Conceptualisation of health among young people: a protocol for systematic review and thematic synthesis of qualitative studies

Conceptualisation of health among young people: a protocol for systematic review and thematic synthesis of qualitative studies | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Conceptualisation of health among young people: a protocol for systematic review and thematic synthesis of qualitative studies Katrin Metsis, Joanna Inchley, Andrew James Williams, Sebastian Vrahimis, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3879104/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Self-reported health is a widely used health indicator in surveys and questionnaires. The measure gained attention when research identified its association with mortality in the 1970s and 1980s. The measure is also associated with morbidity and other health outcomes such as the utilisation of health services. Self-reported health is a particularly useful measure for young people because this age group is generally clinically healthy. However, self-reported health starts to decline during early adolescence. It is known that many chronic conditions have long latency periods that are initiated early in life. Despite its widespread use, however, self-reported health remains a poorly understood concept. Methods This paper presents the protocol for a systematic review that will identify and synthesise qualitative studies that investigate how young people conceptualise health in the survey context, and overall. The population of the review is young people aged 10–24 years, with or without health conditions. We will search the databases of MEDLINE (Ovid®), PsycINFO (APA PsycNet), ProQuest Sociology Collection, and Web of Science Core Collection™. We will also utilise techniques of reference checking and forward citation searching, as this strategy has been shown to result in a higher number of high-quality studies in social science systematic reviews. Google Scholar and Google Search were used during preliminary searches; Google Scholar is utilised for forward citation searching. We will include studies written in English, German, or Finnish; there will be no lower date limit. One reviewer will screen all citations. A second reviewer will independently screen a sample of 20% of the abstracts. Data will be extracted by one researcher, two other researchers will independently review all data extracted, and quality appraisal completed by the first reviewer. We will utilise the Quality Framework for the appraisal of included articles, and thematic analysis to synthesise selected qualitative studies. Discussion The results of this systematic review will improve the understanding of the self-assessments of health and the interpretation of the results of quantitative research. Also, an improved understanding of the conceptualisation of health will inform the development of health policies and interventions that support young people’s health. Systematic review registration PROSPERO CRD42022367519 Preventive Medicine Self-reported health Young people Adolescent Concept Formation Qualitative Research Self Report Inequalities Background Self-reported health (SRH) is a widely used health indicator in surveys and questionnaires. This systematic review will identify and synthesise qualitative studies that investigate how young people conceptualise health in the survey context and overall. The term SRH is also referred to as self-assessed health, self-rated health, general health, or global health. The measure gained attention when research identified its association with mortality in the 1970s and 1980s ( 1 ). Later, different studies have demonstrated that SRH is associated with functional health, treatment outcomes, biomarkers, and utilisation of health services in different population groups, including young people ( 2 – 5 ). The measure is included in national and international surveys such as the Scottish Health Survey and the European Union Statistics on Income and Living Conditions (EU-SILC). SRH measure is useful for studying young people’s health for several reasons. First, children and adolescents do not often present objective clinical symptoms; however, SRH starts to decline during early adolescence due to subjective complaints ( 6 ). It is known that many chronic conditions such as cardiovascular disease or cancers have long latency periods; the World Health Organization (WHO) has estimated that 70% of premature deaths among adults are primarily due to behaviours initiated during adolescence ( 7 ). Lynch and Smith ( 8 ) have shown that many risk factors of coronary heart disease, type 2 diabetes, or chronic obstructive pulmonary disease are present across life course stages, including adolescence. Because clinical endpoints are not common in adolescence and young adulthood, SRH is an appropriate measure to assess health ( 9 , 10 ). Despite its widespread use and association with objective health outcomes, however, SRH remains a poorly understood measure ( 1 ). Research has found that the main aspects which impact self-ratings of health among adults are physical health problems, functional capacities, health behaviours, and psychological aspects ( 11 ). Studies focusing on young people have found that rating their health is based on social, mental, and physical aspects such as lifestyle, possessions and space, perceived stressors, social belonging, medical conditions, and physical appearance ( 12 ). These different factors are captured in the definition of SRH as suggested by Tissue ( 13 ): ‘…it represents a summary statement about the way in which numerous aspects of health, both subjective and objective, are combined within the perceptual framework of the individual respondent.’ (p.93) Jylhä ( 1 ) has concluded that the rating of a person’s health arises from the cognitive reasoning process where people evaluate information about their conditions and sensations. Numerous definitions of health capture different dimensions of health. As Larson ( 14 ) has pointed out, this is also the reason why there is no agreement on the meaning of health - health is a complex phenomenon that includes medical, social, economic, and other components. The most prominent definition, the WHO definition of health that is part of its constitution ( 15 ), describes health as: A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’ (p.1) The Constitution of the WHO ( 15 ) also asserts that the highest attainable standard of health is a fundamental right of every human being and fundamental to the attainment of peace and security. The WHO definition of health was expanded on by the Ottawa Charter for Health Promotion ( 16 ): ‘to reach a state of complete physical mental and social wellbeing, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living.’ (p.1) Larson ( 14 ) has categorised the WHO definition of health as a separate conceptual model of health due to its prominence and comprehensive nature. Larson ( 14 ) presents three further models of health: medical, wellness, and environmental models of health. The medical model refers to the absence of disease and disability. The wellness model has an emphasis on the link between mind and body; and stresses that health is more than the absence of illness incorporating positive dimensions of well-being, energy, and ability to work. The environmental model places individuals within physical, social, and other environments, and emphasises their ability to maintain a healthy balance. However, Larson ( 14 ) suggests that models simplify health and invites one to reflect on the complexity, as even a health assessment based on all four models would be a simplification of reality. Given the plethora of different definitions of health that incorporate different dimensions, McCartney et al. ( 17 ) reviewed the definitions of health and suggested that, for public health, the best definition should incorporate different dimensions of health, and apply to individuals and populations. McCartney et al. ( 17 ) suggested the adoption of the definition of health as provided by Last in the dictionary of public health ( 18 ): ‘A structural, functional and emotional state that is compatible with effective life as an individual and as a member of society’. Given the complexity of the concept of health, it is important to understand how the term is understood within a research context. This paper presents the protocol of a systematic review of qualitative studies that identify and synthesise qualitative primary studies that investigate how young people conceptualise health in the context of the surveys, and in general. The systematic review is part of a PhD project that investigates health inequalities among Scottish young people by using the data from the UK Censuses and Scottish Longitudinal Study. These data sources include a general health question that is used to operationalise health. The systematic review will complement quantitative analysis by synthesising the themes and factors that have been identified by young people when they discuss the meaning of health. Methods The aim of this systematic review is to synthesise qualitative primary studies that investigate how young people conceptualise health in the context of the surveys, and in general. The review question will be answered by addressing the following sub-questions. How do young people reason when they answer self-reported health questions in the surveys? How do young people reason when they rate health as very good, good, fair, or bad? How do young people understand the concept of health generally? The review protocol was registered in the PROSPERO, registration number is CRD42022367519. The guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) ( 19 ) are followed in reporting this protocol; a completed checklist is provided as an additional file (Additional file 1). PICOS framework ( 20 ) was used to formulate the research question and search strategy. Participants and eligibility criteria The study population is young people aged 10–24 years, with or without health conditions. The term ‘young people’ covers two life stages. The WHO( 21 ) defines ‘adolescence’ as a life stage between 10–19 years. Second, people aged 15–24 are defined as ‘youth’. People aged 10–24 are defined as ‘young people’. This grouping is visualised in Box 1. Adolescents: aged 10–19 Youth: aged 15–24 Young people: aged 10–24 years Box 1. Study population The outcome of this review will be the synthesis of factors that are discussed by young people when they explore the concept of health. To achieve this outcome, we will locate and synthesise qualitative primary studies. We will apply the definition of qualitative research as proposed by Aspers and Corte ( 22 ): ‘iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied.’ (p. 155) Studies using the data collection methods listed below will be included. Different types of interviews (individual semi-structured or in-depth interviews, focus groups, or group discussions). Visual methods such as photography, drawings, or mind maps. Written accounts that describe photographs. Data from open-ended survey questions under the condition that data were analysed by using qualitative methods such as content analysis. Studies using the word ‘health’ in the research question(s) will be included. Studies using the word ‘feel’ will also be included if the study aims to investigate the perception of health. Some studies have used the word ‘feel’ when exploring the conceptualisation of health because of cultural reasons. For example, as Joffer et al. ( 23 ) explain, in Sweden, ‘feel’ is often used when asking about one’s health. Spencer ( 24 ) has explored the meaning of health by using the word ‘feel’, which captures the holistic conceptualisation of health. The exclusion criteria are as follows. Studies exploring the concept of wellbeing, quality of life, or health-related quality of life will be excluded. Studies that investigated the conceptualisation of health in the context of certain phenomena such as healthy eating will be excluded because this explores the concept of health from pre-defined aspects. Papers without any empirical aspect will be excluded. Conference abstracts will be excluded. Editorials, opinion pieces, and book reviews are excluded. Studies are limited to those written in English, German, or Finnish. There is no lower date limit for publications. Visual methods such as photovoice ( 25 ) are known to add details to interviewees’ perceptions of phenomena and allow participants to express their ideas in a non-verbal way. There is no consensus if the open-ended questions in the surveys are qualitative or quantitative data ( 26 ). Compared to the interview data, written data can result in less depth as respondents’ statements cannot be further explored ( 27 ). However, open-ended questions can also be seen as descriptions of phenomena with concepts used by ordinary citizens ( 28 ). These descriptions can be analysed by using qualitative methods, for example, content analysis allows for developing categories that increase the understanding of the phenomenon. Because one of the aims of this review is to understand the concept of health in the survey context, we felt that written accounts, if analysed as qualitative data, will contribute to the understanding of the phenomenon. We will consider the impact of different data collection methods and types of data during the synthesis of the studies. Inclusion and exclusion criteria by the PICOS framework ( 20 ) are summarised in Table 1 . Table 1 Inclusion and exclusion criteria by the PICOS framework Inclusion criteria Exclusion criteria Population 10-24-year-old respondents with or without health conditions. The study includes participants from a wider age range, and it is not possible to separate 10-24-year-olds. Intervention Studies that investigate how young people conceptualise health 1) in a survey context, and 2) overall. The study question includes the term ‘health’ or ‘feel’. Concepts of wellbeing, quality of life, health-related quality of life. Comparison Not Applicable Not Applicable Outcome ‘Conceptualisation of health’: synthesis of factors discussed by young people when they discuss the concept of health. Not reporting outcomes of interest. Insufficient detail for data synthesis. Studies that investigated the conceptualisation of health in the context of certain phenomena such as physical activity or diet. Study type Qualitative studies Visual methods such as photography, mind maps, drawings, and written descriptions of drawings or photographs. Open-ended survey questions that have been analysed by qualitative methods. Mixed methods studies if it is possible to extract qualitative findings only. Quantitative studies Mixed method studies if it is not possible to separate qualitative findings. Conference abstracts, opinion pieces. Book reviews. Studies without any empirical aspect. Search strategy Different authors ( 29 – 31 ) have drawn attention to the problems of the inclusion of qualitative evidence in systematic reviews. In this review, the identification of the keywords will be an iterative process. In preliminary searches, we used general keywords such as ‘adolesc*’, ‘health’, ‘self-reported health’. We also used pre-identified relevant studies to identify suitable search terms. From these sources we compiled a list of keywords that were used in searches; these will be refined during the searches. We identified both MeSH terms for the MEDLINE searches and keywords. We tested three tools to identify search terms. Tools such as PICO are frequently used in systematic reviews ( 32 ). However, it is felt that his tool is not suitable for identifying qualitative studies ( 32 ). As a response, Cooke et al. ( 33 ) developed the SPIDER tool which includes five core concepts: Sample Phenomenon of interest Design Evaluation Research type. However, Methley et al. ( 34 ) found that although the SPIDER tool had a higher specificity compared to the PICO and PICOS ( 20 ) tools it omitted many relevant articles, possibly due to problems in the indexing of qualitative studies. We, therefore, compiled a search strategy for all three tools. We found that the PICO framework resulted in search terms that brought up a very large number of studies, and similarly to Methley et al. ( 34 ), the number of studies was reduced when using the SPIDER tool. Therefore, we used the PICOS framework to identify final search terms; this tool is also recommended by Methley et al. ( 34 ) when time and resources are limited. The search strategy for MEDLINE (Ovid) is included in Additional file 2. We will search the following databases. MEDLINE (Ovid®) PsycINFO (APA PsycNet) ProQuest Sociology Collection (Applied Social Sciences Index & Abstracts (ASSIA) / Sociological Abstracts / Sociology Database Web of Science Core Collection™. These databases represent social sciences and medicine, the ProQuest Sociology Collection will capture sociological literature. We will also use the techniques of reference checking and forward citation searching; Papaioannou et al. ( 30 ) and Greenhalgh et al. ( 35 ) have demonstrated that compared to conventional database searches, this strategy results in a higher number of high-quality studies in social science systematic reviews. Google Scholar and Google Search were used as supplementary tools during preliminary searches; Google Scholar will be utilised for forward citation searching. Studies are limited to those written in English, German, or Finnish. There is no lower date limit for publications. Data extraction A reference library will be created and maintained in EndNote20; the title and abstract of retrieved studies will be uploaded to the library. The search strategy was discussed with all authors. One researcher (KM) will search databases. One researcher (KM) will screen all titles and abstracts, and a second researcher (SV) will independently screen a sample of 20% of the abstracts to establish an inter-rater agreement. Disagreements will be resolved by discussion, where consensus cannot be reached, a third researcher (FS) will be consulted. Data will be extracted by one researcher (KM). MS Word and Excel documents will be used to manage data extraction. A second and third researchers (SV and LB) will independently review all data extracted and quality appraisal completed by the first reviewer. The following information will be extracted from the included studies. Study reference Country Aim of the study Sample characteristics Format of the health question Data collection method Data analysis method Key findings Quality appraisal Dixon-Woods et al. ( 31 ) have recognised that the formal synthesis of qualitative research is difficult because of the underdeveloped techniques for searching, selecting, and appraisal. However, because qualitative evidence is increasingly used to inform decision-making processes, the question has arisen about whether and how the trustworthiness of qualitative evidence should be appraised ( 36 – 38 ). Although several appraisal tools have been developed for qualitative research, there is no consensus on the appropriate quality criteria to evaluate the qualitative findings. It is also argued that many tools incorporate quality dimensions that characterize quantitative results ( 38 ). The Cochrane Handbook ( 39 ) emphasises that researchers need to decide which appraisal tool is most appropriate for a particular review. The purpose of the critical appraisal in this review is to provide an understanding of the methodological quality and context of existing evidence; studies will not be excluded based on the results. To select the appraisal tool, we have considered three instruments. The Critical Appraisal Skills Programme (CASP) quality assessment tool for qualitative studies ( 40 ). The Joanna Briggs Institute’s (JBIs) Critical Appraisal Checklist for Qualitative Research ( 41 ). The Quality Framework (the QF) ( 37 ). For the appraisal of included articles, the QF was chosen. The JBI’s Critical Appraisal Checklist for Qualitative Research was not chosen because it has an emphasis on congruity between philosophy, methodology and methods ( 36 , 41 ). The purpose of this review is to synthesise studies that investigate the conceptualisation of health among young people. Maijd and Vanstone ( 36 ) have argued that if the appraisal framework has an emphasis on theoretical underpinnings, then descriptive studies that do not include rigorous theoretical discussion can be classified as untrustworthy. However, descriptive research can produce findings that are relevant to understanding respondent perspectives ( 36 , 42 ). We felt that the CASP qualitative checklist ( 40 ) which is easy to administer and widely used in qualitative evidence synthesis did not cover the dimensions of qualitative research as thoroughly as the QF. One potential reason, as Williams et al. ( 38 ) argued, is that this tool was developed during the 1990s alongside quantitative research tools. The QF ( 37 ) was developed as a response to the growing need to appraise qualitative evidence which is increasingly used in government evaluations. Although the framework was developed to assess qualitative evaluation across Government Departments, it is also suitable to appraise evidence from different types of qualitative inquiry such as reports or journal papers ( 37 ). The framework includes 18 questions and a set of quality indicators for each question that can be used to guide the appraisal process. To make the appraisal results transparent, we will develop a grading system. Strategy for data synthesis A thematic analysis strategy ( 43 , 44 ) will be used to synthesise selected qualitative studies. This approach is recommended by the Cochrane systematic review group for the synthesis of qualitative studies ( 32 ). We will apply the adoption of the thematic analysis as outlined by Thomas and Harden ( 44 ). This comprises three stages: 1) coding of the findings of primary studies, 2) organising the codes into descriptive themes, and 3) developing analytical themes. NVivo software will be used to synthesise included qualitative studies. Depending on the data, we will analyse the results by gender, age, location, or data collection method. Discussion This review will synthesise qualitative studies that investigate how young people understand the concept of health, and how they reason when rating their health. The results will improve the understanding of self-assessments of health and thus the interpretation of quantitative health research. Also, an improved understanding of the conceptualisation of health will inform the development of health policies and interventions that support young people’s health. Protocol amendments Amendments made to this protocol when conducting the review will be outlined in PROSPERO and reported in the final manuscript. Dissemination plans The findings of this systematic review will be disseminated through publication in a peer-reviewed journal, relevant conferences, and as a chapter of the Doctoral Thesis (PhD). Abbreviations EU-SILC: the European Union Statistics on Income and Living Conditions survey CASP: The Critical Appraisal Skills Programme SRH: self-reported health QF: the Quality Framework WHO: the World Health Organization Declarations Acknowledgments We would like to thank Vicki Cormie, the University of St Andrews librarian for her advice in developing the search strategy for this review. Authors' contributions KM led on the conceptualisation of the review question and wrote the manuscript with input from FS, JI, and AJW. KM defined the search items with input from FS, JI, and AJW; and designed the search strategy with input from FS. All authors have read and approved the final manuscript. Funding This systematic review is part of the PhD project undertaken by Katrin Metsis. There is no funding related to this review. Katrin Metsis is a part-time staff member at the University of St Andrews and undertakes PhD studies part-time. The University of St Andrews had no role in the design of the study and will not have a role in the analysis and in writing the manuscript. Availability of data and materials Not applicable Ethics approval and consent to participate Not applicable Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. References Jylhä M. What is self-rated health and why does it predict mortality? 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Available at: https://jbi.global/critical-appraisal-tools Accessed: 06.05.2022 [Internet]. 2014 [cited 2022 May 6]. Available from: https://jbi.global/critical-appraisal-tools Sandelowski M. Focus on Research Methods Whatever Happened to Qualitative Description? Res Nurs Health. 2000;23. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006 Jan;3(2):77–101. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008 Dec 10;8(1):45. Additional Declarations The authors declare no competing interests. Supplementary Files MetsisEtalAdditionalFile1PRISMAP.docx Additional file 1. Prisma-P checklist. MetsisEtalAdditionalFile2MedlineSearch.docx Additional file 2. MEDLINE (Ovid) search strategy. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3879104","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":268978437,"identity":"a042abab-7161-4e92-9e3b-26e8761cf603","order_by":0,"name":"Katrin Metsis","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIie3RMWrDMBSA4VcEziKj9RlBzhARCGTyVWwMnkyyeghGWXyEkNDQY2S2EXhy9xYt6pLJg3OBtg6lXYJFsnXQN0mgnychAMf5hxBIbfr8d/OnsiVeIvbtz+l7E7rgfvlIEuyquTi8FAVMXmud5yqEiTKEtuMJ51FsLic1TFsly7ZVsaTpjNC38WTKIyUOpwrDKlsE21JHABkQ2tuSuOT+sUBg3ZB86nBY2BPOE4/7kiDgdYrUTxKvUywXC55TIvaNCiR286VsvuISz7P6aHk+6vXF9JuCAcvEu9ykIWPJh+ma8eSWB9ZfcRzHce7xDdT/TpJVUaSoAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-0827-6557","institution":"University of St Andrews","correspondingAuthor":true,"prefix":"","firstName":"Katrin","middleName":"","lastName":"Metsis","suffix":""},{"id":268978438,"identity":"a3d8ea3b-6e67-428e-9ba4-e1005c79c095","order_by":1,"name":"Joanna Inchley","email":"","orcid":"","institution":"University of Glasgow","correspondingAuthor":false,"prefix":"","firstName":"Joanna","middleName":"","lastName":"Inchley","suffix":""},{"id":268978439,"identity":"1cdc3659-c4f8-48f4-889e-0c1a5b8399e0","order_by":2,"name":"Andrew James Williams","email":"","orcid":"","institution":"University of St Andrews","correspondingAuthor":false,"prefix":"","firstName":"Andrew","middleName":"James","lastName":"Williams","suffix":""},{"id":268978972,"identity":"a75fa3a3-fef3-4da5-8db1-e8867c89a008","order_by":3,"name":"Sebastian Vrahimis","email":"","orcid":"","institution":"University of St Andrews","correspondingAuthor":false,"prefix":"","firstName":"Sebastian","middleName":"","lastName":"Vrahimis","suffix":""},{"id":268978973,"identity":"52483c7c-56f4-4c04-b741-d2513cd56537","order_by":4,"name":"Lamorna Brown","email":"","orcid":"","institution":"University of St Andrews","correspondingAuthor":false,"prefix":"","firstName":"Lamorna","middleName":"","lastName":"Brown","suffix":""},{"id":268978974,"identity":"d42fa08a-e229-47cb-96b8-84092afca40a","order_by":5,"name":"Frank Sullivan","email":"","orcid":"","institution":"University of St Andrews","correspondingAuthor":false,"prefix":"","firstName":"Frank","middleName":"","lastName":"Sullivan","suffix":""}],"badges":[],"createdAt":"2024-01-19 15:19:54","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-3879104/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3879104/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50137250,"identity":"c82e1bc9-71f8-447d-aa52-c744a097f616","added_by":"auto","created_at":"2024-01-25 05:44:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":276404,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3879104/v1/4898a6eb-6f78-4233-ab0e-8ae480521231.pdf"},{"id":50137139,"identity":"52e73d5b-797e-411f-8ac9-c4862346be0f","added_by":"auto","created_at":"2024-01-25 05:44:18","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":35194,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 1. Prisma-P checklist.\u003c/p\u003e","description":"","filename":"MetsisEtalAdditionalFile1PRISMAP.docx","url":"https://assets-eu.researchsquare.com/files/rs-3879104/v1/ef054e1009e6131b4d31dde9.docx"},{"id":50137132,"identity":"b0104ef7-9090-4ee5-8fa2-2b6df2bfd79b","added_by":"auto","created_at":"2024-01-25 05:44:18","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":17445,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 2. MEDLINE (Ovid) search strategy.\u003c/p\u003e","description":"","filename":"MetsisEtalAdditionalFile2MedlineSearch.docx","url":"https://assets-eu.researchsquare.com/files/rs-3879104/v1/18487f3189e03c40e615a66d.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eConceptualisation of health among young people: a protocol for systematic review and thematic synthesis of qualitative studies\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eSelf-reported health (SRH) is a widely used health indicator in surveys and questionnaires. This systematic review will identify and synthesise qualitative studies that investigate how young people conceptualise health in the survey context and overall. The term SRH is also referred to as self-assessed health, self-rated health, general health, or global health. The measure gained attention when research identified its association with mortality in the 1970s and 1980s (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Later, different studies have demonstrated that SRH is associated with functional health, treatment outcomes, biomarkers, and utilisation of health services in different population groups, including young people (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The measure is included in national and international surveys such as the Scottish Health Survey and the European Union Statistics on Income and Living Conditions (EU-SILC).\u003c/p\u003e \u003cp\u003eSRH measure is useful for studying young people\u0026rsquo;s health for several reasons. First, children and adolescents do not often present objective clinical symptoms; however, SRH starts to decline during early adolescence due to subjective complaints (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). It is known that many chronic conditions such as cardiovascular disease or cancers have long latency periods; the World Health Organization (WHO) has estimated that 70% of premature deaths among adults are primarily due to behaviours initiated during adolescence (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Lynch and Smith (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) have shown that many risk factors of coronary heart disease, type 2 diabetes, or chronic obstructive pulmonary disease are present across life course stages, including adolescence. Because clinical endpoints are not common in adolescence and young adulthood, SRH is an appropriate measure to assess health (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite its widespread use and association with objective health outcomes, however, SRH remains a poorly understood measure (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Research has found that the main aspects which impact self-ratings of health among adults are physical health problems, functional capacities, health behaviours, and psychological aspects (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Studies focusing on young people have found that rating their health is based on social, mental, and physical aspects such as lifestyle, possessions and space, perceived stressors, social belonging, medical conditions, and physical appearance (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). These different factors are captured in the definition of SRH as suggested by Tissue (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;it represents a summary statement about the way in which numerous aspects of health, both subjective and objective, are combined within the perceptual framework of the individual respondent.\u0026rsquo; (p.93)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eJylh\u0026auml; (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) has concluded that the rating of a person\u0026rsquo;s health arises from the cognitive reasoning process where people evaluate information about their conditions and sensations.\u003c/p\u003e \u003cp\u003eNumerous definitions of health capture different dimensions of health. As Larson (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) has pointed out, this is also the reason why there is no agreement on the meaning of health - health is a complex phenomenon that includes medical, social, economic, and other components. The most prominent definition, the WHO definition of health that is part of its constitution (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), describes health as:\u003c/p\u003e \u003cp\u003e \u003cem\u003eA state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.\u0026rsquo; (p.1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe Constitution of the WHO (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) also asserts that the highest attainable standard of health is a fundamental right of every human being and fundamental to the attainment of peace and security. The WHO definition of health was expanded on by the Ottawa Charter for Health Promotion (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;to reach a state of complete physical mental and social wellbeing, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living.\u0026rsquo; (p.1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eLarson (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) has categorised the WHO definition of health as a separate conceptual model of health due to its prominence and comprehensive nature. Larson (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) presents three further models of health: medical, wellness, and environmental models of health. The medical model refers to the absence of disease and disability. The wellness model has an emphasis on the link between mind and body; and stresses that health is more than the absence of illness incorporating positive dimensions of well-being, energy, and ability to work. The environmental model places individuals within physical, social, and other environments, and emphasises their ability to maintain a healthy balance. However, Larson (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) suggests that models simplify health and invites one to reflect on the complexity, as even a health assessment based on all four models would be a simplification of reality. Given the plethora of different definitions of health that incorporate different dimensions, McCartney et al. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) reviewed the definitions of health and suggested that, for public health, the best definition should incorporate different dimensions of health, and apply to individuals and populations. McCartney et al. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) suggested the adoption of the definition of health as provided by Last in the dictionary of public health (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;A structural, functional and emotional state that is compatible with effective life as an individual and as a member of society\u0026rsquo;.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eGiven the complexity of the concept of health, it is important to understand how the term is understood within a research context. This paper presents the protocol of a systematic review of qualitative studies that identify and synthesise qualitative primary studies that investigate how young people conceptualise health in the context of the surveys, and in general. The systematic review is part of a PhD project that investigates health inequalities among Scottish young people by using the data from the UK Censuses and Scottish Longitudinal Study. These data sources include a general health question that is used to operationalise health. The systematic review will complement quantitative analysis by synthesising the themes and factors that have been identified by young people when they discuss the meaning of health.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe aim of this systematic review is to synthesise qualitative primary studies that investigate how young people conceptualise health in the context of the surveys, and in general. The review question will be answered by addressing the following sub-questions.\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\n \u003cp\u003eHow do young people reason when they answer self-reported health questions in the surveys?\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eHow do young people reason when they rate health as very good, good, fair, or bad?\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eHow do young people understand the concept of health generally?\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe review protocol was registered in the PROSPERO, registration number is CRD42022367519. The guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e) are followed in reporting this protocol; a completed checklist is provided as an additional file (Additional file 1). PICOS framework (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e) was used to formulate the research question and search strategy.\u003c/p\u003e\n\u003cp\u003eParticipants and eligibility criteria\u003c/p\u003e\n\u003cp\u003eThe study population is young people aged 10\u0026ndash;24 years, with or without health conditions. The term \u0026lsquo;young people\u0026rsquo; covers two life stages. The WHO(\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e) defines \u0026lsquo;adolescence\u0026rsquo; as a life stage between 10\u0026ndash;19 years. Second, people aged 15\u0026ndash;24 are defined as \u0026lsquo;youth\u0026rsquo;. People aged 10\u0026ndash;24 are defined as \u0026lsquo;young people\u0026rsquo;. This grouping is visualised in Box 1.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAdolescents: aged 10\u0026ndash;19\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eYouth: aged 15\u0026ndash;24\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eYoung people: aged 10\u0026ndash;24 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003cp\u003eBox 1. Study population\u003c/p\u003e\n \u003cp\u003eThe outcome of this review will be the synthesis of factors that are discussed by young people when they explore the concept of health. To achieve this outcome, we will locate and synthesise qualitative primary studies. We will apply the definition of qualitative research as proposed by Aspers and Corte (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e):\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied.\u0026rsquo;\u003c/em\u003e (p. 155)\u003c/p\u003e\n \u003cp\u003eStudies using the data collection methods listed below will be included.\u003c/p\u003e\n \u003col\u003e\n \u003cli\u003e\n \u003cp\u003eDifferent types of interviews (individual semi-structured or in-depth interviews, focus groups, or group discussions).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eVisual methods such as photography, drawings, or mind maps.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eWritten accounts that describe photographs.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eData from open-ended survey questions under the condition that data were analysed by using qualitative methods such as content analysis.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ol\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eStudies using the word \u0026lsquo;health\u0026rsquo; in the research question(s) will be included. Studies using the word \u0026lsquo;feel\u0026rsquo; will also be included if the study aims to investigate the perception of health. Some studies have used the word \u0026lsquo;feel\u0026rsquo; when exploring the conceptualisation of health because of cultural reasons. For example, as Joffer et al. (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e) explain, in Sweden, \u0026lsquo;feel\u0026rsquo; is often used when asking about one\u0026rsquo;s health. Spencer (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e) has explored the meaning of health by using the word \u0026lsquo;feel\u0026rsquo;, which captures the holistic conceptualisation of health.\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe exclusion criteria are as follows.\u003c/p\u003e\n \u003col\u003e\n \u003cli\u003e\n \u003cp\u003eStudies exploring the concept of wellbeing, quality of life, or health-related quality of life will be excluded.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eStudies that investigated the conceptualisation of health in the context of certain phenomena such as healthy eating will be excluded because this explores the concept of health from pre-defined aspects.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePapers without any empirical aspect will be excluded.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eConference abstracts will be excluded.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eEditorials, opinion pieces, and book reviews are excluded.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eStudies are limited to those written in English, German, or Finnish.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eThere is no lower date limit for publications.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eVisual methods such as photovoice (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e) are known to add details to interviewees\u0026rsquo; perceptions of phenomena and allow participants to express their ideas in a non-verbal way. There is no consensus if the open-ended questions in the surveys are qualitative or quantitative data (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e). Compared to the interview data, written data can result in less depth as respondents\u0026rsquo; statements cannot be further explored (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e). However, open-ended questions can also be seen as descriptions of phenomena with concepts used by ordinary citizens (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e). These descriptions can be analysed by using qualitative methods, for example, content analysis allows for developing categories that increase the understanding of the phenomenon. Because one of the aims of this review is to understand the concept of health in the survey context, we felt that written accounts, if analysed as qualitative data, will contribute to the understanding of the phenomenon. We will consider the impact of different data collection methods and types of data during the synthesis of the studies. Inclusion and exclusion criteria by the PICOS framework (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e) are summarised in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eInclusion and exclusion criteria by the PICOS framework\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInclusion criteria\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eExclusion criteria\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePopulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10-24-year-old respondents with or without health conditions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe study includes participants from a wider age range, and it is not possible to separate 10-24-year-olds.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudies that investigate how young people conceptualise health 1) in a survey context, and 2) overall.\u003c/p\u003e\n \u003cp\u003eThe study question includes the term \u0026lsquo;health\u0026rsquo; or \u0026lsquo;feel\u0026rsquo;.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConcepts of wellbeing, quality of life, health-related quality of life.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComparison\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot Applicable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot Applicable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOutcome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lsquo;Conceptualisation of health\u0026rsquo;: synthesis of factors discussed by young people when they discuss the concept of health.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot reporting outcomes of interest. Insufficient detail for data synthesis.\u003c/p\u003e\n \u003cp\u003eStudies that investigated the conceptualisation of health in the context of certain phenomena such as physical activity or diet.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudy type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQualitative studies\u003c/p\u003e\n \u003cp\u003eVisual methods such as photography, mind maps, drawings, and written descriptions of drawings or photographs.\u003c/p\u003e\n \u003cp\u003eOpen-ended survey questions that have been analysed by qualitative methods.\u003c/p\u003e\n \u003cp\u003eMixed methods studies if it is possible to extract qualitative findings only.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQuantitative studies\u003c/p\u003e\n \u003cp\u003eMixed method studies if it is not possible to separate qualitative findings.\u003c/p\u003e\n \u003cp\u003eConference abstracts, opinion pieces.\u003c/p\u003e\n \u003cp\u003eBook reviews.\u003c/p\u003e\n \u003cp\u003eStudies without any empirical aspect.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eSearch strategy\u003c/p\u003e\n \u003cp\u003eDifferent authors (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e) have drawn attention to the problems of the inclusion of qualitative evidence in systematic reviews. In this review, the identification of the keywords will be an iterative process. In preliminary searches, we used general keywords such as \u0026lsquo;adolesc*\u0026rsquo;, \u0026lsquo;health\u0026rsquo;, \u0026lsquo;self-reported health\u0026rsquo;. We also used pre-identified relevant studies to identify suitable search terms. From these sources we compiled a list of keywords that were used in searches; these will be refined during the searches. We identified both MeSH terms for the MEDLINE searches and keywords.\u003c/p\u003e\n \u003cp\u003eWe tested three tools to identify search terms. Tools such as PICO are frequently used in systematic reviews (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e). However, it is felt that his tool is not suitable for identifying qualitative studies (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e). As a response, Cooke et al. (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e) developed the SPIDER tool which includes five core concepts:\u003c/p\u003e\n \u003col\u003e\n \u003cli\u003e\n \u003cp\u003eSample\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePhenomenon of interest\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eDesign\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eEvaluation\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eResearch type.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eHowever, Methley et al. (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e) found that although the SPIDER tool had a higher specificity compared to the PICO and PICOS (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e) tools it omitted many relevant articles, possibly due to problems in the indexing of qualitative studies. We, therefore, compiled a search strategy for all three tools. We found that the PICO framework resulted in search terms that brought up a very large number of studies, and similarly to Methley et al. (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e), the number of studies was reduced when using the SPIDER tool. Therefore, we used the PICOS framework to identify final search terms; this tool is also recommended by Methley et al. (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e) when time and resources are limited. The search strategy for MEDLINE (Ovid) is included in Additional file 2.\u003c/p\u003e\n \u003cp\u003eWe will search the following databases.\u003c/p\u003e\n \u003col\u003e\n \u003cli\u003e\n \u003cp\u003eMEDLINE (Ovid\u0026reg;)\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePsycINFO (APA PsycNet)\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eProQuest Sociology Collection (Applied Social Sciences Index \u0026amp; Abstracts (ASSIA) / Sociological Abstracts / Sociology Database\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eWeb of Science Core Collection\u0026trade;.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eThese databases represent social sciences and medicine, the ProQuest Sociology Collection will capture sociological literature. We will also use the techniques of reference checking and forward citation searching; Papaioannou et al. (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e) and Greenhalgh et al. (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e) have demonstrated that compared to conventional database searches, this strategy results in a higher number of high-quality studies in social science systematic reviews. Google Scholar and Google Search were used as supplementary tools during preliminary searches; Google Scholar will be utilised for forward citation searching. Studies are limited to those written in English, German, or Finnish. There is no lower date limit for publications.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eData extraction\u003c/p\u003e\n \u003cp\u003eA reference library will be created and maintained in EndNote20; the title and abstract of retrieved studies will be uploaded to the library. The search strategy was discussed with all authors. One researcher (KM) will search databases. One researcher (KM) will screen all titles and abstracts, and a second researcher (SV) will independently screen a sample of 20% of the abstracts to establish an inter-rater agreement. Disagreements will be resolved by discussion, where consensus cannot be reached, a third researcher (FS) will be consulted. Data will be extracted by one researcher (KM). MS Word and Excel documents will be used to manage data extraction. A second and third researchers (SV and LB) will independently review all data extracted and quality appraisal completed by the first reviewer.\u003c/p\u003e\n \u003cp\u003eThe following information will be extracted from the included studies.\u003c/p\u003e\n \u003c/div\u003e\n \u003col\u003e\n \u003cli\u003e\n \u003cp\u003eStudy reference\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eCountry\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eAim of the study\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eSample characteristics\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eFormat of the health question\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eData collection method\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eData analysis method\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eKey findings\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eQuality appraisal\u003c/p\u003e\n \u003cp\u003eDixon-Woods et al. (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e) have recognised that the formal synthesis of qualitative research is difficult because of the underdeveloped techniques for searching, selecting, and appraisal. However, because qualitative evidence is increasingly used to inform decision-making processes, the question has arisen about whether and how the trustworthiness of qualitative evidence should be appraised (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e). Although several appraisal tools have been developed for qualitative research, there is no consensus on the appropriate quality criteria to evaluate the qualitative findings. It is also argued that many tools incorporate quality dimensions that characterize quantitative results (\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eThe Cochrane Handbook (\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e) emphasises that researchers need to decide which appraisal tool is most appropriate for a particular review. The purpose of the critical appraisal in this review is to provide an understanding of the methodological quality and context of existing evidence; studies will not be excluded based on the results. To select the appraisal tool, we have considered three instruments.\u003c/p\u003e\n \u003col\u003e\n \u003cli\u003e\n \u003cp\u003eThe Critical Appraisal Skills Programme (CASP) quality assessment tool for qualitative studies (\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eThe Joanna Briggs Institute\u0026rsquo;s (JBIs) Critical Appraisal Checklist for Qualitative Research (\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eThe Quality Framework (the QF) (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eFor the appraisal of included articles, the QF was chosen. The JBI\u0026rsquo;s Critical Appraisal Checklist for Qualitative Research was not chosen because it has an emphasis on congruity between philosophy, methodology and methods (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e). The purpose of this review is to synthesise studies that investigate the conceptualisation of health among young people. Maijd and Vanstone (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e) have argued that if the appraisal framework has an emphasis on theoretical underpinnings, then descriptive studies that do not include rigorous theoretical discussion can be classified as untrustworthy. However, descriptive research can produce findings that are relevant to understanding respondent perspectives (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e). We felt that the CASP qualitative checklist (\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e) which is easy to administer and widely used in qualitative evidence synthesis did not cover the dimensions of qualitative research as thoroughly as the QF. One potential reason, as Williams et al. (\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e) argued, is that this tool was developed during the 1990s alongside quantitative research tools. The QF (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e) was developed as a response to the growing need to appraise qualitative evidence which is increasingly used in government evaluations. Although the framework was developed to assess qualitative evaluation across Government Departments, it is also suitable to appraise evidence from different types of qualitative inquiry such as reports or journal papers (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e). The framework includes 18 questions and a set of quality indicators for each question that can be used to guide the appraisal process. To make the appraisal results transparent, we will develop a grading system.\u003c/p\u003e\n \u003cp\u003eStrategy for data synthesis\u003c/p\u003e\n \u003cp\u003eA thematic analysis strategy (\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e) will be used to synthesise selected qualitative studies. This approach is recommended by the Cochrane systematic review group for the synthesis of qualitative studies (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e). We will apply the adoption of the thematic analysis as outlined by Thomas and Harden (\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e). This comprises three stages: 1) coding of the findings of primary studies, 2) organising the codes into descriptive themes, and 3) developing analytical themes. NVivo software will be used to synthesise included qualitative studies. Depending on the data, we will analyse the results by gender, age, location, or data collection method.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis review will synthesise qualitative studies that investigate how young people understand the concept of health, and how they reason when rating their health. The results will improve the understanding of self-assessments of health and thus the interpretation of quantitative health research. Also, an improved understanding of the conceptualisation of health will inform the development of health policies and interventions that support young people\u0026rsquo;s health.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eProtocol amendments\u003c/h2\u003e \u003cp\u003eAmendments made to this protocol when conducting the review will be outlined in PROSPERO and reported in the final manuscript.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eDissemination plans\u003c/h2\u003e \u003cp\u003eThe findings of this systematic review will be disseminated through publication in a peer-reviewed journal, relevant conferences, and as a chapter of the Doctoral Thesis (PhD).\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEU-SILC: the European Union Statistics on Income and Living Conditions survey\u003c/p\u003e\n\u003cp\u003eCASP: The Critical Appraisal Skills Programme\u003c/p\u003e\n\u003cp\u003eSRH: self-reported health\u003c/p\u003e\n\u003cp\u003eQF: the Quality Framework\u003c/p\u003e\n\u003cp\u003eWHO: the World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Vicki Cormie, the University of St Andrews librarian for her advice in developing the search strategy for this review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKM led on the conceptualisation of the review question and wrote the manuscript with input from FS, JI, and AJW. KM defined the search items with input from FS, JI, and AJW; and designed the search strategy with input from FS. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis systematic review is part of the PhD project undertaken by Katrin Metsis. There is no funding related to this review. Katrin Metsis is a part-time staff member at the University of St Andrews and undertakes PhD studies part-time. The University of St Andrews had no role in the design of the study and will not have a role in the analysis and in writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJylh\u0026auml; M. What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Soc Sci Med. 2009;69(3):307\u0026ndash;16. \u003c/li\u003e\n\u003cli\u003eKananen L, Enroth L, Raitanen J, Jylh\u0026auml;v\u0026auml; J, B\u0026uuml;rkle A, Moreno-Villanueva M, et al. Self-rated health in individuals with and without disease is associated with multiple biomarkers representing multiple biological domains. Sci Rep. 2021;11(1):1\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eIdler EL, Benyamini Y. Self-Rated Health and Mortality: A Review of Twenty-Seven Community Studies. J Health Soc Behav. 1997 Mar;38(1):21. \u003c/li\u003e\n\u003cli\u003eHetlevik \u0026Oslash;, Vie T, Meland E, Breidablik H, Jahanlu D. Adolescent self-rated health predicts general practice attendance in adulthood: Results from the Young-HUNT1 survey. Scand J Public Health. 2019 Feb 29;47(1):37\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eVie T, Hufthammer K, Holmen T, Meland E, Breidablik HJ. Is self-rated health a stable and predictive factor for allostatic load in early adulthood? Findings from the Nord Tr\u0026oslash;ndelag Health Study (HUNT). Soc Sci Med. 2014 Sep 1;117:1\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eHaugland S, Wold B, Stevenson J, Aaroe LE, Woynarowska B. Subjective health complaints in adolescence: a cross-national comparison of prevalence and dimensionality. The European Journal of Public Health. 2001 Mar 1;11(1):4\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. The Second Decade: Improving Adolescence Health and Development [Internet]. Vol. 50. 2001. Available from: https://apps.who.int/iris/bitstream/handle/10665/64320/WHO_FRH_ADH_98.18_Rev.1.pdf;jsessionid=0183C43771E817E638DEF413E6FA3A10?sequence=1\u003c/li\u003e\n\u003cli\u003eLynch J, Smith GD. A Life Course Approach to Chronic Disease Epidemiology. Annu Rev Public Health. 2005 Apr 21;26(1):1\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eKestil\u0026auml; L, Martelin T, Rahkonen O, H\u0026auml;rk\u0026auml;nen T, Koskinen S. The contribution of childhood circumstances, current circumstances and health behaviour to educational health differences in early adulthood. BMC Public Health. 2009;9. \u003c/li\u003e\n\u003cli\u003eBauldry S, Shanahan MJ, Boardman JD, Miech RA, Macmillan R. A Life Course Model of Self-Rated Health through Adolescence and Young Adulthood. Soc Sci Med. 2012;75(7):1311\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eSimon J, De Boer J, Joung I, Bosma H, Mackenbach J. How is your health in general? A qualitative study on self-assessed health. Eur J Public Health. 2005;15(2):200\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eBreidablik HJ, Meland E, Lydersen S. Self-rated health in adolescence: A multifactorial composite. Scand J Public Health. 2008;36(1):12\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eTissue T. Another look at self-rated health among the elderly. J Gerontol. 1972;27(1):91\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eLarson JS. The conceptualization of health. 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Qual Health Res. 2012;22(10):1435\u0026ndash;43. \u003c/li\u003e\n\u003cli\u003eMethley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S. PICO, PICOS and SPIDER: A comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Serv Res. 2014;14(1). \u003c/li\u003e\n\u003cli\u003eGreenhalgh T, Thorne S, Malterud K. Time to challenge the spurious hierarchy of systematic over narrative reviews? Eur J Clin Invest. 2018;48(6):1\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eMajid U, Vanstone M. Appraising Qualitative Research for Evidence Syntheses: A Compendium of Quality Appraisal Tools. Qual Health Res. 2018 Nov 1;28(13):2115\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eSpencer L, Ritchie J, Lewis J, Dillon L. Quality in Qualitative Evaluation: A framework for assessing research evidence A Quality Framework. London: Cabinet Office. 2003. \u003c/li\u003e\n\u003cli\u003eWilliams V, Boylan AM, Nunan D. Critical appraisal of qualitative research: necessity, partialities and the issue of bias. BMJ Evid Based Med. 2020 Feb 1;25(1):9\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eHannes K. Chapter 4: Critical appraisal of qualitative research. In: Noyes J, Booth A, Hannes K, Harden A, Harris J, Lewin S, Lockwood C (editors). Supplementary Guidance for Inclusion of Qualitative Research in Cochrane Systematic Reviews of Interventions. Version 1. (updated August 2011). Cochrane Collaboration Qualitative Methods Group, 2011. Available from URL http://cqrmg.cochrane.org/supplemental-handbook-guidance [Internet]. 2011. Available from: https://methods.cochrane.org/qi/supplemental-handbook-guidance\u003c/li\u003e\n\u003cli\u003eCritical Appraisal Skills Programme. CASP qualitative research checklist. Available at :https://casp-uk.net/casp-tools-checklists/ Accessed: 05.05.2022 [Internet]. 2022 [cited 2022 May 6]. Available from: https://casp-uk.net/casp-tools-checklists/\u003c/li\u003e\n\u003cli\u003eThe Joanna Briggs Institute. JBI Critical Appraisal Checklist for Qualitative Research. Available at: https://jbi.global/critical-appraisal-tools Accessed: 06.05.2022 [Internet]. 2014 [cited 2022 May 6]. Available from: https://jbi.global/critical-appraisal-tools\u003c/li\u003e\n\u003cli\u003eSandelowski M. Focus on Research Methods Whatever Happened to Qualitative Description? Res Nurs Health. 2000;23. \u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006 Jan;3(2):77\u0026ndash;101. \u003c/li\u003e\n\u003cli\u003eThomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008 Dec 10;8(1):45. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of St Andrews","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Self-reported health, Young people, Adolescent, Concept Formation, Qualitative Research, Self Report, Inequalities","lastPublishedDoi":"10.21203/rs.3.rs-3879104/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3879104/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSelf-reported health is a widely used health indicator in surveys and questionnaires. The measure gained attention when research identified its association with mortality in the 1970s and 1980s. The measure is also associated with morbidity and other health outcomes such as the utilisation of health services. Self-reported health is a particularly useful measure for young people because this age group is generally clinically healthy. However, self-reported health starts to decline during early adolescence. It is known that many chronic conditions have long latency periods that are initiated early in life. Despite its widespread use, however, self-reported health remains a poorly understood concept.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis paper presents the protocol for a systematic review that will identify and synthesise qualitative studies that investigate how young people conceptualise health in the survey context, and overall. The population of the review is young people aged 10–24 years, with or without health conditions. We will search the databases of MEDLINE (Ovid®), PsycINFO (APA PsycNet), ProQuest Sociology Collection, and Web of Science Core Collection™. We will also utilise techniques of reference checking and forward citation searching, as this strategy has been shown to result in a higher number of high-quality studies in social science systematic reviews. Google Scholar and Google Search were used during preliminary searches; Google Scholar is utilised for forward citation searching. We will include studies written in English, German, or Finnish; there will be no lower date limit. One reviewer will screen all citations. A second reviewer will independently screen a sample of 20% of the abstracts. Data will be extracted by one researcher, two other researchers will independently review all data extracted, and quality appraisal completed by the first reviewer. We will utilise the Quality Framework for the appraisal of included articles, and thematic analysis to synthesise selected qualitative studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results of this systematic review will improve the understanding of the self-assessments of health and the interpretation of the results of quantitative research. Also, an improved understanding of the conceptualisation of health will inform the development of health policies and interventions that support young people’s health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSystematic review registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePROSPERO CRD42022367519\u003c/p\u003e","manuscriptTitle":"Conceptualisation of health among young people: a protocol for systematic review and thematic synthesis of qualitative studies","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-25 05:44:13","doi":"10.21203/rs.3.rs-3879104/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"979ea962-4527-40d5-a473-0d8606b21c08","owner":[],"postedDate":"January 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":28338453,"name":"Preventive Medicine"}],"tags":[],"updatedAt":"2024-01-25T05:44:13+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-25 05:44:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3879104","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3879104","identity":"rs-3879104","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}