A Healthy Person

Abstract

The purpose of this exploratory study was to investigate how nursing students in Indonesia and Scandinavia characterize a healthy person. Two hundred thirty-two nursing students from Indonesia, 50 students from Sweden, and 119 students from Norway participated by answering an open-ended question. Qualitative content analysis was used to identify patterns of health in a cultural and national context. The characteristics of a healthy person were summarized in the theme “external and inner balance,” which are intertwined because of the wholeness of self-image and appearance. The subcategories were having a strong and positive body image, feeling well and having inner harmony, following the rules of life, coping with challenges, and acting in unison with the environment. There were more similarities than differences between the Indonesian and Scandinavian nursing students’ understanding of being a healthy person. The difference is that the Scandinavian students mentioned individuality, whereas the Indonesian students referred to collective values.

Introduction

Health is a worldwide phenomenon of interest to all human beings. The World Health Organization (WHO) is the coordinating authority for health within the United Nations’ system and responsible for managing questions pertaining to health in all continents. According to Kleinman and Benson (2006), the cultural perspective takes account of all aspects of human experience including illness, disease, and health in the context of patients, practitioners, and health care service delivery. It is stated in the Ottawa Charter (World Health Organization [WHO], 1986) that health is a resource for everyday life. Hughner and Kleine (2004) identified 18 themes about lay health worldviews, which were classified into four categories: definitions of health, explanation of health, external and/or uncontrollable factors impinging on health, and the place health occupies in people’s life. The literature review comprised European and U.S. articles from 1973 to 2003, but no studies from Asia. In a Scandinavian context the lay perspective on health is characterized by three qualities: (a) wholeness, which means that health is a holistic phenomenon related to all aspects of life and society; (b) pragmatism, indicating that health is a relative phenomenon experienced and evaluated according to what people find reasonable to expect, given their age, medical condition, and social situation; and (c) individualism, because health is a personal phenomenon, every human being is unique, thus, health and strategies for health must be individualized (Fugelli & Ingstad, 2001). Nursing theories address the understanding of health in specialist and general terms.

The social determinants of health take account of poverty, education, and social structure, which influence the health of populations and limit the ability of many people to achieve health equity (Koh, Piotrowski, Kumanyika, & Fielding, 2011). In Indonesia, the life expectancy at birth is 71 years. In contrast, the life expectancy at birth in both Sweden and Norway is 81 years (WHO, 2015). Swami et al. (2010) revealed that a heavier body was preferred in countries with a low socioeconomic status (SES) compared with those with a high SES, despite the fact that the thin ideal and body dissatisfaction have become international in nature. In Sweden and Norway, people, but especially women, are increasingly affected by reduced mental health and well-being (The National Board of Health and Welfare, 2009). In addition, loneliness is a growing health challenge in Scandinavia (Nicolaisen & Thorsen, 2014), although late-life loneliness differs between countries in Europe, especially among women (Hansen & Slagsvold, 2015). In addition, changes in lifestyle have led to problems, especially in Scandinavia. The main health problems in Indonesia are related to biological diseases (such as heart, pulmonary and digestive diseases, infectious and parasitic diseases), pregnancy complications, injuries, poison, and malnutrition (Rokx, Giles, & Satriavan, 2010).

The connection between spirituality, social life, and health is defined as the way that religiosity moderates the relationship between social isolation and psychological well-being (Momtaz, Hamid, Ibrahim, Yahaya, & Chai, 2011). Indonesian society is mainly religious and approximately 87% of the population identify themselves as Muslim (Burhani, 2014). In contrast, Scandinavian society is historically influenced by Christian values and beliefs, although it has become more secularized in recent decades (Vexen Crabtree, 2006).

The Ottawa Charter (WHO, 1986) focuses on health promotion, stating that “Health promotion is the process of enabling people to increase control over, and to improve, their health” (p. 1). Health professionals have an important role in society when it comes to achieving political and social aims that enable people to increase control over, and to improve, their health (WHO, 2009). This especially applies to the way nurses perform professional care to promote health and prevent illness and disease. The development of advanced nursing practice is a global trend and a challenge for every nation (Sheer & Wong, 2008).

The nursing education systems in Indonesia and Scandinavia differ in some ways in terms of level and funding. Nursing education in Indonesia ranges from senior high school level to Diploma III or bachelor’s level, and 39% of nurses are educated at both governmental and private nursing academies (Hennessy, Hicks, & Koesno, 2006; Law of the Republic of Indonesia, number 38, 2014). Nursing education in Scandinavia takes place in bachelor’s programs at public universities and university colleges. It is important to gain up-to-date knowledge of nursing students’ comprehension of health to encourage prospective health promotion services.

The aim of this study was to explore how nursing students in Indonesia and Scandinavia characterize a healthy person.

Method

Design

The study employed a qualitative, exploratory design.

Sample and Participants

The participants were recruited from first year nursing students in the bachelor’s program in university colleges and universities in Scandinavia, and the Diploma III and bachelor’s programs in Indonesia. Students in the cohort started their educational program in 2011, and in the countries under study, students are admitted to the programs once a year or twice a year. Three student cohorts were recruited in Indonesia. Demographics of the participants and the number of eligible and responding students are presented in Table 1. Of a total of 438 students, 401 students (91%) responded to the open-ended question regarding what characterizes a healthy person, 232 students (123 students in the diploma program and 109 in the bachelor’s degree programs) in Indonesia, 50 students in Sweden, and 119 students in Norway.

Table 1.

Number of ENS and RNS (Question About What Characterizes a Healthy Person).

	Indonesia		Scandinavia
			Sweden		Norway
	ENS	RNS	ENS	RNS	ENS	RNS
	257	232 (90%)	61	50 (82%)	120	119 (99%)
Age (mean), years		18.4		24.3		25.1
Gender/sex
● Women, %		74.7		85.9		85.2
● Men, %		25.3		14.1		14.8
Birth in country, %		100		87.5		88.6
Married/cohabitating, %		0		53.1		40.9
Highest education prior to nursing education, % (upper secondary school)		95.7		81.3		80.6

Note. ENS = eligible nursing student; RNS = responding nursing student.

Data Collection

Data were collected between March and May 2012 during ordinary lessons in the nursing education programs. In Indonesia and Sweden, the data were collected in one session, whereas in Norway data were gathered in two sessions because of the difference in the scheduling of the two groups of students in the same semester. The participants were presented with the open-ended question, “What are the characteristics of a person who you think is healthy?” in connection with a questionnaire survey focusing on health status, family life, sense of coherence, critical thinking, and research utilization. The results of the questionnaire survey will be presented elsewhere. Translation of the responses to the open-ended question took place in Scandinavia by translation from Norwegian to Swedish and from Norwegian to Bahasa and back again by professional translators following the Eurostat procedure (European Communities, 2005).

Data Analysis

The responses from participants in Indonesia were translated from Bahasa to Norwegian. The Scandinavian answers were analyzed in their original language. The students’ responses were mainly short statements, in some cases with examples. The responses were interpreted as condensed meaning units. All condensed meaning units were finally translated into English. Data were analyzed using qualitative content analysis to search for manifest and latent meanings in the text (Graneheim & Lundman, 2004). The primary aim of content analysis is to describe the phenomenon in a conceptual form. The analysis explored the data to identify patterns in the way nursing students interpreted the concept of health in their cultural and national context. An example of the analysis process from condensed meaning units to codes, categories, and themes is presented in Table 2. After preliminary data analysis by Scandinavian researchers, a workshop was arranged in Banda Aceh, Indonesia (January 2014), for Indonesian and Scandinavian researchers and nursing teachers that comprised peer debriefing of the preliminary findings to enhance credibility. Indonesia and Scandinavia are different societies concerning religion and to a certain extent also regarding the prevalence and incidence of diseases. The debriefing emphasized the Indonesian cultural characteristics compared with those of Scandinavia. Discussing these factors in the workshop, the authors achieved a deeper understanding of the nursing students’ perspectives on being a healthy person, which validated the results of the study.

Table 2.

Example of the Analyses Process of the Category “Following the Rules of Life,” From Condensed Meaning Units to Code, Category, and Theme.

Condensed Meaning Units	Code	Category	Theme
Able to perform activities normally Able to produce something useful Able to do things oneself Able to perform activities that one likes	Every day habits	Following the rules of life	External and inner balance

Research Ethics

Approval of informed consent, anonymity, and safe-keeping of data were obtained from the Norwegian Social Science Data Services (NSD), which accepted the research protocol on March 22, 2012 (No. 29212). In Sweden, approval of the project was obtained from the Regional Ethical Review Board in Uppsala on January 19, 2011 (Dnr 2010/462), whereas in Indonesia the project followed national guidelines for ethical principles in medical research involving human subjects based on the Declaration of Helsinki (World Medical Association, 2014). Instead of a written informed consent, the students gave their consent indirectly by answering the questionnaire after having read the information about the research project.

Findings

The participants in Indonesia and Scandinavia provided various descriptions of the characteristics of a healthy person. The characteristics are presented in the form of similarities and differences in the opinions of what being a healthy person means in Indonesia and Scandinavia.

The analysis resulted in one theme and five categories that characterize a healthy person (see Table 3). The theme summarizes the entire character of a healthy person as “external and inner balance,” which are strongly intertwined. In any single individual, these factors cannot be experienced as divided, because they represent the wholeness of self-image and appearance. External balance refers to following the important rules of life associated with the respective cultural norms, having a strong body that can cope with practical challenges, participating in activities, and self-presentation. Inner balance is related to feelings of well-being and coping, inner harmony, positive self-esteem, and being in control. The categories are, having a strong and positive body image, feeling well and having inner harmony, following the rules of life, coping with challenges, and acting in unison with the environment. Indonesian students characterized a healthy person by reference to collective values and self-presentation, whereas the Scandinavian students referred to individuality and inner harmony.

Table 3.

Overview of “The Characteristics of a Healthy Person.”

Theme	Categories	Codes (Indonesia)	Codes (Sweden–Norway)
	Having a strong and positive body image	● Absence of disease ● Strong body ● Perfect body image ● Facial expression	● Absence of disease ● Strong body ● Perfect body image ● Meeting each day with a smile
External and inner balance	Feeling well and having inner harmony	● Not feeling oppressed ● Self-confidence ● Positive attitude to life	● Not feeling oppressed ● Self-confidence ● Positive attitude to life
	Following the rules of life	● Being kind to others ● Everyday habits ● Obedient to God	● Being kind to others ● Everyday habits
	Coping with challenges	● Gaining control ● Coping with everyday life ● Searching for solutions ● Being proactive	● Gaining control ● Coping with challenges ● Performing practical tasks
	Acting in unison with the environment	● Self-presentation in the environment ● Hygiene	● Self-presentation in the environment

Note. The italicized text indicates differences whereas the others indicate similarities.

Having a Strong and Positive Body Image

The participants stated that the condition of the body was important for experiencing health, using terms, such as, presenting a smiling face, the absence of disease, being physically strong, and having an almost perfect body. In both continents, the absence of disease was characterized by statements such as “seldom being ill” and “having no injury or symptoms of disease” to underline their opinion. A strong and perfect body was mentioned as characteristic of a healthy person, described as having little or no reduction in normal function and not experiencing tiredness. Scandinavian students’ understanding of a perfect body was to “appear wholesome” and that “weight should be what is considered normal,” whereas the Indonesian students’ understanding was “to present an ideal body,” and having “a perfect body with no deficits.” Similar statements were used in all three settings, such as “to be in good shape” and “strong, not feeling tired and always appearing well.” Having “a good body image” was described as a characteristic of health in both regions. The Indonesian nursing students emphasized the importance of smiling and presenting a cheerful face, expressed in terms such as “always being happy when encountering other people,” having a “clean face,” and “smiling a lot.” When a Scandinavian student underlined that being healthy is “meeting each day with a smile,” we interpreted this as an optimistic and positive attitude of meeting daily challenges.

Feeling Well and Having Inner Harmony

Well-being and inner harmony represent emotions and subjective comprehension of being whole and integrated, described as not feeling oppressed, and being self-confident. The Indonesian participants used terms such as “not being oppressed,” whereas the Swedish participants described attitudes of self-determination in statements such as “to think in one’s own way and respecting oneself, and accepting the fact that others think differently,” and “that one is in control and can live life to the fullest.” This might be interpreted as being independent, which is an inner value and strength, and might give the person a feeling of well-being and harmony. None of the Norwegian participants mentioned anything about feeling oppressed. Self-confidence was expressed, especially by the Scandinavian participants: “being satisfied with oneself and life” and “having faith in oneself.” The Indonesian participants used terms that might refer to emotions: “to be confident under all conditions” and “to control one’s emotions.” However, these statements are ambiguous as they could be interpreted as suppressing emotions.

Statements from the Indonesian students underlined a positive attitude to life, such as “thinking positively” and “being creative.” The Scandinavian students expressed their positive attitude to life by the following statements: “satisfied with the situation and being capable of doing whatever one wants,” “being satisfied with the circumstances of life,” and “having joy of life and being able to find delight in small things.” The Swedish participants stated that feelings of joy and happiness are important for being healthy: “a happy person who attempts to gild the everyday life of others.”

Following the Rules of Life

The participants referred to different rules and norms of life: being good to others, being kind to one’s family, friends and colleagues, performing everyday tasks, and being obedient to God. Participants from all nursing faculties in Indonesia described a standard of supporting other people both in everyday life and in professional relationships in terms as “being able to interact and contribute to other people and their needs” and “being fair to others.” There were no significant differences between the Indonesian students’ statements about being good to others and those from Scandinavia: “to be gentle and nice to others” and “encounter others with respect and understanding.” Such norms can be interpreted as general interpersonal and humanistic rules.

There were similar descriptions of everyday habits from both Indonesian and Scandinavian students, such as “eating enough, maintaining good food habits and eating healthy food,” and “being physically active and exercising.” Only the Swedish participants mentioned the negative aspects of smoking and drugs: “no smoking and no intoxicating substances.” In an overall perspective regarding the rules of life, the following statement underlines the health aspects of rules of life: “to be willing to maintain one’s own health status,” which can be interpreted as general recommendations for health promotion.

Only Indonesian students described being obedient to God: “a person who believes in God and always follows God’s law” and being “thankful to God.” None of the participants from Scandinavia expressed anything about spiritualty and religion in connection with health.

Coping With Challenges

All participants mentioned that coping with challenges in life by means of gaining control, searching for solutions, and performing practical activities was important for health. There are some nuances between Scandinavian and Indonesian students’ description of gaining control, where the former stated “to gain control of one’s body” and “to feel in control by living fully,” whereas the latter expressed “to have physical and psychological control in relation to other people” and “to control one’s own emotions.” The Scandinavian participants described everyday life and well-being in the context of control: “to have a sense of satisfaction with life” and “to cope with challenges in everyday life.” In addition, the Swedish students highlighted “daring to fail” as a coping strategy. Our understanding is that the Scandinavian participants focused on personal and internal control as a coping strategy, whereas the Indonesian participants emphasized social and external control.

The coping strategies mentioned by the Indonesian students were linked to searching for solutions in the context of illness and disease: having “no pain when performing activities” and “being able to solve one’s own problems.” In addition, the Indonesian participants mainly characterized practical activities involving skills as being proactive: “performing all activities in a normal manner” and “performing useful activities and being productive.” The Scandinavian participants mentioned the same aspects in other words: “carrying out activities without pain” and “to maintain the activities of everyday life.” An interpretation is that the meaning of the coping strategies described by the participants is almost identical in both continents, although there are some subtle differences regarding being proactive.

The Swedish participants described attitudes of self-determination in statements such as “to think in one’s own way and respect oneself, and accept the fact that others think differently,” and “that one is in control and can live life to the fullest.” An interpretation is that the statements from the Scandinavian students reflect autonomy and self-efficacy.

Acting in Unison With the Environment

The participants in Indonesia, Sweden, and Norway characterized how a person presents herself or himself. The Indonesian participants described self-presentation in terms such as “neat appearance, being clean and looking well,” and being “always glad and happy.” The Indonesian participants also mentioned “being a person who spreads happiness” and “having a positive attitude regarding one’s own situation.” Only the Indonesian students clearly referred to standards of hygiene, both in personal and environmental terms: “to maintain personal hygiene,” and maintaining “a strong immune system” and “hygiene in the environment.”

Discussion

The aim of the present study was to explore how nursing students in Indonesia and Scandinavia characterize a healthy person, which led to the theme “external and inner balance.” The findings mainly revealed similarities rather than differences among the nursing students. When describing what it means to be a healthy person, the Indonesian students appear to be influenced by collective values, the self-presentation and external balance, whereas the Scandinavian students seem to recognize a healthy person by reference to individuality and inner balance.

The fact that the understanding of being healthy comprises some similarities in both settings is somewhat surprising, given observed differences in culture, standards of living, and the prevalence of disease. An explanation might be that the WHO’s definition of health has influenced the comprehension of health and the nursing education all over the world. According to Strength and Cagle (1999) and Gillund, Rystedt, Wilde-Larsson, and Kvigne (2012), nursing education in Indonesia is influenced by the U.S. nursing curricula. The participants in this study were first-year nursing program students, which may have led to a theoretical comprehension of a healthy person.

The findings in the present study suggest that the participants’ interpretation of having a strong and an attractive body is in line with young people’s attitude to body satisfaction and weight, irrespective of ethnicity (Mikolajczyk, Iannotti, Farhat, & Thomas, 2012). However, studies examining the correlation of body satisfaction with fitness and subjective well-being reveal that older adults may value bodily function more than bodily appearance (Reboussin et al., 2000). In the present study, there was rather a tendency for the participants—young adults—to mention an attractive body and satisfactory bodily function at the same time. Their description of having a strong body and the absence of disease and illness is in line with Hughner and Kleine’s (2004) results about lay health worldviews and represents an understanding of health that emphasize illness. The participants also pointed out that the appearance of the body is of importance. In the Western world, the ideal body is slim, well-shaped, and trained, demonstrating wholesomeness and control (Laliberte Rudman, 2015). It is reasonable to assume that this ideal also influences young people in Indonesia. The Indonesian students highlighted the appearance of the face, for instance, being clean and smiling, which may be a result of the Islamic clothing requirements for women, where the body is covered except for the face and hands (Rinaldo, 2010). The face, therefore, has greater prominence. Body and self-presentation are fundamental in all interpersonal communication.

For all individuals, the mental, physical, and social aspects of health are closely interwoven, constituting a vital parts of one’s life. Mental health is important for the overall well-being of individuals and societies (WHO, 2001). In the present study, the category “feeling well and having inner harmony” can be understood as representing aspects of mental health. The WHO’s definition of health also includes well-being. An investigation of physical and mental health among old people in Scandinavia (Moe, Hellzen, Ekker, & Enmarker, 2013) indicates that although both women and men among the oldest old are vulnerable in terms of health, they have an inner harmony that contributes to strengthening independence, integrity, and enjoyment of life. As the participants in the present study are young adults, they cannot be directly compared with old adults (Moe et al., 2013). However, mental health problems are increasing among young people in Scandinavia (The National Board of Health and Welfare, 2009) as is loneliness, particularly among older people (Cacioppo, Hughes, Waite, Hawkley, & Thisted, 2006). Nevertheless, an investigation of the effects of daily spiritual and religious activities among young adults (Rounding, Hart, Hibbard, & Carroll, 2011) identified less depressive symptoms and more feelings of deep peace, harmony, and gratitude. The Indonesian participants underlined their obedience to God. Spiritual reflection and religious practice may enhance inner harmony.

An important topic regarding what it means to be a healthy person concerns “following the rules of life”: dealing with everyday tasks and being kind to others. These rules of life might contribute to general social support and to improved mental health, and can be interpreted as general humanistic and interpersonal precepts for a healthy life in both Indonesia and Scandinavia. For the Indonesian students, these rules are intertwined with Islamic norms, as the majority of the population identify themselves as Muslim (Burhani, 2014). In Scandinavia, the rules of life are intertwined with secular beliefs and there is a strong focus on a healthy lifestyle, such as eating healthy food, exercising, and not smoking (WHO, 1986). In the present study, kindness to others and having friends was found among the experiences of well-being and health. Kindness to others, such as close friends and family, is a fundamental value that might strengthen one’s self-esteem, which is of importance for health and well-being.

Previous studies have focused on how people cope with challenges following disease, physical disorders, and mental health problems (Bajaj et al., 2013; Chawla et al., 2013; Wang et al., 2014). The category “coping with challenges” deals with being proactive, gaining control, and searching for solutions, which together express the nursing students’ positive attitudes and efforts to live as healthy a life as possible. The participants, especially those from Indonesia, were mainly young adults and, therefore, they might have experienced few challenges in their life span, leading to the interpretation that both Indonesian and Scandinavian nursing students lack experiences of crisis, illness, and disease. On the contrary, such experiences might be abundant for the Indonesian students, who have experienced the tsunami disaster of 2004 and political conflicts in the Aceh region. From a critical perspective, the participants’ life experiences should not devalue their positive self-image of viewing themselves as a resource, both in managing their own health and promoting health activities for their fellow human beings, friends, and families. In contrast to the WHO definition of health, which focuses on complete well-being and the absence of disease in universal terms, the participants underlined coping with challenges in everyday life, which is in line with the view of health as a holistic, relative, and personal phenomenon (Fugelli & Ingstad, 2001).

Participants in both Indonesia and Scandinavia were aware of the importance of their self-presentation to others in all human relationships. The Indonesian participants especially highlighted the importance of looking well and being happy as an indicator of health and life satisfaction. This is in accordance with an investigation among Turkish nursing school students (Yildirim, Kilic, & Akyol, 2013) that revealed a positive relationship between students’ satisfaction with life and quality of life. The Scandinavian participants in the present study did not describe specific behavioral conditions to characterize their attitude to self-presentation. A comparative study of modesty in self-presentation between Japanese and U.S. participants (Yamagishi et al., 2012) indicates a cultural difference between Western and Asian people, where most of the Americans exhibited a self-enhancement tendency, which was less pronounced among the Japanese.

Challenges regarding domestic and environmental hygiene are often related to the poverty of the population in a country and the household sanitation (Nath, 2003). Despite sanitation and environmental hygiene differences between Indonesia and Scandinavia because of different standards of living, there appeared to be no real distinction between the nursing students’ focus on this issue, although the Indonesian participants expressed their understanding of hygiene as an important factor for preventing infections and disease more directly.

Bryer, Cherkis, and Raman (2013) defined traditional nursing students as women aged 24 years or younger, who have no dependent children, whereas non-traditional students are men aged 25 years or older with dependent children. This definition might be provocative in some European countries and likewise in Asia. Approximately half the Scandinavian participants but none of the Indonesian students were married or cohabitating. In addition, the mean age of the Scandinavian participants was somewhat higher than that of their Indonesian counterparts. There were no differences between traditional and non-traditional nursing students in the present study (cf. Bryer et al., 2013) in the sense of employment, having children, or being single parents. Among non-traditional nursing students, there seems to be a difference in health behaviors and perceived barriers to health promotion (Bryer et al., 2013). In line with the statements in the Ottawa Charter, health promotion needs to be strengthened all over the world to prevent risky health behaviors. This is particularly true in Indonesia, where nurses are an essential part of the health care system because they represent the largest group of health care workers in the country and thus have an important mission to fulfill this aim. Consequently, it will be valuable to develop the teaching of health promotion for nursing students.

Approximately half the participants from Indonesia were taking part in a Diploma III program for nursing students, whereas the rest were in an ordinary bachelor’s degree program (Indonesian Educational and Cultural Minister, 1999). All the Scandinavian participants attended a bachelor’s program in nursing (Norge, Kunnskapsdep, 2008). The differences between a Diploma III program and a bachelor’s program are primarily linked to the depth and volume of central topics. Whether or not the differences in the nursing education programs influenced the participants’ responses is unclear. However, the participants had in common the fact that they were all in the first year of their nursing education program.

Methodological Considerations

The research is an international collaboration between the Scandinavian university colleges and universities, and Indonesian colleges. Conducting multicultural studies is challenging because of cultural and linguistic differences, particularly in qualitative investigations.

Despite cultural differences between the two settings, researchers from Indonesia, Sweden, and Norway cooperated in all parts of the study. Communication within the research group in the course of face-to-face meetings, email correspondence, workshops, and participation at a research conference mainly took place in English. Translation of the open-ended questions from Norwegian to Swedish and from Norwegian to Bahasa and vice versa might have strengthened the understanding of the data. An Indonesian student who attended a master’s program in Norway assisted in the translation process. In addition, one of the members of the research group attended a Norwegian master’s program. These persons gained knowledge of Scandinavian culture and the health care system. Such multicultural relations might have strengthened the credibility of the findings (cf. Lincoln & Guba, 1985).

The quality of the empirical data was strengthened by the translation process, as a person whose first language was Bahasa translated all the Indonesian answers into Norwegian. The translated responses from Indonesia were analyzed in parallel with the Scandinavian responses. The credibility of the analysis was strengthened by researcher triangulation in the course of a workshop attended by researchers and teachers in Indonesia, and by a workshop between researchers in Norway in September 2015. In connection with a questionnaire survey focusing on health status, sense of coherence, and family life, the participants’ responses to the open-ended questions could have influenced, or even weakened, the credibility of the study.

Approximately 400 nursing students participated in the present study and the representation from Indonesia and Scandinavia was almost identical. In addition, the participants from Indonesia were recruited from different nursing education levels, such as bachelor’s degree programs and diploma degree programs, which might enhance credibility and possibly transferability.

Conclusion

Despite the great differences in culture and living conditions between Indonesia and Scandinavia, there seem to be more similarities than differences in the nursing students’ understanding of being a healthy person. Being healthy is to experience an inner and external balance in life, understood as the mental, physical, and interpersonal components of health. Inner and external balance involve feeling well and having inner harmony, a strong and positive body image, the ability to cope with challenges, being guided by the humanistic and health promotion rules of life, and actively acting in unison with the environment. The Indonesian nursing students focused on obedience to God and following Muslim rules of life. The Scandinavian students mainly characterized a healthy person by reference to individuality, whereas the Indonesian students referred to collective values. The consequences for nursing education might be to foster an awareness of every human being’s own perception of being healthy and to develop the focus on cultural competence to meet personal needs.

Author Biographies

Sevald Høye, RN, PhD, is a professor at Hedmark University of Applied Sciences, Department of Nursing, Elverum, Norway.

Kari Kvigne, RN, PhD, is a professor at Hedmark University of Applied Sciences, Department of Nursing, Elverum, Norway and at Nord University, Department of Nursing, Sandnessjøen, Norway.

Ilyas Aiyub, RN, MMH, is director at Akademi Keperawatan Ibnu Sina, Aceh, Indonesia.

Margrethe V. Gillund, RN, MNSc, is an associate professor at Hedmark University of Applied Sciences, Department of Nursing, Elverum, Norway.

Hasan Hermansyah, BScPH, MPH, DrPH, is a lecturer at Polytechnic of Health, Ministry of Health, Aceh Province, Indonesia.

Gun Nordström, RN, PhD, is a professor at Hedmark University of Applied Sciences, Department of Nursing, Elverum, Norway.

Ingrid Rystedt, MD, PhD, is an associate professor at Karlstad University, Department of Health Science, Discipline of Nursing Science, Karlstad, Sweden.

Abubakar Suwarni, SKM, MPH, is ex director at Akademi Keperawatan Ibnu Sina, Aceh, Indonesia and head officer at Dinas Kesehatan Aceh Jaya, Aceh, Indonesia.

Anne Trollvik, RN, PhD, is an associate professor at Hedmark University of Applied Sciences, Department of Nursing, Elverum, Norway.

Bodil Wilde-Larsson, RN, PhD, is a professor at Karlstad University, Department of Health Science, Discipline of Nursing Science, Karlstad, Sweden and at Hedmark University of Applied Sciences, Department of Nursing, Elverum, Norway.

Reidun Hov, RN, PhD, is an associate professor at Hedmark University of Applied Sciences, Department of Nursing, Elverum, Norway.