Participants shared a variety of stories when discussing health and well-being. The large majority told stories related to major life events (e.g., getting married, the birth of a child, losing a loved one, purchasing a home), followed by stories surrounding a stage or time in their lives such as being a student, a certain time in their careers, or life after retirement. All participants spoke about other people and their roles in their lives, particularly family members. Many of the narratives also included routines or activities participants typically engage in, or used to engage in, such as hobbies, quality time activities with loved ones, and job-related activities. These stories also tended to highlight participants values, beliefs, identities and life goals. Next, we attend to ‘small story’ narratives [29] and draw out specific themes or domains related to health and well-being.
Well-being and health domains
A total of eight domains emerged from our data regarding well-being and health. While the same domains emerged for both constructs, participants spoke about different domains with different levels of frequency during the two sections of the interview (e.g., well-being and health). Figure 1 showcases the domains separately for well-being and health, arranged by decreasing frequency of mentions for each domain. This figure also showcases definitions for each domain on the lower panel. Figure 2 highlights the percent of participants mentioning each domain, and the percentage of data elements coded under each domain. Notably, participants spent substantially more time discussing well-being (883 data elements) as compared to health (454 data elements). Calculations were done separately for well-being and health. Figure 2 displays percentages calculated based on these values. The following sections delineate findings separately for well-being and health.
Well-being findings
Figure 1, panel a, shows the well-being “flower” illustrating the domains of well-being. Larger petals correspond to higher numbers of data elements assigned to that code. Leaves were drawn to represent and draw attention to key domains most often discussed by participants. Petals within leaves represent sub-themes within the domain depicted by the leaf. Figure 1 also presents all domain definitions.
Family
For well-being, family emerged as the most frequently discussed domain (mentioned by 96% of participants when discussing well-being and accounting for 39% of all well-being data elements). Family appears to be a cornerstone element of well-being in this sample, with participants often describing their personal well-being as intimately tied to - and often indistinguishable from- their family. For instance, when discussing times of personal high and low well-being, participants mentioned the well-being of their children, the health of family members, their relationships with spouses and parents, family members as motivators to engage in health promoting activities, and other aspects of family life. The following quote highlights the intricate connection between family and participants’ well-being:
“I am more of a family man. The old concept is always inseparable from home. After getting married, with children, we continue to live with my parents. The home gives me the feeling like sheltering from the wind. And this kind of warmth is my first choice of well-being.” Male participant
Within the family theme, purpose and meaning was the largest sub-theme (see petal inside family leaf, Fig. 1, panel a). Participants mentioned family as the key driver in terms of finding purpose and meaning in their everyday lives. Stress was the second largest sub-theme within family, followed by resilience. Participants discussed stressors in the family including physical health problems of family members, conflicts with in-laws, stressors associated with raising young children and others. Nonetheless, families appear to provide invaluable support, as highlighted by the following quotes:
“Like for my operation, I didn't take the sick leave for a month, but my husband did for a month to take care of me, very sweet. After the operation, he didn’t know how to cook, so he asked my sister to come over and help. He helped buying food, but he wouldn't cook. So, he would help prepare, and wait for my return for work to cook, but I don't have to do the dishes after dinner. He did them all. After operation, he would help me shower. He took care of me. He is very caring. So, I think I am very content.” Female participant
“Because the old house was not good at that time, we bought a house in the south and have everyone lived there with us. The in-laws and the uncles lived with us, and we were responsible for the payment of the house loan. Later we moved out. They still live there, even though we paid for it. But that loan was not from the bank. It was from a relative, no interest. It was much less pressure.” Another female participant
Participants also discussed, with less frequency (and thus not explicitly depicted on Fig. 1), other family-related issues and their impact on well-being including changes in cultural values related to families (e.g., effects of nuclearization of families, changes in respect for elders), emotions evoked by one’s family (e.g., deep joy and happiness at seeing one’s children do well), and social comparisons related to being married or having children as desirable outcomes that were seen as important for attaining higher well-being.
Finances
The second most discussed well-being domain was finances. When speaking about their well-being, this domain was mentioned by 96% of participants and accounted for 22% of the data elements for well-being. Financial stress emerged as the largest sub-theme within finances. Our participants discussed various stressors such as the financial pressures of affording general life expenses; starting and failing in business; issues with employment, loans and debt; and others. The following quote highlights some of the impacts of financial issues:
A male participant described the following when discussing having failed in a business and incurring financial stress as a result:
“I used to be in tears when I talked about this. It’s so pitiful. It went down just like this. And, it would take me another 10 years to recover. I was the saddest at that time. I couldn’t eat, I couldn’t sleep. It’s really painful. I dare not say anything, there was no money, I was very worried, thinner than now.”
Financial security emerged as the second largest sub-theme within this domain. Participants discussed financial security and satisfaction as a key driver of and contributor to their well-being. The following quote showcases the importance placed on financial security by some participants in terms of their overall well-being.
“Money is very important. Let me tell you, marriage and love life are very important, but money is more important. With enough money, there would be nothing to worry. Once you had the house, you don’t need to make a lot of money. Only to make enough to spend.” Female participant
Housing-related issues constituted the third largest sub-theme within finances. Participants shared about the importance of owning a home, the stressors associated with having landlords that often-raised rent and/or did not keep up properties, the importance of helping family members and especially their children buy a home, and other aspects of home ownership as an important area of well-being.
Work-life
The third largest domain was work-life, representing 10% of total well-being mentions, and mentioned by 79% of participants. This domain included job-related tasks and their impact on health (e.g., inability to sleep, having little time for pleasurable activities or family time), and social relations from work as potential avenues for support and motivators for healthy behaviors. For instance, female participants often mentioned walking with other female co-workers or finding out about exercise classes and opportunities through co-workers. Participants also spoke about job-related stressors (e.g., conflicts with superiors, or pressures of having their own business) and about their jobs and/or careers as an aspect of purpose and meaning in their lives. Purpose and meaning derived from work was discussed across various occupations, from physicians to cleaning staff in our sample. The following quote highlights job related stress and negative impacts on well-being:
“Because I am in public relations, a lot of activities. So, I have to stay up late, work overtime. It made me very tired, and at that time, it also made me very tired in my mind. My health started to have some problems. It was that time! It was tremendous. And the point was that, our boss would swear. It was not minor yelling. He used to swear. So, the pressure was tremendous.” Female participant
Other well-being domains
The fourth most frequently discussed domain for well-being was lifestyle behaviors (9% of data elements), followed by sense of self (8% of well-being’s data elements), physical health (5% of well-being’s data elements), resilience (4% of well-being’s data elements) and religion and spirituality (2% of data elements). See Fig. 2 for further details regarding the percent of participants mentioning each domain.
Health findings
Figure 1, panel b, shows how participants discussed the concept of health. Physical health was discussed the most, accounting for 41% of the data elements from the health portion of the interview and discussed by 100% of participants. Disease-related comments were the most frequently mentioned sub-category within the physical health domain (28% of all data elements under physical health). Participants discussed a variety of issues including chronic health conditions, their related risk factors (e.g., high blood pressure, high cholesterol) and their impact on daily functioning; disease management; physical injuries; and other diseases, including issues such as colds or allergies. For instance, when asked to describe a time of poor health, a participant shared the following:
“The worst was that I had diabetes! When I was hospitalized because of diabetes for insulin, that was the worst. I felt very depressed at first, and I let go. Anyway, I eat, take medication, only that I don’t exercise. I go to see the doctor regularly, do blood test, pick up the medication. Sometimes I don’t have breakfast, I only eat lunch. I used to watch my glycated hemoglobin count. I used to check daily, not anymore. When I found out that I had diabetes, I checked every day for a year. I stopped. Anyway, whatever the sickness, after a long time, you would get used to it. Now it’s mainly to have it well-controlled, just like this!” Male participant
Health care use was also frequently discussed in the context of physical health. Participants spoke about use of both western medicine and traditional Chinese medicine approaches to managing diseases. Notably, they spoke more often about Western medicine (35 data elements) compared to traditional Chinese medicine (8 data elements), but generally spoke favorably about both. The following quote highlights a participant’s interactions with both health care systems:
“One day, I decided to go to see the Chinese medicine doctor. Took the Chinese medicine for a week. Now, so many people have seen me and say that my hands are really all better.” Female participant speaking about skin concern on her hands.
“The medication is helpful, 2 tablets a day and it is under control.” Male participant discussing diabetes management with Western medicine.
Aging-related changes in physical health were often brought up by participants (see Fig. 1, panel b). This included age-related changes such as menopause for our female participants; increased disease and comorbidities; weight gains over time; decreased ability to recover quickly after an injury or illness; increased number of aches; lower mobility or physical stamina; and changes in appearance.
“I worked in Taichung, it was 20, 30, or 40 years ago. The former boss asked me to have dinner together with other co-workers. Everyone’s health is a lot worse now, with silver hair. We all are either grandmothers or grandfathers. We couldn’t recognize each other when we first met. I was so saddened, asked myself not to think too much. I have to let it go.” Female participant
Within the physical health domain, participants also discussed issues related to the link between mental and physical health, vitality, pain, health literacy, social comparisons, and good physical health as a stepping stone to being able to engage in valued activities:
“This is very important. You can't do anything, if you are not healthy, right? So, health is more important than wealth. I pay a lot of attention to be healthy. If you are not healthy, you can't be volunteers. And you can't do other things. So, we have to take care of ourselves to take care of others.” Female participant discussing overall physical health during the health portion of the interview.
Lifestyle behaviors
The second most frequently discussed domain within the health portion of the interview was lifestyle behaviors, which accounted for 22% of the data elements and was mentioned by 88% of our participants. This domain included multiple health behaviors and daily practices such as physical activity, diet, self-care and leisure behaviors, and sleep. Participants discussed both engagement or lack of engagement in these behaviors and their influences on their health. The following quotes showcase a couple of these comments:
“I am so afraid of being old, I do exercises. Go take a look at the secretary. She goes to the sports center. I asked the secretary how could you be so beautiful always? The secretary replied that she goes to exercise often, so I go to exercise too. I had my exercises already. I danced on Mondays, Wednesdays, and Fridays. Although I am not a very advanced dancer, it is always better than sitting on the couch and watching TV at home. At least three days a week, I go to exercise. If not, I will walk to the park or the playground for two laps or go sit and chat with everyone.” Female participant highlighting positive social influences on her exercise.
“I have this concept that the health is not based on western medicine, it comes from your normal three meals. In fact, my concept is that a normal diet for cancer patients is also the best chemotherapy. Because, the cells are in need of nutrients. I feel that everyone should take care of oneself. It is from the diet of three meals, should not drink. Don’t get those unhealthy drinks, including those delicate processed foods, don't take those.” Male participant discussing diet.
Family
The third most frequently discussed domain within the health portion of the interview was family (11% of data elements in this section and mentioned by 79% of participants). Similar sub-themes were found in this section compared to the well-being portion of the interview. Participants highlighted their families as a key motivator for maintaining good health. A participant recalled the following after dealing with some health problems:
“I lost weight. I didn’t dare to go out, and my health was very poor. I couldn’t cook, couldn’t do anything, I remember during that time, my mother and two sisters came to take care of me for a month. In less than a year, I could live by myself. I want to say that I couldn't fall apart. If I fell apart, my mother would have to come to take care of me. I can't let my elderly mother to take care of me for rest of my life. My children were still so young. So, I told myself that I had to get better soon.” Female participant
Other health domains
As seen in Fig. 1, participants also mentioned, in decreasing order of frequency, work-life, resilience, finances, sense of self, and spirituality and religion during the health portion of the interview. See Fig. 2 for more details regarding % mentions and % of participants mentioning each.
Post-coding analyses
Connections among petals
Although domains are presented in Fig. 1 as distinct petals for clarity purposes, participants often discussed multiple domains concurrently. Post-coding analyses revealed a pattern of complex interconnections shown in the form of Sankey diagrams [39, 40] in Figs. 3 and 4 for well-being and health, respectively. Straight lines connecting the same domains across the diagram indicate data elements that were only coded within that domain (i.e., no other domain discussed within the data element). The percentages shown in the figures (and also evident by the width of the lines) represent the proportion of data elements in that domain that were not double-coded. Curved lines connecting different domains across the graph indicate instances in which participants spoke about the two domains concurrently (i.e., double coding). Again, the thickness of these curved lines indicates the frequency of interconnectedness. As the figures show, mentioning multiple domains in the same data element was common. For example, for well-being, family was mentioned along with another domain 53% of the time. In the case of health, physical health was mentioned alongside another domain 66% of the time.
Contributors to and detractors from well-being and health
Our post-coding analyses also explored how participants discussed each domain in terms of contributing to or detracting from their health and well-being. These findings are presented in Fig. 5. For instance, while family was most often discussed by individuals in terms of contributions to well-being (211 data elements), it was also discussed as a detractor (163 data elements). Many of these mentions of family as a detractor can be explained by our stress sub-theme, which captured pressures of raising young children, conflicts with in-laws, worries and issues regarding illnesses of family members, and stressors related to caring for elderly loved ones. Finances was also a domain discussed in terms of both contributions to and detractions from health and well-being. Some participants discussed financial stability as positively impacting their well-being and constituting “content” in their lives. Other times they spoke about financial concerns such as housing issues as detracting from their well-being. In the context of the health portion of our interview, physical health was more often discussed as a detractor than as a contributor (115 data elements vs 87).
Exploring low-ladder ratings on well-being and health
We further explored the interviews of participants who self-rated their well-being and/or health as being low or poor (i.e., ladder ratings ≤4 out of 8) in order to find information that could be useful in the development of targeted intervention for this sub-group. Seven participants rated their well-being and/or health within this range (n = 2 for well-being, n = 6 for health, and one with low ratings on both). In terms of demographics, males were overrepresented in this sub-sample (6 of 7 participants or 86%) compared to their proportion in the overall sample (46%). The one female on this sub-sample had a low rating on health, not well-being. While we found no overall differences in the frequency of mentions of domains for these participants, we did find differences in the content of two domains in the health portion of these interviews: physical health and lifestyle behaviors. Within the physical health domain, these participants were more likely to discuss the impacts of age-related changes (6 of 7 participants) compared to the overall sample (14 of 24 participants). They often tied their low health ratings to aging-related physical health symptoms including the development of chronic conditions such as diabetes, joint pain, and less energy and vitality. For lifestyle behaviors, all of these participants discussed lacking in exercise as being related to their current physical health issues. Many of them recalled involvement in sports or higher levels of physical activity at a younger age. However, they expressed current levels of inactivity due to work-related stress, lack of time and energy or other barriers. They also discussed difficulties with sleep quality as contributing to lower ladder ratings. Given the small sample of participants in this follow-up analysis, we encourage future studies exploring this information.