In 1948, the World Health Organisation (WHO) defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (1). This definition was innovative because it considered the mental and social aspects of health next to the physical aspect for the first time. However, the use of the word “complete” is suggested to make health achievement rather unfeasible for most people and would thereby imply that most people are mostly unhealthy (2). Since the introduction of the WHO definition, almost three-quarters of a century has passed, and a need to move towards a more dynamic approach to health in research and practise has emerged. This need was reflected in the concept of “positive health”, developed in 2011 by Huber and colleagues, which describes health as “the ability to adapt and to self-manage, in the face of social, physical and emotional challenges” (2). The concept was further operationalized in 2016, after a shift in the Netherlands from a welfare state to a participation society in 2013, where the latter emphasised the need for individuals' adaptability and self-management (3). The further operationalization of positive health was based on a mixed-methods study among 140 stakeholders, such as healthcare professionals, patients with chronic diseases, and policymakers (4). Finally, positive health addressed six dimensions: bodily functions, mental functions and perception, spirituality or existentialism, quality of life, social and societal participation, and daily functioning (4). Moreover, the Handbook of Positive Health was developed, including a conversational tool with which a health worker and client can evaluate the client's condition in each dimension, considering what the client wants to maintain or improve and what requires guidance (4). Several studies have applied positive health, for example in health education and healthcare (5–8). However, specific skills within the six positive health dimensions needed to maintain or improve one's health have not yet been described. Defining these skills is relevant and critical to guide health workers in helping individuals practise received health advice by subsequently adapting and self-managing their health.

It is essential to build on existing concepts when defining these skills, such as health literacy, perceived as a crucial determinant influencing people's health. For example, a widely used definition of health literacy by Sørensen et al. (9) is “people's knowledge, motivation, and competencies to access, understand, appraise, and apply health information in order to make judgements and take decisions in everyday life concerning healthcare, disease prevention, and health promotion”. This definition emphasises that knowledge and motivation related to understanding and applying health information are vital yet insufficient when the skills to apply this knowledge and motivation are lacking. Furthermore, the definition of skills for maintaining and improving positive health should build on existing taxonomies and evidence for behaviour change techniques. These techniques are systematic practises integrated into behaviour change interventions as key elements (10, 11). Lastly, it should be emphasised that health literacy and interrelated skills should be viewed as strongly related on a continuum rather than as separate concepts.

Maintaining and improving health by strengthening skills to adapt and self-manage health may benefit a wide range of individuals; however, it is imperative to focus on individuals who would benefit most. People with a low socioeconomic position (SEP) have a relatively low healthy life expectancy (i.e. living in good health for a shorter amount of time) compared to those with a high SEP (12, 13). Many people with a low SEP also have relatively limited health literacy levels (14–16). In the Netherlands, it has been suggested that a quarter of adults are insufficiently health literate, and among people with a low SEP, 38% have been estimated as having insufficient health literacy levels (17). On behalf of the working group on positive health literacy at the Amsterdam Public Health Research Institute, this perspective article aims to propose ways forward in defining skills within the six positive health dimensions contributing to the maintenance and improvement of individuals' health by answering the following questions:

Which skills within the six positive health dimensions do individuals need to maintain or improve their health?

Before discussing the skills within the positive health dimensions that individuals need to maintain or improve their health, we should clarify the terminology regarding skills because they are occasionally mistaken for competencies. Skills are approached as specific abilities needed to achieve a goal. They are part of the broader concept of competencies, referring to a broader set of characteristics that include knowledge, thought patterns, and mindsets (18).

Different approaches to define skills within the six positive health dimensions are possible. We begin by defining skills for maintaining and improving positive health based on the health literacy concept because it is an important determinant of health (19) and includes previously defined skills. Below, we elaborate on these concepts and associated skills related to positive health.

Maintaining and improving skills for positive health is important for everyone, although the potential to increase health is probably relatively high for people with a low SEP who also have limited health literacy levels. People with a low SEP often face multiple short-term problems (e.g. financial problems) (50), which can leave little cognitive space to engage in long-term health behaviour change (44, 51). Therefore, it is crucial to support people with a low SEP in addressing and coping with these problems and, if possible, help resolve them. The subsequent cognitive space may be an enabling factor in having more opportunities to engage in health behaviours. Besides, it is essential to give people with a low SEP the opportunity to gain a better grip on their health. Furthermore, limited health literacy has been related to adverse mental health outcomes (e.g. loneliness, social isolation) (52–54), unhealthy eating behaviour and physical inactivity (16), poorer take-up of preventive services (55), and low general literacy levels (55, 56). Taken together, people with a low SEP who also have limited health literacy levels may benefit most from improving the skills for maintaining and improving positive health. Here, it is important to emphasise that people do not need to improve all the skills listed. It is especially important to first identify all relevant skills that affect health, then discuss with clients which skills they want to work on and then determine on which skills it is meaningful and feasible to intervene. Thus, the skills to be worked on differ from individual to individual (57).

The Handbook of Positive Health states that the diversity of patients in the consulting room is increasing, creating increased complexity (58). This complexity requires a broader view and more time because a tailored approach is needed. The authors inquire, “Are there special concerns about working with positive health in people with low socioeconomic status?”. The most vulnerable people always benefit the least from any intervention. As individuals and their environment are inseparably linked (59), responsibility for health and lifestyle should not be placed entirely on the individual. Policy should be put in place to create a healthy environment, which also should facilitate and support that clients can properly learn and adopt the proposed skills. This could be done, for example, by addressing organisational health literacy and providing suitable health promotion interventions.

Positive health offers a broad perspective, making it an interesting concept within public health because it focuses less on solving health problems and more on people's ability to adapt and self-manage physical, emotional, and social challenges. However, the positive health tool used in practise is currently aimed at what to achieve within the six positive health dimensions, not how to maintain and improve them. This perspective article aimed to define skills within the six positive health dimensions contributing to maintaining and improving individuals' health while suggesting how these skills can be improved among people with a low SEP who also have limited health literacy levels. We proposed specific skills by describing health literacy, executive functions, and life skills. It is essential to remember that the systems surrounding individuals influence health (Figure 1) and to include organisational health literacy. The defined skills may also be applicable to other practical conversation tools. Examples are the Dutch Leefstijlroer (lifestyle rudder) for healthcare professionals to discuss healthy lifestyles with clients (69), the 4Domeinen model (4-domains model) for professionals in the medical and social fields to inventory life domains and perceived health with patients (70) and the CONNECT instrument with which a physician can assess patients' health condition (71). The suggested skills are a first step towards their more comprehensive definition, which, like the concept of health, is subject to change. Thus, we are open to receiving ideas about additions or adjustments to the defined skills.

Concerning positive health among people with a low SEP who also have limited health literacy levels, these individuals can benefit from help in solving and dealing with problems in various life areas possibly hindering health behaviour change. We proposed that health promotion interventions could incorporate the defined skills to improve health with practical exercises and learning objectives. Furthermore, intervention materials should be suitable for end-users, and implementation tools should be aligned with the implementers.

A possible limitation of this paper is that we have not conducted a systematic literature review, and this is therefore the first theoretical attempt of defining the skills. Future empirical research should show whether these defined and suggested skills are relevant in practise. Additionally, we recognise that difficult social conditions can impair health in individuals. Even though positive health can be a tool to work towards increased health, it does not release governments from their task to invest in social equality and circumstances. Individuals should not be blamed for adverse conditions due to a lack of skills for positive health.

Increasing the health of people with a low SEP who also have limited health literacy levels can contribute to individual health while contributing to the reduction of health inequalities. This reduction has proven insufficient over the years in Europe, despite various attempts in research, practise, and policy (72). Systems thinking, which considers multiple components of systems holistically (73), is needed to understand and address socioeconomic health inequalities (74). Several theoretical models have emphasised the importance of considering individual and environmental levels to reduce socioeconomic health inequalities (31, 59). Thus, there remains a way ahead to incorporate the suggestions of the defined skills for maintaining and improving positive health into components of systems surrounding individuals.

All in all, the defined and suggested skills within the six positive health dimensions can hopefully contribute to improved individual health while allowing people to flourish in life.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

LB and IS conceptualised the study. HS wrote the first draft of the manuscript and final draft of the manuscript. LB, CR, WK, MF, KA, and IS edited the text. All authors contributed to manuscript revision, read, and approved the submitted version.