Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 7-Day Trial for You or Your Team.

Learn More →

Exploring subjective constructions of health in China: a Q-methodological investigation

Exploring subjective constructions of health in China: a Q-methodological investigation Background: With an increasing awareness of people’s satisfaction and feeling, health-related quality of life (HRQoL) has become an essential aspect of measuring health. HRQoL is fundamentally a foreign concept introduced to China from the West. While a growing number of studies applied western HRQoL measures, few content validity tests examined the legitimacy of applying Western developed HRQoL measures in a Chinese cultural setting. If there are distinct differences in health conceptualisation between China and the West, it can be argued that those western measures may fail to ask the most appropriate and important questions among a Chinese population in assessing health. As a limited number of studies have investigated Chinese people’s understandings of health, this study aimed to explore how health is defined and described in China. Methods: A Q-methodological study was conducted to explore subjective constructions of health among Chinese participants. A scoping review of Chinese generic HRQoL measures, supplemented by a series of qualitative interviews conducted in China, produced a list of 42 statements representing aspects of health considered as being important in a Chinese cultural setting. Chinese participants in face-to-face interviews ranked and sorted these statements. Data were analysed to identify clusters of participants who shared a similar perspective, using a by- person factor analysis procedure. Results: 110 Chinese participants with various demographics characteristics completed sorting interviews. Five independent factors emerged: (I) “Physical independence and social interaction skills”; (II) “Physical health”; (III) “Sensations and feelings”; (IV) “Lifestyles”; (V) “Learning and working abilities”. Conclusions: The Q-study showed that many health statements were rated highly as most important by a diverse range of Chinese participants but were not covered in the commonly used Western HRQoL measure EQ-5D. It then suggests that the EQ-5D descriptive system might need modification to improve its capacity to measure health status in China. The study thus raises a general question as to how appropriate the Western-developed HRQoL measures are when used to assess health in a significantly different cultural setting. Keywords: Health-related quality of life, Health, Cultural differences, China, Q-methodology, Qualitative study * Correspondence: [email protected] Leeds Institute of Health Sciences, University of Leeds, Leeds, UK Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 2 of 15 Introduction Methods With an increasing awareness of people’s satisfaction Design and feeling, health-related quality of life (HRQoL) has The study was reviewed and approved by the School of become an essential aspect of measuring health [1, 2]. Medicine Research Ethics Committee at the University Most of the commonly used HRQoL questionnaires have of Leeds (reference number: MREC17–021). been developed in Europe or North America, with their A Q methodological study was used to fulfil the study descriptive systems being subsequently translated into objective. Q methodology was introduced by William other languages to be used worldwide. Although a grow- Stephenson in 1935 as a way to scientifically assess sub- ing number of studies use western HRQoL measures, jective viewpoints [26, 27]. It is an effective approach for few studies have considered cultural differences in con- combining both qualitative and quantitative techniques ceptual equivalence [3–5], while those assessing cross- to observe individuals’ personal opinions and identify cultural equivalence normally focus on statistical psy- patterns of views across a participant group [28, 29]. It chometric properties [5]. has been used in various health-related studies to inves- Taking the use of EQ-5D in China as an example, the tigate concepts of QoL, experiences of pain and under- Chinese versions of EQ-5D have been widely used in standings of illnesses [30–32]. It has been used in China, including general population and patient-specific Chinese populations in different research areas such as studies [6, 7]. The high ceiling effect is one of the problems education, tourism, nursing and political science [33– encountered when using EQ-5D in China [8–11], suggest- 36]. Q methodology comprises several steps: concourse ing that it may be inefficient to identify differences in health development (wide collection of statements based on status for much of the Chinese population [12]. The pro- things written/said on the research topic – via scoping portion of people reporting a ceiling effect of EQ-5D in review and qualitative interviews), Q-sample generation China (87% in the national population study in the year (selection of statements from the concourse to enable 2008) was much greater than European countries like UK, participants to express different viewpoints), Q-sorting Sweden, and Germany where the proportions reporting no administration (participants rank statements), factor problem were 45, 42, and 66%, respectively. It may be be- analysis and interpretation [26]. These steps are ex- cause Chinese people are generally healthier than people plained in detail in the following sections. living in the West, but this explanation is contradicted by data showing poorer life expectancy, mortality or morbidity Developing concourse and devising the Q-sample in China. A more reasonable hypothesis is that the cultural The first step of a Q-study is to develop the “concourse”, differences between China and the West make the which ‘consists of the things that are written or said European-developed questionnaire less effective. The ques- about a topic that can be ‘socially contested, argued tionnaire was also found to be less sensitive in detecting dif- about and debated … matters of values and beliefs’ [37]. ferences in health status [13, 14]. Additionally, its test-retest The development of the concourse of this study in- reliability is questioned by Chinese researchers [15]. volved: (i) a scoping review of Chinese generic HRQoL Although various validation studies for the Chinese measures, and (ii) qualitative interviews conducted in version of EQ-5D have been conducted, they focused on China focusing on aspects of health considered import- statistical tests, examining psychometric properties such ant in judging health for a Chinese population. Referring as construct validity, reliability and responsiveness, while to the methodological framework of scoping review [38], few studies addressed conceptual equivalence issues currently available HRQoL measures that were devel- [16–19]. Given potential differences in how health is oped in a Chinese cultural setting were identified. Attri- conceptualised in China and the West [20–23], it can be butes that were covered by those HRQoL measures and argued that EQ-5D may fail to ask the most appropriate could be used in subjective health assessment were sys- and important questions for Chinese populations in tematically summarised to develop a Chinese conceptual assessing health. framework of health. Subsequently, a series of semi- Chinese papers on health concepts are predomin- structured face-to-face interviews were conducted to ask antly theoretical and rarely collect data with members participants to talk about health. They were asked to de- of the general population [24, 25]. This study thus in- scribe their own health as well as to illustrate someone vestigated Chinese participants’ subjective understand- in good/poor health. This explored how Chinese lay ings of key concepts that should be used to judge people describe and appraise health to justify the con- health.Bycomparing layChinese people’sunder- ceptual framework and to identify any additional health standings of health with a commonly-used Western concepts. The resulting conceptual framework included HRQoL measure (EQ-5D), this study aimed to ex- a wide range of health attributes likely to be considered plore cultural differences in defining and measuring important by a Chinese population. health between China and the West. Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 3 of 15 Based on the conceptual framework, the Q-sample of a nursing home helped to contact people who had was generated. The Q-sample is a set of statements that long-term health problems; a village head offered help in include the diversity of opinions and perspectives about distributing recruitment leaflets and introducing the re- the research topic so that participants may rank state- searcher to his villagers. The snowballing approach was ments to express their views [26]. The five dimensions also used by asking interviewees to suggest potential par- of EQ-5D were also generated as statements, as a way to ticipants. Once prospective interviewees had confirmed compare the descriptive system with other “Chinese-spe- their willingness to participate, the place, date and time cific” statements. A draft version of Q-sample on various were discussed and arranged. For the privacy of inter- health-related aspects of subjective experiences, feelings viewees and the quality of interviews, interviewing places or perceptions was generated. A more detailed process were selected carefully to ensure interviews could take of how the conceptual framework was transformed into place with minimal interruption. The chosen sites were the Q-sample is presented in the Additional file 1. The various, including private meeting rooms in public tea- ‘condition of instruction’ (guide for participants to sort houses, quiet compartments in cafes, meeting rooms in the Q-sample) was “When judging a person’s health, the places of interviewees’ employment. In the end, how important is it to know about their ___?” 110 participants from cities and villages in Southwest The draft Q-sample was sent to 10 Chinese people China (Chongqing), East China (Shanghai, Jiangsu, (two Chinese clinicians, two Chinese academic re- Zhejiang) and North China (Beijing and Tianjin), searchers who had worked on HRQoL projects and six completed the Q-sort exercise. See Table 1 for sample lay people) for comments. They were asked to identify characteristics. those unclear statements, after which they were asked to give reasons why they thought these statements unclear Table 1 Demographic characteristics of participants (n = 110) and/or suggest alternative wording. They were also Number (percentage) asked to indicate if there were any similar statements. Gender Male 57 (52%) As a result of feedback from participants, the statements were then revised to eliminate ambiguity and repetition Female 53 (48%) and ensured readability to lay people. Five pilot Q-sorts Age < 40 44 (40%) were subsequently conducted. As the participants of the 40–60 35 (32%) pilot study confirmed that they understood the state- 60+ 31 (28%) ments and had no problem in following instructions, no Education background Under high school 20 (18%) further revisions were made on the Q-sample. The final High school 14 (13%) version of the Q-sample contained 42 statements. Secondary specialised 15 (14%) Participants College 18 (16%) To explore the diversity of views, a group of Chinese University 42 (38%) participants (with Chinese nationality; living in China; Self-rating health status 11111 42 (38%) using Chinese as the mother tongue;18 years old or using EQ-5D 11112 15 (14%) older) with various demographic characteristics, includ- 11121 16 (15%) ing age, gender, geographical locations, rural/urban areas, educational background and his/her health condi- 11122 14 (13%) tion, were purposively recruited. As the study required Other 22 (20%) participants to comprehend, compare and rank 42 state- Self-rating health score 80–100 69 (63%) ments written in Chinese, participants were expected to 60–80 35 (32%) be able to read and communicate in Mandarin. Potential < 60 5 (5%) participants were not recruited if they had cognitive Residence place City 63 (57%) problems or had a serious health condition that may limit their ability to complete the Q-sorting exercise. Non-city 47 (43%) Participants were identified and recruited through Region Southwest China 54 (49%) various social groups (such as a Mahjong game club, a East China 34 (31%) nursing home and a village community), where group North China 13 (12%) organisers were contacted to help the researcher to tar- Other 9 (8%) get and access potential participants. For example, a The Chinese version of the EQ-5D-5 L questionnaire was provided to each member of a Mahjong game club agreed to ask other participant to complete after the sorting exercise. One participant declared he members (mostly people in middle or elder age) if they did not have time for completing the questionnaire and his health status were interested in participating in this study; a manager information was missing Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 4 of 15 Q-sorting determine how many factors should be retained for rota- Participants were provided with the Q-sample (42 state- tion and interpretation. The principal aim of factor ex- ments individually printed on numbered cards) and a Q- traction was to keep those factors that were reasonably grid (See Fig. 1). The sorting exercise was conducted in- interpretable and represented a distinct viewpoint [29]. dividually by participants. Participants were asked to The commonly adopted standards include selecting fac- read each statement carefully and split them into three tors with eigenvalues greater than 1.00 [26, 29]and on piles: “a pile for statements that you think are most im- which the Q-sorts of at least two exemplars load signifi- portant”; “a pile for statements that you think are least cantly [26, 40]. The eigenvalue (characteristics value) of important” and “a pile for the rest”. Participants were a factor is closely associated with the variance accounted then asked to sort the cards onto the Q-grid from most for by that factor (Eigenvalue = the variance accounted important (+ 5) to least important (− 5). For example, for by that factor × number of participants/100) [26]. participants needed to place one statement that was Additionally, the Scree test has also been applied in most important to him/her on the rightmost blank cell many studies [41], where eigenvalues would be plotted and two second most important statements on the (+ 4) on a line chart. The slope of the line would indicate column and so on, until all the statements were assigned which factors should be retained: those factors to the left on the grid. of the point where the slope is evidently levelling off. Participants were asked to check their completed Q- The graph below (Fig. 2) draws the scree plot with sort (distribution of statements on the Q-grid) and make the eigenvalues generated for each factor in this any changes. The researcher took a photograph of the study. The graph shows a five-factor solution was po- completed Q-sorts. Finally, the researcher conducted tentially eligible for interpretation. The five factors ex- post-sorting interviews to explore why participants plained 55% of the study variance and appeared to ranked statements as they did. Examples of post-sorting represent distinct viewpoints. questions are presented in the Additional file 1. These interviews were audio-recorded. Interpretation For each factor, exemplars were identified (participants Factor analysis and rotation with Q-sorts loading + 0.4 (p < 0.01) on one factor only). Participants’ Q-sorts were entered into PQMethod ver- These exemplars were merged in PQMethod to produce sion 2.35 (available on http://schmolck.org/qmethod/) a factor array, a single ‘ideal’ Q-sort that best repre- for analysis. The study adopted Principal Component sented each factor (Table 2). The factor array for each Analysis with Varimax rotation to analyse the data, factor represents how a participant with a correlation where similarities within factors and differences across coefficient of 1 would have ranked the 42 statements. them are maximised [39]. The next step was to The pattern of ranked statements within each factor Fig. 1 Q-Grid Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 5 of 15 Fig. 2 Scree Test array was interpreted to identify the different viewpoints function was a fundamental component in life because within the study sample [26]. Interpretation of each fac- they believed that people could have other pursuits, such tor can be achieved by observing the scores of Q-sample as happiness and fortunes, only if they had no problem in its factor array [37] as well as by recognising similar- in conducting these basic physical activities. ities and differences across the factors [40]. A lower In addition to functional abilities, participants empha- value indicated that the statement was less important sised social interaction (“Ability to adapt to the social (for example, ‘-5’ suggested that the statement was least environment” (+ 3), “State of social relations” (+ 1), important) while a higher value indicated that the state- “Ability to communicate with people” (+ 1), “social mor- ment was more important. This interpretation process ality” (+ 1)). Participants indicated that people were by was supplemented by exemplars’ comments collected nature social beings and cannot live in isolation from so- during the post-sorting interviews. The audio recordings ciety. The importance of social wellbeing was noted by of their comments were transcribed. The rationale of linking it with one’s physical and mental health state. their sort, which can be referred to by reading the tran- For example, participant 89 mentioned that maintaining scripts, helped to verify the initial interpretations of each good social relations was critical to one’s health by illus- factor. trating its positive effects on her health condition: “If you have some physical or mental health problems, it Results will be good if you have someone who can listen to you or Demographic information about exemplars in each fac- help you … There was one time when I broke my leg, a tor is presented in Table 3. lot of my friends came to visit me, cared about me, I felt much better, my bodily pain could even be neglected.” Factor one: physical independence and social interaction (No.89, female, 56 years old). skills Statements on individuals’ frame of mind, including Q-sorts of 19 participants exemplified this factor. “Life attitude (such as viewing things optimistically or pes- Factor One exemplars tended to agree that one’s phys- simistically)” (+ 4), “Self-confidence” (+ 3) and “Breadth of ical function was important in judging his/her health. mind” (+ 2), were chosen to be most important as well. Statements including “Ability to wash and dress oneself” Participants stated that because it was likely for people to (+ 5), “Ability to perform usual activities (such as work- encounter different kinds of troubles or challenges in life, ing, studying, shopping, doing housework)” (+ 4) and they were supposed to face problems optimistically and “Ability to walk about” (+ 3) were ranked as most im- confidently to be mentally healthy. Additionally, because a portant. Participants revealed that it was essential to be positive thinking frame of mind was believed to be con- physically independent and keep self-control over one’s nected with good “ability to adapt to the social environ- own life, and according to them, being able to take care ment” and good “state of social relations”, those confident of themselves, to conduct usual activities and to walk and positive people were more likely to be welcomed by around were all basic requirements in obtaining such in- others and more likely to attain social wellbeing. Some dependence. Exemplars who lost or partly lost physical participants also mentioned that a positive mental attitude independence explained that their daily activities had could give one’s body aswell asone’s mind a good signal, been significantly restricted, therefore their quality of life therefore could positively affect one’s physical and mental was largely damaged. Those participants who were phys- states. For example, participant 89 referred to her sister, ically well held the same point that one’s physical who stayed positive in fighting cancer and overcame the Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 6 of 15 Table 2 Factor Arrays: scores against each item by factor Statements Factor Arrays 1 2 345 1. Body constitution that can indicate the susceptibility to diseases 2 3 5 3 3 2. Ability to adapt to weather changes −3 −1 −3 − 1 −5 3. Body weight −20 −10 −1 4. Spiritual appearance 2 2 4 3 0 5. Natural colour and appearance of face −21 −21 −4 6. Feeling of tiredness −11 1 −1 −2 7. Body strength of doing things −12 0 −12 8. Feeling of discomfort −22 2 0 −2 9. Feeling of pain −14 2 2 −3 10. Desire of having food 0 2 0 3 −3 11. Feeling of pressure −10 2 −33 12. Feeling of depression −21 3 −30 13. Feeling of anxiety −10 2 −21 14. Tendency of being angry −2 −10 −1 − 1 15. Feeling of fear −5 −2 − 2 −50 16. Feeling of loneliness −3 −2 −2 −4 −1 17. Self-confidence 3 −2 122 18. Ability to remain stable and peaceful in mood 2 0 1 0 1 19. Sleep quality 1 3 3 4 0 20. Ability to walk about 3 4 −1 −42 21. Ability to perform usual activities 4 3 0 −2 −1 22. Vision 0 1 −50 5 23. Hearing 0 0 −41 4 24. Ability to communicate with people 1 −2 −11 0 25. Ability to wash and dress oneself 5 5 0 −30 26. Dependence on medication −31 0 −2 −2 27. State of sex life −4 −2 −4 −20 28. Ability to think things clearly 2 0 −10 2 29. Ability to perceive changes in surrounding and to respond swiftly 0 0 −2 −11 30. Ability to remember things 1 −1 −32 1 31. Ability to make decisions −1 −4 −31 0 32. Ability to concentrate 0 −1 −22 2 33. State of social relations 1 −40 1 − 2 34. Ability to adapt to the social environment 3 −30 −1 − 1 35. Support from one’s social network 0 −3 −1 −2 −2 36. Social morality 1 −5 −10 1 37. Life attitude 4 −1 424 38. “Breadth of mind” 2 −3 113 39. Regularity in daily life 0 1 3 4 1 40. Diet habits 0 0 2 5 −4 41. Sense of satisfaction with life 1 −11 0 −3 42. Family medical history −42 1 0 −1 Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 7 of 15 Table 3 Demographic characteristics for exemplars in each factor Factor 1 (n = 19) Factor 2 (n = 25) Factor 3 (n = 16) Factor 4 (n = 6) Factor 5 (n =4) Gender Male 7 8 10 6 3 Female 12 17 6 0 1 Age < 40 4 13 12 1 3 40–60 7433 1 60+ 8812 0 (Mean age) 55 43 34 52 30 Education background Under high school3631 0 High school 4121 0 Secondary 3113 1 College 3421 1 University 6 13 8 0 2 Self-rating health state using EQ-5D 11111 8784 0 11112 2320 0 11121 3510 1 11122 1322 1 Other 5630 2 Self-rating health score 80–100 10 17 9 3 3 60–80 8473 1 <60 1300 0 Residence place City 12 13 10 2 3 Non-city 7 12 6 4 1 Region Southwest China 13 12 4 3 1 East China 5473 2 North China 0540 1 Other 1410 0 life-threatening condition as an example to emphasise the provide reliable information for health assessment. Some positive influence of being optimistic. elder participants also explained that these physical feel- Participants in this account did not place much em- ings were not serious and did not interfere with their phasis on psychological feelings: “Feeling of fear” (−5), normal life. They could still conduct routine activities by “Feeling of loneliness” (−3), “Feeling of depression” (−2), tolerating the physical symptoms, thus these symptoms “Tendency of being angry” (− 2), “Feeling of anxiety” (− were least important to participants in judging health. 1) and “Feeling of pressure” (− 1). Some participants said that they normally did not have those negative feelings Factor two: physical health such as depression or loneliness, therefore, did not think Q-sorts of 25 participants exemplified this factor. these statements were important in judging health. Some Physical health is the central focus of this factor. Simi- participants stated that they may have experienced some lar to Factor One, physical function statements including of these feelings but the temporary state of these feelings “Ability to wash and dress oneself” (+ 5), “Ability to walk was “adjustable” and was “not a big deal” (no.37, female, about” (+ 4) “Ability to perform usual activities (such as 46 years old). Physical symptoms were also less empha- working, studying, shopping, doing housework)” (+ 3) sised in this viewpoint. Statements such as “Feeling of were ranked as most important. Participants in this discomfort” (− 2), “Feeling of pain” (− 1), “Feeling of group highlighted the importance of being physically in- tiredness” (− 1) were ranked as less important, although dependent with comparable reasons reported in the pre- they were related to physical health. Similar to those vious factor. psychological feelings, physical symptoms were believed In addition to physical functional abilities, participants to be short-term in most occasions, therefore could not highlighted physical symptoms including “Feeling of Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 8 of 15 pain” (+ 4), “Sleep quality” (+ 3), “Feeling of discomfort” An individual was identified as an exemplar with a Q- (+ 2), “Desire of having food” (+ 2), “Spiritual appear- sort significantly but negatively loaded on Factor two. ance” (+ 2), “Body strength of doing things” (+ 2) and This means the individual had a Q-sort that represents a “Feeling of tiredness” (+ 1) as important health state- reverse view. For example, he viewed physical function ments. Participants tended to link undesirable physical and physical symptom statements as least important, signs with diseases. If a person got sick, certain physical while considered one’s frame of mind as well as social symptoms such as pain or discomfort would appear in wellbeing as most important. With comparable reasons the body, body strength (energy) would be insufficient which were addressed in Factor One, he rated social and he/she may not be able to sleep well or have a good health and frame of mind highly. He also explained that appetite. Meanwhile, it was also believed that if a person he did not experience physical functional problems and did not have good sleep or lost the desire for food, he/ considered them as least important. The part of the view she would not have adequate energy and would fall ill was shared by Factor Three and Four, which will be pre- easily. Therefore, these physical symptoms could directly sented in the following paragraphs. reflect one’s health. Exemplars on this factor showed a clear preference for Factor three: sensations and feelings physical statements. Those statements relating to psy- Q-sorts of 16 participants exemplified this factor chological symptoms as well as cognitive function (such The exemplars on this factor were likely to only empha- as “Feeling of loneliness”(− 2), “Feeling of fear”(− 2), sise health indicators that directly influenced their life. “Tendency of being angry” (− 1) “Feeling of anxiety”(0), Unlike Factor One and Factor Two where physical func- “Feeling of pressure”(0)) as well as cognitive function tional abilities were placed as most important, partici- (such as “Ability to make decisions”(− 4), “Ability to re- pants in this factor did not favour them that much: member things”(− 1), “Ability to concentrate” (− 1) “Ability to wash and dress oneself” (0), “Ability to per- “Ability to think things clearly”(− 1), “Ability to perceive form usual activities (such as working, studying, shop- changes in surrounding and to respond”(− 1)) were ping, doing housework)” (0), “Ability to walk about” (− ranked as less important. Some participants stated that 1). As a participant explained: “Walking about, working, they only considered physical statements to be relevant dressing myself, I do these things every day. Nothing stops to health. For example, a participant stated “Do these me (from doing these things)… I think people around me, (mental) feelings matter? I think a healthy person can all of them do not have such problems… Only those dis- also be depressed or fear things… I think if a person can abled people have these problems.” (no.53, female, 32 eat and sleep well, he is fine” (no. 55, female, 41 years years old). old). Some participants mentioned mental health but For similar reasons, they regarded “Vision” (− 5), emphasised that physical wellbeing was a foundation be- “Hearing” (− 4) as well as those cognitive function cause mental wellbeing cannot be obtained without a (“Ability to make decisions” (− 3), “Ability to remember healthy physical body. things” (− 3), “Ability to concentrate” (− 2), “Ability to In contrast to the first factor where statements relating perceive changes in surrounding and to respond” (− 2), to social wellbeing were considered most important, par- “Ability to think things clearly” (− 1)) as less important. ticipants in Factor Two regarded those statements as It seems that this group of participants did not consider least important. According to them, when judging one’s those worst scenarios when people totally lost vision, health, it was less important to assess one’s behaviours hearing or cognitive abilities. Some participants illus- in front of others (“Social morality” (− 5)) or one’s inter- trated that in his/her age, they were able to see and hear action with other people in the society (“State of social things. They believed that even if people had poor vision relations” (− 4), “Ability to adapt to the social environ- or hearing, they could use glasses and hearing-aid and ment” (− 3), “Breadth of mind” (− 3), “Support from their life would not be affected. Participants also thought one’s social network” (− 3), “Ability to communicate it was not likely for people to lose their cognitive abil- with people” (− 2)), or one’s personality (“Self-confi- ities until reaching a certain age. dence” (− 2)). Some participants considered social well- While exemplars viewed physical function as less im- being as “luxuries” (no.81, male, 23). They stated that portant in health judgement, they emphasised the im- things like social support or confidence were not neces- portance of physical health by highlighting “Body sities for individuals and people could still be healthy constitution that can indicate the susceptibility to dis- even without these things. Some participants said they ease” (+ 5), “Spiritual appearance” (+ 4) and “Sleep qual- could not find connections between these statements ity” (+ 3). Participants generally held the opinion that and health, because, in their understanding, one’s health people with a better body constitution tended to have a status was about one’s own condition and was irrelevant lower possibility of developing diseases and were health- to one’s social connections or social environment. ier. They also mentioned that spiritual appearance Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 9 of 15 directly indicated one’s health status. Participants de- sleeping time and kept a balanced diet were likely to be scribed ‘spiritual appearance’ similar to participants in better in preventing illness and be healthy, while bad the previous qualitative study. They related this term lifestyles undermined one’s health condition. For ex- with an individual’s overall appearance (eye spirit, voice, ample, Participants 14 explained: sitting postures and movement) as well as an individual’s energy. They explained that a person free from diseases “I have a friend who is now 59 (years old) but looks and had few things to worry about would generally have very young. His life is very regular. For most friends a good spiritual appearance, therefore it was a straight- of mine, we often play card games until 2 am or 3 forward sign reflecting one’s health. am, but he never did that. He would go home by 9 Participants also tended to regard lifestyle behaviours pm… He gets up on time, eats three meals on time, (“Regularity in daily life” (+ 3), “Diet habits” (+ 2)) as and sleep on time. He swims in the morning.” (no.14, most important. The group held the point that one’s be- male, 48 years old) haviours in daily life would affect or predict one’s health. Good practices such as maintaining a regular life circle, They also referred to “Sleep quality” (+ 4), “Desire of keeping a healthy diet and having a good rest, in this having food” (+ 3), “Spiritual appearance” (+ 3) and sense, could suggest one’s current health condition and/ “Body constitution” (+ 3) to be most important health or could predict one’s future health. Physical feelings in- indicators, as they believed those aspects were closely as- cluding “Feeling of pain” (+ 2), “Feeling of discomfort” sociated with one’s life quality and could straightfor- (+ 2) and “Feeling of tiredness” (+ 1) were also rated wardly reflect one’s health. On the other hand, highly by the exemplars of this factor. Most of them ex- participants did not emphasise the importance of phys- plained that they had experienced these undesirable feel- ical function: “Ability to walk about” (− 4), “Ability to ings and such feelings had affected their daily life. wash and dress oneself” (− 3), “Ability to perform usual Another central theme of this factor was mental well- activities (such as working, studying, shopping, doing being, as participants tended to highlight the importance housework)” (− 2), as they believed those things were of mental health: “Feeling of depression” (+ 3), “Feeling less likely to affect most people’s normal life because of pressure” (+ 2), “Feeling of anxiety” (+ 2), “Ability to most people would not have problems in these aspects. remain stable and peaceful in mood” (+ 1). Exemplars of While this factor was comparable with Factor Three in this group mentioned that people who were mentally terms of the points addressed above, there were distinct unwell may harm themselves, conduct suicide or hurt differences between the two views. This group of partici- other people. They thus believed that mental problems pants recognised cognitive function abilities were import- were more detrimental than physical diseases. They also ant factors in judging health, when they placed “Ability to tended to agree that nowadays mental problems were remember things” (+ 2), “Ability to concentrate” (+ 2), more prevalent than physical problems. Additionally, “Ability to make decisions” (+ 1), and “Ability to think participants held the point that one’s overall health was things clearly” (0) to be relatively important. This may be mainly affected by one’s mental state because those because exemplars in Factor Four were older than exem- emotions can be controlled subjectively, while one’s plars in Factor Three, since elder people may not have an physical state tended to be stable and sometimes was as good cognitive function as younger people and/or they not able to be changed. They believed that people could may have witnessed more cases where friends/relatives choose to stay in a good mental condition as a way to suffered from cognition problems. improve their health, as Participant 71 described: “Some Another difference between the Fourth and Third fac- people are born disabled and it is not fair to say they are tors was that participants in this group did not regard unhealthy. They cannot control these objective factors mental health indicators as most important: “Feeling of but they can choose to live their own life happily.” (no.71, fear” (− 5), “Feeling of loneliness” (− 4), “Feeling of pres- male, 28 years old). sure” (− 3), “Feeling of depression” (− 3), “Feeling of anx- iety” (− 2), “Ability to remain stable and peaceful in mood” Factor four: lifestyles (0). This may be because exemplars in this account (simi- Q-sorts of 6 participants exemplified this factor lar to Factor One) either had little experience of such Similar to Factor Three, exemplars whose sorts defined negative mental feelings, or they believed such negative the fourth factor attached importance to those health di- feelings could be relieved and would not influence their mension indicators, they believed, that had a direct influ- normal life, as participant 13 explained, “why people feel ence on their life. They seemed to be convinced that anxious or depressed? If some terrible things happen, he lifestyles can significantly affect one’s health: “Diet would be affected and feel bad. But for most people, if they habits” (+ 5), “Regularity in daily life” (+ 4). They tended can sleep well, eat well, have a good body, I think they will to believe that people who had regular eating and hardly feel anxious.” (no.13, male, 50 years old). Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 10 of 15 Factor five: learning and working abilities statements about anxiety and pressure were more im- Q-sorts of 4 participants exemplified this factor portant than “Feeling of depression”, because he had too Vision and hearing were the most important health indi- many responsibilities and stress from work and he had cators in this factor: “Vision” (+ 5), “Hearing” (+ 4). Par- “no time to be depressed” (no. 42, male, 40 years old). ticipant 68 explained that vision and hearing were Physical signs or feelings were regarded as less import- essential if a person wanted to be connected with the ant in this account: “Natural colour and appearance of world and to learn things. If a person lost the ability to see face” (− 4), “Feeling of pain” (− 3), “Desire of having or hear, it became harder for him to get new information food” (− 3), “Feeling of discomfort” (− 2), “Feeling of (no. 68, male, 24 years old). Yet other physical functional tiredness” (− 2). One reason was that exemplars in this abilities, such as “Ability to wash and dress oneself” (0) group were relatively young and were less likely to be and “Ability to perform usual activities” (− 1), were less troubled by negative physical symptoms. Another reason important to participants because they thought those abil- mentioned by participants similar to Factor One: partici- ities were too basic for them to worry about. pants tended to believe these physical symptoms were Participants rated “Frame of mind” highly and chose temporary states and could not provide reliable informa- to believe “Life attitude” (+ 4), “Breadth of mind” (+ 3), tion about an individual’s health status. They believed “Self-confidence” (+ 2) as most important criteria in health was a relatively stable state, except for dramatic judging health. Very similar to the reasons given in Fac- changes, such as an accident. Therefore, participants be- tor one, where frame of mind was regarded as most im- lieved that health should not be judged by symptoms portant, exemplars of Factor Five tended to believe that that varied from time to time. people who had an optimistic attitude, who were toler- ant of things that may be offensive and who were Discussion confident were more likely to face challenges and deal Differences across five factors with problems in life positively, therefore they were The study identified five distinct viewpoints in selecting more likely to have a good mental health state. Partici- key indicators that should be used to judge health. Five pants also mentioned the positive influence of a good diverse views in sorting health statements demonstrate mental attitude on one’s physical health state. that health is a complicated concept and can be under- While exemplars of Factor One considered both frame stood differently. There were various perspectives in of mind and social interaction as most important and thinking about health: exemplars of Factor One and explained the inner relations between the two, partici- Two were likely to perceive health from a functional pants in this account did not seem to favour health indi- point of view, exemplars of Factor Three tended to de- cators relating to social wellbeing: “State of social fine health as the opposite of diseases, while it was relations” (− 2), “Support from one’s social network” (− widely agreed by exemplars of Factor Four that health 2), “Ability to adapt to the social environment” (− 1), was closely linked with one’s lifestyles and daily life “Ability to communicate with people” (0). This may be quality in terms of sleeping and eating. The five view- explained by the age difference between the two groups points also showed a debate between evaluating health of participants. Exemplars in Factor Five (average age as a temporary state or as a longer-term status. While 30) were younger than people in Factor One (average exemplars whose sorts defined Factor One and Five age 55). Younger participants may be more concerned tended to assess health from a long-term basis, partici- about their own work thus did not appreciate social pants of Factor Three were likely to perceive health as wellbeing as much as exemplars of Factor One. a short-term state and considered current sensations Participants in this factor placed cognitive abilities, in- and feelings as most important. Additionally, findings cluding “Ability to think things clearly” (+ 2), “Ability to suggested that diverse priorities were given to different concentrate” (+ 2), “Ability to perceive changes in sur- aspects of health in different viewpoints. For example, rounding and to respond” (+ 1), “Ability to remember participants of Factor One jointly highlighted social things” (+ 1), as important statements. They explained wellbeing and one’s physical state; Factor Three empha- that such abilities were vital in their day-to-day work. sised mental states; while some exemplars whose sorts Similarly, they emphasised “Feeling of pressure”(+ 3) and generated Factor Two revealed that they considered “Feeling of anxiety”(+ 1) over other mental feelings, be- one’s physical fitness to be most important when think- cause these two feelings were more related to their work, ing about health. as Participant 20 expressed: “I cannot control my anxiety. The finding also illustrated how individuals’ demo- I have too much work stress, even when I go back home, I graphic characteristics, social surroundings and their keep thinking about the work I haven’t finished. I could own health experiences had shaped their perceptions of not sleep, I want to sleep but I can’t.” (no.20, female, 30 health. Similar to the previous literature [42–45], age years old) Participant 42 held the point that the was found to be one of the most influential factors in Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 11 of 15 shaping lay understandings of health. For example, Similarities among the viewpoints younger participants were found to talk about mental In addition to the differences described above, similar- health more frequently than the elderly. It might be be- ities in understanding the concept of health were also cause these young individuals were generally in a better detected across the five factors. There were health di- physical health state and were more likely to be exposed mensions that were important concepts to the majority to mental health issues. Meanwhile, the elder partici- of participants. The statement “Body constitution that pants tended to have more physical and cognitive func- can indicate the susceptibility to diseases” was agreed to tion problems compared to the younger participants and be important across the five factors. “Body constitution”, were more likely to highlight the importance of physical has been closely associated with the concept of health in and cognitive abilities. In our study, it was also more Chinese populations according to several studies [49, likely for elder people to raise social wellbeing issues in 50]. Its literal translation into Chinese is “body quality” defining health and this may be because they had more and can be defined as “the characteristics of an individ- experiences in appreciating the impact of social relations ual, including structural and functional characteristics, and hoped to be well involved in social communities temperament, ability to adapt to environmental changes, more [46]. or susceptibility to various health conditions” [51]. This Education was also found to be a salient indicator in term was found to be an understandable and widely re- shaping participants’ understandings of health, similar to ferred concept in describing health among Chinese lay previous findings [43, 44, 47, 48]. While participants people in published literature [49]. The current Q inves- with a higher level of education were more likely to be tigation has further proved it was widely accepted by aware of mental health and social wellbeing, participants Chinese participants as an indicator to assess one’s with a lower level of education were more likely to re- health. strict the scope of health within physical fitness. An ex- “Spiritual appearance” was another statement that was treme example was that several participants who had highly emphasised in the majority of the extracted fac- limited education declared they never heard about “Anx- tors. “Spirit” (“Shen”) is a central notion in traditional iety” and did not understand its meaning (Participant 27 Chinese knowledge and could be referred to one’s con- and 101) and they placed the statement randomly on a sciousness, mind, thoughts and/or vitality [52, 53]. A less important place. Besides, residence place may also possible description of spirit was illustrated in Diagnos- influence individuals’ views according to health. As it tics in Chinese Medicine that “having spirit” means was shown in Factor Five, most of the exemplars whose “one’s mind is clear, vision is bright, talking is clear, sorts defined this factor lived in cities and illustrated complexion is glowing, facial expression is natural, re- they had a stressful job in a competitive working envir- sponse is quick, movement is agile, breathing is smooth onment. It may explain why they were more likely to and steady…” [54] It was recognised in previous qualita- emphasise statements on cognitive abilities and mental tive interviews that the concept of “Spirit” was part of health issues. lay participants’ common knowledge. Since the state- Apart from demographic characteristics, one’s health ment about spirit was also rated highly in the Q-study, it conditions and past health experiences influenced one’s supported the assumption that “Spirit” could be an im- interpretation of health [44, 47, 48]. Participants who re- portant dimension in evaluating health among Chinese ported problems in mobility or doing self-care activities communities. were likely to place statements about physical functional Apart from Factor Two, which firstly prioritised phys- abilities as most important. As a result, none of them ex- ical health statements, other factors all held the point emplified Factor Three, Four and Five. It could also be that one’s “Life attitude (such as viewing things optimis- noted that exemplars of Factor Three and Four were tically or pessimistically)” as well as “Breadth of mind” generally in a good health state in terms of their EQ-5D (such as being tolerant of other people or narrow- results (half of them were in a “11,111” full health state minded to other people) were most important in judging and the majority of them had their self-rating health one’s health. This may reflect Chinese traditional know- scores higher than 80). They highlighted the quality of ledge in appreciating balance and harmony between an sleeping and eating in judging one’s health and empha- individual and the surroundings. It was explained else- sised lifestyle behaviours in maintaining health. It may where that according to Chinese traditional knowledge, be because those participants in a better health condi- because one’s external environment is closely associated tion were more likely to think about health in a higher with his/her daily activities, ideally, a person should be standard and define health in a more positive way. They capable of adjusting to the external environment to were less troubled by function limitation or negative reach a harmonious state [55]. It seemed to be widely feelings/sensations than the participants in the other accepted by many of the participants, as they linked a factors. positive mental-frame with good health and indicated Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 12 of 15 that facing problems in life positively and confidently were asked to think about health, to various extents and avoiding conflicts with other people were good prac- though. As those aspects are also principal domains in tices in adapting to the changes in the environment to frequently cited HRQoL conceptual models such as stay in health. Wilson-Cleary model and PROMIS model [62, 63], it in- The statement about sleep quality was also extensively dicates that Chinese and Western HRQoL measures agreed to be important, as the four of the extracted fac- shared comparable measuring frames. tors rated it with a positive importance level and three However, it is also clear that there are potential differ- of them regarded the statement as most important (at ences in understanding health between China and the least + 3). In a previous scoping review study, sleep was West. Comparing the current findings with the descrip- found to be assessed in all identified Chinese-developed tive system of EQ-5D, there were unique health dimen- HRQoL questionnaires, findings of the current Q study sions that were agreed to be important among Chinese provided additional evidence that sleep was regarded as participants, which are not mentioned in this Western- an important health dimension in China, from an empir- developed HRQoL questionnaire. Health dimensions in- ical perspective. Life regularity was also rated using posi- cluding body constitution [49, 50], spirit [55, 64], life at- tive importance levels by four factors. This may be in titude [65, 66], sleep [67–69] and life regularity [70, 71] line with a phenomenon where the idea of “Yangsheng” have been frequently linked with the concept of health (Health-keeping Behaviours) was widely referred to in the Chinese literature. The importance of such con- across Chinese communities. The idea conveys that good cepts is now supported by the current Q investigation. behaviours, such as keeping a regular lifestyle, can po- These “Chinese-characteristic” health dimensions dem- tentially be associated with “good health”. The massive onstrate cultural differences in defining health between popularity of “Yangsheng” phenomenon in China has China and the West. been addressed in recent literature [56, 57]. Along with The five dimensions of EQ-5D were included as state- the Q-study result, it indicates that considering one’s be- ments in the study. Although self-care, mobility and haviours when thinking about one’s health may be com- usual activities were acknowledged to be important in mon among Chinese lay people. two of the extracted factors, some participants men- There were also statements that were agreed to be less tioned that these physical function abilities were too important across the five factors. Although adaptability basic for them to worry about therefore were less im- to weather changes was assessed in several Chinese- portant. They tended to define health in a more positive developed HRQoL questionnaires [58–60], it was not way and with a higher standard. Views towards physical considered to be most important in the extracted views, feelings of pain and discomfort were also diverse. Some as most participants revealed that it was less relevant to believed they were effective indicators to detect one’s health compared to other statements. Feelings of fear physical health status, while there were participants ar- and loneliness were also found to be less important guing they could only indicate temporary states and, in across the five factors. Participants seemed to agree that most occasions, could not provide reliable information their life was not troubled by such two feelings. Some for health assessment. Similarly, anxiety and depression stated they enjoyed their own space and did not regard were also believed to be not reliable in evaluating health loneliness was a bad thing. Some stated they did not feel according to some participants. Furthermore, the two fearful very often thus did not regard it as important. terms may not be well understood by some Chinese Moreover, “State of sex life” was another statement people, especially those received limited education. placed to be less important in the majority of the identi- The results thus imply that the five dimensions of EQ- fied factors. The sensitive nature of this health dimen- 5D may not be comprehensive in measuring health in sion and its difficulty to be applied in assessing health China, it can be argued that the questionnaire may fail among Chinese populations was mentioned in the litera- to ask the most appropriate and important questions ture [61]. It was also revealed by participants that they among a Chinese population in assessing health. concerned this as a private topic and preferred not to discuss it with other people. Limitations The study was in nature exploratory. It identified five Potential differences in understanding health between distinct views of ranking 42 health statements highlight- China and the west ing the most important health statements within each The findings suggests that Chinese participants’ compre- view. However, this method does not provide one over- hensions of health were comparable to Western ways of arching or set of statements that were most important to describing health to a great degree. Statements about the whole sample of participants. Alternative quantita- function abilities, physical symptoms, emotions and so- tive research is planned to further investigate the con- cial wellbeing were recognised by participants when they cept of health in China. Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 13 of 15 Another limitation was that, because the study investi- Acknowledgements The authors are grateful to the participants and all the social group gated Chinese lay perceptions of health and recruited organisers who helped recruit the participants. The authors would like to only Chinese participants, it was not possible to compare thank Professor Jan van Busschbach for comments on an earlier draft of this Chinese participants’ views with Westerners’ to explicitly paper. The authors would like to express gratitude to the anonymous reviewers for their careful reading of the manuscript and their thoughtful test cultural differences in understanding health between comments and suggestions. China and the West. A Q-methodological investigation is planned to be conducted in the UK using a similar Authors’ contributions All authors conceptualised the research design. ZM conducted the research, study design and materials, but potential obstacles in collected data and analysed data. SA, PK and CDG supervised the whole data translating the Q-statements into English to make them collection and data analysis process. ZM wrote the manuscript. SA, PK and clear and understandable to Non-Chinese participants CDG critically reviewed the manuscript during the writing process. All authors approved the final version of the manuscript. are expected. Although our statements were written, checked for Funding ambiguity and understanding, a small number of partici- The first author’s contribution to this research was supported by the China Scholarship Council (CSC) - University of Leeds Joint Scholarship. pants did not understand some specific statement or in- terpret some statements differently. For instance, for Availability of data and materials those statements on functional abilities, some partici- The datasets used and/or analysed during the current study are available pants imagined situations when one totally lost physical from the corresponding author on reasonable request. abilities, such as cannot walk or cannot see or cannot Ethics approval and consent to participate hear, thus sorted the statements as most important, The study has been reviewed and approved by the School of Medicine while some participants did not expect conditions could Research Ethics Committee at the University of Leeds (reference number: MREC17–021). be that extreme and did not regard them as most im- portant. We acknowledged that such variations in partic- Consent for publication ipants’ interpretation of statements were difficult to Not applicable. control in the sorting exercise and may have influenced Competing interests how they sorted them. The authors declare that they have no competing interests. Author details Leeds Institute of Health Sciences, University of Leeds, Leeds, UK. Conclusion Department of Psychology, Queen’s University Belfast, Belfast, UK. Because EQ-5D is one of the most commonly used Western HRQoL measure in China, it was selected as an Received: 16 August 2019 Accepted: 20 May 2020 example to explore cultural differences between China and the West. The Q-study showed that many health References statements were rated highly as most important by a di- 1. Haraldstad K, Wahl A, Andenæs R, Andersen JR, Andersen MH, Beisland E, et al. A systematic review of quality of life research in medicine and health verse range of Chinese participants but were not covered sciences. Qual Life Res. 2019;28:2641–50. in EQ-5D. It then suggests that the EQ-5D descriptive 2. Bowling A. Health-related quality of life: conceptual meaning, use and system might need modification to improve its capacity measurement. In: Measuring disease: a review of disease-specific quality of life measurement scales. 2nd ed. Buckingham: Open University Press; 2001. to measure health status in China. The study raises a p. 1–22. general question as to how appropriate the Western- 3. Geisinger KF. Cross-cultural normative assessment: translation and developed HRQoL measures are when used to assess adaptation issues influencing the normative interpretation of assessment instruments. Psychol Assess. 1994;6:304. health in a significantly different cultural setting. The 4. Stewart AL, Napoles-Springer A. Health-related quality-of-life assessments in findings documented here are specific to China but the diverse population groups in the United States. Med Care. 2000;38:II102–I24. implications can and should be considered in other 5. Bowden A, Fox-Rushby JA. A systematic and critical review of the process of translation and adaptation of generic health-related quality of life measures countries/regions. in Africa, Asia, Eastern Europe, the Middle East. South America Soc Sci Med. 2003;57:1289–306. 6. Zhou T, Guan H, Liu G, Ma A. Health-related quality of life for disease Supplementary information population in China based on EQ-5D: a systematic review. Zhong guo xun Supplementary information accompanies this paper at https://doi.org/10. zheng yi xue za zhi. 2016;16:135–42. 1186/s12955-020-01414-z. 7. Zhou T, Guan H, Liu G, Ma A. Health-related quality of life for the general population in China: a systematic review. Zhong guo wei sheng shi ye guan li. 2016;33:621–3. Additional file 1: Table A1. the conceptual framework developed from 8. Wang H, Kindig DA, Mullahy J. Variation in Chinese population health the scoping review and qualitative interviews & how it was transformed related quality of life: results from a EuroQol study in Beijing. China Qual into Q-sample. Life Res. 2005;14:119–32. 9. Sun S, Chen J, Johannesson M, Kind P, Xu L, Zhang Y, et al. Population health status in China: EQ-5D results, by age, sex and socio-economic Abbreviation status, from the National Health Services Survey 2008. Qual Life Res. 2011;20: HRQoL: Health-related quality of life 309–20. Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 14 of 15 10. Tan Z, Liang Y, Liu S, Cao W, Tu H, Guo L, et al. Health-related quality of life 36. Bartlett ME, Han W, Bartlett J. Perceptions of mainland Chinese students as measured with EQ-5D among populations with and without specific toward obtaining higher education in the United States. J Int Stud. 2018;8: chronic conditions: a population-based survey in Shaanxi Province. China 623–37. PLoS One. 2013;8:e65958. 37. Stainton RR. Q methodology. In: Smith J, Van Langenhove L, editors. 11. Wu C, Gong Y, Wu J, Zhang S, Yin X, Dong X, et al. Chinese version of the Rethinking methods in psychology. London: Sage; 1995. p. 178–92. EQ-5D preference weights: applicability in a Chinese general population. 38. Arksey H, O'Malley L. Scoping studies: towards a methodological framework. PLoS One. 2016;11:e0164334. Int J Sci Res. 2005;8:19–32. 12. Sun S, Chen J, Kind P, Xu L, Zhang Y, Burström K. Experience-based VAS 39. Baker R, Thompson C, Mannion R. Q methodology in health economics. J values for EQ-5D-3L health states in a national general population health Health Serv Res Policy. 2006;11:38–45. survey in China. Qual Life Res. 2015;24:693–703. 40. Dziopa F, Ahern K. A systematic literature review of the applications of 13. F-l Z, Yue M, Yang H, Wang T, Wu J-H, Li S-C. Validation and comparison of Q-technique and its methodology. Eur J Res Meth Behav Soc Sci. 2011; EuroQol and short form 6D in chronic prostatitis patients. Value Health. 7:39. 2010;13:649–56. 41. Watts S, Stenner P. Understanding the analytic process (1): factor extraction. 14. Yang Z, Busschbach J, Liu G, Luo N. EQ-5D-5L norms for the urban Chinese Doing Q methodological research: theory, method and interpretation. population in China. Health Qual Life Outcomes. 2018;16:210. London: SAGE Publications Ltd; 2014. 15. Fang H, Farooq U, Wang D, Yu F, Younus MI, Guo X. Reliability and 42. Bury M. Chronic illness as biographical disruption. Sociol Health Illn. 1982;4: validity of the EQ-5D-3L for Kashin–Beck disease in China. SpringerPlus. 167–82. 2016;5:1924. 43. Mansour AA-H. The conceptualization of health among residents of 16. Wang F, Li H, Ma A. Study on the application of General Utility Scale on Saskatoon. J Community Health. 1994;19:165–79. Chinese populations. Zhong guo yao wu ping jija. 2015;32:244–7. 44. Baumann B. Diversities in conceptions of health and physical fitness. J 17. Wang HM, Patrick DL, Edwards TC, Skalicky AM, Zeng HY, Gu WW. Validation Health Hum Behav. 1961;2:39–46. of the EQ-5D in a general population sample in urban China. Qual Life Res. 45. Julia L. Lay experiences of health and illness: past research and future 2012;21:155–60. agendas. Sociol Health Illn. 2003;25:23–40. 18. Zhu Y, Shen Y. A construct validity analysis and application of EQ-5D 46. Depp CA, Jeste DV. Definitions and predictors of successful aging: a among type 2 diabetes patients. Zhejiang yu fang yi xue. 2014;26:14–8. comprehensive review of larger quantitative studies. Am J Geriatr Psychiatry. 19. Wu C, Gong Y, Wu J, Zhang S, Yin X, Dong X, et al. Chinese version of the 2006;14:6–20. EQ-5D preference weights: applicability in a Chinese general population. 47. van Dalen H, Williams A, Gudex C. Lay people's evaluations of health: are PLoS One. 2016;11(10):e0164334. there variations between different subgroups? J Epidemiol Community 20. Prior L, Chun PL, Huat SB. Beliefs and accounts of illness. Views from two Health. 1994;48:248–53. Cantonese-speaking communities in England. Sociol Health Illn. 2000;22: 48. Blaxter M. Health and lifestyles. London. New York: Routledge; 2003. 815–39. 49. Lew-Ting C-Y, Hurwicz M-L, Berkanovic E. Personal constitution and health 21. Liu JE, Mok E, Wong T. Perceptions of Chinese cancer patients of the status among Chinese elderly in Taipei and Los Angeles. Soc Sci Med. 1998; favorable and unfavorable words conveyed by their social support 47:821–30. providers. Cancer Nurs. 2005;28:348–54. 50. Chan RY, Chien WT. Concepts of body constitution, health and sub-health 22. Chen AW, Kazanjian A, Wong H. Why do Chinese Canadians not consult from traditional Chinese medicine perspective. World J Transl Med. 2013;2: mental health services: health status, language or culture? Transcult 56–66. Psychiatry. 2009;46:623–41. 51. World Health Organization. International statistical classification of diseases 23. Xiang YT, Chiu HF, Ungvari GS. Quality of life and mental health in Chinese and related health problems (11th Revision). 2018. https://icd.who.int/ culture. Curr Opin Psychiatry. 2010;23:43–7. browse11/l-m/en. Accessed 11 June 2019. 24. Huang Z, Zhang Y, Ran J, Dong W, Su H, Yang Y. Individual cognition on 52. Rossi E. Shen: psycho-emotional aspects of Chinese medicine. Edinburgh: the concept of health. Zhong guo yun dong yi xue za zhi. 2011;30:374–8. Elsevier Health Sciences; 2007. 25. Wang L. A narrative inquiry into the health concept of local adults in 53. Zi T. Illustrating the fundamentals of the yellow Emperor’s classic of internal Chengdu China] [master thesis. Sichuan: University of Sichuan; 2001. medicine. Shaanxi: Shaanxi Normal University Press; 2012. p. 357. 26. Watts S, Stenner P. Doing Q methodology: theory, method and 54. Deng T, Guo Z. Diagnostics in Chinese medicine. Shanghai: Shanghai interpretation. Qual Res Psychol. 2005;2:67–91. Science and Technology Publisher; 1984. 27. Stephenson W. Correlating persons instead of tests. J Pers. 1935;4:17–24. 55. Zhang H, Zhang F-Y, Zhao Y-N, Li Z. Health concepts under the view of 28. Stainton Rogers W, Dyson Rogers PO. Q methodological research in mental Chinese culture. Zhong hua hu li za zhi. 2015;50:1236–9. health and psychotherapy. In: Qualitative research methods in mental 56. Si F, Song X, Gao Y. Current situation of the TCM Yangsheng market. Zhong health and psychotherapy: a guide for students and practitioners. West yi yan jiu. 2013;26:1–3. Sussex: Wiley; 2001. p. 193–208. 57. Sun W. Regimes of healthy living: the reality of ageing in urban China and 29. McKeown B, Thomas DB. Q methodology. 2nd ed. Los Angeles; London; the cultivation of new normative subjects. J Consum Cult. 2016;16:908–25. New Delhi; Singapore. Washington DC: Sage publications; 2013. 58. Wu D, Lai S, Guo X, Wen Z, Liang W, Yang X. Establishment and initial 30. Eccleston C, Amanda CDC, Rogers WS. Patients' and professionals' evaluation of Health Scale of Traditional Chinese Medicine. Zhong guo understandings of the causes of chronic pain: blame, responsibility and zhong xi yi jie he za zhi. 2007;27:847–50. identity protection. Soc Sci Med. 1997;45:699–709. 59. Liu FB, Zhao L, Lang JY, Lin LZ, Liang GH, Fang JQ. Development of the 31. Stenner P, Dancey C, Watts S. The understanding of their illness amongst Chinese Quality of Life Instrument. Zhong guo zu zhi gong cheng yan jiu people with irritable bowel syndrome: a Q methodological study. Soc Sci he lin chuang kang fu. 2007;11:10492–5. Med. 2000;51:439–52. 60. Li X. [The development and evaluation of Chinese PRO scale] [master 32. Stenner PH, Cooper D, Skevington SM. Putting the Q into quality of life; the thesis]. Guangzhou: Guangzhou University of Chinese Medicine; 2007. identification of subjective constructions of health-related quality of life 61. Yu C, Sun Y, He L, Bai W, Liu B. Comparative study on the concepts of using Q methodology. Soc Sci Med. 2003;57:2161–72. health related quality of life from TCM and modernized medicine measures. 33. Peng Y. Democracy and Chinese political discourses. Mod China. 1998;24: Zhong hua zhong yi yao za zhi. 2016;31:4773–8. 408–44. 62. Wilson IB, Cleary PD. Linking clinical variables with health-related quality of 34. Dewar K, Li WM, Davis C. Photographic images, culture, and perception in life: a conceptual model of patient outcomes. JAMA. 1995;273:59–65. tourism advertising: a Q methodology study of Canadian and Chinese 63. Cella D, Riley W, Stone A, Rothrock N, Reeve B, Yount S, et al. The patient- university students. J Travel Tour Mark. 2007;22:35–44. reported outcomes measurement information system (PROMIS) developed 35. Cai D, Stone TE, Petrini MA, McMillan M. An exploration of the health beliefs and tested its first wave of adult self-reported health outcome item banks: of Chinese nurses' and nurse academics' health beliefs: a Q-methodology 2005–2008. J Clin Epidemiol. 2010;63:1179–94. study. Nurs Health Sci. 2016;18:97–104. 64. Hsu E. Spirit (shen), styles of knowing, and authority in contemporary Chinese medicine. Cult Med Psychiatry. 2000;24:197–229. Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 15 of 15 65. An S, Chen C, Li J, Zhang M, Li S, Dou N. Associations of life attitude and personality type with degree of frailty in disabled oldest-old people. Zhong guo gong gong wei sheng. 2018;34:171–6. 66. Li P, Li W. Mentality Health and Physical Health. Jia ting hu shi. 2008;1:203. 67. Wang G, Zhang J, Xu Y, Zhu Y, Ke D, Zhang G. Elementary study of sleep quality and self-rated health on common populations. Zhong guo xing wei yi xue ke xue. 2003;12:80–2. 68. Zhao J, Xie Y, Shi M, Ren Z, Feng X. Relationship between sleep quality and quality of life in military personnel in high altitude area. Zhong guo gong gong wei sheng. 2006;22:665–6. 69. Cheng G, Zhang X, Yang Y. Study of Sleep and Quality of Life of the Workers from Chengdu Air Craft Manufacturing Factory. Xian dai yu fang yi xue. 2008;35:45–7. 70. Su D. A study of health beliefs among Chinese adults] [PhD thesis. Chongqing: Southwest University; 2015. 71. Zhang H, Li H, Gu D. One hundred health proverbs. Beijing: Overseas Chinese Publisher; 2005. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health and Quality of Life Outcomes Springer Journals

Exploring subjective constructions of health in China: a Q-methodological investigation

Download PDF
15 pages

Loading next page...
 
/lp/springer-journals/exploring-subjective-constructions-of-health-in-china-a-q-xBleRHP0tf

References (81)

Publisher
Springer Journals
Copyright
Copyright © The Author(s) 2020
eISSN
1477-7525
DOI
10.1186/s12955-020-01414-z
Publisher site
See Article on Publisher Site

Abstract

Background: With an increasing awareness of people’s satisfaction and feeling, health-related quality of life (HRQoL) has become an essential aspect of measuring health. HRQoL is fundamentally a foreign concept introduced to China from the West. While a growing number of studies applied western HRQoL measures, few content validity tests examined the legitimacy of applying Western developed HRQoL measures in a Chinese cultural setting. If there are distinct differences in health conceptualisation between China and the West, it can be argued that those western measures may fail to ask the most appropriate and important questions among a Chinese population in assessing health. As a limited number of studies have investigated Chinese people’s understandings of health, this study aimed to explore how health is defined and described in China. Methods: A Q-methodological study was conducted to explore subjective constructions of health among Chinese participants. A scoping review of Chinese generic HRQoL measures, supplemented by a series of qualitative interviews conducted in China, produced a list of 42 statements representing aspects of health considered as being important in a Chinese cultural setting. Chinese participants in face-to-face interviews ranked and sorted these statements. Data were analysed to identify clusters of participants who shared a similar perspective, using a by- person factor analysis procedure. Results: 110 Chinese participants with various demographics characteristics completed sorting interviews. Five independent factors emerged: (I) “Physical independence and social interaction skills”; (II) “Physical health”; (III) “Sensations and feelings”; (IV) “Lifestyles”; (V) “Learning and working abilities”. Conclusions: The Q-study showed that many health statements were rated highly as most important by a diverse range of Chinese participants but were not covered in the commonly used Western HRQoL measure EQ-5D. It then suggests that the EQ-5D descriptive system might need modification to improve its capacity to measure health status in China. The study thus raises a general question as to how appropriate the Western-developed HRQoL measures are when used to assess health in a significantly different cultural setting. Keywords: Health-related quality of life, Health, Cultural differences, China, Q-methodology, Qualitative study * Correspondence: [email protected] Leeds Institute of Health Sciences, University of Leeds, Leeds, UK Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 2 of 15 Introduction Methods With an increasing awareness of people’s satisfaction Design and feeling, health-related quality of life (HRQoL) has The study was reviewed and approved by the School of become an essential aspect of measuring health [1, 2]. Medicine Research Ethics Committee at the University Most of the commonly used HRQoL questionnaires have of Leeds (reference number: MREC17–021). been developed in Europe or North America, with their A Q methodological study was used to fulfil the study descriptive systems being subsequently translated into objective. Q methodology was introduced by William other languages to be used worldwide. Although a grow- Stephenson in 1935 as a way to scientifically assess sub- ing number of studies use western HRQoL measures, jective viewpoints [26, 27]. It is an effective approach for few studies have considered cultural differences in con- combining both qualitative and quantitative techniques ceptual equivalence [3–5], while those assessing cross- to observe individuals’ personal opinions and identify cultural equivalence normally focus on statistical psy- patterns of views across a participant group [28, 29]. It chometric properties [5]. has been used in various health-related studies to inves- Taking the use of EQ-5D in China as an example, the tigate concepts of QoL, experiences of pain and under- Chinese versions of EQ-5D have been widely used in standings of illnesses [30–32]. It has been used in China, including general population and patient-specific Chinese populations in different research areas such as studies [6, 7]. The high ceiling effect is one of the problems education, tourism, nursing and political science [33– encountered when using EQ-5D in China [8–11], suggest- 36]. Q methodology comprises several steps: concourse ing that it may be inefficient to identify differences in health development (wide collection of statements based on status for much of the Chinese population [12]. The pro- things written/said on the research topic – via scoping portion of people reporting a ceiling effect of EQ-5D in review and qualitative interviews), Q-sample generation China (87% in the national population study in the year (selection of statements from the concourse to enable 2008) was much greater than European countries like UK, participants to express different viewpoints), Q-sorting Sweden, and Germany where the proportions reporting no administration (participants rank statements), factor problem were 45, 42, and 66%, respectively. It may be be- analysis and interpretation [26]. These steps are ex- cause Chinese people are generally healthier than people plained in detail in the following sections. living in the West, but this explanation is contradicted by data showing poorer life expectancy, mortality or morbidity Developing concourse and devising the Q-sample in China. A more reasonable hypothesis is that the cultural The first step of a Q-study is to develop the “concourse”, differences between China and the West make the which ‘consists of the things that are written or said European-developed questionnaire less effective. The ques- about a topic that can be ‘socially contested, argued tionnaire was also found to be less sensitive in detecting dif- about and debated … matters of values and beliefs’ [37]. ferences in health status [13, 14]. Additionally, its test-retest The development of the concourse of this study in- reliability is questioned by Chinese researchers [15]. volved: (i) a scoping review of Chinese generic HRQoL Although various validation studies for the Chinese measures, and (ii) qualitative interviews conducted in version of EQ-5D have been conducted, they focused on China focusing on aspects of health considered import- statistical tests, examining psychometric properties such ant in judging health for a Chinese population. Referring as construct validity, reliability and responsiveness, while to the methodological framework of scoping review [38], few studies addressed conceptual equivalence issues currently available HRQoL measures that were devel- [16–19]. Given potential differences in how health is oped in a Chinese cultural setting were identified. Attri- conceptualised in China and the West [20–23], it can be butes that were covered by those HRQoL measures and argued that EQ-5D may fail to ask the most appropriate could be used in subjective health assessment were sys- and important questions for Chinese populations in tematically summarised to develop a Chinese conceptual assessing health. framework of health. Subsequently, a series of semi- Chinese papers on health concepts are predomin- structured face-to-face interviews were conducted to ask antly theoretical and rarely collect data with members participants to talk about health. They were asked to de- of the general population [24, 25]. This study thus in- scribe their own health as well as to illustrate someone vestigated Chinese participants’ subjective understand- in good/poor health. This explored how Chinese lay ings of key concepts that should be used to judge people describe and appraise health to justify the con- health.Bycomparing layChinese people’sunder- ceptual framework and to identify any additional health standings of health with a commonly-used Western concepts. The resulting conceptual framework included HRQoL measure (EQ-5D), this study aimed to ex- a wide range of health attributes likely to be considered plore cultural differences in defining and measuring important by a Chinese population. health between China and the West. Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 3 of 15 Based on the conceptual framework, the Q-sample of a nursing home helped to contact people who had was generated. The Q-sample is a set of statements that long-term health problems; a village head offered help in include the diversity of opinions and perspectives about distributing recruitment leaflets and introducing the re- the research topic so that participants may rank state- searcher to his villagers. The snowballing approach was ments to express their views [26]. The five dimensions also used by asking interviewees to suggest potential par- of EQ-5D were also generated as statements, as a way to ticipants. Once prospective interviewees had confirmed compare the descriptive system with other “Chinese-spe- their willingness to participate, the place, date and time cific” statements. A draft version of Q-sample on various were discussed and arranged. For the privacy of inter- health-related aspects of subjective experiences, feelings viewees and the quality of interviews, interviewing places or perceptions was generated. A more detailed process were selected carefully to ensure interviews could take of how the conceptual framework was transformed into place with minimal interruption. The chosen sites were the Q-sample is presented in the Additional file 1. The various, including private meeting rooms in public tea- ‘condition of instruction’ (guide for participants to sort houses, quiet compartments in cafes, meeting rooms in the Q-sample) was “When judging a person’s health, the places of interviewees’ employment. In the end, how important is it to know about their ___?” 110 participants from cities and villages in Southwest The draft Q-sample was sent to 10 Chinese people China (Chongqing), East China (Shanghai, Jiangsu, (two Chinese clinicians, two Chinese academic re- Zhejiang) and North China (Beijing and Tianjin), searchers who had worked on HRQoL projects and six completed the Q-sort exercise. See Table 1 for sample lay people) for comments. They were asked to identify characteristics. those unclear statements, after which they were asked to give reasons why they thought these statements unclear Table 1 Demographic characteristics of participants (n = 110) and/or suggest alternative wording. They were also Number (percentage) asked to indicate if there were any similar statements. Gender Male 57 (52%) As a result of feedback from participants, the statements were then revised to eliminate ambiguity and repetition Female 53 (48%) and ensured readability to lay people. Five pilot Q-sorts Age < 40 44 (40%) were subsequently conducted. As the participants of the 40–60 35 (32%) pilot study confirmed that they understood the state- 60+ 31 (28%) ments and had no problem in following instructions, no Education background Under high school 20 (18%) further revisions were made on the Q-sample. The final High school 14 (13%) version of the Q-sample contained 42 statements. Secondary specialised 15 (14%) Participants College 18 (16%) To explore the diversity of views, a group of Chinese University 42 (38%) participants (with Chinese nationality; living in China; Self-rating health status 11111 42 (38%) using Chinese as the mother tongue;18 years old or using EQ-5D 11112 15 (14%) older) with various demographic characteristics, includ- 11121 16 (15%) ing age, gender, geographical locations, rural/urban areas, educational background and his/her health condi- 11122 14 (13%) tion, were purposively recruited. As the study required Other 22 (20%) participants to comprehend, compare and rank 42 state- Self-rating health score 80–100 69 (63%) ments written in Chinese, participants were expected to 60–80 35 (32%) be able to read and communicate in Mandarin. Potential < 60 5 (5%) participants were not recruited if they had cognitive Residence place City 63 (57%) problems or had a serious health condition that may limit their ability to complete the Q-sorting exercise. Non-city 47 (43%) Participants were identified and recruited through Region Southwest China 54 (49%) various social groups (such as a Mahjong game club, a East China 34 (31%) nursing home and a village community), where group North China 13 (12%) organisers were contacted to help the researcher to tar- Other 9 (8%) get and access potential participants. For example, a The Chinese version of the EQ-5D-5 L questionnaire was provided to each member of a Mahjong game club agreed to ask other participant to complete after the sorting exercise. One participant declared he members (mostly people in middle or elder age) if they did not have time for completing the questionnaire and his health status were interested in participating in this study; a manager information was missing Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 4 of 15 Q-sorting determine how many factors should be retained for rota- Participants were provided with the Q-sample (42 state- tion and interpretation. The principal aim of factor ex- ments individually printed on numbered cards) and a Q- traction was to keep those factors that were reasonably grid (See Fig. 1). The sorting exercise was conducted in- interpretable and represented a distinct viewpoint [29]. dividually by participants. Participants were asked to The commonly adopted standards include selecting fac- read each statement carefully and split them into three tors with eigenvalues greater than 1.00 [26, 29]and on piles: “a pile for statements that you think are most im- which the Q-sorts of at least two exemplars load signifi- portant”; “a pile for statements that you think are least cantly [26, 40]. The eigenvalue (characteristics value) of important” and “a pile for the rest”. Participants were a factor is closely associated with the variance accounted then asked to sort the cards onto the Q-grid from most for by that factor (Eigenvalue = the variance accounted important (+ 5) to least important (− 5). For example, for by that factor × number of participants/100) [26]. participants needed to place one statement that was Additionally, the Scree test has also been applied in most important to him/her on the rightmost blank cell many studies [41], where eigenvalues would be plotted and two second most important statements on the (+ 4) on a line chart. The slope of the line would indicate column and so on, until all the statements were assigned which factors should be retained: those factors to the left on the grid. of the point where the slope is evidently levelling off. Participants were asked to check their completed Q- The graph below (Fig. 2) draws the scree plot with sort (distribution of statements on the Q-grid) and make the eigenvalues generated for each factor in this any changes. The researcher took a photograph of the study. The graph shows a five-factor solution was po- completed Q-sorts. Finally, the researcher conducted tentially eligible for interpretation. The five factors ex- post-sorting interviews to explore why participants plained 55% of the study variance and appeared to ranked statements as they did. Examples of post-sorting represent distinct viewpoints. questions are presented in the Additional file 1. These interviews were audio-recorded. Interpretation For each factor, exemplars were identified (participants Factor analysis and rotation with Q-sorts loading + 0.4 (p < 0.01) on one factor only). Participants’ Q-sorts were entered into PQMethod ver- These exemplars were merged in PQMethod to produce sion 2.35 (available on http://schmolck.org/qmethod/) a factor array, a single ‘ideal’ Q-sort that best repre- for analysis. The study adopted Principal Component sented each factor (Table 2). The factor array for each Analysis with Varimax rotation to analyse the data, factor represents how a participant with a correlation where similarities within factors and differences across coefficient of 1 would have ranked the 42 statements. them are maximised [39]. The next step was to The pattern of ranked statements within each factor Fig. 1 Q-Grid Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 5 of 15 Fig. 2 Scree Test array was interpreted to identify the different viewpoints function was a fundamental component in life because within the study sample [26]. Interpretation of each fac- they believed that people could have other pursuits, such tor can be achieved by observing the scores of Q-sample as happiness and fortunes, only if they had no problem in its factor array [37] as well as by recognising similar- in conducting these basic physical activities. ities and differences across the factors [40]. A lower In addition to functional abilities, participants empha- value indicated that the statement was less important sised social interaction (“Ability to adapt to the social (for example, ‘-5’ suggested that the statement was least environment” (+ 3), “State of social relations” (+ 1), important) while a higher value indicated that the state- “Ability to communicate with people” (+ 1), “social mor- ment was more important. This interpretation process ality” (+ 1)). Participants indicated that people were by was supplemented by exemplars’ comments collected nature social beings and cannot live in isolation from so- during the post-sorting interviews. The audio recordings ciety. The importance of social wellbeing was noted by of their comments were transcribed. The rationale of linking it with one’s physical and mental health state. their sort, which can be referred to by reading the tran- For example, participant 89 mentioned that maintaining scripts, helped to verify the initial interpretations of each good social relations was critical to one’s health by illus- factor. trating its positive effects on her health condition: “If you have some physical or mental health problems, it Results will be good if you have someone who can listen to you or Demographic information about exemplars in each fac- help you … There was one time when I broke my leg, a tor is presented in Table 3. lot of my friends came to visit me, cared about me, I felt much better, my bodily pain could even be neglected.” Factor one: physical independence and social interaction (No.89, female, 56 years old). skills Statements on individuals’ frame of mind, including Q-sorts of 19 participants exemplified this factor. “Life attitude (such as viewing things optimistically or pes- Factor One exemplars tended to agree that one’s phys- simistically)” (+ 4), “Self-confidence” (+ 3) and “Breadth of ical function was important in judging his/her health. mind” (+ 2), were chosen to be most important as well. Statements including “Ability to wash and dress oneself” Participants stated that because it was likely for people to (+ 5), “Ability to perform usual activities (such as work- encounter different kinds of troubles or challenges in life, ing, studying, shopping, doing housework)” (+ 4) and they were supposed to face problems optimistically and “Ability to walk about” (+ 3) were ranked as most im- confidently to be mentally healthy. Additionally, because a portant. Participants revealed that it was essential to be positive thinking frame of mind was believed to be con- physically independent and keep self-control over one’s nected with good “ability to adapt to the social environ- own life, and according to them, being able to take care ment” and good “state of social relations”, those confident of themselves, to conduct usual activities and to walk and positive people were more likely to be welcomed by around were all basic requirements in obtaining such in- others and more likely to attain social wellbeing. Some dependence. Exemplars who lost or partly lost physical participants also mentioned that a positive mental attitude independence explained that their daily activities had could give one’s body aswell asone’s mind a good signal, been significantly restricted, therefore their quality of life therefore could positively affect one’s physical and mental was largely damaged. Those participants who were phys- states. For example, participant 89 referred to her sister, ically well held the same point that one’s physical who stayed positive in fighting cancer and overcame the Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 6 of 15 Table 2 Factor Arrays: scores against each item by factor Statements Factor Arrays 1 2 345 1. Body constitution that can indicate the susceptibility to diseases 2 3 5 3 3 2. Ability to adapt to weather changes −3 −1 −3 − 1 −5 3. Body weight −20 −10 −1 4. Spiritual appearance 2 2 4 3 0 5. Natural colour and appearance of face −21 −21 −4 6. Feeling of tiredness −11 1 −1 −2 7. Body strength of doing things −12 0 −12 8. Feeling of discomfort −22 2 0 −2 9. Feeling of pain −14 2 2 −3 10. Desire of having food 0 2 0 3 −3 11. Feeling of pressure −10 2 −33 12. Feeling of depression −21 3 −30 13. Feeling of anxiety −10 2 −21 14. Tendency of being angry −2 −10 −1 − 1 15. Feeling of fear −5 −2 − 2 −50 16. Feeling of loneliness −3 −2 −2 −4 −1 17. Self-confidence 3 −2 122 18. Ability to remain stable and peaceful in mood 2 0 1 0 1 19. Sleep quality 1 3 3 4 0 20. Ability to walk about 3 4 −1 −42 21. Ability to perform usual activities 4 3 0 −2 −1 22. Vision 0 1 −50 5 23. Hearing 0 0 −41 4 24. Ability to communicate with people 1 −2 −11 0 25. Ability to wash and dress oneself 5 5 0 −30 26. Dependence on medication −31 0 −2 −2 27. State of sex life −4 −2 −4 −20 28. Ability to think things clearly 2 0 −10 2 29. Ability to perceive changes in surrounding and to respond swiftly 0 0 −2 −11 30. Ability to remember things 1 −1 −32 1 31. Ability to make decisions −1 −4 −31 0 32. Ability to concentrate 0 −1 −22 2 33. State of social relations 1 −40 1 − 2 34. Ability to adapt to the social environment 3 −30 −1 − 1 35. Support from one’s social network 0 −3 −1 −2 −2 36. Social morality 1 −5 −10 1 37. Life attitude 4 −1 424 38. “Breadth of mind” 2 −3 113 39. Regularity in daily life 0 1 3 4 1 40. Diet habits 0 0 2 5 −4 41. Sense of satisfaction with life 1 −11 0 −3 42. Family medical history −42 1 0 −1 Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 7 of 15 Table 3 Demographic characteristics for exemplars in each factor Factor 1 (n = 19) Factor 2 (n = 25) Factor 3 (n = 16) Factor 4 (n = 6) Factor 5 (n =4) Gender Male 7 8 10 6 3 Female 12 17 6 0 1 Age < 40 4 13 12 1 3 40–60 7433 1 60+ 8812 0 (Mean age) 55 43 34 52 30 Education background Under high school3631 0 High school 4121 0 Secondary 3113 1 College 3421 1 University 6 13 8 0 2 Self-rating health state using EQ-5D 11111 8784 0 11112 2320 0 11121 3510 1 11122 1322 1 Other 5630 2 Self-rating health score 80–100 10 17 9 3 3 60–80 8473 1 <60 1300 0 Residence place City 12 13 10 2 3 Non-city 7 12 6 4 1 Region Southwest China 13 12 4 3 1 East China 5473 2 North China 0540 1 Other 1410 0 life-threatening condition as an example to emphasise the provide reliable information for health assessment. Some positive influence of being optimistic. elder participants also explained that these physical feel- Participants in this account did not place much em- ings were not serious and did not interfere with their phasis on psychological feelings: “Feeling of fear” (−5), normal life. They could still conduct routine activities by “Feeling of loneliness” (−3), “Feeling of depression” (−2), tolerating the physical symptoms, thus these symptoms “Tendency of being angry” (− 2), “Feeling of anxiety” (− were least important to participants in judging health. 1) and “Feeling of pressure” (− 1). Some participants said that they normally did not have those negative feelings Factor two: physical health such as depression or loneliness, therefore, did not think Q-sorts of 25 participants exemplified this factor. these statements were important in judging health. Some Physical health is the central focus of this factor. Simi- participants stated that they may have experienced some lar to Factor One, physical function statements including of these feelings but the temporary state of these feelings “Ability to wash and dress oneself” (+ 5), “Ability to walk was “adjustable” and was “not a big deal” (no.37, female, about” (+ 4) “Ability to perform usual activities (such as 46 years old). Physical symptoms were also less empha- working, studying, shopping, doing housework)” (+ 3) sised in this viewpoint. Statements such as “Feeling of were ranked as most important. Participants in this discomfort” (− 2), “Feeling of pain” (− 1), “Feeling of group highlighted the importance of being physically in- tiredness” (− 1) were ranked as less important, although dependent with comparable reasons reported in the pre- they were related to physical health. Similar to those vious factor. psychological feelings, physical symptoms were believed In addition to physical functional abilities, participants to be short-term in most occasions, therefore could not highlighted physical symptoms including “Feeling of Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 8 of 15 pain” (+ 4), “Sleep quality” (+ 3), “Feeling of discomfort” An individual was identified as an exemplar with a Q- (+ 2), “Desire of having food” (+ 2), “Spiritual appear- sort significantly but negatively loaded on Factor two. ance” (+ 2), “Body strength of doing things” (+ 2) and This means the individual had a Q-sort that represents a “Feeling of tiredness” (+ 1) as important health state- reverse view. For example, he viewed physical function ments. Participants tended to link undesirable physical and physical symptom statements as least important, signs with diseases. If a person got sick, certain physical while considered one’s frame of mind as well as social symptoms such as pain or discomfort would appear in wellbeing as most important. With comparable reasons the body, body strength (energy) would be insufficient which were addressed in Factor One, he rated social and he/she may not be able to sleep well or have a good health and frame of mind highly. He also explained that appetite. Meanwhile, it was also believed that if a person he did not experience physical functional problems and did not have good sleep or lost the desire for food, he/ considered them as least important. The part of the view she would not have adequate energy and would fall ill was shared by Factor Three and Four, which will be pre- easily. Therefore, these physical symptoms could directly sented in the following paragraphs. reflect one’s health. Exemplars on this factor showed a clear preference for Factor three: sensations and feelings physical statements. Those statements relating to psy- Q-sorts of 16 participants exemplified this factor chological symptoms as well as cognitive function (such The exemplars on this factor were likely to only empha- as “Feeling of loneliness”(− 2), “Feeling of fear”(− 2), sise health indicators that directly influenced their life. “Tendency of being angry” (− 1) “Feeling of anxiety”(0), Unlike Factor One and Factor Two where physical func- “Feeling of pressure”(0)) as well as cognitive function tional abilities were placed as most important, partici- (such as “Ability to make decisions”(− 4), “Ability to re- pants in this factor did not favour them that much: member things”(− 1), “Ability to concentrate” (− 1) “Ability to wash and dress oneself” (0), “Ability to per- “Ability to think things clearly”(− 1), “Ability to perceive form usual activities (such as working, studying, shop- changes in surrounding and to respond”(− 1)) were ping, doing housework)” (0), “Ability to walk about” (− ranked as less important. Some participants stated that 1). As a participant explained: “Walking about, working, they only considered physical statements to be relevant dressing myself, I do these things every day. Nothing stops to health. For example, a participant stated “Do these me (from doing these things)… I think people around me, (mental) feelings matter? I think a healthy person can all of them do not have such problems… Only those dis- also be depressed or fear things… I think if a person can abled people have these problems.” (no.53, female, 32 eat and sleep well, he is fine” (no. 55, female, 41 years years old). old). Some participants mentioned mental health but For similar reasons, they regarded “Vision” (− 5), emphasised that physical wellbeing was a foundation be- “Hearing” (− 4) as well as those cognitive function cause mental wellbeing cannot be obtained without a (“Ability to make decisions” (− 3), “Ability to remember healthy physical body. things” (− 3), “Ability to concentrate” (− 2), “Ability to In contrast to the first factor where statements relating perceive changes in surrounding and to respond” (− 2), to social wellbeing were considered most important, par- “Ability to think things clearly” (− 1)) as less important. ticipants in Factor Two regarded those statements as It seems that this group of participants did not consider least important. According to them, when judging one’s those worst scenarios when people totally lost vision, health, it was less important to assess one’s behaviours hearing or cognitive abilities. Some participants illus- in front of others (“Social morality” (− 5)) or one’s inter- trated that in his/her age, they were able to see and hear action with other people in the society (“State of social things. They believed that even if people had poor vision relations” (− 4), “Ability to adapt to the social environ- or hearing, they could use glasses and hearing-aid and ment” (− 3), “Breadth of mind” (− 3), “Support from their life would not be affected. Participants also thought one’s social network” (− 3), “Ability to communicate it was not likely for people to lose their cognitive abil- with people” (− 2)), or one’s personality (“Self-confi- ities until reaching a certain age. dence” (− 2)). Some participants considered social well- While exemplars viewed physical function as less im- being as “luxuries” (no.81, male, 23). They stated that portant in health judgement, they emphasised the im- things like social support or confidence were not neces- portance of physical health by highlighting “Body sities for individuals and people could still be healthy constitution that can indicate the susceptibility to dis- even without these things. Some participants said they ease” (+ 5), “Spiritual appearance” (+ 4) and “Sleep qual- could not find connections between these statements ity” (+ 3). Participants generally held the opinion that and health, because, in their understanding, one’s health people with a better body constitution tended to have a status was about one’s own condition and was irrelevant lower possibility of developing diseases and were health- to one’s social connections or social environment. ier. They also mentioned that spiritual appearance Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 9 of 15 directly indicated one’s health status. Participants de- sleeping time and kept a balanced diet were likely to be scribed ‘spiritual appearance’ similar to participants in better in preventing illness and be healthy, while bad the previous qualitative study. They related this term lifestyles undermined one’s health condition. For ex- with an individual’s overall appearance (eye spirit, voice, ample, Participants 14 explained: sitting postures and movement) as well as an individual’s energy. They explained that a person free from diseases “I have a friend who is now 59 (years old) but looks and had few things to worry about would generally have very young. His life is very regular. For most friends a good spiritual appearance, therefore it was a straight- of mine, we often play card games until 2 am or 3 forward sign reflecting one’s health. am, but he never did that. He would go home by 9 Participants also tended to regard lifestyle behaviours pm… He gets up on time, eats three meals on time, (“Regularity in daily life” (+ 3), “Diet habits” (+ 2)) as and sleep on time. He swims in the morning.” (no.14, most important. The group held the point that one’s be- male, 48 years old) haviours in daily life would affect or predict one’s health. Good practices such as maintaining a regular life circle, They also referred to “Sleep quality” (+ 4), “Desire of keeping a healthy diet and having a good rest, in this having food” (+ 3), “Spiritual appearance” (+ 3) and sense, could suggest one’s current health condition and/ “Body constitution” (+ 3) to be most important health or could predict one’s future health. Physical feelings in- indicators, as they believed those aspects were closely as- cluding “Feeling of pain” (+ 2), “Feeling of discomfort” sociated with one’s life quality and could straightfor- (+ 2) and “Feeling of tiredness” (+ 1) were also rated wardly reflect one’s health. On the other hand, highly by the exemplars of this factor. Most of them ex- participants did not emphasise the importance of phys- plained that they had experienced these undesirable feel- ical function: “Ability to walk about” (− 4), “Ability to ings and such feelings had affected their daily life. wash and dress oneself” (− 3), “Ability to perform usual Another central theme of this factor was mental well- activities (such as working, studying, shopping, doing being, as participants tended to highlight the importance housework)” (− 2), as they believed those things were of mental health: “Feeling of depression” (+ 3), “Feeling less likely to affect most people’s normal life because of pressure” (+ 2), “Feeling of anxiety” (+ 2), “Ability to most people would not have problems in these aspects. remain stable and peaceful in mood” (+ 1). Exemplars of While this factor was comparable with Factor Three in this group mentioned that people who were mentally terms of the points addressed above, there were distinct unwell may harm themselves, conduct suicide or hurt differences between the two views. This group of partici- other people. They thus believed that mental problems pants recognised cognitive function abilities were import- were more detrimental than physical diseases. They also ant factors in judging health, when they placed “Ability to tended to agree that nowadays mental problems were remember things” (+ 2), “Ability to concentrate” (+ 2), more prevalent than physical problems. Additionally, “Ability to make decisions” (+ 1), and “Ability to think participants held the point that one’s overall health was things clearly” (0) to be relatively important. This may be mainly affected by one’s mental state because those because exemplars in Factor Four were older than exem- emotions can be controlled subjectively, while one’s plars in Factor Three, since elder people may not have an physical state tended to be stable and sometimes was as good cognitive function as younger people and/or they not able to be changed. They believed that people could may have witnessed more cases where friends/relatives choose to stay in a good mental condition as a way to suffered from cognition problems. improve their health, as Participant 71 described: “Some Another difference between the Fourth and Third fac- people are born disabled and it is not fair to say they are tors was that participants in this group did not regard unhealthy. They cannot control these objective factors mental health indicators as most important: “Feeling of but they can choose to live their own life happily.” (no.71, fear” (− 5), “Feeling of loneliness” (− 4), “Feeling of pres- male, 28 years old). sure” (− 3), “Feeling of depression” (− 3), “Feeling of anx- iety” (− 2), “Ability to remain stable and peaceful in mood” Factor four: lifestyles (0). This may be because exemplars in this account (simi- Q-sorts of 6 participants exemplified this factor lar to Factor One) either had little experience of such Similar to Factor Three, exemplars whose sorts defined negative mental feelings, or they believed such negative the fourth factor attached importance to those health di- feelings could be relieved and would not influence their mension indicators, they believed, that had a direct influ- normal life, as participant 13 explained, “why people feel ence on their life. They seemed to be convinced that anxious or depressed? If some terrible things happen, he lifestyles can significantly affect one’s health: “Diet would be affected and feel bad. But for most people, if they habits” (+ 5), “Regularity in daily life” (+ 4). They tended can sleep well, eat well, have a good body, I think they will to believe that people who had regular eating and hardly feel anxious.” (no.13, male, 50 years old). Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 10 of 15 Factor five: learning and working abilities statements about anxiety and pressure were more im- Q-sorts of 4 participants exemplified this factor portant than “Feeling of depression”, because he had too Vision and hearing were the most important health indi- many responsibilities and stress from work and he had cators in this factor: “Vision” (+ 5), “Hearing” (+ 4). Par- “no time to be depressed” (no. 42, male, 40 years old). ticipant 68 explained that vision and hearing were Physical signs or feelings were regarded as less import- essential if a person wanted to be connected with the ant in this account: “Natural colour and appearance of world and to learn things. If a person lost the ability to see face” (− 4), “Feeling of pain” (− 3), “Desire of having or hear, it became harder for him to get new information food” (− 3), “Feeling of discomfort” (− 2), “Feeling of (no. 68, male, 24 years old). Yet other physical functional tiredness” (− 2). One reason was that exemplars in this abilities, such as “Ability to wash and dress oneself” (0) group were relatively young and were less likely to be and “Ability to perform usual activities” (− 1), were less troubled by negative physical symptoms. Another reason important to participants because they thought those abil- mentioned by participants similar to Factor One: partici- ities were too basic for them to worry about. pants tended to believe these physical symptoms were Participants rated “Frame of mind” highly and chose temporary states and could not provide reliable informa- to believe “Life attitude” (+ 4), “Breadth of mind” (+ 3), tion about an individual’s health status. They believed “Self-confidence” (+ 2) as most important criteria in health was a relatively stable state, except for dramatic judging health. Very similar to the reasons given in Fac- changes, such as an accident. Therefore, participants be- tor one, where frame of mind was regarded as most im- lieved that health should not be judged by symptoms portant, exemplars of Factor Five tended to believe that that varied from time to time. people who had an optimistic attitude, who were toler- ant of things that may be offensive and who were Discussion confident were more likely to face challenges and deal Differences across five factors with problems in life positively, therefore they were The study identified five distinct viewpoints in selecting more likely to have a good mental health state. Partici- key indicators that should be used to judge health. Five pants also mentioned the positive influence of a good diverse views in sorting health statements demonstrate mental attitude on one’s physical health state. that health is a complicated concept and can be under- While exemplars of Factor One considered both frame stood differently. There were various perspectives in of mind and social interaction as most important and thinking about health: exemplars of Factor One and explained the inner relations between the two, partici- Two were likely to perceive health from a functional pants in this account did not seem to favour health indi- point of view, exemplars of Factor Three tended to de- cators relating to social wellbeing: “State of social fine health as the opposite of diseases, while it was relations” (− 2), “Support from one’s social network” (− widely agreed by exemplars of Factor Four that health 2), “Ability to adapt to the social environment” (− 1), was closely linked with one’s lifestyles and daily life “Ability to communicate with people” (0). This may be quality in terms of sleeping and eating. The five view- explained by the age difference between the two groups points also showed a debate between evaluating health of participants. Exemplars in Factor Five (average age as a temporary state or as a longer-term status. While 30) were younger than people in Factor One (average exemplars whose sorts defined Factor One and Five age 55). Younger participants may be more concerned tended to assess health from a long-term basis, partici- about their own work thus did not appreciate social pants of Factor Three were likely to perceive health as wellbeing as much as exemplars of Factor One. a short-term state and considered current sensations Participants in this factor placed cognitive abilities, in- and feelings as most important. Additionally, findings cluding “Ability to think things clearly” (+ 2), “Ability to suggested that diverse priorities were given to different concentrate” (+ 2), “Ability to perceive changes in sur- aspects of health in different viewpoints. For example, rounding and to respond” (+ 1), “Ability to remember participants of Factor One jointly highlighted social things” (+ 1), as important statements. They explained wellbeing and one’s physical state; Factor Three empha- that such abilities were vital in their day-to-day work. sised mental states; while some exemplars whose sorts Similarly, they emphasised “Feeling of pressure”(+ 3) and generated Factor Two revealed that they considered “Feeling of anxiety”(+ 1) over other mental feelings, be- one’s physical fitness to be most important when think- cause these two feelings were more related to their work, ing about health. as Participant 20 expressed: “I cannot control my anxiety. The finding also illustrated how individuals’ demo- I have too much work stress, even when I go back home, I graphic characteristics, social surroundings and their keep thinking about the work I haven’t finished. I could own health experiences had shaped their perceptions of not sleep, I want to sleep but I can’t.” (no.20, female, 30 health. Similar to the previous literature [42–45], age years old) Participant 42 held the point that the was found to be one of the most influential factors in Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 11 of 15 shaping lay understandings of health. For example, Similarities among the viewpoints younger participants were found to talk about mental In addition to the differences described above, similar- health more frequently than the elderly. It might be be- ities in understanding the concept of health were also cause these young individuals were generally in a better detected across the five factors. There were health di- physical health state and were more likely to be exposed mensions that were important concepts to the majority to mental health issues. Meanwhile, the elder partici- of participants. The statement “Body constitution that pants tended to have more physical and cognitive func- can indicate the susceptibility to diseases” was agreed to tion problems compared to the younger participants and be important across the five factors. “Body constitution”, were more likely to highlight the importance of physical has been closely associated with the concept of health in and cognitive abilities. In our study, it was also more Chinese populations according to several studies [49, likely for elder people to raise social wellbeing issues in 50]. Its literal translation into Chinese is “body quality” defining health and this may be because they had more and can be defined as “the characteristics of an individ- experiences in appreciating the impact of social relations ual, including structural and functional characteristics, and hoped to be well involved in social communities temperament, ability to adapt to environmental changes, more [46]. or susceptibility to various health conditions” [51]. This Education was also found to be a salient indicator in term was found to be an understandable and widely re- shaping participants’ understandings of health, similar to ferred concept in describing health among Chinese lay previous findings [43, 44, 47, 48]. While participants people in published literature [49]. The current Q inves- with a higher level of education were more likely to be tigation has further proved it was widely accepted by aware of mental health and social wellbeing, participants Chinese participants as an indicator to assess one’s with a lower level of education were more likely to re- health. strict the scope of health within physical fitness. An ex- “Spiritual appearance” was another statement that was treme example was that several participants who had highly emphasised in the majority of the extracted fac- limited education declared they never heard about “Anx- tors. “Spirit” (“Shen”) is a central notion in traditional iety” and did not understand its meaning (Participant 27 Chinese knowledge and could be referred to one’s con- and 101) and they placed the statement randomly on a sciousness, mind, thoughts and/or vitality [52, 53]. A less important place. Besides, residence place may also possible description of spirit was illustrated in Diagnos- influence individuals’ views according to health. As it tics in Chinese Medicine that “having spirit” means was shown in Factor Five, most of the exemplars whose “one’s mind is clear, vision is bright, talking is clear, sorts defined this factor lived in cities and illustrated complexion is glowing, facial expression is natural, re- they had a stressful job in a competitive working envir- sponse is quick, movement is agile, breathing is smooth onment. It may explain why they were more likely to and steady…” [54] It was recognised in previous qualita- emphasise statements on cognitive abilities and mental tive interviews that the concept of “Spirit” was part of health issues. lay participants’ common knowledge. Since the state- Apart from demographic characteristics, one’s health ment about spirit was also rated highly in the Q-study, it conditions and past health experiences influenced one’s supported the assumption that “Spirit” could be an im- interpretation of health [44, 47, 48]. Participants who re- portant dimension in evaluating health among Chinese ported problems in mobility or doing self-care activities communities. were likely to place statements about physical functional Apart from Factor Two, which firstly prioritised phys- abilities as most important. As a result, none of them ex- ical health statements, other factors all held the point emplified Factor Three, Four and Five. It could also be that one’s “Life attitude (such as viewing things optimis- noted that exemplars of Factor Three and Four were tically or pessimistically)” as well as “Breadth of mind” generally in a good health state in terms of their EQ-5D (such as being tolerant of other people or narrow- results (half of them were in a “11,111” full health state minded to other people) were most important in judging and the majority of them had their self-rating health one’s health. This may reflect Chinese traditional know- scores higher than 80). They highlighted the quality of ledge in appreciating balance and harmony between an sleeping and eating in judging one’s health and empha- individual and the surroundings. It was explained else- sised lifestyle behaviours in maintaining health. It may where that according to Chinese traditional knowledge, be because those participants in a better health condi- because one’s external environment is closely associated tion were more likely to think about health in a higher with his/her daily activities, ideally, a person should be standard and define health in a more positive way. They capable of adjusting to the external environment to were less troubled by function limitation or negative reach a harmonious state [55]. It seemed to be widely feelings/sensations than the participants in the other accepted by many of the participants, as they linked a factors. positive mental-frame with good health and indicated Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 12 of 15 that facing problems in life positively and confidently were asked to think about health, to various extents and avoiding conflicts with other people were good prac- though. As those aspects are also principal domains in tices in adapting to the changes in the environment to frequently cited HRQoL conceptual models such as stay in health. Wilson-Cleary model and PROMIS model [62, 63], it in- The statement about sleep quality was also extensively dicates that Chinese and Western HRQoL measures agreed to be important, as the four of the extracted fac- shared comparable measuring frames. tors rated it with a positive importance level and three However, it is also clear that there are potential differ- of them regarded the statement as most important (at ences in understanding health between China and the least + 3). In a previous scoping review study, sleep was West. Comparing the current findings with the descrip- found to be assessed in all identified Chinese-developed tive system of EQ-5D, there were unique health dimen- HRQoL questionnaires, findings of the current Q study sions that were agreed to be important among Chinese provided additional evidence that sleep was regarded as participants, which are not mentioned in this Western- an important health dimension in China, from an empir- developed HRQoL questionnaire. Health dimensions in- ical perspective. Life regularity was also rated using posi- cluding body constitution [49, 50], spirit [55, 64], life at- tive importance levels by four factors. This may be in titude [65, 66], sleep [67–69] and life regularity [70, 71] line with a phenomenon where the idea of “Yangsheng” have been frequently linked with the concept of health (Health-keeping Behaviours) was widely referred to in the Chinese literature. The importance of such con- across Chinese communities. The idea conveys that good cepts is now supported by the current Q investigation. behaviours, such as keeping a regular lifestyle, can po- These “Chinese-characteristic” health dimensions dem- tentially be associated with “good health”. The massive onstrate cultural differences in defining health between popularity of “Yangsheng” phenomenon in China has China and the West. been addressed in recent literature [56, 57]. Along with The five dimensions of EQ-5D were included as state- the Q-study result, it indicates that considering one’s be- ments in the study. Although self-care, mobility and haviours when thinking about one’s health may be com- usual activities were acknowledged to be important in mon among Chinese lay people. two of the extracted factors, some participants men- There were also statements that were agreed to be less tioned that these physical function abilities were too important across the five factors. Although adaptability basic for them to worry about therefore were less im- to weather changes was assessed in several Chinese- portant. They tended to define health in a more positive developed HRQoL questionnaires [58–60], it was not way and with a higher standard. Views towards physical considered to be most important in the extracted views, feelings of pain and discomfort were also diverse. Some as most participants revealed that it was less relevant to believed they were effective indicators to detect one’s health compared to other statements. Feelings of fear physical health status, while there were participants ar- and loneliness were also found to be less important guing they could only indicate temporary states and, in across the five factors. Participants seemed to agree that most occasions, could not provide reliable information their life was not troubled by such two feelings. Some for health assessment. Similarly, anxiety and depression stated they enjoyed their own space and did not regard were also believed to be not reliable in evaluating health loneliness was a bad thing. Some stated they did not feel according to some participants. Furthermore, the two fearful very often thus did not regard it as important. terms may not be well understood by some Chinese Moreover, “State of sex life” was another statement people, especially those received limited education. placed to be less important in the majority of the identi- The results thus imply that the five dimensions of EQ- fied factors. The sensitive nature of this health dimen- 5D may not be comprehensive in measuring health in sion and its difficulty to be applied in assessing health China, it can be argued that the questionnaire may fail among Chinese populations was mentioned in the litera- to ask the most appropriate and important questions ture [61]. It was also revealed by participants that they among a Chinese population in assessing health. concerned this as a private topic and preferred not to discuss it with other people. Limitations The study was in nature exploratory. It identified five Potential differences in understanding health between distinct views of ranking 42 health statements highlight- China and the west ing the most important health statements within each The findings suggests that Chinese participants’ compre- view. However, this method does not provide one over- hensions of health were comparable to Western ways of arching or set of statements that were most important to describing health to a great degree. Statements about the whole sample of participants. Alternative quantita- function abilities, physical symptoms, emotions and so- tive research is planned to further investigate the con- cial wellbeing were recognised by participants when they cept of health in China. Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 13 of 15 Another limitation was that, because the study investi- Acknowledgements The authors are grateful to the participants and all the social group gated Chinese lay perceptions of health and recruited organisers who helped recruit the participants. The authors would like to only Chinese participants, it was not possible to compare thank Professor Jan van Busschbach for comments on an earlier draft of this Chinese participants’ views with Westerners’ to explicitly paper. The authors would like to express gratitude to the anonymous reviewers for their careful reading of the manuscript and their thoughtful test cultural differences in understanding health between comments and suggestions. China and the West. A Q-methodological investigation is planned to be conducted in the UK using a similar Authors’ contributions All authors conceptualised the research design. ZM conducted the research, study design and materials, but potential obstacles in collected data and analysed data. SA, PK and CDG supervised the whole data translating the Q-statements into English to make them collection and data analysis process. ZM wrote the manuscript. SA, PK and clear and understandable to Non-Chinese participants CDG critically reviewed the manuscript during the writing process. All authors approved the final version of the manuscript. are expected. Although our statements were written, checked for Funding ambiguity and understanding, a small number of partici- The first author’s contribution to this research was supported by the China Scholarship Council (CSC) - University of Leeds Joint Scholarship. pants did not understand some specific statement or in- terpret some statements differently. For instance, for Availability of data and materials those statements on functional abilities, some partici- The datasets used and/or analysed during the current study are available pants imagined situations when one totally lost physical from the corresponding author on reasonable request. abilities, such as cannot walk or cannot see or cannot Ethics approval and consent to participate hear, thus sorted the statements as most important, The study has been reviewed and approved by the School of Medicine while some participants did not expect conditions could Research Ethics Committee at the University of Leeds (reference number: MREC17–021). be that extreme and did not regard them as most im- portant. We acknowledged that such variations in partic- Consent for publication ipants’ interpretation of statements were difficult to Not applicable. control in the sorting exercise and may have influenced Competing interests how they sorted them. The authors declare that they have no competing interests. Author details Leeds Institute of Health Sciences, University of Leeds, Leeds, UK. Conclusion Department of Psychology, Queen’s University Belfast, Belfast, UK. Because EQ-5D is one of the most commonly used Western HRQoL measure in China, it was selected as an Received: 16 August 2019 Accepted: 20 May 2020 example to explore cultural differences between China and the West. The Q-study showed that many health References statements were rated highly as most important by a di- 1. Haraldstad K, Wahl A, Andenæs R, Andersen JR, Andersen MH, Beisland E, et al. A systematic review of quality of life research in medicine and health verse range of Chinese participants but were not covered sciences. Qual Life Res. 2019;28:2641–50. in EQ-5D. It then suggests that the EQ-5D descriptive 2. Bowling A. Health-related quality of life: conceptual meaning, use and system might need modification to improve its capacity measurement. In: Measuring disease: a review of disease-specific quality of life measurement scales. 2nd ed. Buckingham: Open University Press; 2001. to measure health status in China. The study raises a p. 1–22. general question as to how appropriate the Western- 3. Geisinger KF. Cross-cultural normative assessment: translation and developed HRQoL measures are when used to assess adaptation issues influencing the normative interpretation of assessment instruments. Psychol Assess. 1994;6:304. health in a significantly different cultural setting. The 4. Stewart AL, Napoles-Springer A. Health-related quality-of-life assessments in findings documented here are specific to China but the diverse population groups in the United States. Med Care. 2000;38:II102–I24. implications can and should be considered in other 5. Bowden A, Fox-Rushby JA. A systematic and critical review of the process of translation and adaptation of generic health-related quality of life measures countries/regions. in Africa, Asia, Eastern Europe, the Middle East. South America Soc Sci Med. 2003;57:1289–306. 6. Zhou T, Guan H, Liu G, Ma A. Health-related quality of life for disease Supplementary information population in China based on EQ-5D: a systematic review. Zhong guo xun Supplementary information accompanies this paper at https://doi.org/10. zheng yi xue za zhi. 2016;16:135–42. 1186/s12955-020-01414-z. 7. Zhou T, Guan H, Liu G, Ma A. Health-related quality of life for the general population in China: a systematic review. Zhong guo wei sheng shi ye guan li. 2016;33:621–3. Additional file 1: Table A1. the conceptual framework developed from 8. Wang H, Kindig DA, Mullahy J. Variation in Chinese population health the scoping review and qualitative interviews & how it was transformed related quality of life: results from a EuroQol study in Beijing. China Qual into Q-sample. Life Res. 2005;14:119–32. 9. Sun S, Chen J, Johannesson M, Kind P, Xu L, Zhang Y, et al. Population health status in China: EQ-5D results, by age, sex and socio-economic Abbreviation status, from the National Health Services Survey 2008. Qual Life Res. 2011;20: HRQoL: Health-related quality of life 309–20. Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 14 of 15 10. Tan Z, Liang Y, Liu S, Cao W, Tu H, Guo L, et al. Health-related quality of life 36. Bartlett ME, Han W, Bartlett J. Perceptions of mainland Chinese students as measured with EQ-5D among populations with and without specific toward obtaining higher education in the United States. J Int Stud. 2018;8: chronic conditions: a population-based survey in Shaanxi Province. China 623–37. PLoS One. 2013;8:e65958. 37. Stainton RR. Q methodology. In: Smith J, Van Langenhove L, editors. 11. Wu C, Gong Y, Wu J, Zhang S, Yin X, Dong X, et al. Chinese version of the Rethinking methods in psychology. London: Sage; 1995. p. 178–92. EQ-5D preference weights: applicability in a Chinese general population. 38. Arksey H, O'Malley L. Scoping studies: towards a methodological framework. PLoS One. 2016;11:e0164334. Int J Sci Res. 2005;8:19–32. 12. Sun S, Chen J, Kind P, Xu L, Zhang Y, Burström K. Experience-based VAS 39. Baker R, Thompson C, Mannion R. Q methodology in health economics. J values for EQ-5D-3L health states in a national general population health Health Serv Res Policy. 2006;11:38–45. survey in China. Qual Life Res. 2015;24:693–703. 40. Dziopa F, Ahern K. A systematic literature review of the applications of 13. F-l Z, Yue M, Yang H, Wang T, Wu J-H, Li S-C. Validation and comparison of Q-technique and its methodology. Eur J Res Meth Behav Soc Sci. 2011; EuroQol and short form 6D in chronic prostatitis patients. Value Health. 7:39. 2010;13:649–56. 41. Watts S, Stenner P. Understanding the analytic process (1): factor extraction. 14. Yang Z, Busschbach J, Liu G, Luo N. EQ-5D-5L norms for the urban Chinese Doing Q methodological research: theory, method and interpretation. population in China. Health Qual Life Outcomes. 2018;16:210. London: SAGE Publications Ltd; 2014. 15. Fang H, Farooq U, Wang D, Yu F, Younus MI, Guo X. Reliability and 42. Bury M. Chronic illness as biographical disruption. Sociol Health Illn. 1982;4: validity of the EQ-5D-3L for Kashin–Beck disease in China. SpringerPlus. 167–82. 2016;5:1924. 43. Mansour AA-H. The conceptualization of health among residents of 16. Wang F, Li H, Ma A. Study on the application of General Utility Scale on Saskatoon. J Community Health. 1994;19:165–79. Chinese populations. Zhong guo yao wu ping jija. 2015;32:244–7. 44. Baumann B. Diversities in conceptions of health and physical fitness. J 17. Wang HM, Patrick DL, Edwards TC, Skalicky AM, Zeng HY, Gu WW. Validation Health Hum Behav. 1961;2:39–46. of the EQ-5D in a general population sample in urban China. Qual Life Res. 45. Julia L. Lay experiences of health and illness: past research and future 2012;21:155–60. agendas. Sociol Health Illn. 2003;25:23–40. 18. Zhu Y, Shen Y. A construct validity analysis and application of EQ-5D 46. Depp CA, Jeste DV. Definitions and predictors of successful aging: a among type 2 diabetes patients. Zhejiang yu fang yi xue. 2014;26:14–8. comprehensive review of larger quantitative studies. Am J Geriatr Psychiatry. 19. Wu C, Gong Y, Wu J, Zhang S, Yin X, Dong X, et al. Chinese version of the 2006;14:6–20. EQ-5D preference weights: applicability in a Chinese general population. 47. van Dalen H, Williams A, Gudex C. Lay people's evaluations of health: are PLoS One. 2016;11(10):e0164334. there variations between different subgroups? J Epidemiol Community 20. Prior L, Chun PL, Huat SB. Beliefs and accounts of illness. Views from two Health. 1994;48:248–53. Cantonese-speaking communities in England. Sociol Health Illn. 2000;22: 48. Blaxter M. Health and lifestyles. London. New York: Routledge; 2003. 815–39. 49. Lew-Ting C-Y, Hurwicz M-L, Berkanovic E. Personal constitution and health 21. Liu JE, Mok E, Wong T. Perceptions of Chinese cancer patients of the status among Chinese elderly in Taipei and Los Angeles. Soc Sci Med. 1998; favorable and unfavorable words conveyed by their social support 47:821–30. providers. Cancer Nurs. 2005;28:348–54. 50. Chan RY, Chien WT. Concepts of body constitution, health and sub-health 22. Chen AW, Kazanjian A, Wong H. Why do Chinese Canadians not consult from traditional Chinese medicine perspective. World J Transl Med. 2013;2: mental health services: health status, language or culture? Transcult 56–66. Psychiatry. 2009;46:623–41. 51. World Health Organization. International statistical classification of diseases 23. Xiang YT, Chiu HF, Ungvari GS. Quality of life and mental health in Chinese and related health problems (11th Revision). 2018. https://icd.who.int/ culture. Curr Opin Psychiatry. 2010;23:43–7. browse11/l-m/en. Accessed 11 June 2019. 24. Huang Z, Zhang Y, Ran J, Dong W, Su H, Yang Y. Individual cognition on 52. Rossi E. Shen: psycho-emotional aspects of Chinese medicine. Edinburgh: the concept of health. Zhong guo yun dong yi xue za zhi. 2011;30:374–8. Elsevier Health Sciences; 2007. 25. Wang L. A narrative inquiry into the health concept of local adults in 53. Zi T. Illustrating the fundamentals of the yellow Emperor’s classic of internal Chengdu China] [master thesis. Sichuan: University of Sichuan; 2001. medicine. Shaanxi: Shaanxi Normal University Press; 2012. p. 357. 26. Watts S, Stenner P. Doing Q methodology: theory, method and 54. Deng T, Guo Z. Diagnostics in Chinese medicine. Shanghai: Shanghai interpretation. Qual Res Psychol. 2005;2:67–91. Science and Technology Publisher; 1984. 27. Stephenson W. Correlating persons instead of tests. J Pers. 1935;4:17–24. 55. Zhang H, Zhang F-Y, Zhao Y-N, Li Z. Health concepts under the view of 28. Stainton Rogers W, Dyson Rogers PO. Q methodological research in mental Chinese culture. Zhong hua hu li za zhi. 2015;50:1236–9. health and psychotherapy. In: Qualitative research methods in mental 56. Si F, Song X, Gao Y. Current situation of the TCM Yangsheng market. Zhong health and psychotherapy: a guide for students and practitioners. West yi yan jiu. 2013;26:1–3. Sussex: Wiley; 2001. p. 193–208. 57. Sun W. Regimes of healthy living: the reality of ageing in urban China and 29. McKeown B, Thomas DB. Q methodology. 2nd ed. Los Angeles; London; the cultivation of new normative subjects. J Consum Cult. 2016;16:908–25. New Delhi; Singapore. Washington DC: Sage publications; 2013. 58. Wu D, Lai S, Guo X, Wen Z, Liang W, Yang X. Establishment and initial 30. Eccleston C, Amanda CDC, Rogers WS. Patients' and professionals' evaluation of Health Scale of Traditional Chinese Medicine. Zhong guo understandings of the causes of chronic pain: blame, responsibility and zhong xi yi jie he za zhi. 2007;27:847–50. identity protection. Soc Sci Med. 1997;45:699–709. 59. Liu FB, Zhao L, Lang JY, Lin LZ, Liang GH, Fang JQ. Development of the 31. Stenner P, Dancey C, Watts S. The understanding of their illness amongst Chinese Quality of Life Instrument. Zhong guo zu zhi gong cheng yan jiu people with irritable bowel syndrome: a Q methodological study. Soc Sci he lin chuang kang fu. 2007;11:10492–5. Med. 2000;51:439–52. 60. Li X. [The development and evaluation of Chinese PRO scale] [master 32. Stenner PH, Cooper D, Skevington SM. Putting the Q into quality of life; the thesis]. Guangzhou: Guangzhou University of Chinese Medicine; 2007. identification of subjective constructions of health-related quality of life 61. Yu C, Sun Y, He L, Bai W, Liu B. Comparative study on the concepts of using Q methodology. Soc Sci Med. 2003;57:2161–72. health related quality of life from TCM and modernized medicine measures. 33. Peng Y. Democracy and Chinese political discourses. Mod China. 1998;24: Zhong hua zhong yi yao za zhi. 2016;31:4773–8. 408–44. 62. Wilson IB, Cleary PD. Linking clinical variables with health-related quality of 34. Dewar K, Li WM, Davis C. Photographic images, culture, and perception in life: a conceptual model of patient outcomes. JAMA. 1995;273:59–65. tourism advertising: a Q methodology study of Canadian and Chinese 63. Cella D, Riley W, Stone A, Rothrock N, Reeve B, Yount S, et al. The patient- university students. J Travel Tour Mark. 2007;22:35–44. reported outcomes measurement information system (PROMIS) developed 35. Cai D, Stone TE, Petrini MA, McMillan M. An exploration of the health beliefs and tested its first wave of adult self-reported health outcome item banks: of Chinese nurses' and nurse academics' health beliefs: a Q-methodology 2005–2008. J Clin Epidemiol. 2010;63:1179–94. study. Nurs Health Sci. 2016;18:97–104. 64. Hsu E. Spirit (shen), styles of knowing, and authority in contemporary Chinese medicine. Cult Med Psychiatry. 2000;24:197–229. Mao et al. Health and Quality of Life Outcomes (2020) 18:165 Page 15 of 15 65. An S, Chen C, Li J, Zhang M, Li S, Dou N. Associations of life attitude and personality type with degree of frailty in disabled oldest-old people. Zhong guo gong gong wei sheng. 2018;34:171–6. 66. Li P, Li W. Mentality Health and Physical Health. Jia ting hu shi. 2008;1:203. 67. Wang G, Zhang J, Xu Y, Zhu Y, Ke D, Zhang G. Elementary study of sleep quality and self-rated health on common populations. Zhong guo xing wei yi xue ke xue. 2003;12:80–2. 68. Zhao J, Xie Y, Shi M, Ren Z, Feng X. Relationship between sleep quality and quality of life in military personnel in high altitude area. Zhong guo gong gong wei sheng. 2006;22:665–6. 69. Cheng G, Zhang X, Yang Y. Study of Sleep and Quality of Life of the Workers from Chengdu Air Craft Manufacturing Factory. Xian dai yu fang yi xue. 2008;35:45–7. 70. Su D. A study of health beliefs among Chinese adults] [PhD thesis. Chongqing: Southwest University; 2015. 71. Zhang H, Li H, Gu D. One hundred health proverbs. Beijing: Overseas Chinese Publisher; 2005. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Journal

Health and Quality of Life Outcomes – Springer Journals

Published: Jun 3, 2020

There are no references for this article.