Lifestyle behaviors during exam periods and their association with academic performance among Palestinian medical students: a cross-sectional study.

The traditional definition of health, as established by the World Health Organization [], has often been regarded as insufficient to capture the complexity and multidimensionality of health in modern society. In response, the concept of Positive Health was introduced, defining health as “the ability to adapt and self-manage in the face of social, physical, and emotional challenges” []. This dynamic and broad perspective contrasts with traditional biomedical models by emphasizing personal strengths, resilience, and the pursuit of a meaningful life, even in the presence of adversity. Rather than focusing solely on disease or limitations, Positive Health focuses on people’s capacity to adapt and self-manage in line with their values, goals, and context [, ]. This broader view aligns closely with Antonosky’s Salutogenesis approach operationalised in the Sense of Coherence with General and Specific Resistance Resources [, ] and the Capability Approach developed by Sen [] and Nussbaum []. Both approaches highlight not only what people do or achieve (), but what they are able to do (), given their personal and contextual circumstances. Together, these frameworks move beyond viewing health as a static or clinical condition, offering instead a dynamic lens that accounts for real-life complexity, individual agency, and structural context. By recognizing health as a context-sensitive and evolving phenomenon shaped by social, economic, and environmental determinants, Positive Health and the Capability Approach enable a more inclusive and meaningful understanding of health—also for people in vulnerable or disadvantaged positions [, ]. Several attempts have been made to operationalize this broader perspective on health. One of the first was a 44-item Positive Health questionnaire, which was criticized for lacking comprehensiveness and discriminant validity []. A shortened 17-item version showed improved psychometric properties [], but failed to capture essential elements such as empowerment and contextual factors like financial security and living conditions []. These elements are central to the Capability Approach, which emphasizes the importance of individual resources and opportunities for achieving wellbeing [, ]. To better integrate the broad and dynamic nature of Positive Health with the Capability Approach’s focus on these resources and opportunities, the Context-sensitive Positive Health Questionnaire (CPHQ) was developed []. This 32-item questionnaire showed promising psychometric properties, but also had some limitations. Although grounded in both Positive Health and the Capability Approach, the alignment between the theoretical framework and the item structure was only partial. Conceptual domains such as social support, exclusion, and environmental safety were included but showed weak empirical associations with existing validation measures, raising concerns about their integration and measurement relevance. Additionally, stakeholder involvement during development was limited, particularly from professionals in the medical, social, and policy domains—whose perspectives are essential for broad applicability of the CPHQ. Finally, there was insufficient evidence regarding the instrument’s applicability to diverse and vulnerable populations, such as individuals in vulnerable or disadvantaged positions [, ]. To address these issues, the original CPHQ was revised in co-creation with stakeholders from healthcare, welfare, and policy sectors, as well as with direct input from citizens and patients, including those with a lower socioeconomic position (SEP) []. Through structured focus group discussions, stakeholders, citizens and patients critically assessed the original items for comprehensibility, relevance, and cultural sensitivity. They also identified domains that were insufficiently covered in the initial questionnaire. Consequently, several items were reformulated to improve clarity and to better capture contextual nuances, with a stronger emphasis on social inclusion, meaningfulness, and resilience. This iterative, participatory process resulted in a more concise 28-item version that is better aligned with the perspectives of both professionals and end-users. Although this revised version better reflects the lived experiences of diverse users, systematic quantitative validation is necessary to establish its psychometric quality. Such validation is essential to confirm reliability, dimensional structure, and generalizability across different populations, ensuring the instrument accurately and consistently measures the intended constructs.