undesirable characteristic.

Discussion

The purpose of the present study was to explore and describe the interpretation which adolescents ascribe to the term wellness. The findings showed that the adolescents were well-informed about wellness and gave their interpretations in terms of holistic well-being incorporating healthy living, not necessarily a lack of sickness / illness, caring for oneself physically, mind (psychological, emotional) and spiritual well-being and having a healthy personality.

Healthy living is the practice of health-enhancing behaviour such as eating healthy diets, being physically active, keeping a healthy weight and maintaining personal safety and mental well-being.[21] In this study, the adolescents were of the view that wellness required the participation of an individual in a healthy lifestyle. There are so many benefits attributed to living a healthy lifestyle. For instance, healthy living decreases the risk of diseases, such as cardiovascular diseases and diabetes. It also improves the general quality of life and impacts on the holistic health and well-being of a person.[21] It is valuable to practice healthy living early in life because during adolescence, young people are known to experiment with risky and unhealthy habits, such as smoking of cigarettes and drinking of alcohol.[22] Thus, encouraging young people to establish a healthy lifestyle is advantageous because habits learnt during the adolescence tend to stay for a lifetime.

Disease or illness has conventionally been defined as physical symptoms or problems caused by the presence of infectious or disease processes in the human body.[23] Even though in their discussions, some of the adolescents affirmed that wellness further included the absence of disease or illness in the body and the ability of the human body to fight diseases through a properly functioning immune system, some believed that it transcended the presence of illness in the body. This perception that wellness does not simply mean the absence of sickness in the body is remarkable because it shows that the participants indeed possess a holistic understanding of the concept of wellness described by different wellness models.

Self-care refers to the actions that persons initiate and execute on their own behalf in preserving life health.[24] It is also referred to as activities of daily living (ADLs). Basic self-care activities include feeding oneself, bathing or showering, wearing clean clothes, toileting, personal hygiene and grooming.[25] There was a general agreement among the adolescents that wellness also included the practice of self-care activities; such as bathing, feeding, wearing clean apparels and generally caring for the physical appearance. They also indicated that in assessing an individual’s state of wellness, they would consider the outward physical appearance of the person in order to make up their minds about the state of that person’s wellness. It may be that these participants placed emphasis on the physical appearance of an individual because as young people, there is a strong desire to be acceptance and to be found appealing to others especially when it concerns the opposite sex. It is clear that in assessing wellness, an individual’s physical appearance is viewed as important. It is one of the fundamentals of practicing a wellness lifestyle and should not be overlooked or disregarded. The advantages of individuals engaging in self-care practices have been well documented and includes reduced stress levels increased sense of well-being and life satisfaction, improved health status, quality of life and better health outcomes.[26]

Emotional well-being is defined as the experience of awareness, security, the control of feelings and having a realistic and positive outlook on life and the future. It also includes the ability of a person to make a realistic assessment of his or her limitations, as well as being able to independently cope with stress.[5]

Psychological well-being includes having a focus in life, autonomy, self-acceptance, personal growth and development and experiencing and sharing positive associations with people.[27] Emotional and psychological well-being are closely related to the mental domain. Volition as part of the mental domain is associated with logical reasoning and appropriate thought processes. Spiritual well-being, refers to an individual’s awareness and connection with a being or force that is transcendent that gives a deep sense of wholeness; it also includes the values, principles and attitudes of the person.[28]

Spirituality does not necessarily express itself through religion, which is the devotion to the values, beliefs and doctrine of a community.[29]

The adolescents in this study conceptualised spiritual well-being as an essential part of wellness. This illustrates that spirituality could be viewed as a fundamental component of wellness among young people. Similar findings have been reported in other studies[28-30] that show that adolescents are spiritual and they tap into their religious belief system when confronted with critical life situations in a way that is similar to adults. Spirituality assists young people with mitigating negative circumstances while it supports the healing process. For instance, a qualitative study by Pérez, Little and Henrich conducted among school-based adolescents experiencing depression reports that spirituality is an important factor in coping with depressive symptoms.[31] They perceived wellness as displaying a balance between the physical, emotional (mind) and spiritual spheres of life These assertions are noteworthy because it shows that the adolescent participants have a holistic view of wellness.

A healthy personality is defined as an individual having the ability to function well as a person, having sufficient knowledge of the self and self-acceptance, being able to cope with and manage the challenges of life, having people skills, as well as possessing a realistic perception and acceptance of reality.[32] It was clear that the adolescents in this study understood the dimensions of a healthy personality and they related it to wellness.

They reflected that wellness was expressed as an understanding, acceptance and respect of oneself and the ability to relate well with other people. For them, maintaining healthy, nonthreatening relationships with their peers was seen to be important and bullying was regarded as an undesirable characteristic. This finding confirms the report of Burton and Leoschut that learners at secondary schools in South Africa experience bullying from their peers while they are at school and as a result of the bullying, they were traumatized.[33]

Bullying comprises one or more people singling out and deliberately and repeatedly hurting or harming physically or mentally. Reasons reported to be responsible for young people engaging in bullying include personality problems, inability to deal with feelings, history of bullying at home, seeking attention and wanting to feel important in order to develop the healthy personalities they desperately seek.[34]

Professionals such as health care providers, teachers and counsellors need to create a supportive environment where adolescents are equipped to make choices towards practicing a wellness lifestyle.[35]

Conclusion

Targeting adolescents early with wellness information particularly in schools has many potential benefits. Not only will it help them to consciously engage in practicing a wellness lifestyle early during adolescence, it will help to prevent the practice of unhealthy habits later on in adulthood. Also, it is imperative to consider adolescents’ understandings of wellness when planning, designing, implementing and evaluating adolescent wellness programs.

Acknowledgments

Special thanks to the adolescents who participated in this study for sharing their experiences. We would also like to express our appreciation for the support of staff members at Emil Weder High School, Genadendal in the Theewaterskloof Municipality, Overberg District of the Western Cape Province, South Africa.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study‏.