healthy criticism meaning in research

Levels of critique in models and concepts of human information behaviour research

Aslib Journal of Information Management

ISSN : 2050-3806

Article publication date: 19 August 2021

Issue publication date: 6 September 2021

To elaborate the nature of critique presented in the models and concepts of human information behaviour (HIB) research by identifying the issues to which the critique is directed and the ways in which the critique is conducted.

Design/methodology/approach

Conceptual analysis focusing on 58 key studies on the topic. First, the objects and ways of conducting the critique were identified. Thereafter, three levels of depth at which the critique is conducted were specified. The conceptual analysis is based on the comparison of the similarities and differences between the articulations of critique presented at these levels.

At the lowest level of depth, critique of HIB research is directed to the lack of research by identifying gaps and complaining the neglect or paucity of studies in a significant domain. At the level of critiquing the shortcomings of existing studies, the attention is focused on the identification and analysis of the inadequacies of concepts and models. Finally, constructive critiques of research approaches dig deeper in that they not only identify weaknesses of existing studies but also propose alternative in which the shortcomings can be avoided, and the conceptualizations of HIB enhanced.

Research limitations/implications

As the study focuses on critiques addressed to HIB models and concepts, the findings cannot be generalized to concern the field of Library and Information Science (LIS) as a whole. Moreover, due to the emphasis of the qualitative research approach, the findings offer only an indicative picture of the frequency of the objects critiqued in HIB research.

Originality/value

The study pioneers by providing an in-depth analysis of the nature of critiques presented in a LIS research domain.

• Human information behaviour
• Information seeking

Savolainen, R. (2021), "Levels of critique in models and concepts of human information behaviour research", Aslib Journal of Information Management , Vol. 73 No. 5, pp. 772-791. https://doi.org/10.1108/AJIM-01-2021-0028

Emerald Publishing Limited

Copyright © 2021, Reijo Savolainen

Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

Introduction

Critique is an integral element of scientific discourse and a significant factor the advancement of research. The word critique originates from Greek kritikḗ , a noun derivative from kritikós , i.e. “discerning, capable of judging” ( Merriam-Webster, 2020b ). Criticism – a related word–usually means “the act of criticizing” or a “remark or comment that expresses disapproval,” but criticism can also refer to the activity of making judgments about the qualities of books and movies, for example ( Merriam-Webster, 2020a ). In common usage, the terms critique and criticism primarily mean to make a negative assessment of something, merely finding fault or complaining ( Boland, 2013 , pp. 2–4). In scientific discourse, however, the above terms can be interpreted more broadly because they mean an appraisal of both the negative and positive aspects of an issue. Critique not only reveals vague concepts and methodological flaws also offers constructive ideas about how to avoid such shortcomings and how to enhance a research approach. In this regard, critical notions presented by peers are particularly important, and the nature of critique evidences the maturity of a research domain ( Frawley, 2015 ).

The present study was inspired by the observation that so far, the picture of the nature of critique exercised within library and information science (LIS) has remained unclear. This is also evident in individual LIS domains such as human information behaviour (HIB) research – the context of the present investigation. This domain was chosen for the object of study because since the 1960s, HIB research literature offers a rich body of texts incorporating critical notions about the shortcomings of studies on information needs, seeking and use, as well as they ways in which HIB research could be enhanced. The critique directed to HIB research appears at diverse levels of abstraction. Many of the most radical criticisms deal with the metatheoretical assumptions of studies on informational phenomena. For example, Hjørland (2004) and Frohmann (2004) have objected the antirealist, idealistic and nominalist tendencies in HIB research by asserting that they remove the attention from reality to subjective phenomena such an individual's cognitive structures having no real explanatory power. More recently, Talja and Nyce (2015) critiqued research approaches which take the construct of task as a point of departure – a popular approach in studies on work-related information seeking and retrieval. Another recurrent topic of critical discourse is the lack of HIB theories. Vakkari (1997) reviewed information seeking literature up to mid-1990s and concluded that research conducted in this domain suffers from the lack of theoretical growth and is often plagued by unspecific definitions of basic concepts and their relations. More recently, Willson et al. (2020) crystallized the long-time problem of HIB research by pointing out that “while there is a long and rich tradition of creating models and frameworks in information behaviour … this has not been the case with the development of theories”. Nevertheless, during the two last decades, there are examples of studies indicating progress in this regard. Cole (2013 , pp. 4–5) noted that since the 1990s, a paradigm shift has occurred giving rise to more sophisticated research in theorizing HIB. This is due to the growing interest in the development of scientific models so that the research can move beyond straightforward descriptions of phenomena to the ability to predict and explain phenomena related to HIB.

The above examples form only a part of the critical notions presented in HIB research. They are indicative of diverse objects of critique, for example, vague conceptualizations of HIB phenomena ( Vakkari, 1997 ) and the narrow focus of the models for work-task related information seeking ( Talja and Nyce, 2015 ). The above examples also suggest that the nature of the critique presented in the domain of HIB can be best examined by concentrating on the models and concepts of human information behaviour. Therefore, to substantiate the picture of the nature of critique in this domain, conceptual analysis was made by focusing on the critical notions directed towards individual concepts and models of HIB research. To achieve this, an attempt was made to identify the objects of critique, as well as the ways in which researchers criticize such concepts and models. Furthermore, attention was devoted to the levels at which the critiques are presented. It is suggested that at the lowest level of depth, critiques are confined to the identification of gaps in prior research, while at the deepest level, critical notions also incorporate constructive ideas about how to elaborate a concept or refine model, for example. The findings of the present investigation contribute to HIB research by demonstrating how the critique manifests itself at various levels of depth and how the critical notions are articulated in scientific discourse.

The rest of the article is organized as follows. First, to give background, the nature of critique is characterized, followed by the explication of the research framework, research questions and methodology. The main part of the article will be reserved to the communication of the findings. The last sections discuss the findings and reflect their value.

Approaches to critique

Since the Enlightenment, critique has played an overarching role in how Western society understands itself and its basic institutions. Kant pioneered by approaching critique in terms of reflective examination of the validity and limits of a human capacity ( Raffnsøe, 2015 ). Importantly, Kant also set the agenda for the major strands of critique in contemporary philosophical thought, culminating in the works of Husserl, Popper, Habermas and Foucault. They have approached critique as a systematic inquiry into the conditions and consequences of a concept, a theory or a discipline, attempting to understand their validity and limitations.

From the perspective of social sciences, critique can generally be understood as the discourse of discontent ( Werneck and Loretti, 2018 ). There is a small number of studies examining the features of critique presented in diverse domains of research such as sociology, management science and psychology. Savage (1981 , pp. 1–61) analysed the critiques directed to the sociological theories of Talcott Parsons. The critiques were identified by two major criteria: the object of critique and the “technique” of critique, that is, the fundamental conditions of existence of diverse modes of critique in relation to the conceptions of knowledge and discourse. Five modes of critique were found: the critique of the subject, the realist mode of critique, the epistemological critique, internal critique and evolutionist critique. Frawley (2015) examined the issues critiqued in the domain of happiness research. Three major criticisms were identified: the culture-bound and normative character of happiness, “bad science” and scientism, and diminished subjectivity and individualization. More recently, Rudolph et al. (2020) made a systematic review of critiques addressed to research on “healthy leadership”. The study revealed several weaknesses, for example, unclear construct definitions and operationalizations of “healthy leadership” behaviour.

In the domain of HIB research, there are no prior studies directly comparable to the investigations made by Frawley (2015) and Rudolph et al. (2020) , for example. However, there are a few examples of related work. First, at the level of metatheoretical and methodological discussion, researchers have critiqued the ontological and epistemological assumptions of the traditional user studies which draw on institution-centred viewpoint ( Dervin and Nilan, 1986 ). Second, at a more concrete level of discussion, there are investigations focusing on the critique of individual HIB concepts such as information need ( Wilson, 1981 ) and information use ( Kari, 2007 ). In addition, there are a few studies identifying shortcomings in individual models for information seeking (e.g. Case and Given, 2016 , pp. 148–175; Wilson, 1999 ). On the other hand, HIB studies such as these are limited in that they do not discuss in more detail the nature of critique directed to a concept or model. For example, the level at which the critique is presented is not reflected. However, these studies offer fruitful research material for the present investigation because the critical notions articulated in prior HIB studies allow the analysis of both the objects of critique and the ways in which the critiques are presented.

To bridge this gap, Boltanski's (2011) approach to critique is particularly relevant for the present study because he suggests that critique applies to all forms of descriptions or judgments on reality. Drawing on Boltanski's ideas, Ward (2020 , pp. 55–56) developed an analytical tool which specifies the degrees of critique in a particular domain of public discourse, that is, vaccine criticism. First, critique on vaccination can manifest itself in doubt presented by the critic. Ultimately, doubt is based on the pervasiveness of uncertainty which gives people a “grip” to express their dissatisfaction or discontent. Underlining uncertainty in an opponent's claims to factuality represents the lowest degree of critique. Second, the critique manifesting itself in re-prioritizing goes deeper because the critic proposes a different evaluation of the importance of the statements on reality in their opponent's discourse. Third, side-stepping consists in pointing out an important element that is not taken into consideration by the actor who is criticized. The critic does not only re-evaluate the importance of one or several aspects of reality as they are presented in the discourse of the criticized; the critic also identifies significant elements of reality which are ignored. Sometimes, the critique can proceed to the ultimate degree, resulting in the revealing of the unknown . The critic demonstrates that the actor whose discourse is being criticized fails recognize the element put forward by the critique as existing, as real. Thus, taking a novel viewpoint to an issue at hand, the critic reveals a fundamental divergence on what constitutes the world.

Research framework

The prior section suggests that critique is a multifaceted discursive phenomenon that can be approached from diverse viewpoints. For example, attention can be directed to the ways in which researchers have critiqued the theories proposed by a scholar ( Savage, 1981 ) or how researchers have criticized studies conducted in various domains ( Frawley, 2015 ; Rudolph et al. , 2020 ). The research framework of the present investigation mainly draws on Ward's (2020) study discussed above. Although the categorization indicative of the degrees of critique was developed for the analysis vaccine criticism, Ward's approach is sufficiently generic for the examination of critical scientific discourse in the domain of HIB research.

However, to be better applicable for the needs of the present study, Ward's categories were used selectively, and they were modified to some extent. First, the term level of critique was preferred over the expression of “degree of critique” because the former is more indicative of the depth of criticism. The word “degree” is less clear in this regard because it may also refer to extent to which an issue is critiqued, for example, partially or wholly – an aspect which will not be examined in the present investigation. Second, Ward's category of “doubt” was excluded from the study because doubt tends to be a pervasive element of all critique, independent of its level of depth. Third and most importantly, Ward's three other categories were used in a modified form in the research framework. As these categories are indicative of different degrees of critique which does not merely refute an existing conceptualization but also proposes a constructive alternative, the categories of “re-prioriziting”, “side-stepping” and “revealing the unknown” were combined and named as critiquing constructively to enhance research approaches . In the combined construct, the component of “re-prioritizing” suggests that the object of the critique can be conceptualized more adequately by taking an alternative way. The component of “sidestepping” identifies significant elements worth further attention, and the component of “revealing the unknown” is indicative of the ways in which prior studies have failed recognize how a research approach can be elaborated further. As the above three components are often closely intertwined in the articulations of constructive critiques, the combined construct was preferred because the specification of such critiques into three sub-levels would not have offered added value to the analysis.

The research framework was substantiated further by adding two categories which were derived inductively from the preliminary analysis of the research material. First, the category of critiquing the lack of research exemplifies criticism at the lowest level of depth because critique of this kind merely indicates research issues that have been neglected in prior research. Second, critical notions can appear at a deeper level when the critic identifies and analyses flaws in existing HIB concepts ad models. This category was named as critiquing the shortcomings of existing studies.

Level 1: Critiquing the lack of research. The critic identifies the lack or paucity of research on a relevant issue by depicting gaps in prior HIB models and concepts.

Level 2: Critiquing the shortcomings of existing studies. The critic identifies and analyses weaknesses of HIB concepts and models by focusing on their flaws.

Level 3: Critiquing constructively to enhance research approaches. The critic not merely identifies and analyses the weaknesses of existing studies but also presents an alternative approach to enhance the conceptualizations and models of HIB.

Moreover, drawing on Savage's (1981 , pp. 1–61) study, the research framework was substantiated by two key aspects constitutive of critique. First, the object of critique is generally understood as something towards which cognition is directed, as contrasted with the thinking subject, that is, the critic. An object of critique may be, for example, a vague concept or a narrow model for HIB. Second, based on the preliminary analysis of the research material, the research framework was finalized by adding the aspect indicative of the approach used in the critique, for example, fault-finding or the analysis of the limitations of a HIB model. The research framework is presented in Figure 1 .

Figure 1 suggests that critiques can be examined by focusing on three levels at which researchers present critical notions about the shortcomings of HIB research. At the lowest level of depth, such critiques may be directed to the lack, neglect or insufficiency of HIB research in a domain. As the findings section indicates, critique of this kind is very common in HIB research. Researchers may contend, for example, that prior studies have largely ignored research topics such as affective factors of HIB ( Fourie and Julien, 2014 ). Second, the critic may dig deeper when he or she identifies shortcomings in the conceptualization of key concepts such as information use ( Kari, 2007 ). Finally, at the deepest level of critique, scholars may present constructive critique focusing on individual research approaches, conceptualizations and models. Critique of this type is not only based on fault-finding but it also offers an alternative viewpoint from which a phenomenon may be approached more fully. For example, Niedzwiedska (2003) presented critique of this kind while evaluating the relevance of Wilson's (1997) general model for information behaviour.

Research questions and methodology

At various levels of critique, what are the main objects of critique in HIB models and concepts?

What is the quantitative share of diverse objects of such critiques?

At various levels of critique, what kind of approaches are used while critiquing such objects?

To sharpen the focus of the study, three major limitations appeared to be necessary. First, no attention will be devoted to critiques directed to the metatheoretical, that is, ontological and epistemological assumptions of HIB research. Examples of such critiques can be found in Dervin and Nilan's (1986) review of the institution-centred approach to user studies and Frohmann's (2004) critical notions for the dominating position of the cognitive viewpoint in information science. Second, the present investigation excludes the critiques directed to the methodological approaches of HIB research (e.g. Davenport, 2010 ; Hertzum and Hansen, 2019 ). Third, due to the qualitative approach adopted in the study, the quantitative features of critique are characterized only in a limited sense by depicting the frequency of diverse objects of critique ( RQ2 ). This is because a more detailed analysis specifying the quantitative relationships between the objects, approaches and levels of HIB critiques would require a separate study.

The research material was identified by conducting literature searches in eight major databases: Academic Search Ultimate (Ebsco), Google Scholar, Lisa, Sage Journals Online, Science Direct, Scopus, Springer Link and Wiley Online. The search terms included critique, criticism, lack, neglect, shortcoming, weakness, information behaviour, concept and model. It appeared that these searches extensively identified literature relevant to the research topic. Moreover, diverse databases such as Lisa, Science Direct and Scopus retrieved the same items, thus suggesting that the initial sample of studies is saturated and that additional searches from other databases would not have resulted in the identification of new material directly relevant to the topic. In addition, the review articles published in the volumes of Annual Review of Information Science and Technology in 1966–2011 were examined to obtain relevant research material. The searches resulted in the identification of 92 potentially relevant investigations from the period of 1966–2020. A closer reading revealed that 38 of these studies are less relevant for the analysis because they mainly describe the findings of prior investigations or fail to specify sufficiently the object of critique referred to in RQ1 or the approach used in the critique ( RQ3 ). Therefore, these studies were excluded from the final sample which thus includes 58 investigations published within the period of 1966–2020. Of them, most are journal articles (50 items); the sample also includes three books, four book chapters and one conference paper.

Identify the concept of interest and associated expressions.

Identify and select an appropriate setting and sample for data collection.

Collect relevant data to identify the attributes of the concept and the contextual basis of the concept.

Analyse data regarding the above characteristics of the concept.

Identify an exemplar of the concept.

Identify implications for further development of the concept.

In the present investigation, the concept of interest is critique as an element of HIB research (step 1). The data collection is described above (step 2). As to step 3, the terminology proposed by Rodgers (2000) was slightly modified in that the present study prefers the term constituent, not attribute, while examining the characteristics of critique presented in HIB research. At the next phase (step 4), the constituents of such activities were analysed. More precisely, five constituents specified in Figure 1 were examined, that is, the object of critique, the approach of critique and the three levels of critique.

To achieve this, the research material containing altogether 58 items was first read carefully as a whole to obtain an overview. Thereafter, the research material was coded by the present author by identifying sentences and text paragraphs indicative of the objects of critique and the approach to critique. To strengthen the reliability of the coding, only explicit expressions indicative of the object of critique or approaches to critique were coded. Moreover, the initial coding was refined by repeated reading of the research material. In this regard, the study drew on Miles and Huberman (1994 , p. 65). They proposed that check-coding the same data is very useful for the lone researcher and that code–recode consistencies should be at least 90%. Following this advice, the coding was refined until it was found that the codes appropriately describe the data and that there are no anomalies.

In the coding, particular attention was directed to text portions in which the critics expressed their discontent with an issue. Five main types of objects of critique were inductively identified from the research material: (1) Neglect or ignorance of a significant issue of HIB research, (2) Paucity of HIB research in a domain, (3) Vague conceptualization of HIB, (4) Too narrow HIB models or concepts and (5) Too general HIB models or concepts. Importantly, an individual study critiquing an issue may focus on one or more objects of critique. For example, Kari (2007) focused on the critique of the vague conceptualizations of information use, while Afzal (2017) concentrated on two objects of critique: the neglect of research offering an exact operationalization of the concept of information need and the vague conceptualizations of the above construct. In the coding, all relevant text portions were equipped by the above codes so that an individual code was used one or more times within an article or book. In the quantitative analysis of the objects of critiques, however, an individual code was used only once per article or book; other instances of the same code were ignored.

The coding was continued by identifying approaches to critique characteristic of the three levels of critique specified in Figure 1 . To this end, the attention was directed to the depth at which the critique was presented, that is, whether the critic merely depicted neglected research topics and complained about the lack of prior research (level 1). At this level, a typical approach to critique is an identification of a HIB domain which is lacking research or a complaint about the neglect or insufficiency of research. For example, Fourie and Julien (2014) identified gap in research on the nature of affective factors in information seeking. Critiques presented at the level 2 focus on the shortcomings of existing studies. Two main approaches to critique characteristic of this level were identified: fault-finding and identifying and analysing the weaknesses of a study. For example, shortcomings of this kind deal with vague definitions of concepts such as information need ( Wilson, 1981 ) and information experience ( Savolainen, 2020 ) or the narrow applicability of a model for information seeking ( Burnett and Jaeger, 2008 ). Finally, critical notions presented at level 3 offer a constructive alterative to enhance a HIB model or concept. Therefore, the approach to critique characteristic of this level is the identification and analysis of the weaknesses of a study, accompanied by a proposal for an alternative approach. For example, after having critiqued the limited applicability of a model for everyday life information seeking ( Savolainen, 1995 ), the critic suggests how the scope of the model can be extended so that it more adequately depicts the ways in which people seek information in daily contexts ( Ocepek, 2018a , b ).

The coded material was analysed both quantitatively and qualitatively. First, to get an indicative quantitative picture of the objects of critique, the distribution of the codes assigned to five types of objects of critique was calculated by means of descriptive statistics. The analysis was continued by qualitatively comparing the characterizations of the objects of critiques and approaches to critique at levels 1–3. Then, exemplars depicting information seeking were identified regarding the three levels of critique characterized above (step 5). For example, at the level of critiquing constructively to enhance research approaches, Niedzwiedska's (2003) proposal to elaborate Wilson's (1997) general model for information behaviour served as an exemplar. Finally, implications for further analysis of the concept of critique were identified (step 6); these implications will be reflected in the concluding section.

Objects of critique: a quantitative overview

To put the qualitative findings in a broader context, an indicative quantitative picture of the objects of critique is presented in Table 1 , based on the distribution of 114 codes assigned to such objects in the sample of 58 studies.

Table 1 indicates that the critics most frequently expressed their discontent by asserting that prior studies have ignored or neglected an important research issue. Almost equally frequent were critiques addressed towards models or concepts that were assessed as too narrow to adequately capture the phenomena of HIB. Quite often, the critics also identified HIB issues plagued by the paucity of research, as well as directed attention to the vague conceptualizations of HIB phenomena. Finally, quite seldom, HIB models or concepts deemed too general were taken as an object of critique.

All in all, the quantitative findings suggest that the critical notions are most often presented at the lowest level of critique because altogether 50.8% of the codes assigned to the objects of critique deal with the neglect or paucity of research. The rest of the codes were assigned to objects that are characteristic of more sophisticated critiques presented at levels 2 and 3, that is, critiquing the shortcomings of existing studies and critiquing constructively to enhance research approaches. Of objects of this kind, the critical notions for the HIB models and concepts deemed too narrow are particularly important, similar to criticisms directed to vague conceptualizations of HIB phenomena. To elaborate the quantitative picture, the characteristics of critique are reviewed qualitatively in the following sections by proceedings from level 1 to level 3.

Critiquing the lack of research

In HIB research, the critical notions are often presented in contexts in which the critic asserts that earlier investigations have neglected a significant research issue. The object of critique is a gap in research and the way of critique is commonly the description of the content of such gaps. Afzal (2017) offers a typical example of critique of this kind by contending that there is “an apparent lack of conceptualisation and operationalization of constructs relevant to human information behaviour, including the construct of information need”. In a similar fashion, Bronstein (2017 , p. 935) asserted that “despite the central role that information plays in integrating immigrants into a new society … very limited empirical research exists that examines their information behaviours, needs, and practices”.

The above examples are characteristic of the critique of this kind in that the critical notions deal with the relative lack of research in a domain. The analysis of the research material revealed no cases in which the critic identified a unique topic which has totally been neglected in prior HIB research. The gap in research is rather due to the fact that earlier studies have only indirectly or marginally dealt with the neglected topic because the main emphasis is placed on other phenomena. Cox et al. (2017) study exemplifies well the critique of the relative lack of research. They complained the paucity of studies examining the features of embodied experience in HIB. The critics first emphasized the “centrality of embodied experience to all aspects of human life” and then pointed out that “the relative neglect of the body in information behaviour studies is surprising and potentially problematic” ( Cox et al. , 2017 , pp. 386–387). To support their view, they asserted that in the major models of information, there is “virtually no mention of the embodied, though there are some hints” ( Cox et al. , 2017 , pp. 388). For example, studies of information grounds tend to focus on “people talking to each other and how the character of interaction is shaped by various conditions” ( Cox et al. , 2017 , p. 388). Surprisingly, however, “the information grounds idea does not attend to the physical realities such as proximity of the participants, their facial expression and gestures, and other practical matters such as being within earshot of another” ( Cox et al. , 2017 , p. 388). The critics concluded that “in a number of major theories and studies of serious leisure, while the body does not pass completely unnoticed, its role in information activities is never seen as central or fully theorized” ( Cox et al. , 2017 , p. 390). Interestingly, their conclusion indicates that the critique can be deepened to the next level even within the same sentence by indicating shortcomings of existing studies, for example, the failure to conceptualize a phenomenon in sufficient detail.

Other researchers have continued the list of neglected research topics such as affective aspects of HIB ( Fourie and Julien, 2014 ), information use ( Kari, 2007 ), information creation ( Gorichanaz, 2019 ) and the concept of “everyday” in studies on everyday information behaviour ( Ocepek, 2018a ). As most research topics tend to be inexhaustible and there is always too little research on them, it is likely that the above list is endless, and that critique presented at this level will prevail in HIB research also in the future. Although critiques of this kind often appear in the form of complaining about the ignorance or neglect of a research topic, they can incorporate arguments by which the critics demonstrate why neglected issues such as information creation are worth further study ( Gorichanaz, 2019 ). For a researcher, the critique of the lack or paucity of prior studies provides an opportunity to justify the choice of the research topic; his or her study at hand is badly needed because it will bridge a significant gap in research. For example, Afzal (2017) used this strategy. He first asserted that the gap in in-depth studies of information need can only be filled by conducting a detailed conceptual analysis of this construct. Thereafter, as a remedy, he proposed a methodology for the conceptualization, operationalization and empirical validation of the concept of information need.

Critiquing the shortcomings of existing studies

Critical notions for the shortcomings of existing investigations go deeper in that they reveal significant weakness in the conceptualizations of HIB research. Typically, the object of critique is a vague concept or a model that is too narrow or general for the needs of empirical research. The ways in which the critique is presented varies widely, ranging from fault-finding to the specification of the weakness of individual constructs.

Since the 1960s, there are numerous studies incorporating critique of this kind ( Case and Given, 2016 , pp. 351–359). Early critiques of HIB research were presented in the volumes of the Annual Review of Information Science and Technology (ARIST), more specifically, in the chapters reviewing the studies on information needs and uses. Many of these critiques concentrated on the methodological flaws of user studies, for example, their insufficient reliability and validity (e.g. Menzel, 1966 ). Paisley (1968) was among the first researchers devoting critical attention to the poor conceptualizations of user studies. In his view, they fail to take into account “the full array of information sources that are available; the uses to which information will be put; the background, motivation, professional orientation and other individual characteristics of the user; the social, political, economic and other systems that powerfully affect the use and his work; the consequences of information–for example, productivity” ( Paisley, 1968 , p. 2). The critique directed to poorly designed research settings was particularly characteristic of the early ARIST articles. Later on, the role of fault-finding became less significant because the critiques of this kind became more analytic and the main attention was directed to the specification of the weaknesses.

Many of the critiques of the shortcomings of existing studies deal with insufficient and unclear definitions of the key concepts of HIB, most notably information need and information use. Kari's (2007) study on the conceptualization of information use offers a typical example. He asserted that information use is often defined vaguely, or not defined at all; therefore, it is no wonder that there has been a lot of confusion in the literature about the meaning of this concept. To support his argument, Kari cited the definition proposed by Bouazza (1989 , p. 146): “information use is that seeking behaviour that leads to the use of information in order to meet an individual's needs”. According to Kari, the main weakness of the above definition is that information use is purportedly approached in terms of two stages of the same process, but the latter stage is not even defined. Another object of critique was the definition of information use proposed by Hughes (2006) . She suggested that information use covers information seeking, information skills, utilization of information, information literacy, information needs context and learning outcomes, as well as transcending information behaviour. In Kari's (2007) view, this approach “breaks all boundaries … without proper justification, such an impressionistic notion really plumbs new depths and does a great disservice to the concept of information use”.

The above examples suggest that the critique can be devastating if the attention is merely directed to the obscurity of individual definitions. Similar criticisms may also appear when researchers introduce novel constructs to HIB research. For example, Fourie and Julien (2014) critiqued that the terms “affect” and “emotion” are often used interchangeably and typically left undefined. Researchers tend to opt for an intuitive, or an “yknow” interpretation of such concepts by characterizing them in a “cursory manner with ad hoc connotations” ( Yu, 2012 , p. 2). More recently, Savolainen (2020 , p. 673) assessed critically the use of the novel concept of “information experience”. He contended that researchers examining such experiences have seldom reflected the nature of the second part of the compound word, that is, experience; it tends to be taken as a black-boxed or self-explanatory concept.

The critiques directed to the shortcomings of studies have sometimes been extended to deal with the consequences of such weaknesses. For example, Savolainen (2020 , p. 673) concluded that the unreflective use of the concept of information experience tends to reduce its discriminatory power and result in a vague understanding of the phenomenon which is being studied. The question of the consequences of the shortcomings also arises in contexts in which terminology originally developed outside the domain of HIB research is applied in empirical research. Perhaps the best example of critical notions of this kind can be found in Davenport's (2010) study. In her view, the application of the sense-making methodology (SMM) developed by Dervin (1999) is not without problems because some of its terms such as “verbing” are idiosyncratic in nature and they exemplify “linguistic sleights of hand” ( Davenport, 2010 , p. 551). Similarly, Savolainen (2006 , p. 1,124) observed that the use of idiosyncratic SMM lexicon may result in “translation problems between the vocabularies of sense making and other approaches”. Thus, the findings of SMM studies can be reliably compared only with themselves and not with mainstream HIB research.

Researchers have also critiqued the shortcomings of individual HIB models. Many of the critical notions deal with the abstract features of such frameworks. For example, Ingwersen and Järvelin (2005 , p. 62) hold that Dervin's (1983) sense-making metaphor of situations, gaps and uses “does not say much about information seeking in various contexts and does not suggest testable hypotheses”. This problem is rendered more difficult if the model is both abstract and excessively complex. Similarly, Godbold's (2006) general model for information behaviour has been critiqued because the model attempts to merge together various aspects of the frameworks proposed by Dervin, Wilson, Ellis and Kuhlthau, resulting in a “quite complicated figures that are hard to translate into a study design or even into an explanation of how and why people behave as they do” ( Case and Given, 2016 , p. 173).

On the other hand, HIB models and theories have been critiqued for their simplicity and narrow applicability. Burnett and Jaeger (2008 , 2011 , p. 164) identified a number of shortcomings in the small world theories proposed by Chatman (1999 , 2000) . The main weakness of her theories is that they do not adequately consider the interactions between small worlds and the broader society within which they exist, nor do they account for interactions across and between multiple small worlds. More recently, Case and Given (2016 , p. 150) drew critical attention to the limitations of Krikelas's (1983) model for information seeking, because it just exhibits “one-dimensional flowchart in which all of the arrows travel in one direction, i.e. there are no two-way influences among the boxes and no one part of the process encompasses another”. In this case, as Case and Given (2016 , p. 150) put it, the model's “simplicity implies oversimplification”. Sometimes, the critical notions for the limitations of a study appear in the form of self-criticism. For example, Liu (2017 , p. 683) reflected critically the limitations of his unifying model for human information behaviour, based on equilibrium analysis. He cautioned that the framework of equilibrium analysis may not be able to incorporate detailed facets of problematic situations, resources and social environments which contextualize individuals' information practices. Moreover, as Liu's model is constructed basically from an individual's perspective, it does not take into account the fact that information seeking is often a social process.

Finally, the shortcomings of HIB models have been critiqued by drawing on novel empirical evidence which contradicts with the assumptions of a framework. In a study on collaborative information behaviour among students Hyldegård (2006 , p. 294) demonstrated that contrary to the assumptions of Kuhlthau's (2004) Information Search Process (ISP) model, negative feelings were not replaced by positive feelings such as clarity during the information-seeking process. This finding suggests that the ISP model works best as a framework depicting information seeking among solitary actors, but the model is less applicable if information seekers act as members of a collaborative group. Savolainen (2015) addressed more explicit critique to the ISP model while examining how it conceptualizes the construct of uncertainty. The ISP model draws on a traditional view on the nature of uncertainty in that the focus is placed on the negative (undesirable) uncertainty causing anxiety among users. However, recent studies have shown that there can be a positive impact from uncertainty as well (e.g. Chowdhury et al. , 2014 ). Positive (and arguably desirable) uncertainty may influence the information-seeking process because the individual is motivated by eager anticipation to find new or related sources of information.

Critiquing constructively to enhance research approaches

Constructive critique is not merely confined to the identification of flaws in prior studies but digs deeper by suggesting alternative approaches about how to avoid similar weaknesses and how to enhance the research approach. Again, the objects of critiques vary considerably, ranging from individual concepts to diverse models for HIB. Similarly, the approaches to critique vary regarding the depth by which the critic first analyses the flaws of a study and then presents the constructive alternative.

Examples of constructive critique can be found since the 1960s. Paisley (1968) – after first having identified numerous shortcomings in studies on information needs and uses – proposed a research framework which enables a more systematic investigation of individual, social and cultural factors affecting information seeking among scientists and engineers in particular. In early HIB research, one of the most radical constructive critiques was presented in Wilson's (1981) study. He objected the shallow characterizations of the concept of information need – a factor commonly used to explain why people engage in information seeking. Wilson (1981 , pp. 5–6) asserted that the association of the terms “information” and “need” causes confusion; “this association imbues the resulting concept with connotations of a basic ‘need’ qualitatively similar to other basic ‘human needs”. To avoid this problem, Wilson (1981 , p. 8) advised to “to remove the term information needs from our professional vocabulary and to speak instead of information-seeking towards the satisfaction of needs”. Wilson's alternative approach draws on the identification of human needs of three types: (1) physiological needs, such as the need for food, water and shelter, (2) affective needs, such as the need for attainment or for domination and (3) cognitive needs, such as the need to plan and need to learn a skill. The novel approach would not only enable the avoiding of the vague term “information need” but also offer a firmer (psychological) basis to examine how the satisfaction of human needs may incorporate attempts to seek information.

According to Ellis (2011 , pp. 21–22), Wilson's (1981) critique was influential in that it “more or less demolished the concept of information need as a valid starting ground or basis for explanations of information behaviour”. On the other hand, this effect seems to have remained temporary only. Wilson's constructive critique did not result in the removal of the concept of information need from the vocabulary of HIB research; on the other hand, the alternative view advocated by Wilson got no wider support among HIB researchers. As before, the term of information need was used in the ARIST chapters on “information needs and uses” (e.g. Dervin and Nilan, 1986 ). In fact, Wilson himself returned to the use of the term information need in his later studies and employed the above term in the general model for information behaviour ( Wilson, 1997 ). This suggests that critiques – despite their constructive intent – may not resonate in the research community if the alternative approach is not regarded as a remarkably better way to conceptualize an aspect of HIB.

One of the most detailed constructive critiques directed to HIB models is presented by Niedzwiedzka (2003) . Based on detailed conceptual analysis, she evaluated Wilson's (1997) general model for information behaviour by presenting critical remarks on the content and graphical presentation of his framework. The critique was motivated by the practical need to categorize factors and mechanisms that ought to be taken into consideration while investigating the information behaviour among managers. The critique was directed to three main issues indicative of the shortcomings of Wilson's model. First, Niedzwiedzka (2003) asserted that Wilson's model does not clearly differentiate the phase of the occurrence of information need from the phase when a decision to seek information is undertaken. This notion is important because not every need for information experienced by the individual leads to information seeking. Second, Wilson's diagram separates the component of “context” from the intervening variables, which influence information behaviour. However, this is not logical because the intervening variables themselves form a context of information behaviour. Moreover, Wilson's diagram suggests that the intervening variables influence the user only at the stage of information acquisition, while such variables may also influence when an information need is experienced, and information is processed and used. Third, Wilson (1997) treated the features of information source as a separate class of variables, while the source is an element of information environment (context); thus, information sources can be included in a general class of environmental variables.

The constructive elements of the critique are based on the assumption that Wilson's diagram can be elaborated so that it illustrates better the nature of contextual factors and takes into account the features of information seeking characteristic of managers. Niedzwiedzka (2003) argued that especially top-level managers tend to obtain a considerable part of work-related information through intermediaries such as secretaries. To finalize her critique, Niedzwiedzka (2003) created a new version of Wilson's diagram by adding novel components depicting the role of the intermediaries. Moreover, Wilson's diagram was restructured by placing the intervening variables as components of the context of information behaviour. Finally, in the modified version, a phase of the need occurrence was separated from a phase of making a decision to seek information, thus suggesting that also at this stage the activating mechanisms can play a significant role.

Niedzwiedzka's (2003) study offers a rare example of attempts to enhance existing HIB models by means of constructive critique, rather than proposing still another new framework to depict information seeking among a particular group of people. However, similar to Wilson's (1981) critique of information need, the framework being criticized, i.e. Wilson's (1997) model retained its central position in HIB research, while the modified version proposed by Niedzwiedzka (2003) is referred to relatively seldom. According to Google Scholar (23 November 2020), her study has been cited 201 times since 2004, as compared to 1,395 references to Wilson's (1997) article within the period of 2004–2020. The above scores are not directly comparable because Wilson's (1997) article reviews a number of other HIB models, too. On the other hand, as Wilson has also presented his model in other articles (e.g. Wilson, 1999 ), the total number of studies referring to his framework is even higher than the above score.

In addition to individual models, constructive critique can be directed more broadly to HIB research conducted in a particular domain. Ocepek (2018a) urged recently that research on everyday information behaviour (EIB) should be strengthened by reflecting more deeply the nature of everyday phenomena. A more elaborate approach is needed because major theoretical works in EIB such the theory of life in the round ( Chatman, 1999 ) and the model for everyday life information seeking (ELIS) ( Savolainen, 1995 ) are limited in that they focus on the context immediately surrounding an individual's information behaviours. Therefore, they fail to articulate the rationale for exploring the everyday or how it relates to information behaviours in other contexts.

Ocepek's (2018a , pp. 399–400) constructive alternative is based on the assumption that everyday is more than simply non-work contexts. To support her argument, Ocepek (2018b) draws on the ideas of Lefebvre (2008) in particular. Lefebvre (2008 , p. 31) characterizes the everyday as the nexus of work, leisure and family life, approaching them in “their unity and their totality”. Therefore, EIB research should focus on the banal and quotidian parts of life along with the more traditional EIB domains, such as serious leisure. By studying how individuals use information in the quotidian parts of life, an everyday-focused EIB could gain deeper insights into how all people interact with information in diverse mundane domains such as the grocery store because of the similarities in the ways in which individuals typically approach these domains. The broader perspective would also open possibilities to renew EIB research by removing artificial borders between work and non-work contexts. The novel approach is justified further by taking concrete examples from Ocepek's (2018b) empirical observations about how people make use of sensory-based information sources in the quotidian task of grocery shopping. Her study indicated that sensory-based information about products obtained through sight, taste, touch and smell exemplifies a new type of information source which can be examined in relation to information seeking, encountering, sharing and browsing.

In a similar critical spirit, Dalmer (2019) urged that the construct of ELIS proposed by Savolainen (1995) needs to be re-evaluated while examining the issues of health-related information seeking, for example. This is because Savolainen's approach “dichotomises work from everyday life and excludes the workful character of finding, using, or managing health information in people's everyday life” ( Dalmer, 2019 , pp. 715–716). Thus, there is a danger that studying individuals' everyday health information practices in non-work contexts forces a false dichotomy between work and non-work and removes some contextual cues and richness in fully understanding people's everyday health information practices. As a remedy, Dalmer (2019 , p. 716) proposed that health information practice-based ELIS studies investigate participants' work (paid) contexts “not only to examine the skills, habits, and resources that arise from paid work environments, but also for the organisational constraints and coordination that work contexts establish and impose on people's experiences of their everyday health information practices”.

Interestingly, constructive proposals such as these may be questioned by counter-arguments, thus suggesting that presenting an alternative viewpoint is not necessarily the final world in a debate about how to interpret HIB concepts and models. Taking the ELIS model as an example, Dalmer's (2019 , pp. 715–716) key argument that the above model forces “a false dichotomy between work and non-work” may be contested by checking how the above issue was approached in Savolainen's (1995) study. Contrary to Dalmer's interpretation, Savolainen emphasized that “the concept of ELIS should not be interpreted as an attempt to create a false dichotomy between processes of job-related and ‘other' information seeking because job-related information seeking and ELIS complement each other” ( Savolainen, 1995 , p. 266). Later empirical studies have supported Savolainen's view on this issue (e.g. Dankasa, 2016 ). Drawing on an investigation of ELIS among university students Given (2002 , p. 28) demonstrated that for all of these students, everyday experiences also provided information solutions for academic work. Similarly, the academic context initiated new ELIS needs (e.g. child-care) that they would otherwise not have held. Their experiences reinforced Savolainen's (1995) call to avoid the “false dichotomy” between the everyday and other life contexts in favour of an examination of the complexities of individuals' information-seeking behaviours. All in all, the above examples suggest that in order to build an alternative approach on a firm basis, the object of critique should be depicted correctly because otherwise the constructive elements of the critique may lose their potential to renew HIB research.

The present study contributed to HIB research by examining the nature of critique addressed to the concepts and models developed in the above domain. To achieve this, research question 1 focused on the main objects of critique, while research question 2 examined the quantitative share of diverse objects of critique. Finally research questions 3 dealt with the ways in which the critique is conducted. The objects and approaches were then examined at three levels of depth. As the emphasis of the present study was placed on the qualitative analysis, the answers to research questions 1 and 3 are summarized in Table 2 .

Table 2 suggests that at the lowest level of depth, critiques are directed to the lack of research by identifying gaps and complaining the neglect or paucity of studies in a domain. The quantitative findings presented in Table 1 suggest that critique of this kind is quite common in HIB research. Critical notions such as these typically appear in the introductory section of a study where the researcher justifies the choice of the research topic by asserting it has been neglected in earlier studies. However, merely critiquing gaps in prior studies tends to offer a weak or sometimes even trivial justification for the choice research topic because there are always issues that have been insufficiently researched so far. The qualitative findings indicate that the objects of critique at this level of depth vary widely, depending on the topic of the study at hand. However, many of the critiques of this kind deal with the lack of in-depth studies on information need and information use in particular. The dearth of investigations on these topics suggest is probably due to that researchers avoid them because information need and information use are notoriously complex phenomena and thus hard to conceptualize and operationalize. The findings also indicate that critique of this kind is addressed to the relative lack of research; there may be a few prior investigations but they are only indirectly relevant for the research topic. Characteristic of critique of this kind, the critical notions are presented in a descriptive way by depicting the gaps identified by the critic. Typically, researchers do not speculate further about why a gap exists in prior HIB investigations. However, such reflections can be found in critical studies on metatheoretical issues. For example, Frohmann (2004) and Olsson (2006) asserted that certain research topics are neglected, due to the dominating position of the cognitive viewpoint in particular.

Critiques of the shortcomings of existing studies dig deeper in that they analyse the flaws of an individual investigation. At this level, too, the objects of critique vary widely, ranging from vague concepts to overly abstract or narrow models for HIB. Critiques of this kind appeared to be fairly common since the 1960s. Early critiques were often confined to the fault-finding, that is, merely identifying flaws in the conceptualizations of HIB phenomena or demonstrating that the research approaches are narrow or biased in some way. Later on, analytic approaches became more common, as the critics explained in more detail why a construct or model is inadequate. Similar to the critique of the lack of research, many of the critical notions revealing weaknesses in existing research focus on the conceptualizations of “difficult” issues such as information need and information use.

Finally, the constructive critiques of research approaches represent the most sophisticated form of the critical evaluations. In this case, too, the objects of critique vary a lot, but many of the most detailed critiques are addressed to the conceptualizations of information need and the limitations of individual HIB models. Different from the critiques discussed above, constructive critiques offer remedies by which the shortcomings of the conceptualizations and models can be avoided. Most importantly, constructive critiques suggest an alternative viewpoint to the object being criticized. On the other hand, constructive critique may represent the most radical form of criticism because the critic suggests that an existing construct or model should be elaborated by adding new components or restructuring them in a novel way. Therefore, constructive critiques often incorporate normative elements because the critic advocates that the novel approach proposed by the scholar should be adopted in order to renew a research approach, as perhaps best exemplified by Dalmer's (2019) study.

All in all, supporting the view of Werneck and Loretti (2018) , the findings suggest that independent of the level of depth, critiques are based on the discourse of discontent. Discontent is expressed when the critic identifies a gap in research, finds ambiguity in a concept or doubts that a model is too narrow to capture the richness of HIB phenomena. The findings also support the assumption that critique is an integral constituent of HIB research and potentially one of the factors enabling the renewal of the research domain. However, as the studies of Niedzwiedzka (2003) and Wilson (1981) exemplify, even the most constructive critiques may not result in the adoption of a new terminology or a refined model. Nevertheless, it is evident that critiques presented at various levels of depth are useful, independent on whether they appear in the identification of the lack of research on a significant issue, in the demonstration of the shortcomings of existing studies or in the constructive evaluation of a concept or model. The critical notions keep research in motion and motivate scholars to avoid complacency and intellectual laziness.

It is also evident that the critiques presented at diverse levels are not necessarily separate. For example, the critique of the gaps in research may be followed by critical notions about the shortcomings of related research, as exemplified by Cox et al. (2017) . To begin with, they criticized the paucity of research on the phenomena on embodied experience and then demonstrated that certain studies relevant to this topic have failed to conceptualize the issues of embodied experience in the context of information behaviour. Similarly, a critique directed to the shortcomings of a model is a necessary point of departure for the presentation of a constructive alternative, as exemplified by Niedzwiedzka's (2003) proposal for the elaboration of Wilson's (1997) general model for information behaviour.

Due to the lack of investigations examining the nature of critique presented in the domain of HIB research, the findings cannot be directly compared to prior studies on similar topics. This is mainly because earlier HIB investigations with an explicit critical intent have concentrated on the critique of metatheoretical or methodological issues (e.g. Davenport, 2010 ; Dervin and Nilan, 1986 ; Frohmann, 2004 ; Olsson, 2006 ). However, a few comparative notions can be made to investigations made in other fields of study, despite the facts that such investigations are heterogeneous regarding their topics and methodological approaches ( Frawley, 2015 ; Rudolph et al. , 2020 ; Savage, 1981 ). Most importantly, the above studies share a common feature with the present investigation in the objects of critiques deal with the content of research which is interpreted as inadequate in some respect. For example, in studies examining healthy leadership, scholars have criticized the unclear conceptualizations of such leadership ( Rudolph et al. , 2020 ), while HIB researchers have critiqued vague definitions of information use. This suggests that flaws identified in the content of research is a necessary point of departure of all scientific critique, independent of the research domain. In philosophy, as well as in human and social sciences and HIB studies in particular, an important precondition for the critique of such a content is the existence of diverse views, constructs and models. As suggested above, critiques addressed to them keep research in motion and able to continually renew itself.

The study offered a unique contribution to HIB research by identifying three levels of depth at which critiques to HIB constructs and models are addressed. However, as the present investigation represents one of the first steps to analyse the nature of critique, additional research is required to elaborate the picture of critical notions presented in HIB research. Quantitative investigations are needed to specify how the objects, approaches and levels of critique are related in this domain. To achieve this, quantitative content analysis and bibliometric methods hold good potential to examine the substantiate features of critiques addressed to HIB research. For example, approaching such critiques in terms of negative citations offers a relevant avenue for research ( Catalini et al. , 2015 ). Negative citations are indicative of the limitations, inconsistencies or flaws of research and they may question or limit the scope and impact of a contribution or a scholar. One of the topics of further investigations is the ways in which critiques directed to HIB studies have influenced the research domain and the extent to which such critiques are justified. For example, it is evident Dervin and Nilan's (1986) critical review of the institution-centred studies is one of the most influential contributions resulting in the renewal of HIB research since the 1990s, along with the lines of the user-centred approach ( Vakkari, 1997 ). However, little is known about the influence of critiques presented by scholars such as Wilson (1981) , Frohmann (2004) and Hjørland (2011) , for example. Further studies on the nature and influence of critiques would also be useful in that they may reveal whether the ways of critiques are more constructive or radical compared to those presented in other fields of study, for example, communication research and sociology.

The research framework

The percentage distribution of codes assigned to objects of critique ( n  = 114)

Summary of the research findings

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Meaning and Health: A Systematic Review

• Published: 30 November 2013
• Volume 9 , pages 1055–1079, ( 2014 )

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• Ann Marie Roepke 1 , 3 ,
• Eranda Jayawickreme 2 &
• Olivia M. Riffle 3  

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The research base linking meaning with physical health is significantly underdeveloped in comparison to that linking subjective well-being and physical health. We address this deficit by first providing an overview of the study of meaning, and then examining evidence of its positive relationship to physical health in a systematic review of relevant literature. We searched PsycINFO and PubMed databases for studies of varying design and populations, excluding studies that did not have clear measures of meaning and physical health and/or did not address their relationship. Overall, higher levels of meaning are clearly associated with better physical health, as well as with behavioral factors that decrease the probability of negative health outcomes or increase that of positive health outcomes. Methodological challenges and future directions are discussed.

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Theoretical Issues in the Further Development of the Sense of Coherence Construct

Measuring Three Distinct Aspects of Meaning in Life: The Multidimensional Existential Meaning Scale (MEMS)

How Mindfulness Enhances Meaning in Life: A Meta-Analysis of Correlational Studies and Randomized Controlled Trials

We thank Ed Diener for pointing out these important measurement issues.

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Acknowledgments

The authors are very grateful to Dr. Suzanne C. Danhauer of the Wake Forest University School of Medicine for her valuable comments during preparation of this manuscript.

Support for this publication is provided by the Robert Wood Johnson Foundation through a grant, “Exploring the Concept of Positive Health,” to the Positive Psychology Center of the University of Pennsylvania, Martin Seligman, project director.

This publication is also made possible through the support of a grant from the John Templeton Foundation. The opinions expressed in this publication are those of the authors and do not necessarily reflect the views of the John Templeton Foundation

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Roepke, A.M., Jayawickreme, E. & Riffle, O.M. Meaning and Health: A Systematic Review. Applied Research Quality Life 9 , 1055–1079 (2014). https://doi.org/10.1007/s11482-013-9288-9

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Published : 30 November 2013

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DOI : https://doi.org/10.1007/s11482-013-9288-9

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• 13 Department of Primary and Community Care, Radboud University Nijmegen Medical Centre
• 14 Netherlands Organisation for Health Research and Development, The Hague, Netherlands
• Correspondence to: M Huber m.huber{at}louisbolk.nl
• Accepted 15 June 2011

The WHO definition of health as complete wellbeing is no longer fit for purpose given the rise of chronic disease. Machteld Huber and colleagues propose changing the emphasis towards the ability to adapt and self manage in the face of social, physical, and emotional challenges

The current WHO definition of health, formulated in 1948, describes health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” 1 At that time this formulation was groundbreaking because of its breadth and ambition. It overcame the negative definition of health as absence of disease and included the physical, mental, and social domains. Although the definition has been criticised over the past 60 years, it has never been adapted. Criticism is now intensifying, 2 3 4 5 and as populations age and the pattern of illnesses changes the definition may even be counterproductive. The paper summarises the limitations of the WHO definition and describes the proposals for making it more useful that were developed at a conference of international health experts held in the Netherlands. 6

Limitations of WHO definition

Most criticism of the WHO definition concerns the absoluteness of the word “complete” in relation to wellbeing. The first problem is that it unintentionally contributes to the medicalisation of society. The requirement for complete health “would leave most of us unhealthy most of the time.” 4 It therefore supports the tendencies of the medical technology and drug industries, in association with professional organisations, to redefine diseases, expanding the scope of the healthcare system. New screening technologies detect abnormalities at levels that might never cause illness and pharmaceutical companies produce drugs for “conditions” not previously defined as health problems. Thresholds for intervention tend to be lowered—for example, with blood pressure, lipids, and sugar. The persistent emphasis on complete physical wellbeing could lead to large groups of people becoming eligible for screening or for expensive interventions even when only one person might benefit, and it might result in higher levels of medical dependency and risk.

The second problem is that since 1948 the demography of populations and the nature of disease have changed considerably. In 1948 acute diseases presented the main burden of illness and chronic diseases led to early death. In that context WHO articulated a helpful ambition. Disease patterns have changed, with public health measures such as improved nutrition, hygiene, and sanitation and more powerful healthcare interventions. The number of people living with chronic diseases for decades is increasing worldwide; even in the slums of India the mortality pattern is increasingly burdened by chronic diseases. 7

Ageing with chronic illnesses has become the norm, and chronic diseases account for most of the expenditures of the healthcare system, putting pressure on its sustainability. In this context the WHO definition becomes counterproductive as it declares people with chronic diseases and disabilities definitively ill. It minimises the role of the human capacity to cope autonomously with life’s ever changing physical, emotional, and social challenges and to function with fulfilment and a feeling of wellbeing with a chronic disease or disability.

The third problem is the operationalisation of the definition. WHO has developed several systems to classify diseases and describe aspects of health, disability, functioning, and quality of life. Yet because of the reference to a complete state, the definition remains “impracticable, because ‘complete’ is neither operational nor measurable.” 3 4

Need for reformulation

Various proposals have been made for adapting the definition of health. The best known is the Ottawa Charter, 8 which emphasises social and personal resources as well as physical capacity. However, WHO has taken up none of these proposals.

Nevertheless, the limitations of the current definition are increasingly affecting health policy. For example, in prevention programmes and healthcare the definition of health determines the outcome measures: health gain in survival years may be less relevant than societal participation, and an increase in coping capacity may be more relevant and realistic than complete recovery.

Redefining health is an ambitious and complex goal; many aspects need to be considered, many stakeholders consulted, and many cultures reflected, and it must also take into account future scientific and technological advances. The discussion of experts at the Dutch conference, however, led to broad support for moving from the present static formulation towards a more dynamic one based on the resilience or capacity to cope and maintain and restore one’s integrity, equilibrium, and sense of wellbeing. 6 The preferred view on health was “the ability to adapt and to self manage.”

Participants questioned whether a new formulation should be called a definition, because this implied set boundaries and trying to arrive at a precise meaning. They preferred that the definition should be replaced by a concept or conceptual framework of health. A general concept, according to sociologist Blumer, 9 represents a characterisation of a generally agreed direction in which to look, as reference. But operational definitions are also needed for practical life such as measurement purposes.

The first step towards using the concept of “health, as the ability to adapt and to self manage” is to identify and characterise it for the three domains of health: physical, mental, and social. The following examples attempt to illustrate this.

Physical health

In the physical domain a healthy organism is capable of “allostasis”—the maintenance of physiological homoeostasis through changing circumstances. 10 When confronted with physiological stress, a healthy organism is able to mount a protective response, to reduce the potential for harm, and restore an (adapted) equilibrium. If this physiological coping strategy is not successful, damage (or “allostatic load”) remains, which may finally result in illness. 11

Mental health

In the mental domain Antonovsky describes the “sense of coherence” as a factor that contributes to a successful capacity to cope, recover from strong psychological stress, and prevent post-traumatic stress disorders. 12 13 The sense of coherence includes the subjective faculties enhancing the comprehensibility, manageability, and meaningfulness of a difficult situation. A strengthened capability to adapt and to manage yourself often improves subjective wellbeing and may result in a positive interaction between mind and body—for example, patients with chronic fatigue syndrome treated with cognitive behavioural therapy reported positive effects on symptoms and wellbeing. This was accompanied by an increase in brain grey matter volume, although the causal relation and direction of this association are still unclear. 14

Social health

Several dimensions of health can be identified in the social domain, including people’s capacity to fulfil their potential and obligations, the ability to manage their life with some degree of independence despite a medical condition, and the ability to participate in social activities including work. Health in this domain can be regarded as a dynamic balance between opportunities and limitations, shifting through life and affected by external conditions such as social and environmental challenges. By successfully adapting to an illness, people are able to work or to participate in social activities and feel healthy despite limitations. This is shown in evaluations of the Stanford chronic disease self management programme: extensively monitored patients with chronic illnesses, who learnt to manage their life better and to cope with their disease, reported improved self rated health, less distress, less fatigue, more energy, and fewer perceived disabilities and limitations in social activities after the training. Healthcare costs also fell. 15 16

If people are able to develop successful strategies for coping, (age related) impaired functioning does not strongly change the perceived quality of life, a phenomenon known as the disability paradox. 17

Measuring health

The general concept of health is useful for management and policies, and it can also support doctors in their daily communication with patients because it focuses on empowerment of the patient (for example, by changing a lifestyle), which the doctor can explain instead of just removing symptoms by a drug. However, operational definitions are needed for measurement purposes, research, and evaluating interventions.

Measurement might be helped by constructing health frames that systematise different operational needs—for example, differentiating between the health status of individuals and populations and between objective and subjective indicators of health. The measurement instruments should relate to health as the ability to adapt and to self manage. Good first operational tools include the existing methods for assessing functional status and measuring quality of life and sense of wellbeing. WHO has developed several classification systems measuring gradations of health. 18 These assess aspects like disability, functioning, and perceived quality of life and wellbeing.

In primary care, the Dartmouth Cooperative Group (COOP)/Wonca (the world organisation of family doctors) assessment of functional status, validated for different social and cultural settings, has been developed to obtain insight into the perceived health of individuals. The COOP/Wonca Functional Health Assessment Charts present six different dimensions of health, each supported by cartoon-like drawings. 19 20 Each measures the ability to perform daily life activities on a 1 to 5 scale.

Such instruments offer valuable information about a variety of aspects, from functioning to the experienced quality of life. Yet there are few instruments for measuring aspects of health like the individual’s capacity to cope and to adapt, or to measure the strength of a person’s physiological resilience. A new formulation about health could stimulate research on this.

Just as environmental scientists describe the health of the earth as the capacity of a complex system to maintain a stable environment within a relatively narrow range, 21 we propose the formulation of health as the ability to adapt and to self manage . This could be a starting point for a similarly fresh, 21st century way of conceptualising human health with a set of dynamic features and dimensions that can be measured. Discussion about this should continue and involve other stakeholders, including patients and lay members of the public.

Cite this as: BMJ 2011;343:d4163

We thank Jennie Popay, Atie Schipaanboord, Eert Schoten, and Rudy Westendorp for their thoughts.

Contributors and sources: This paper builds on a two day invitational conference in the Netherlands on defining health, organised by the Health Council of the Netherlands ( Gezondheidsraad ) and the Netherlands Organisation for Health Research and Development ( ZonMw ). At the conference a multidisciplinary group of 38 international experts discussed the topic and were guided by a review of the literature. MH organised the conference and drafted the report and this article. LG, HvdH, ARJ, DK, BL, KL, MIL, JvdM, PS, RS, and CvW contributed as speakers. HS hosted the conference with JAK, who chaired it. All authors contributed to the article. JAK is guarantor.

Competing interests: All authors have completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

Provenance and peer review: Not commissioned; externally peer reviewed.

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• ↵ Blumer H. Symbolic interactionism: perspective and method. Prentice Hall, 1969.
• ↵ Schulkin J. Allostasis, homeostasis, and the costs of physiological adaptation. Cambridge University Press, 2004.
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• ↵ Antonovsky A. Health, stress and coping. Jossey-Bass, 1979.
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• ↵ De Lange FP, Koers A, Kalkman JS, Bleijenberg G, Hagoort P, Van der Meer JWM, et al. Increase in prefrontal cortical volume following cognitive behavioural therapy in patients with chronic fatigue syndrome. Brain 2008 ; 131 : 2172 -80. OpenUrl Abstract / FREE Full Text
• ↵ Lorig KR, Sobel DS, Stewart AL, Brown BW, Bandura A, Ritter P, et al. Evidence suggesting that a chronic disease self management program can improve health status while reducing utilization and costs: a randomized trial. Med Care 1999 ; 37 : 5 -14. OpenUrl CrossRef PubMed Web of Science
• ↵ Lorig KR, Ritter PL, González VM. Hispanic chronic disease self management: a randomized community-based outcome trial. Nurs Res 2003 ; 52 : 361 -9. OpenUrl CrossRef PubMed Web of Science
• ↵ Von Faber M, Bootsma-van der Wiel A, van Exel E, Gussekloo J, Lagaay AM, van Dongen E, et al. Successful aging in the oldest old: who can be characterized as successfully aged? Arch Intern Med 2001 ; 161 : 2694 -700. OpenUrl CrossRef PubMed Web of Science
• ↵ WHO. WHO family of international classifications. www.who.int/classifications .
• ↵ Van Weel C, König-Zahn C, Touw-Otten FWMM, van Duijn NP, Meyboom-de Jong B. Measuring functional health status with the COOP/Wonca charts. Northern Centre for Health Care Research, University of Groningen, 1995. www.globalfamilydoctor.com/research/research.asp?refurl=r#R4 .
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What’s the Definition of Health?

The WHO’s definition has been the target of criticism in the medical literature since its first appearance in 1948.

A Curious Reader asks: What’s the definition of health?

According to the World Health Organization , health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” The apparent fullness of this definition carries a powerful intuitive appeal: A comprehensive definition of health should cover all aspects of life, it would seem. However, the WHO definition has been the target of criticism in the medical literature since its first appearance in that organization’s constitution in 1948. The American bioethicist Daniel Callahan, for instance, writes for The Hastings Center Studies (Callahan’s own institution) that “one of the grandest games” in the field of medicine “is that version of king-of-the-hill where the aim of all players is to upset the World Health Organization definition of ‘health.’ ”

Citing the Austrian-British philosopher Ludwig Wittgenstein’s famous aphorism “meaning is use,” Callahan goes on to rehearse a handful of well-known problems with the WHO definition, including: (1) that it is hopelessly vague; (2) that it casts “the medical profession” and “the psychological profession in the role of high priests;” and (3) that it has the potential for misuse in the hands of Savonarola-style moralists, who will simply reframe their agendas in the language of “mental and social well-being.”

Writing in 1973, Callahan acknowledged that, in making these points, he was already “beating a dead horse.” Nevertheless, the same WHO definition endures, maintaining a place of prominence in the official documents governing a major international institution. And for Callahan, the possibility of tyranny by the medical profession is reason enough to be cantankerous about what might seem like mere semantics.

But it’s easy enough to criticize. What definition would Callahan have us use instead? Ultimately, he suggests that simpler is better: Health means physical health, full stop. “The image of a physically well body is a powerful one and, used carefully, it can be suggestive of the kind of wholeness and adequacy of function one might hope to see in other areas of life,” he concludes.

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Better heart health at midlife linked to less cognitive decline in Black women

by American Heart Association

Better heart health may mean middle-aged Black women are less likely to show cognitive decline than those with poor heart health, a study has found.

Researchers said the study highlights the importance of heart health in protecting the brain. "Better cardiovascular health in women in their 40s is important to prevent later-life Alzheimer's disease, dementia and to maintain independent living ," the study's lead author, Dr. Imke Janssen, said in a news release. She is a professor of family and preventive medicine at Rush University Medical Center in Chicago.

The study, published in the Journal of the American Heart Association , compared key heart health measures to Black and white women 's scores on cognitive tests over 20 years. The cognitive tests assessed processing speed and working memory.

The heart health standards, developed by the American Heart Association and known as Life's Essential 8, include weight, blood pressure , blood glucose and cholesterol, plus behaviors such as eating healthy foods, being physically active, not smoking and getting enough sleep.

Black women with good heart health showed little decline in mental processing during the study. Black women with lower heart health, especially as indicated by blood pressure and smoking, had a 10% decrease in processing speed over 20 years.

Processing speed is the pace at which the brain recognizes visual and verbal information. Working memory is the ability to remember and use small pieces of information for daily tasks, including remembering names and doing math.

Previous research has linked heart health to a lower risk of cognitive decline, Janssen said, but questions remain about when the cognitive benefits of heart health begin, whether they occur among people of different races and whether they affect different types of brain function.

The study involved 363 Black and 402 white women from the Chicago site of the Study of Women's Health Across the Nation . The Chicago SWAN group started cognitive testing in 1997, when the women were between 42 and 52 years old. Heart health was assessed only at the time of enrollment, but cognitive testing continued every one to two years through 2017.

In the study, processing speed did not decline among white women with poorer heart health, and heart health did not affect working memory for Black or white women.

"We were surprised that we did not find results like those of past studies, which showed cognitive decline in Black and white men and women (with poorer heart health), and found cardiovascular health to be more important for white adults rather than people in Black subgroups," Janssen said.

"We think these differences are due to the younger age of our participants, who began cognitive testing in their mid-40s, whereas previous studies started with adults about 10 to 20 years older."

The authors acknowledged several limitations to the study. It included women from just one study site, relied on self-reported measures of heart health and did not include measures that may account for racial differences in access to health care or the potential influence of structural racism on Black participants.

The next step in the research, Janssen said, would be a clinical trial to confirm whether optimizing heart health in Black women at midlife could slow cognitive aging, maximize independence and reduce racial inequities in dementia risk.

"Take care of your heart ," she said, "and it will benefit your brain."

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Health: redefined

Obinna ositadimma oleribe.

1 Excellence and Friends Management Care Centre (EFMC), Dutse Abuja FCT, Nigeria

Omole Ukwedeh

Nicholas jonathan burstow.

2 Liver Unit, Department of Surgery and Cancer, St. Mary’s Hospital Campus, Imperial College London, Praed Street, London, W2 1NY, United Kingdom

Asmaa Ibrahim Gomaa

3 National Liver Institute, Menoufiya University, Shbeen El Kom, Egypt

Mark Wayne Sonderup

4 Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa

Nicola Cook

Wendy spearman, simon david taylor-robinson.

For many years the definition of 'health' has remained unchanged as a narrow concept, encompassing physical wellbeing from a medical context. This somewhat focused definition has attracted criticism from individuals and professional bodies alike. Recent attempts have been made to redefine health, each offering an alternative viewpoint from sociological, environmental, societal and economic standpoints. We summarize and contextualize these definitions and provide an alternative, new, all-encompassing definition of health.

Over the past years, different healthcare professionals, whether groups or individuals, have developed and defended various definitions of what a true state of “health” actually means. Despite several different definitions, there are still debates and disagreements on the precise meaning of health. In this review, the notion of “health” is discussed, reviewed and redefined.

What is “health”? : Health is an amorphous word that lacks a single definition. To some, “health is wealth” -given that in the absence of good health, an individual or society cannot attain its full potential. Mahatma Gandhi validated this in 1948 when he said: “It is health that is real wealth and not pieces of gold and silver [ 1 ].” He was alluding to the idea that health is more important than monetary wealth, and that a society cannot prosper unless its people are healthy. Health is necessary for productivity and to fully enjoy life. Health is relative and has situational, professional and even societal definitions. For example, to an athlete, health may mean being physically fit so as to complete a 5000m race. For an employee forced to miss work due to a bout of influenza, health may mean being able to return to work. In contrast to physical health, a person in an unhappy relationship may be concerned about their mental health. Finally, references to “health” are used in a non-medical context. For example: “efforts to build a healthy economy” or a sports team having a “healthy starting line-up.” With so many possible applications of the word, the question arises as to what it actually means to be healthy. The word “health” is derived from an old English word, “hale”, which means “wholeness, being whole or sound.” Despite its origins, there are several etymological meanings and these definitions have evolved over time. Early definitions focused on biomedical aspects: health was seen as the ability of the body to carry out its biological functions and any disruption in these functions was viewed as a disease. For instance, the Oxford online dictionary (2016), defines health as: “a state of being, free from illness or injury [ 2 ].” Similarly, Merriam-Webster online dictionary (2016) defines health simply as: “the condition of being well or free from disease [ 3 ].” That is, the condition of being sound in body, mind, or spirit; especially freedom from physical disease or pain [ 3 ]. While these definitions have merit, their scope is limited. Perhaps the most established modern day definition of health was termed by the World Health Organization (WHO) in 1948, when it stated: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity [ 4 ].” For the first time, domains of health beyond merely biomedical aspects were considered, emphasizing the importance of mental and social wellbeing.

Criticisms of the current definition, and existing alternatives : However, although comprehensive, the WHO definition of health has received criticism [ 5 , 6 ]. Most criticisms center on the word “complete”, which many believe to be absolute, and difficult to measure. Furthermore, questions arise over whether it is even possible for a person to be without any physical, mental or social challenges. Smith argues that this prerequisite for completeness would mean many would be unhealthy most of the time [ 7 ]. In addition, the increase in the prevalence of chronic disease would mean that many with even minor long-term ailments would be persistently classified as being ill [ 8 ]. Indeed, this need for “complete” wellbeing brings the risk of over-medicalization; redefining and treating conditions not previously identified as health problems, leading to individuals receiving unnecessary interventions [ 8 ]. In 1982, Stokes, Noren and Shindell took the concept further by defining health as: “a state characterized by anatomic, physiologic, and psychological integrity; an ability to perform personally valued family, work, and community roles; an ability to deal with physical, biologic, psychological, and social stress [ 9 ].” Thus, for one to be healthy, one needs to be in perfect physical, psychological and social state. Interestingly, this definition introduces the concept of resilience, whereby health is not an absolute state of well-being as previously described [ 4 ], but also a means of coping with stressors experienced by an individual [ 9 ]. It therefore follows, that health is determined by a person's physical, psychological, social, religious and economic environment. For instance, an individual living in a comfortable and safe environment, with clean running water and healthy food, is more likely to experience good health than someone who does not have access to such amenities. A child raised in a hostile environment is more likely to develop emotional problems later in life [ 10 ]. A soldier returning from conflict may carry psychological trauma in the form of post-traumatic stress disorder.

Studies have also shown that people with low socio-economic status have increased mortality, because they are more likely to adopt detrimental lifestyles, such as smoking, alcohol and poor dietary habits [ 11 ]. The presence of family and friends may also influence health, aiding or even hindering recovery from illness. With increasing globalization, family members may find themselves living countries apart, thus unable to help one another in times of need. Furthermore, vast socioeconomic disparities both inter-country and inter-community, discrepancies between private and public healthcare services, limited healthcare work forces and geopolitical strife further contribute to disparities in individual health. On account of the limitations in the WHO and various other definitions of health, several groups have called for the review of the WHO definition of health [ 8 ]. At a Health Council of the Netherlands conference in 2009, experts argued that health was not static, but dynamic. In the conference, their preferred notion of health was: “the ability to adapt and to self-manage [ 12 ].” This concept viewed health as a dynamic process and a resource for everyday life, not merely an object to be obtained for the sake of itself, in keeping with the definition provided by Stokes, Noren and Shindell [ 9 ]. Thus to be healthy, one requires the capacity to maintain homeostasis and recover from insults [ 13 ]. This definition encompasses the ability to handle stress, to acquire skills and to maintain relationships. This ability is known as resilience, without which it would be difficult to remain healthy. Clearly, health is a complex and multifaceted term, and further attempts have been made to define it by individuals and professions alike. For instance, Suresh Vatsyayann, in 2013, saw health as: “an ever-evolving state of mind, body, and relationships perceived by an individual, a family, a group or a community for self in a particular time, space and context [ 14 ].” It can, therefore, be seen as one's ability to live his dream [ 15 ] or a person's mental or physical condition [ 2 ]. We agree with Kaila that true health is the intersection of one's physical, mental, emotional, social, economic, and spiritual state of being at any one time [ 16 ]. The aforementioned shortcomings of the WHO's definition of health, coupled with ever-more encompassing and complex descriptions of health, necessitate the need for a new, single, universal definition of health to replace the outdated one created over 60 years ago.

Redefining health : To develop this comprehensive acceptable definition of health, the following questions must be considered: Is health a state of complete well-being? Is a healthy person someone whose body is free from disease and able to carry on normal activities without fatigue [ 4 ]? Or is health a dynamic condition, encompassing resilience to stressors and recovery from insults in order to maintain an inner equilibrium or homeostasis [ 9 , 12 , 13 ]? Can the person with severe rheumatoid arthritis, who, with the help of therapy is able to carry out their daily routine, be said to be healthy? Or the university student, recently diagnosed with mental illness, who, after therapy, is able to return to their studies? Finally, what about the teenager diagnosed with Huntington's disease, who is currently symptom-free and able to function normally, but will not remain so forever? Can they be said to be healthy? Whatever definition is developed or adapted, to attain health, people have to draw from the resources available in the community. In other words, one cannot be healthy if their society is unhealthy. That is why, according to Public Health Agency of Canada, health is: “a positive concept that emphasizes social and personal resources, as well as physical capacities [ 17 ].” Sadly, today, the world is unhealthy. People's attitudes and habits, combined with an ever-ageing population that may not follow a healthy lifestyle, are making it more unhealthy, and events in the news can be personally disturbing. People involved in making the world an unhealthy place through acts of omission or commission like terrorism, manslaughter, kidnapping and other social vices cannot be said to be healthy, irrespective of their physical, mental, economic, emotional, or even spiritual condition. This is why we suggest redefining health as: “a satisfactory and acceptable state of physical (biological), mental (intellectual), emotional (psychological), economic (financial), and social (societal) wellbeing.” This state would result in maximum productivity, positive contributions and relevant existence in a degenerating and decaying world. It is the state of having the overall physical, mental, emotional, and social abilities to add values not just to one's self, but to society, resulting in the development of a better and sustainable world where things work, people live in harmony and community existence is enhanced.

Our definition is all encompassing. We believe that this definition will help answer some of the common questions raised on health, resolve most of the current debates on the meaning of health, and help expand the meaning of health and the functions of healthcare workers to include services outside the current health ecosystem.

Competing interests

The authors declare no competing interests.

Acknowledgments

This work was supported by the Wellcome Global Centre at Imperial College London for financial and logistic support and the National Institute for Health Research Biomedical Research Centre at Imperial College London for infrastructure support. All authors also acknowledge funding from the Wellcome Institutional Strategic Support Fund at Imperial College London.

Authors’ contributions

Obinna Ositadimma Oleribe and Simon David Taylor-Robinson conceived the study; Obinna Ositadimma Oleribe, Omole Ukwedeh, Nicholas Jonathan Burstow and Simon David Taylor-Robinson drafted the manuscript; Asmaa Ibrahim Gomaa, Mark Wayne Sonderup, Nicola Cook, Imam Waked and Wendy Spearman critically revised the manuscript for intellectual content. All authors read and approved the final manuscript. Wendy Spearman and Simon David Taylor-Robinson are guarantors of the paper.

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A New Use for Wegovy Opens the Door to Medicare Coverage for Millions of People with Obesity

Juliette Cubanski , Tricia Neuman , Nolan Sroczynski , and Anthony Damico Published: Apr 24, 2024

The FDA recently approved a new use for Wegovy (semaglutide), the blockbuster anti-obesity drug, to reduce the risk of heart attacks and stroke in people with cardiovascular disease who are overweight or obese. Wegovy belongs to a class of medications called GLP-1 (glucagon-like peptide-1) agonists that were initially approved to treat type 2 diabetes but are also highly effective anti-obesity drugs. The new FDA-approved indication for Wegovy paves the way for Medicare coverage of this drug and broader coverage by other insurers. Medicare is currently prohibited by law from covering Wegovy and other medications when used specifically for obesity. However, semaglutide is covered by Medicare as a treatment for diabetes, branded as Ozempic.

What does the FDA’s decision mean for Medicare coverage of Wegovy?

The FDA’s decision opens the door to Medicare coverage of Wegovy, which was first approved by the FDA as an anti-obesity medication. Soon after the FDA’s approval of the new use for Wegovy, the Centers for Medicare & Medicaid Services (CMS) issued a memo indicating that Medicare Part D plans can add Wegovy to their formularies now that it has a medically-accepted indication that is not specifically excluded from Medicare coverage . Because Wegovy is a self-administered injectable drug, coverage will be provided under Part D , Medicare’s outpatient drug benefit offered by private stand-alone drug plans and Medicare Advantage plans, not Part B, which covers physician-administered drugs.

How many Medicare beneficiaries could be eligible for coverage of Wegovy for its new use?

Of these 3.6 million beneficiaries, 1.9 million also had diabetes (other than Type 1) and may already have been eligible for Medicare coverage of GLP-1s as diabetes treatments prior to the FDA’s approval of the new use of Wegovy.

Not all people who are eligible based on the new indication are likely to take Wegovy, however. Some might be dissuaded by the potential side effects and adverse reactions . Out-of-pocket costs could also be a barrier. Based on the list price of $1,300 per month (not including rebates or other discounts negotiated by pharmacy benefit managers), Wegovy could be covered as a specialty tier drug, where Part D plans are allowed to charge coinsurance of 25% to 33%. Because coinsurance amounts are pegged to the list price, Medicare beneficiaries required to pay coinsurance could face monthly costs of $325 to $430 before they reach the new cap on annual out-of-pocket drug spending established by the Inflation Reduction Act – around $3,300 in 2024, based on brand drugs only, and $2,000 in 2025. But even paying $2,000 out of pocket would still be beyond the reach of many people with Medicare who live on modest incomes . Ultimately, how much beneficiaries pay out of pocket will depend on Part D plan coverage and formulary tier placement of Wegovy.

Further, some people may have difficulty accessing Wegovy if Part D plans apply prior authorization and step therapy tools to manage costs and ensure appropriate use. These factors could have a dampening effect on use by Medicare beneficiaries, even among the target population.

When will Medicare Part D plans begin covering Wegovy?

Some Part D plans have already announced that they will begin covering Wegovy this year, although it is not yet clear how widespread coverage will be in 2024. While Medicare drug plans can add new drugs to their formularies during the year to reflect new approvals and expanded indications, plans are not required to cover every new drug that comes to market. Part D plans are required to cover at least two drugs in each category or class and all or substantially all drugs in six protected classes . However, facing a relatively high price and potentially large patient population for Wegovy, many Part D plans might be reluctant to expand coverage now, since they can’t adjust their premiums mid-year to account for higher costs associated with use of this drug. So, broader coverage in 2025 could be more likely.

How might expanded coverage of Wegovy affect Medicare spending?

The impact on Medicare spending associated with expanded coverage of Wegovy will depend in part on how many Part D plans add coverage for it and the extent to which plans apply restrictions on use like prior authorization; how many people who qualify to take the drug use it; and negotiated prices paid by plans. For example, if plans receive a 50% rebate on the list price of $1,300 per month (or $15,600 per year), that could mean annual net costs per person around $7,800. If 10% of the target population (an estimated 360,000 people) uses Wegovy for a full year, that would amount to additional net Medicare Part D spending of $2.8 billion for one year for this one drug alone.

It’s possible that Medicare could select semaglutide for drug price negotiation as early as 2025, based on the earliest FDA approval of Ozempic in late 2017 . For small-molecule drugs like semaglutide, at least seven years must have passed from its FDA approval date to be eligible for selection, and for drugs with multiple FDA approvals, CMS will use the earliest approval date to make this determination. If semaglutide is selected for negotiation next year, a negotiated price would be available beginning in 2027. This could help to lower Medicare and out-of-pocket spending on semaglutide products, including Wegovy as well as Ozempic and Rybelsus, the oral formulation approved for type 2 diabetes. As of 2022, gross Medicare spending on Ozempic alone placed it sixth among the 10 top-selling drugs in Medicare Part D, with annual gross spending of $4.6 billion, based on KFF analysis . This estimate does not include rebates, which Medicare’s actuaries estimated to be  31.5% overall in 2022  but could be as high as  69%  for Ozempic, according to one estimate.

What does this mean for Medicare coverage of anti-obesity drugs?

For now, use of GLP-1s specifically for obesity continues to be excluded from Medicare coverage by law. But the FDA’s decision signals a turning point for broader Medicare coverage of GLP-1s since Wegovy can now be used to reduce the risk of heart attack and stroke by people with cardiovascular disease and obesity or overweight, and not only as an anti-obesity drug. And more pathways to Medicare coverage could open up if these drugs gain FDA approval for other uses . For example, Eli Lilly has just reported clinical trial results showing the benefits of its GLP-1, Zepbound (tirzepatide), in reducing the occurrence of sleep apnea events among people with obesity or overweight. Lilly reportedly plans to seek FDA approval for this use and if approved, the drug would be the first pharmaceutical treatment on the market for sleep apnea.

If more Medicare beneficiaries with obesity or overweight gain access to GLP-1s based on other approved uses for these medications, that could reduce the cost of proposed legislation to lift the statutory prohibition on Medicare coverage of anti-obesity drugs. This is because the Congressional Budget Office (CBO), Congress’s official scorekeeper for proposed legislation, would incorporate the cost of coverage for these other uses into its baseline estimates for Medicare spending, which means that the incremental cost of changing the law to allow Medicare coverage for anti-obesity drugs would be lower than it would be without FDA’s approval of these drugs for other uses. Ultimately how widely Medicare Part D coverage of GLP-1s expands could have far-reaching effects on people with obesity and on Medicare spending.

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• Heart Disease
• Medicare Advantage

news release

• An Estimated 1 in 4 Medicare Beneficiaries With Obesity or Overweight Could Be Eligible for Medicare Coverage of Wegovy, an Anti-Obesity Drug, to Reduce Heart Risk

Also of Interest

• An Overview of the Medicare Part D Prescription Drug Benefit
• FAQs about the Inflation Reduction Act’s Medicare Drug Price Negotiation Program
• What Could New Anti-Obesity Drugs Mean for Medicare?
• Medicare Spending on Ozempic and Other GLP-1s Is Skyrocketing

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• Specifically, the final rule provides that it is an unfair method of competition—and therefore a violation of Section 5 of the FTC Act—for employers to enter into noncompetes with workers after the effective date.
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• The average worker’s earnings will rise an estimated extra $524 per year. 

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Changing the Habit of Self-Criticism

The habit of critical self-talk matters as much as what we say..

Posted November 4, 2022 | Reviewed by Ekua Hagan

• Self-criticism is strongly associated with depression, anxiety, trauma, addictions, and eating disorders.
• The habitual behavior of self-critical thinking impacts depression and anxiety as much as the self-critical thoughts themselves.
• Practicing specific mental techniques can significantly change the habit of self-criticism.

Which aspect of self-criticism causes more distress: the content of your self-criticism, or the habit of criticizing yourself throughout the day?

Seeing yourself as lazy, fat, stupid, or unsuccessful—either with words or as a general attitude—can certainly cause a great deal of emotional pain. Self-criticism is positively linked with a range of mental health conditions , including depression , anxiety , eating disorders, posttraumatic stress disorder, addictions, and self-harm .

As a clinical psychologist, I’ve heard many patients describe intense self-criticism about different aspects of themselves. Self-criticism seems to make everything worse, as though it forms an extra layer of pain on top of other stressors and mental health difficulties.

When I first meet with self-critical patients, they often seem resigned to their self-criticism. “That’s just the way I am,” they tell me. “I’ve always been like that,” they’ll insist, as though it’s a pre-programmed, unchangeable feature, such as height or eye color.

However, self-criticism is influenced by family and cultural contexts, including emotional abuse , racial discrimination , and homophobia . The evidence shows that many of us internalize negative messages so that our own minds habitually perpetuate self-criticism. The research also indicates that self-criticism can be changed .

How the Habitual Nature of Self-Criticism Impacts Mental Health

What if the habit of self-criticism is just as important as the content of the self-critical thoughts themselves? When I was researching self-criticism for my new book, The Self-Talk Workout , I read a set of research studies that underscore the value of treating self-criticism as a powerful mental habit, rather than only addressing the substance of self-critical thoughts.

Researchers Bas Verplanken and colleagues highlight a few different features of self-criticism that bring its habitual quality into focus. These include the frequency with which you criticize yourself, the extent to which self-criticism happens automatically, the efficiency with which your mind leaps to criticize yourself in any difficult situation, and the degree to which self-criticism occurs outside of your intent, awareness, or control.

Verplanken et al. created a self-report measure called the Habit Index of Negative Thinking (HINT). Analyzing responses to the following questions, the research team assessed the degree to which participants engaged in self-critical thinking by having them respond to the following:

Thinking negatively about myself is something... I do frequently. I do automatically. I do unintentionally. That feels sort of natural to me. I do without further thinking. That would require mental effort to leave. I do every day. I start doing before I realize I’m doing it. I would find hard not to do. I don’t do on purpose. That’s typically "me." I have been doing for a long time. (Verplanken et al., p. 541)

The researchers found that levels of habitual self-criticism as measured by the HINT contributed to symptoms of depression and anxiety over a 9-month period in a sample of 1,102 respondents (641 women and 461 men). Self-criticism predicted depression and anxiety even beyond the content of the negative thoughts themselves, as measured by the Dysfunctional Attitude Scale , and even after accounting for work stress, home stress, age, and gender .

These results don’t tell us that the habit of self-criticism causes more mental health problems than the self-criticism itself, but rather that both aspects of self-criticism impact depression and anxiety. Perhaps it’s a bit like smoking : the smoking itself causes health problems, but the habit or addiction to smoking propagates the behavior.

How to Change the Habit of Self-Criticism

Awareness of default behaviors can be a valuable step toward changing habits, but awareness or intentions alone (“I should really be nicer to myself”), are unlikely to produce real change. Instead, the research indicates that people make significant changes in self-criticism from specific mental techniques that reduce self-judgment and promote self-compassion .

The term “self-compassion” means treating yourself in a friendly and caring manner, even during moments of difficulty or failure. Self-compassion is not the same as self-esteem , which involves evaluating yourself positively or negatively.

Mindfulness meditation and lovingkindness meditation are two specific approaches that decrease self-criticism. Both practices are concentration workouts because they train your mental attention away from habitual thoughts. These workouts might not seem particularly easy, or as though they work immediately, but the research evidence is strong that they reduce self-criticism over time.

Mindfulness meditation is not about clearing your mind, but rather the practice of noticing and reshaping your mental experience. You can start by tuning into the sensations of your breath, and then redirecting your attention back to the breath, for about 10 minutes or longer.

The goal is not to repress the thoughts that arise, but instead to return your attention back to the breath with as little self-criticism as possible (“My mind wandered, that’s OK, now back to the breath”). When you notice self-criticism about becoming distracted, simply handle it as you would any other thought (“There’s the self-criticism, that’s OK, back to the breath).”

Some people get discouraged at how much their minds wander but it’s that very pull towards the habit of self-criticism that repeated meditation can change through regular practice. In fact, reducing judgment seems to be a key mechanism explaining why mindfulness improves mental health.

Another approach that meaningfully reduces self-criticism is lovingkindness meditation (LKM). The practice involves several minutes of silently repeating phrases to yourself, such as, “May I be safe. May I be happy. May I be healthy. May I live with ease.”

My students sometimes say that repeating phrases feels strange or awkward at first but that after a few weeks of regular practice, they notice less self-criticism. Studies demonstrate that LKM significantly reduces self-criticism , posttraumatic stress disorder , and depression .

If it sounds hard to add five or ten minutes of practice to your day to change the habit of self-criticism, I encourage people to begin with a single breath: “Inhale, my friend; exhale, my friend.” One breath without self-criticism can be a starting point to shift your mental habits and build a relationship with yourself that is more friendly, encouraging, and compassionate.

Rachel Goldsmith Turow, Ph.D. , is a psychotherapist, research scientist, mindfulness teacher, and an adjunct faculty member at Seattle University and at the Icahn School of Medicine at Mount Sinai. Her current work emphasizes evidence-based techniques to decrease self-criticism and cultivate self-encouragement and self-compassion.

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