Abstract

Definitions of self-care in health are intended to influence health care policy by focussing attention on what behaviours can be encouraged to benefit public health. To serve this purpose such definitions are succinct but broadly drafted to encompass the full range of behaviours implied by the term. Current definitions have common themes (such as disease prevention) but differ in specific aspects (e.g. explicit inclusion of self-medication).

At the level of the individual, defining what self-care means may have a different purpose. By exposing people to the full array of behaviours for which there is a strong evidence base, we might audit their behaviour against an ideal benchmark and derive a prioritised action plan personal to them. We propose a research agenda which would explore the domains, behaviours, weightings and measures of self-care in healthy people in order to develop an index of overall self-care behaviour and thereby identify an individual’s self-care deficit. This in turn could be used to generate a prioritised action plan for behaviour change.

The ability to quantify self-care behaviour and self-care deficits may be an important driver to healthcare policy to set alongside evolving definitions of self-care.

INTRODUCTION

Agreeing on a definition of self-care is not simply a matter of semantics or philosophy: such definitions are intended to have practical uses. In articulating what self-care means, a definition may highlight themes that policy and spending should address in order to change behaviour at a population level. Definitions may also have utility at an individual level in identifying deficits which might be the focus of personal interventions. Finally, a definition may serve to set the agenda for research to explore the drivers of self-care behaviour and new interventions to change it.

Definitions of self-care in healthy people mirror the times in which they were drafted and may need to evolve to remain relevant to the changing health priorities of individuals and populations. This article reflects on how the World Health Organisation (WHO) and others have defined self-care in recent decades, and what common themes emerge.

It may be that a single definition of self-care is not enough for all purposes. A ‘policy setting’ definition should ideally be brief; whereas a definition designed to quantify self-care behaviour at a personal level may need to be more comprehensive in nature.

RECENT EXAMPLES OF SELF-CARE DEFINITIONS

Probably the oldest definition which remains often quoted is that of the WHO, dating back to 1983 (Health Education in Self-Care: Possibilities and Limitations. Report of a Scientific Consultation. Geneva, Switzerland: World Health Organization; November 21–25, 1983.)¹:

‘Self Care in health refers to the activities individuals, families and communities undertake with the intention of enhancing health, preventing disease, limiting illness, and restoring health. These activities are derived from knowledge and skills from the pool of both professional and lay experience. They are undertaken by lay people on their own behalf, either separately or in participative collaboration with professionals.’

A later WHO definition, taken from the paper ‘The role of the pharmacists in self-care and self medication: report of the 4th WHO consultative group on the role of the pharmacist’, Geneva, 1998², is more specific in several areas, and has served as the basis for many derivatives:

‘Self-Care is what people do for themselves to establish and maintain health, and to prevent and deal with illness. It is a broad concept encompassing hygiene (general and personal), nutrition (type and quality of food eaten), lifestyle (sporting activities, leisure etc.), environmental factors (living conditions, social habits, etc.), socio-economic factors (income level, cultural beliefs, etc.) and self-medication.’

Finally, at a recent working group organized by the WHO on the occasion of World Health Day 2013, the following self-care definition was given:

‘Self-Care is the ability of individuals, families and communities to promote health, prevent disease, and maintain health and to cope with illness and disability with or without the support of a health-care provider.’

This definition was first introduced as a working definition in the WHO paper on ‘self-care in the context of primary healthcare’ of 2009³. It is often referred to as the ‘WHO 2009’ definition.

Of course the WHO is not the only body to put into words an explicit statement of what it means by self-care. The UK Department of Health definition of self-care, taken from the paper ‘Self-Care – A Real Choice’, 2005⁴ states:

‘Self care is a part of daily living. It is the care taken by individuals towards their own health and well being, and includes the care extended to their children, family, friends and others in neighbourhoods and local communities. Self-Care includes the actions individuals and carers take for themselves, their children, their families and others to stay fit and maintain good physical and mental health; meet social and psychological needs; prevent illness or accidents; care for minor ailments and long-term conditions; and maintain health and wellbeing after acute illness or discharge from hospital.’

These examples are compared in Table 1:

Table 1: Themes in Recent Definitions of Self-Care

Some common themes emerge:

• All of these definitions are aimed primarily at healthy people.
• All definitions refer to prevention of disease or illness as one of the primary aims of self-care. Most health care systems are designed to treat illness as it presents. The behaviours that maintain health or prevent disease often relate to aspects of lifestyle (e.g. diet, exercise and risk avoidance) which are matters of personal choice no matter how much healthcare professionals may seek to influence them.
• Several definitions encompass the concept of collaboration between individuals and healthcare providers. Conceptually, everything that happens outside a doctor’s office is part of self-care; the aim for collaboration recognises that a patient must be an active participant in, rather than a passive recipient of, treatment.
• All definitions include the behaviour of individuals as self-care, but several broaden this to families and communities. This recognises that carers essentially practise self-care by proxy, and that some aspects of self-care (e.g. accident prevention, providing facilities to encourage exercise) cannot be achieved unless people act together.

Inevitably, there are also differences of emphasis. For example, only the WHO 1998 definition (which as noted first appeared in a report on the role of pharmacists) mentions self-medication. As pressure on professional healthcare resources grows, it would not be a surprise to see a focus on self-treatment of minor illness and perhaps self-medication to reduce risk of serious illness feature more prominently in future definitions.

Arguably, the definitions in common currency neglect some emerging features of modern life. Increasingly individuals carry with them technology that allows them to seek information about their health and monitor their own body in health and disease. Health literacy will have to keep pace with the means to access information if we expect people to use these tools to practise more effective self-care.

SELF-CARE AT THE PERSONAL LEVEL: MEASURING SELF-CARE IN HEALTH

In order to produce the most positive change at the population level, we may need a definition that can be implemented at the level of the individual, the prime unit of self-care. Here, defining the broad categories of self-care may not be enough: we may need to define comprehensively the behaviours that constitute the ideal, as a benchmark for comparison. When one is aware of all that can be done, it becomes possible to audit one’s own personal self-care ‘assets’, while recognising where there are ‘deficits’ as a means to plan behaviour change.

As an illustration, an evidence-based registry of effective self-care practices might include the following domains (or ‘pillars’) of self-care, and specific behaviours:

1. Health literacy – includes: the capacity of individuals to obtain, process and understand basic health information and services needed to make appropriate health decisions.
2. Self-awareness of physical and mental condition – includes: knowing your body mass index (BMI), cholesterol level, blood pressure; engaging in health screening.
3. Physical activity – practicing moderate intensity physical activity such as walking, cycling, or participating in sports at a desirable frequency.
4. Healthy eating – includes: having a nutritious, balanced diet with appropriate levels of calorie intake.
5. Risk avoidance or mitigation – includes: quitting tobacco, limiting alcohol use, getting vaccinated, practicing safe sex, using sunscreens.
6. Good hygiene – includes: washing hands regularly, brushing teeth, washing food.
7. Rational and responsible use of products, services, diagnostics and medicines – includes: being aware of dangers, using responsibly when necessary.

With appropriate weighting of individual items within each domain (e.g. smoking status), and derivation of measures meaningful for each behaviour, it may be possible to arrive at a personal self-care index or score. As well as providing a score out of a maximum possible, the instrument would allow the most important weighted deficits to be identified. With access to this information, the next step would be to derive a prioritised action plan.

Such an approach has been applied to self-care in people with specific illnesses (e.g. the self care of heart failure index⁵), but not, so far as we are aware, to currently healthy people before they become unwell. Adjusting self-care behaviours before disease develops, but even as risk accumulates, is largely an individual choice so an individual self-care score may be a significant motivating factor.

Clearly, to have maximum utility and credibility, such a tool would need to be developed with all of the rigour applied to ‘Patient Reported Outcomes’ (PROs) and health status instruments⁶. Such a programme of research would face considerable challenges. To agree on relevant measures for specific behaviours and how to weight their contribution to an overall score would require expert consensus as a starting point. Nevertheless, such an exercise could produce an instrument suitable for use when individuals seek general health information as well as when they consult a health care professional. Once we can measure self-care, the evaluation of programmes to influence self-care behaviour would be enabled and this could provide a welcome stimulus to future research on interventions.

The concept of self-care measurement could also be applied in a broader context. It may be possible to compare how well communities (e.g. at the level of cities or towns) provide support for behaviours within the main domains or pillars of self-care. This may provide a means of auditing the impact of policies intended to improve self-care. For example, do the miles of dedicated cycle lanes, or the availability of public parks in a community, relate to the level of regular exercise among its residents? New policies could even be subjected to prospective research through cluster randomisation of communities to the new intervention or standard provisions. Thus measurement may enable the aspirations expressed in the broader ‘policy setting’ definitions of self-care.

DISCUSSION

Definitions of self-care in health are important in articulating the areas to which policy and spending should be directed with the aim of improving public health by this means. Popular definitions in current use show broad agreement on the scope and purpose of self-care and have an appropriate emphasis on disease prevention where changes in lifestyle behaviour are largely matters of individual choice. Such definitions will evolve only slowly, but future iterations might be expected to include reference to appropriate self-medication in light of the growing range of options available, including some directed at risk-reduction and disease prevention. The increasing availability of technology to access healthcare information and to monitor health parameters may suggest the future need for explicit mention of health literacy.

In contrast to definitions aimed at healthcare policy, definitions of self-care which aim to educate and change behaviour at a personal level need to be more comprehensive, explicit and instructive. It may be possible to design an evidence-based instrument to measure the degree to which an individual is engaged in the panoply of self-care activities that will influence health. Scoring existing behaviours and identifying behavioural deficits can in turn lead to a prioritised plan of action for behaviour change. Research to identify the domains, activities, weightings and items to measure would need to be undertaken to produce a tool with a rigorous scientific underpinning.

In defining self-care we should keep in mind the purpose of such definitions. As well as seeking to set a policy agenda, we might also set our sights on a different target: defining self-care in such a way as to enable measurement in individuals. Such a research agenda may have significant utility in changing self-care behaviour which, after all, is the real aim behind defining self-care.

Correspondence to: David Webber, International Self-Care Foundation, Suite 6, 6/F., Tower 1, Silvercord, 30 Canton Road, Hong Kong. Email: davidewebber1@gmail.com.