How Are You Doing… Really? A Review of Whole Person Health Assessments

Abstract

Policy Points.

• A redirection of measurement in health care from a narrow focus on diseases and care processes towards assessing whole person health, as perceived by the person themself, may provide a galvanizing view of how health care can best meet the needs of people and help patients feel heard, seen, and understood by their care team.

• This review identifies key tensions to navigate as well as four overarching categories of whole person health for consideration in developing an instrument optimized for clinical practice. The categories (body and mind, relationships, living environment and finances, and engagement in daily life) include nine constituent domains.

• To maximize value and avoid unintended consequences of implementing a new measure, it is essential to ensure adequate time with the person providing the responses. Use of the instrument should be framed around the goal of better understanding a person's whole health and strengthening their relationship with the care team and not for comparisons across physicians or meeting a target score.

Context

Frustration with the burden of proliferating measures in health care focused on diseases and care processes has added to the growing desire to measure what matters to people, including understanding how people are doing in terms of their whole health. There is no consensus in the literature on an ideal whole person health instrument for use in practice. To provide a foundation for assessing whole person health and support further instrument development, this review summarizes past work on assessing person‐reported whole health, articulates conceptual domains encompassing whole health, and identifies lessons from existing instruments, including considerations for administration.

Methods

A scoping literature review and instrument review were conducted. Concepts from the literature and instruments were thematically coded using a grounded theory approach.

Findings

We identified four overarching categories of whole person health, consisting of nine domains: body and mind (physical well‐being, mental/emotional well‐being, meaning and purpose [spiritual well‐being], sexual well‐being), relationships (social well‐being), living environment and finances (financial well‐being, environmental well‐being), and engagement in daily life (autonomy and functioning, activities). A tenth domain of global well‐being was used for instruments that assessed well‐being as a whole. In total, 281 instruments were examined; most were specific to a single domain or subdomain. Fifty instruments assessed at least three domains; only five assessed all domains identified. Two key tensions must be navigated in the development of a whole person health instrument: comprehensiveness versus brevity, and standardization versus flexibility.

Conclusions

The array of whole person health domains identified in this review and lack of consensus on how best to measure health present an opportunity to develop a new instrument to support a shift to whole health care. In addition to better tools for assessment, a shift to whole health care will require broader system transformation in payment, care delivery, and the ecology of measurement.

Whole health, or “physical, behavioral, spiritual, and socioeconomic well‐being as defined by individuals, families, and communities,” ¹ is a resource for everyday life. ² The National Academies of Sciences, Engineering, and Medicine (NASEM)’s publication of a 2023 report on whole health reflects increasing attention to reorient health care around whole health, indicating a need to move beyond assessments of health that focus on physical aspects alone.

As the NASEM describes, the first step toward advancing whole person health is to understand what matters to people. The NASEM whole health report calls for work to identify existing measures that reflect the foundational elements of whole health and to identify and fill gaps requiring new measures. ¹ Around the same time of publication of this report, the Centers for Medicare and Medicaid Services (CMS) developed the Universal Foundation, a preliminary aligned measure set for use across value‐based care programs and measurement initiatives. In creating the Universal Foundation, the CMS underscored the need not only for improved measures but also for reduced measurement burden and parsimony in measure use. Within the Universal Foundation, the CMS identified the lack of a measure of holistic well‐being as a current gap. ³ This gap limits clinician knowledge of all aspects of health that matter to people, the ability of the CMS to assess the adequacy of efforts to address whole person health, and policymakers’ consideration of health in all policies and appropriate allocation of resources.

Two reviews in the last several years have examined instruments to assess whole health or well‐being. Linton and colleagues describe a lack of consensus on how to assess well‐being, stemming from differences in definitions; theoretical grounding; and the disciplines, perspectives, and purposes of the instrument developers. ⁴ The most commonly reported theoretical influences are the World Health Organization (WHO) definition of health and Diener's model of subjective well‐being; many instruments have also been presented in the literature without description of how they relate to theories of health and well‐being. ⁴ The authors note there is no universally accepted measure despite the large and growing number of instruments available. However, they suggest consensus on a single instrument may be unrealistic given the range of purposes for assessing well‐being. Thomas and colleagues specifically examined instruments of whole health that include a component of patient–clinician interaction. ⁵ They did not identify an existing approach that was ready for implementation in general practice but concluded some instruments may be suitable if adapted and evaluated further.

Recognizing the need for better assessment of what matters to patients, the CMS/the Department of Health and Human Services has funded the Vitality Signs project to develop a patient‐reported survey to enable all health outcomes—physical, behavioral, emotional, psychological, cultural, and social—by directing attention to those things patients and clinicians find most important about their care. ⁶ Such an instrument is intended to ensure that patients feel heard, seen, and understood by their care team. The first step of this project was a literature review to understand the current landscape of assessing whole health.

The goal of this review is to summarize past work on assessing patient‐reported whole health, articulate the conceptual domains encompassing whole health and their influencers, and identify lessons and best practices from existing instruments, including considerations for administration. To achieve this goal, this review not only explores existing instruments but also identifies themes of whole health in the literature that may not be assessed through current instruments. Our results span definitions and theories of well‐being and related concepts; identified domains, subdomains, and overarching categories of whole health; decision‐making considerations related to instrument design features including key tensions to navigate; and an exploration of existing instruments of well‐being or whole health, including a deep dive into selected instruments.

Methods

Search Strategy

The core research team was comprised of four individuals: two board certified family physicians, one psychology fellow, and one psychology graduate student. Additionally, the research team regularly consulted with the broader interprofessional Vitality Signs project team, including individuals with expertise in public health, communications, finance, biostatistics, anthropology, and policy. These consultations involved reviewing results and discussing potential new directions and interpretations. A scoping literature review ⁷ and separate instrument review were conducted by the research team. Reporting of methods and results were guided by the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) framework. ⁸ Literature review searches were conducted in PubMed, Google Scholar, and Google (for gray literature). Measure review was conducted in the Health and Psychosocial Instruments (HaPI) database. This database contains bibliographic information on behavioral health measurement tools from leading journals in health and sciences. Search terms varied across databases and were selected from learnings from initial database searches, subject matter expert opinion, and consultation with a professional librarian (see the online supplemental information for specific data syntax used). The literature search was limited to records within the last ten years (2013‐2023); a snowball review of seminal articles cited was performed to ensure both old and new citations of relevance were being reviewed. Additional resources recommended by experts in the field were screened for inclusion. Initial test searches in PubMed resulted in measures specific to certain populations (e.g., health professions students) and disease states, as well as some case studies or case reports. This led the research team to add further exclusions to the search criteria.

Inclusion and Exclusion Criteria

Articles and resources were excluded from the literature review if they were as follows: (1) not an appropriate level of evidence or format (e.g., thesis, dissertation, PowerPoint presentation); (2) related to a survey or measure that is not patient or person reported; (3) not related to overall well‐being; (4) diagnostic or disease focused; (5) focused on an intervention or self‐help strategies; (6) specific to a certain disease‐defined population; (7) specific to health care workers or health professions students; (8) a testing of a well‐being instrument in a specific population; (9) inclusive of overall well‐being, but the focus of article was unrelated or not applicable to project aims (e.g., neurobiological and genetic mechanisms of well‐being); (10) results already included in a separate review or meta‐analysis; (11) more recent evidence on the same project available; and/or (12) unable to be retrieved from accessible databases.

Measures were excluded from the review if they were as follows: (1) not patient or person reported; (2) diagnostic or disease focused or did not include overall well‐being; (3) specific to health care professionals or students; (4) specific to a symptom; (5) an old version of a measure or measure no longer in use; and/or (7) a subscale of a measure. The search was not limited based on age of the respondent population; both adult and youth measures were reviewed.

Data Extraction

The search of PubMed resulted in 52,738 articles. Three researchers reviewed results sorted by relevance together until it was apparent that saturation, meaning further data collection was no longer producing novel insights, had been reached after 300 results. The research team then conducted a title and abstract review. The initial Google Scholar search resulted in 17,800 resources. Four researchers reviewed abstracts or brief descriptions until it was determined that saturation had been met after the first 150 results and review of additional result pages were of low yield. The gray literature search followed the same process and was conducted in .gov, .edu, and .org web domains.

The initial search of measures through the HaPI database resulted in 4,099 instruments, of which 2,831 were duplicates and removed. Measures were extracted based on inclusion/exclusion criteria using Covidence. Researchers documented the survey/measure name, population, indication/purpose of measure, total number of items, and response scale type(s). Measures were flagged for detailed review of individual question items if they fit one or more of the following criteria: (1) were recommended by experts, (2) filled a gap in data on a subdomain or domain, and/or (3) were determined by the research and larger interdisciplinary Vitality Signs team to be most aligned with the project aim of creating a person‐reported whole health instrument suited for general use in clinical care, including measures that captured a significant number of whole health domains or assessed overall well‐being that were broadly applicable (i.e., not specific to a subpopulation).

Analysis

Concepts extracted from identified articles, resources, and measures were thematically analyzed and labeled as domains and subdomains. First, after familiarization with the content, concepts from the literature and measure items or sections were coded with subdomains. Subdomains were eventually clustered together into larger themes or domains. For example, subdomains such as “negative emotions” and “optimism” were categorized under the domain “mental and emotional well‐being.” Using a grounded theory approach, researchers iteratively updated domains, recategorized subdomains, and created new domains as they were identified throughout the literature review through collaborative discussions across the research team. ⁹ Coding was undertaken by three reviewers, and any discrepancies were solved through discussion with the fourth researcher of the literature review team. Although there was inevitable overlap among domains and subdomains that may cross multiple domains, the domains provided a way of organizing and categorizing various aspects of whole person health. Given the interconnectedness of domains and potential utility of a more simplified categorization structure for instrument development, the creation of overarching categories, or “lumping,” was implemented to categorize domains into more primary concepts. To create overarching categories, a similar process of iterative recategorization and collaborative discussion was undertaken across the research team. Moreover, as reviewers read through the literature, multiple terms, definitions, and theories related to health and whole health emerged that were documented.

In addition to determining domains and subdomains of whole health, another purpose of the literature search was to examine decision points in instrument design related to features (e.g., frequency of administration, question response types, etc.). As researchers examined measures and the literature, specific instrument features and related considerations were identified.

During review of existing instruments with the broader project team, 11 instruments were identified as being well positioned to inform future survey development. With input from the broader project team's diverse perspectives and expertise, these instruments were selected for their comprehensiveness, utility, frequency of usage, relevance to project aims, and illustration of different approaches to assessment through variations in instrument design. Researchers then assigned the identified domains to each of these selected instruments to better understand the comprehensiveness of each measure.

Findings

The PRISMA diagram outlines the search strategy for inclusion and exclusion of instruments, articles, and other results in this review (Figure 1).

Figure 1.

PRISMA Flow Diagram of Selection Process of Instruments, Articles, and Gray Literature

HaPI, Health and Psychosocial Instruments; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta‐Analyses.

A search of patient‐reported instruments to measure whole person health was performed in the HaPI database and supplemented by additional findings in our literature review and recommendations from experts. In total, 281 instruments were included in our review; most of these instruments were specific to a single domain or subdomain of whole person health. Of the single‐domain instruments, 12 assessed global well‐being or life satisfaction. There were 50 instruments that assessed at least three domains of whole health. Only four instruments (plus one short‐form version) ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ included questions specific to all of the domains of whole health.

More specifically, of the 281 instruments, 74 were specific only to a subdomain (e.g., body image) and 12 were an alternate version (e.g., short‐form, parent version) of an included base version of an instrument. Thus, we reviewed 197 unique instruments that included at least one domain of whole health. Of these 197 instruments, 110 were specific to a single domain (e.g., physical well‐being). There were 87 instruments that examined at least two domains of whole health, including 61 instruments that asked about global well‐being.

In the literature review, 60 articles from PubMed, 55 articles from Google Scholar, 46 results from Google, and 32 articles referred from experts were identified for inclusion. From these articles, researchers identified key whole health terms and definitions, subdomains and domains of whole health to inform thematic analysis, and considerations for instrument design, each of which is detailed below.

Definitions of Whole Health and Related Terms

Review of existing whole health literature revealed numerous overlapping terms and definitions of related concepts. A glossary of these terms is found in Table 1. Definitions were identified from well‐known national and international organizations when available. Related theories that were identified are listed in the online supplemental information.

Table 1.

Definitions of Whole Health and Related Terms

Term	Definition
Health	Not merely the absence of disease or infirmity but a state of complete physical, mental, and social well‐being. 15
	The ability to derive maximum benefit from life's journey. 16
Whole health	Whole health is physical, behavioral, spiritual, and socioeconomic well‐being as defined by individuals, families, and communities. 1
Whole health care	To achieve whole health, whole health care is an interprofessional, team‐based approach anchored in trusted longitudinal relationships to promote resilience, prevent disease, and restore health. It aligns with a person's life mission, aspiration, and purpose. 1
Well‐being	How people think, feel, and function—at a personal and social level—and how they evaluate their lives as a whole. 17
Psychological well‐being	The combination of feeling good and functioning effectively. Feeling good incorporates not only positive emotions of happiness and contentment but also interest, engagement, confidence, and affection. Functioning effectively involves developing one's potential, having some control over one's life, having a sense of purpose, and experiencing positive relationships. 18
Positive mental health	A state of well‐being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community. 19
Hedonic well‐being	The type of happiness or contentment that is achieved when pleasure is obtained and pain is avoided. 20
Eudaimonic well‐being	The type of happiness or contentment that is achieved through self‐actualization and having meaningful purpose in one's life. 20
Evaluative well‐being	The global evaluation that people make about their life, which is usually assessed by reporting how satisfied people are with their lives. 21
Subjective well‐being	An umbrella term used to describe the level of well‐being people experience according to their subjective evaluations of their lives. These evaluations, which can be both positive and negative, include judgments and feelings about life satisfaction, interest and engagement, affective reactions such as joy and sadness to life events, and satisfaction with work, relationships, health, recreation, meaning and purpose, and other important domains. 22
Life satisfaction	The extent to which a person finds life rich, meaningful, full, or of high quality. 20
QoL	Individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. This refers to a subjective evaluation that is embedded in a cultural, social, and environmental context. 23
Health‐related QoL	An individual's or a group's perceived physical and mental health over time and their correlates—including health risks and conditions, functional status, social support, and socioeconomic status. 24
Flourishing	A state in which all aspects of a person's life are good. This includes not only psychological well‐being but physical health and character. 25
Thriving	A multidimensional phenomenon that encompasses elements of subjective well‐being, environmental adjustment, and life satisfaction. Thriving has been said to differ in comparison with other concepts such as QoL or health‐related QoL, as it acknowledges that a person's abilities or disabilities are only one component of overall well‐being. 26
Happiness	An emotion of joy, gladness, satisfaction, and well‐being. 20
PRO	Any report of the status of a patient's health condition or health behavior that comes directly from the patient without interpretation of the patient's response by a clinician or anyone else. 27
Person‐centered care	Integrated health care services delivered in a setting and manner that is responsive to individuals and their goals, values, and preferences in a system that supports good provider–patient communication and empowers individuals receiving care and providers to make effective care plans together. 28

PRO, patient‐reported outcome; QoL, quality of life.

Content of Existing Instruments

From the 281 whole person health instruments and additional literature analyzed, the literature review team identified ten domains of whole health. In creating these domain categories, the review team noted a lack of agreement in the literature on domain category definitions. Additionally, many concepts cross multiple domains; for example, the subdomains of fatigue and sleep can be considered both in the domains of physical as well as mental and emotional well‐being. In such instances, the research team selected a domain of best fit to simplify categorization. To provide greater coherence to the domains of whole person health, we generated four broad categories that capture the different domains and may better reflect the interconnectedness of whole person health.

Domains of Whole Health

The literature review team identified nine domains of whole health: physical well‐being, mental/emotional well‐being, meaning and purpose (spiritual well‐being), sexual well‐being, social well‐being, environmental well‐being, financial well‐being, autonomy and function, and activities. A tenth overarching domain of life satisfaction and global well‐being was used when the instrument assessed well‐being as a whole outside of individual domains. The literature review team defined these domains by using both existing, well‐accepted definitions as well as creating new definitions based on terms gathered from the literature when an appropriate definition did not already exist. The domain definitions are listed below, and their constituent subdomains can be found in Table 2. The subdomains can be conceptualized as influencers of each domain and are inclusive of health capabilities (the conditions that affect health and one's ability to make health choices). ²⁹ For example, the subdomain of self‐efficacy is a health capability that influences the domain of autonomy and functioning. The relation of the domains to existing theories of well‐being and whole health is included in the online supplemental information.

Table 2.

Domains and Subdomains of Whole Health, as Categorized by the Literature Review Team Based on Existing Instruments and Additional Concepts Identified in the Literature

Domain	Subdomains
Life satisfaction and global well‐being	Overarching assessment of well‐being or life; life satisfaction
Physical well‐being	Exercise, nutrition/healthy eating, pain, physical symptoms, experience of illness or injury; oral health; effects of medications and treatments; senses (vision, hearing); mobility
Mental/emotional well‐being	Mental health, positive emotions, happiness, negative emotions, optimism, pessimism, resilience, empathy, stability, coping ability, adapting to change, balance, being grounded, self‐stigma, self‐acceptance, feeling loved and valued, being able to love, perceived stress; energy, fatigue, sleep; cognitive function; control of thoughts/emotions/feelings; body image; risk‐taking behaviors, substance use; burnout
Meaning and purpose (spiritual well‐being)	Religious well‐being, faith, relationship with God; existential well‐being, self‐transcendence; connection to higher purpose; acceptance of death, attitude toward one's own aging; sense of meaning; living in line with values; sense of coherence; source of hope and strength in life challenges; sense of direction; feeling useful; identity; character; personal growth; creativity; curiosity; connection to nature; spiritual practices
Sexual well‐being	Sexual satisfaction; sexual function; comfort with sexuality and sexual identity; sexual self‐esteem; sexual safety and security
Social well‐being	Relationships (close relationships and “weaker” relationships), marital satisfaction, friendships and peer relationships, parenting, early life attachments, family, positive interactions with others, caregiving relationships; family responsibilities and home life; relationships with pets; loneliness, social connectedness, belonging; social support, sense of community; social contribution; social capital; social media, bullying; relationships/interactions with care providers; experience of racism, trauma and abuse, adverse childhood experiences, discrimination or unfair treatment, feeling respected
Environmental well‐being	Environmental exposures (microbes, toxins, pollution, noise, traffic); climate (including extreme temperatures and weather catastrophes); physical safety, violence, crime; housing, living conditions (cleanliness, lack of pests or infestations, satisfaction with living environment); transportation accessibility/options; work conditions; food access; proximity to opportunities (leisure, arts, employment, education); access to green space; access to clean water and air; accessibility of information
Financial well‐being	Income, financial security, disposable income/ability to afford nonessentials, money for emergencies; ability to afford basic needs, housing stability, food security, transportation affordability; insurance status, out‐of‐pocket costs of health care; financial risk‐taking; ability to provide for dependents/one's family
Autonomy and functioning	Control over daily life; independence, self‐efficacy; life management skills, self‐care; functioning and limitations; ability to communicate; ADLs, IADLs
Activities	Satisfaction with and engagement in employment, school/education, volunteering, caregiving, housework, leisure/recreation, play, hobbies; feelings about how time is spent; work–life balance; political and civic engagement, voting; mastery, competence; lifelong learning; achievement of desired goals, accomplishment

ADL, activity of daily living; IADL, independent ADL.

Life Satisfaction and Global Well‐Being

Life satisfaction and global well‐being is described as an overarching self‐assessment of satisfaction with life or how one feels they are doing holistically across all domains of well‐being. ³⁰

Physical Well‐Being

Physical well‐being is described as the state of one's body, including experience or absence of symptoms, illness, or injury. Physical well‐being is affected by health habits such as diet and exercise as well as effects of medications and treatments.

Mental and Emotional Well‐Being

The WHO describes mental health as “a state of mental well‐being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community.” ³¹ We use the term mental and emotional well‐being rather than psychological well‐being, as the latter is often used more broadly and includes other domains (e.g., social well‐being, spiritual well‐being). Influencers of this domain include experience and control of emotions, resilience, feeling loved, stress, energy levels, and risk‐taking behaviors.

Meaning and Purpose (Spiritual Well‐Being)

Spiritual well‐being is described as “a connection to something greater than oneself and in some cases faith in a higher power,” ⁴ or “all aspects of well‐being pertaining to the search for purpose and meaning in life. This may include the belief in a higher power, but spiritual wellness does not have to be aligned with a religion.” ³² As the term spirituality infers religious belief or affiliation to some, the alternate term meaning and purpose may be more inclusive. Meaning and purpose also includes the idea of living life in line with one's values, a sense of direction, and a sense of identity.

Social Well‐Being

Social well‐being is described as how well an individual is connected to others in their local and wider social community, including social interactions, the depth of key relationships, and the availability of social support. ⁴ Beyond individual social connections, having a sense of community, including engaging in social activities, group membership, and trust in one's governance contribute to a sense of belonging and increased social cohesion. ³³ , ³⁴ , ³⁵ Negative influencers of social well‐being include adverse childhood events, trauma, bullying, and experience of racism or discrimination.

Sexual Well‐Being

Sexual well‐being is described as the satisfaction with sexual relationships and functioning, sexual awareness, sexual self‐esteem, sexual safety and security, sexual respect, resilience to sexual experience, comfort with sexuality, and self‐determination in one's sexual life. ³⁶ Sexual self‐determination refers to the ability to make decisions and choices regarding one's sexuality free from undue external influences or interference (including coercion or exploitation). Sexual well‐being is relevant to people regardless of whether they are sexually active and irrespective of partnership status. ³⁷

Financial Well‐Being

Financial well‐being is described as being able to fully meet current and ongoing financial obligations for oneself and one's family, feeling secure in one's financial future, and having the financial freedom to make choices that allow for enjoyment of life. ³⁸ This includes being able to afford basic needs. ³⁹ Financial well‐being may be less related to being wealthy or rich and more about the level of financial equality in society and individual control of finances and resources, including being able to plan financially for the present and future. ⁴⁰ Given the significant impact of health care costs on financial well‐being, we include health insurance status and cost of care within this domain.

Environmental Well‐Being

Environmental well‐being encompasses the relationship with one's surroundings and the conditions where one lives, works, learns, and plays. This includes safety, access to material needs and opportunities in the built environment (including to work, education, and healthy foods), freedom from unhealthy exposures, housing, transportation, and access to green space. ⁴¹

Autonomy and Functioning

Autonomy and functioning refers to the ability to make one's own decisions and the level of capability to participate in or perform desired activities, tasks, and roles. We also include the related concept of having a sense of control over one's life in this domain. The concepts of autonomy and control often focus on the ability to make decisions free from the influence of others, implying feeling independent and in control as reflective of ideal well‐being. However, this may be less relevant in non‐Western cultures, and some theories suggest one does not need a sense of control to be well. ²⁵ , ⁴² Although functioning, autonomy, and control are separate concepts, we have combined them here given the overlap of some subdomains (e.g., independence). Functioning crosses multiple well‐being domains (e.g., physical, social); however, the concept of participating in or performing desired tasks and roles is experienced as distinct and thus was felt to merit its own domain. This domain also includes the health capabilities of self‐efficacy, self‐care, and life management skills.

Activities

The domain of activities characterizes daily life or how one's time is spent, including satisfaction with and engagement in employment, education, volunteering, caregiving, political or civic action, housework, recreation, play, and hobbies. Competence and achievement in these areas also fall within this domain. ⁴³

Given the overlap and interconnectedness of concepts that fall within the ten domains of whole person health, the team further grouped the domains into four overarching categories (Table 3). These overarching categories could also be assessed broadly under instruments of global well‐being. These broader categories are derived from the grounded theory approach to the data, combining the most interconnected domains rather than following preconceived categories of whole person health. The broader categories are intended to reflect the significance of the whole person health domains to individuals, centering a person's experience of health rather than academically or clinically defined categories.

Table 3.

A Proposed Simplification of Domains of Whole Person Health Into Overarching Categories

Unifying Concept	Overarching Category	Domain
Global well‐being/life satisfaction	Body and mind	Physical well‐being
		Mental/emotional well‐being
		Meaning and purpose (spiritual well‐being)
		Sexual well‐being
	Relationships	Social well‐being
	Living environment and finances	Environmental well‐being
		Financial well‐being
	Engagement in daily life	Autonomy and functioning
		Activities

Instrument Design Features

Examining whole health instruments and related literature in depth elucidated 14 key instrument design features (e.g., response types, frequency of instrument administration). Considerations regarding these design features are vital in whole person health instrument design (Table 4).

Table 4.

Whole Person Health Instrument Design Features and Decision‐Making Considerations

Feature	Options	Considerations
Preamble	Respondent‐facing brief rationale for use of instrument and explanation; facilitator‐facing instruction	1. Introduction statements to the instrument and prior to each section ensure proper framing of the questions and differentiate different sections. 44
Types of questions – response types	Likert scale, multiple choice, open ended, visual representation, mix, item response theory	1. Use of open‐ended questions allows for respondents to answer in their own words without an a priori framework.
		2. Open‐ended questions are more useful when asked at the end. 45
		3. Open‐ended questions are more difficult for physicians to interpret. 45
		4. Absent a strong relationship with the instrument administrator, respondents may not feel as comfortable or spend the time elaborating on free‐text answers. 46
		5. When using a Likert scale, word choice for the scale values is important. 47
		6. Preferred number of responses depends on need for specificity and likely depends on the domain of well‐being assessed. 44
		7. Use of a Likert scale to assess well‐being may require more discussion to gain context.
		8. Incorporating a visual tool may assist with clinical reasoning, care planning, and monitoring change over time. 5
Types of questions – content	Ratings of how someone is doing overall and in different domains (e.g., physical, mental/emotional), questions about unmet needs, patient's rating of what they want to prioritize to talk about or have addressed, patient goals, patient context (e.g., who your social supports are, what makes your life meaningful)	1. Taking a multidimensional approach (asking questions that cross domains) allows for understanding about how different domains work together to affect well‐being. 48
		2. If an instrument only asks about life satisfaction, it may miss out on the other domains that make one well or unwell. 49
		3. Avoid placing a subjective well‐being question after a question that is likely to elicit a major emotional response. 44
Types of questions – time assessed	Related to the past 2 weeks, past 30 days, historical information, reflective of today/in the moment, if there has been a change over a given period of time	1. Using general time frames is more favorable than specific callback times, as it captures a more stable reflection of one's well‐being. 50
		2. In asking about overall subjective well‐being, longer enumeration times (at minimum a year) lead to higher reliability. 44
		3. In asking about effect, a 24‐hour recall period or less is recommended. 44
Timing – relation to visit	Before a visit, during check in, during the visit	1. The least disruptive time to administer a survey is during rooming or before the visit starts. 51
Timing – frequency	Annually, only at establish care and well‐being visits, all visits	1. Stability is typically observed in subjective well‐being over 15–18 months. 52
		2. Annual administration of subjective well‐being surveys avoids fluctuations. 44
Administration – facilitated vs. not	Self‐completed, questions asked by team member for all patients, questions asked by team member for those needing extra assistance, whether facilitated administration requires training	1. For quality‐of‐life instruments, face‐to‐face administration and use of a trained interviewer may help eliminate bias against respondents with low levels of education and address the tendency of respondents to avoid negative responses. 53
Administration – mode	Paper, electronic, both available	1. Lower subjective well‐being scores are observed with computer surveys. 44
Setting	Home, primary care clinic, any outpatient clinic, clinics and social services settings	1. An instrument created to measure well‐being should be adaptable to capture well‐being at multiple levels (individual to national levels). 1
Length of instrument	Amount of average time to complete: <1 min, 5 min, 10 min, >10 min; number of questions: 1, 5, 10–15, >15	1. Single‐ or two‐item assessments do not capture the complex and multifaceted nature of well‐being. 25 , 44
		2. Length of instrument is an important consideration in a time‐constrained setting such as primary care. 5
		3. Use of item response theory led to 50% fewer questions answered without sacrificing accuracy of instrument. 54
Scoring/coding	Mechanism to flag specific items for review, coding system to identify areas of need, none	1. Use of directional statements (positive, negative) allows for more accurate coding of subjective well‐being than free response. 44
		2. Color‐coding systems can highlight areas of need and prompt action. 44
Integration with other sources of data	Incorporation of demographics, clinician assessment, clinical data, none	1. Effective measurement systems (though not necessarily a given individual instrument) encompass both clinical and social outcomes and balance objective and subjective outcome measures. 1
Use of responses – by health care professionals, care team (including health‐adjacent or community professionals)	Review by clinician for discussion or care planning, care pathways to different team members, reporting to payers, comparison with past results	1. Results can be used to nudge coordination of care across nontraditional disciplines. 51
Use of responses – by payers	Incentivize use of the instrument (yes/no), incentivize target score, incentivize improvement, use in alternative payment models, use in care delivery requirements	1. The use of quality measures that are linked to incentives leads to increased reporting burden. 3
		2. Typically, <10% of variation in PROMs are attributable to provider‐level interventions and less utility in comparing PROMs as performance level indicators. 55

min, minute; PROM, patient‐reported outcome measure.

Key Tensions

In the review of whole person health literature, two key tensions were elucidated when considering instrument content.

Comprehensiveness Versus Brevity

Well‐being is complex and multidimensional ²⁵ ; the NASEM lists “comprehensive and holistic” as one of the five foundational aspects of whole health. ¹ Efforts to collapse these dimensions into brief instruments risk missing nuanced aspects of whole health, ⁴⁹ although global measures may allow understanding and tracking an individual's overall health or well‐being as an outcome. Conversely, more specific terms may overly narrow the realm of considered options or information perceived as relevant, and asking questions that cross domains can allow for understanding how different domains interrelate to affect well‐being. ⁴⁸ Specifically assessing the different domains and subdomains of whole health may not only enhance the comprehensiveness of understanding an individual's whole health but also provide more nuanced information about needs requiring potential intervention. At the same time, brevity enhances feasibility of use; a lengthy instrument may be impractical in a time‐constrained setting.

Standardization Versus Flexibility

Every person is unique and has unique priorities regarding well‐being that may change over time; conceptualizations of the meaning of health and well‐being may also vary by individual or by certain population characteristics. ⁵ , ²⁵ , ⁴⁴ , ⁵⁶ Standardization may also be perceived as overly mechanical and lead to clinicians to miss patient cues and patients to feel they are not being heard. ⁵ Flexibility in instrument content and design may enable a more person‐centered whole health assessment. ⁵ However, standardization creates a consistent structure to trend responses in addition to predictability and ease of administration. ¹

Selected Instruments

Through review of the 281 whole health instruments, the literature review team selected 11 instruments that were well positioned to inform the development of a new whole person health survey for more detailed review. These instruments were selected for their comprehensiveness, utility, frequency of usage, relevance to project aims, and/or illustration of different approaches to assessment through variations in instrument design.

Table 5 lists detailed characteristics of these instruments as well as related commentary. Some points of commentary are relevant across multiple instruments; for example, the instruments that include only Likert scale response items may require further discussion to give sufficient context to responses. Additionally, some questions may be difficult to answer because of being high level or vague, for example, “How satisfied are you with yourself?” The domains in our model included in each of these instruments are displayed in the online supplemental information.

Table 5.

Characteristics of Selected Whole Health Instruments

Selected Instrument	Purpose of Instrument	Number of Items	Scale	Relevant Features	Commentary
Personal Health Inventory/HOPE Note	Assesses current perceptions of well‐being, what matters to the person, self‐ratings across domains of whole health and readiness for change. Developed for use with veterans by the Veterans Administration. 57	24	Likert scale; open‐ended questions; 30‐day lookback (number of days)	1. Multiple response types	1. Multiple response types include numbers that enable comparisons over time, with open‐ended questions for more context.
					2. Some descriptions of domains could potentially be alienating to someone whose needs are more basic (e.g., need to live in a less noisy environment vs. need to decrease exposure to violence).
					3. The instrument asks about readiness for change without first asking if changes are needed or what the person wishes to prioritize.
Cantril Self‐Anchoring Scale (Cantril Ladder)	Asks people to imagine their best possible life at the top of a ladder and the worst possible life at the bottom. 58 The two‐item version asks where they will stand 5 years from now.	One‐ and two‐item versions	Likert scale	1. Visual representation of a ladder	1. The instrument incorporates a person's perspective of what their best life is.
					2. It is used in national and international Gallup polls; also incorporated in other longer instruments.
					3. It does not capture information about specific domains of well‐being.
					4. It asks where a person feels they stand at this time without providing a specified lookback period.
WHOQOL‐BREF Scale	Assesses an individual's perception of position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. 23	26	Likert scale	–	1. The instrument covers all ten whole person health domains.
					2. It includes life situations that may not be universally applicable (e.g., work situation for students or retirees).
					3. Developed internationally using a cross‐cultural approach.
Well‐Being Assessment (100 Million Healthier Lives)	A short, holistic tool to measure and track health and well‐being outcomes and improvements for those working to improve the health of their communities. 17	12‐ and 24‐item versions (adult); 12‐item version (youth)	Likert scale	1. Visual representation of a ladder	1. Items are pulled from other validated measures. The 24‐item version includes the Flourishing Index; both version lengths include Cantril Ladder.
Flourishing Index	A measurement approach to human flourishing, based around five central domains: happiness and life satisfaction, physical and mental health, meaning and purpose, character and virtue, and close social relationships. 59	12	Likert scale	–	1. The instrument includes two questions on “character and virtue” that may be predicated on a level of privilege and control of one's circumstances.
PROMIS Global Health Scale	A measurement tool to assess health and well‐being in adults and children from the general population, as well as those living with chronic conditions. 60	10	Likert scale	1. One section with no time frame assessed and the second part with a 1‐week assessment period for ratings of emotional problems, fatigue, and pain.	1. A 1‐week time frame may not be long enough to demonstrate the individual's well‐being baseline and could potentially reflect a more temporary fluctuation, 44 , 50 though this level of recency may be relevant depending on purpose.
WIT‐Y	An instrument designed to assess the well‐being of youth who are or have been in contact with the child welfare system. 14	8	Visual Likert scales; open‐ended questions	1. Visual representations of current and desired well‐being instead of using a true Likert scale.	1. Some items lump together disparate concepts (e.g., stable housing, safety and sense of control in one question)
				2. Includes a “blueprint” planning document for addressing an area of well‐being.	2. Incorporating a visual tool has been recommended by some experts to assist with clinical reasoning, care planning, and monitoring change over time. 5
SF‐20	Assesses physical functioning, role functioning, social functioning, mental health, current health perceptions, and pain. 61	20 (multiple version lengths exist: 12 and 36)	Yes/no questions; Likert scale	–	1. Although it crosses six domains, the questions are very focused on functioning and impact of health on activities.
PERMA Profiler	Assesses positive emotion, engagement, relationships, meaning, and accomplishment. 50	23	Likert scale	–	1. For briefness, the 15 PERMA questions could be used, but the full measure is recommended. 50
CIT/BIT	Intended to (1) measure a broad range of psychological well‐being constructs and represent a holistic view of positive functioning; and (2) predict important health outcomes that are useful for researchers and health practitioners. 62	CIT: 54; BIT: 10	Likert scale	–	1. Although the CIT has been recommended as a broad multidimensional inventory by some experts, others have criticized it for having redundant items, concerns about validity and reliability, and lack of clear theoretical grounding for how items are categorized. 25
WBS	A brief screening tool that can be used within the health care context to gather information about veterans’ satisfaction, involvement, and functioning related to what is most important to them in their daily lives. 63	3	Assigning a percentage of time that a statement is true	1. Patient determination of the “most important things you do or wish to do” prior to selecting percentages.	1. The stated goal of this tool is to change the conversation between providers and patients from a narrower disease treatment focus to a broader conversation surrounding well‐being.
				2. Clinician or self‐administered.	2. The tool is focused on functioning and activities.
					3. It lumps together responses for what things (potentially multiple) the person feels are most important.

BIT, Brief Inventory of Thriving; CIT, Comprehensive Inventory of Thriving; HOPE, Healing‐Oriented Practices and Environments; PERMA, Positive Emotion, Engagement, Relationships, Meaning, and Accomplishments; PROMIS, Patient‐Reported Outcomes Measurement Information System; SF‐20, 20‐Item Short‐Form Survey; WBS, Well‐Being Scale; WHOQOL‐BREF, World Health Organization Quality of Life Brief Version; WIT‐Y, Well‐Being Indicator for Youth.

Consumer Assessment of Healthcare Providers and Systems

Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a program of the Agency for Healthcare Research and Quality to understand the patient experience. ⁶⁴ CAHPS is the only measure of person‐centered care in many CMS Innovation Center demonstration projects and in the CMS‐proposed Universal Foundation. ³ Although these surveys are focused on patient experience, they do contain some questions related to overall well‐being. Given their widespread use and inclusion of overall well‐being items, we include discussion of CAHPS here to touch on how these surveys are distinct from the other instruments we review and the Vitality Signs project aims.

There are several versions of CAHPS; the CAHPS for Merit‐Based Incentive Payment System (MIPS) survey is a version of the CAHPS Clinician and Group Survey utilized as a quality measure in the CMS Quality Payment Program. Including demographic questions, the CAHPS for MIPS survey contains 59 questions with yes/no, multiple choice, or Likert scale responses. CAHPS for MIPS survey includes questions on ratings of overall health, mental and emotional health, and functioning, but most questions assess experience of care rather than self‐reported health. CAHPS surveys are used for quality improvement, public reporting, certification and recognition, value‐based purchasing, and health services research ⁶⁴ ; they are not used at the point‐of‐care to inform an individual's care.

Discussion

This literature and instrument review was designed to provide an overview of the range of approaches and domains in existing diverse efforts to assess whole person health and to inform the development of a new survey that supports a shift to whole health care. To do so, we summarize past work on assessing patient‐reported whole health, articulate the conceptual domains encompassing whole person health, and identify lessons and best practices from existing instruments, including considerations for administration and relevant instrument design features.

There are many overlapping concepts related to whole health and well‐being described in the literature; there is a lack of consensus regarding what language should be used to describe health, or what comprises it. The broader definitions of health by the WHO and whole health by the NASEM are not embodied in how health and health care are viewed currently in the United States. Health, explicitly or implicitly, has generally been narrowly defined as the absence of disease, perpetuating a biomedical paradigm that undermines health care's role in fostering full health potential. ⁶⁵ The increasing trend toward addressing health‐related social needs in health care reflects perhaps the beginning of a shift in the biomedical paradigm, with early lessons and unanswered questions regarding which aspects of a broader definition of health are best addressed through health care or other health‐impacting sectors in an improved collaboration with health care. We have utilized the term whole health, as defined by the NASEM. Some experts have called out, however, that this rebranding of health as whole health avoids “directly challenging the existing tacit biomedical definition of health.” ⁶⁵

Whole person health is more than the sum of its parts, and any attempt to classify its component pieces is arbitrary by nature. At the same time, identifying different domains facilitates understanding of what comprises whole person health and exploration of themes for instrument development. Our literature and instrument review revealed there is no consensus among researchers on how to categorize domains of whole person health or well‐being. Our domains expand on a biomedical or disease‐focused framework in line with existing theories of health and well‐being and encompass their dimensions or components.

Depending on the purpose behind separating domains of whole health, differing levels of “lumping” or “splitting” may be useful. We have described domains of whole health in two ways: ten domains best understood as interdependent, interconnected, and influencing of one another; and four simplified overarching categories that combine some of the most interconnected domains. These simplified categories (body and mind, relationships, living environment and finances, and engagement in daily life) may be more closely aligned with the lived experience of the human condition and could serve as a starting point for instrument development. The category of body and mind pertains to internal states, relationships to interactions with others, living environment and finances to interactions with the world around you, and engagement in daily life to what one does. Alternatively, a survey could seek to stimulate reflection on a more unifying and personal meaning of whole person health rather than identifying and touching on all relevant domains. A whole person health instrument could also be tailored for different use cases; for example, a more comprehensive assessment across domains could be performed more infrequently at an annual physical or well visit, whereas a briefer instrument could be implemented more regularly. The well‐being priorities of children and adolescents may not be reflected in well‐being measures developed for adults ⁶⁶ ; different versions of a whole health instrument may be required for youth and adults.

In comparison with the domains described in the review by Linton and colleagues, ⁴ this simplified version of our model mirrors their domains of personal circumstances (our “living environment and finances”) and activities and functioning (our “engagement in daily life”). In contrast to their model, we combined their domains of physical, mental, and spiritual well‐being, along with sexual well‐being (which they did not characterize as a domain), under the overarching category of “body and mind.”

There is no consensus on an ideal instrument to assess well‐being or how to include patient‐defined well‐being within more traditional health assessments, though instruments may also need to vary based on purpose. ⁴ Over 200 well‐being instruments were identified in our search, and many others exist that are disease focused and intentionally excluded in our review. Only four instruments (plus one short form of an instrument) comprehensively assess all of the domains of whole health we identified; many well‐being instruments are specific to a small number of domains, for example, focused on mental and emotional well‐being. Many of the well‐being instruments are also similar to one another; some are composite instruments that pull from other validated measures.

We identified 14 design features and two key tensions to consider in the development of an improved whole person health instrument. An improved instrument will need to balance comprehensiveness with brevity (and thus feasibility in a time‐constrained clinical setting) as well as standardization with flexibility. This flexibility could involve more open‐ended questions and/or structuring an instrument such that the individual directs the scope of what they wish to discuss or prioritize. Newer instruments from the Veterans Administration's work on whole health (included in Table 5 of selected instruments above) present examples of the direction and work needed to balance these tensions for real‐world clinical practice. ⁵⁷ , ⁶³

One of the aims of introducing an instrument of whole health is to ensure that patients feel better heard, seen, and understood by their care team. Achieving this requires additional considerations to instrument design and administration beyond flexibility; the manner in which an instrument is implemented may be as important as the questions themselves. How those who administer or review the instrument ask questions and discuss responses matter, both in terms of communication skills ⁶⁷ and how the information is utilized. Responses should only be collected if they will be used in some way; patients may paradoxically feel less heard if they take the time to complete an instrument that is not used to inform their care. Additionally, whether the clinician and patient have a preexisting and ongoing relationship may influence the use and impact of the instrument. ⁵ Involving patients and families of diverse backgrounds in instrument design and implementation will help address these considerations.

Given the growing interest by federal agencies in assessing whole health and improving equity, it is likely that a well‐developed patient‐reported instrument of whole health will be adopted by measurement programs. The current use and conceptualization of measurement in health care is fraught with controversy and unintended consequences. Many experts have concluded that on the whole, pay for performance as it has been implemented to date has led to relatively small benefits, incurred at high cost in terms of money, time, and relative neglect of nonmeasured aspects of care. ⁶⁸ , ⁶⁹ , ⁷⁰ Given the disconnect of measures from patient priorities and the purpose and function of care delivery, some have asked, “Are we even measuring quality?” ⁶⁸ Introducing a new survey of patient‐reported whole health has the potential to elevate patient priorities and recenter measurement around the purpose and function of care delivery. Such an instrument may also support federal goals to better address equity in health care by drawing greater attention to the impact of the social determinants of health on a patient's overall well‐being. However, it also has the potential for unintended harms. Several steps could prevent potential harms.

First, a new instrument should supplant other measures to avoid adding to administrative burden. Although a new whole health instrument may have potential uses in a wide range of settings, primary care may present an ideal setting for initial implementation and for the facilitation of integrated care. However, primary care physicians are already tasked with more daily work than is feasible for a typical patient panel. ⁷¹ A new instrument requires adequate time for a clinician or team to review and discuss responses with patients. Ultimately, a whole health instrument could be utilized across and outside of clinical contexts as well, including in a variety of community settings.

Second, the identification of needs outside of what has been traditionally addressed in health care should be framed in the context of enhancing understanding of a person's whole health, and clinicians should be supported by connections to additional nontraditional resources as is feasible. A patient may question why they filled out an instrument that explicitly or indirectly identifies needs if there are not resources or supports available to address them. This could also contribute to moral injury if clinicians identify needs they feel they are ill equipped to solve.

Third, a whole health instrument should be used for learning and to improve care rather than holding clinicians accountable to a given score or comparing clinician scores. Most variation in patient‐reported outcome measures is because of patient‐level factors rather than clinician‐level factors ⁵⁵ ; further, assessing aspects of whole health that are not addressed in health care involves many societal‐level factors outside of a clinician or health system's control. Given the wide array of factors impacting whole health, accountability for whole health may make sense at the level of systems, government and society monitoring trends over time, but not at the level of individual clinicians and practices obtaining a snapshot. Considering shared accountability for whole health at a higher system level could support addressing the fragmentation across sectors that impact health.

Ultimately, a patient‐reported instrument to assess whole health would constitute one component of much broader change that would be required to shift to whole health care, including new approaches to the ecology of measurement and restructuring of health care payment. To support addressing whole health needs, payment systems will require greater flexibility of funds and uniting financing streams across health care, social services, mental health, and public health. The NASEM Implementing High‐Quality Primary Care report describes principles for a new ecology of measurement, including accounting for people‐centered rather than patient‐centered needs; addressing macro‐, meso‐, and microlevels; maintaining flexibility in reflecting people's and populations’ needs and goals; encompassing both clinical and social outcomes; balancing subjective and objective outcome measures; distinguishing the use of measures for learning from those intended for accountability; and limiting measures to a small number. ¹

The Vitality Signs project is incorporating findings from this instrument and literature review into the next steps of instrument development, which will include crowdsourcing, listening sessions, and focus groups to ground the work in the words of real people and what matters to them. These next steps will also explore whether existing measures lend themselves to adaptation to meet project aims or if there is a gap that requires a novel instrument. The vision for the project is aspirational: its use would be an intervention in itself, resulting in a strengthened relationship in which a person seeking care feels heard and better understood by their care team. As a recently published reflection piece notes, “The power of a question, the gift of genuine curiosity, and the desire to understand patients in the context of their life stories could be the tools necessary to bridge any existing gap in quality of care.” ⁷²

Conclusion

The broad array of whole person health domains identified in this review, and the lack of consensus on how best to describe and measure health, provides an important and immediate opportunity to develop a way to assess a person's whole health that includes but transcends biomedicine and behavior and directs attention toward what matters most to people. For those pursuing this opportunity, this literature review contributes to the field of whole health assessment: a framework of influencers, domains, and overarching categories for instrument development; an exploration of instrument design features; a review of selected whole health instruments; and considerations regarding conceptual tensions to navigate and how to avoid potential harms.

Funding/Support

This work was supported by the US Department of Health and Human Services, Centers for Medicare and Medicaid Services (award 2K2CMS331882).

Conflicts of Interest Disclosures

The authors have no conflicts of interest to declare.

Supporting information

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