However, diet is also associated with mental wellbeing, with research highlighting the benefits of vitamins and minerals on psychological wellbeing \citep*{Rooney_2013}.
A healthier diet has generally been found to correlate with better mental health \citep{Dimov2019}\citep*{Emerson2019}\citep*{Kulkarni2015}. The Mediterranean diet has proven useful in slowing age-related deterioration, including improvements in cognitive function and reducing risk of cognitive impairment and dementia \citep*{Petersson2016}. XXX
Sleep
Sleep deficiency is a growing problem, facilitated through societal changes, including longer working hours and commuting further to work, shift work, increased dependence on technology \citep{Luyster2012}. The ideal amount of sleep is 7-8 hours each night for adults \citep{Hirshkowitz2015}, with less or more being associated with higher mortality risks \citep{Kwok2018,Cappuccio2010}\citep{Grandner2010} as a result from health-related issues, such as worsened immune function, cardiovascular disease, obesity, diabetes, hypertension, coronary heart disease and stroke \citep{Besedovsky2012}\citep*{Buxton2010a} \citep{Cappuccio2011}\citep{Itani2017} \citep{Jike2018}. Poor sleep has also been associate with an increased development risk of certain cancers, including prostate and breast cancer \citep{Kakizaki2008}\citep{Kakizaki2008a}.
Some of the noted pathways through which poor sleep is associated with health-related problems includes impaired glucose intolerance, increased cortisol levels, alterations in sympathetic nervous system activity, reduced leptin levels, and increased ghrelin levels \citep{Buxton2010}\citep{Spiegel2005}.
The importance of sleep has been highlighted among mental health disorders, with many suffering with insomnia, the treatment of which results in mental health improvements (paranoia and hallucinations) \citep{Freeman2017}. Analyses on nearly 100,000 questionnaires completed by adolescents in Japan found a U-shaped association between mental health status and sleep duration \citep{Kaneita2007}. Additionally, they reported a positive correlation between mental health status and subjective sleep assessment. Similarly, among an elderly population, sleep problems were associated with worsened mental and physical health-related quality of life \citep{Reid2006}.
Sleep deficiency also links with other aspects of the GENIAL model which subsequently impacts on health and wellbeing. An underlying effect of vagal function influences sleep quality, with reduced vagal function being associated with more disrupted sleep \citep*{El-Sheikh2013}, whereas increased vagal function predicts better subjective and objective sleep quality \citep{Werner2015,Grimaldi2016}. Reduced HRV has also been detected early during early developmental stages of sleep-related breathing disorders \citep{Aeschbacher2016}. Linking to the community and social aspect of GENIAL, both an overall sleep deficiency and minor, day-to-day reductions in sleep, triggers pathways to social withdrawal and loneliness. One pathway through which this occurs is via cortical hypersensitivity that warn of human contact, along with impairment in the ability to recognise the social intent of others \citep*{Ben2018}. Connecting with the environmental domain of GENIAL, utilising nature as a therapy-based intervention for sleep improvements has provided hopeful results. For example, forest walking, which subsequently increases physical activity and emotional improvements, can improve the length and quality of sleep \citep{Morita2011}. On a larger scale (over 250,000 participants), whilst correlational, it is interesting to note that those who live closer to green spaces are more likely to achieve a healthier duration of sleep (8 hours), even after controlling for well-known sleep influencers, including mental and physical health \citep*{Astell-Burt2013}.
Among an elderly population with comorbid medical and mental illness, sleep was still a useful predictor for general physical and mental health-related quality of life status, highlighting the importance to incorporate sleep into clinical evaluations and use sleep as a target for clinical interventions (Reid et al., 2006). An intervention developed to improve sleep among children with ADHD focused on providing sleep hygiene practices and standardised behavioural strategies (Hiscock et al., 2015). Results found those who received the intervention reported less sleep problems and reduced ADHD symptoms up to six months later, compared to the control group. Sleep was found to mediate the impact of the intervention on reducing ADHD symptoms to some degree. Also, individuals with depression and comorbid insomnia benefit from additional CBT targeting the symptoms of insomnia, resulting in improvements of symptoms of both disorders (Manber et al., 2008).
According to our GENIAL model XXX
Community
and Community Wellbeing
TO INETRAGTE: Loneliness has become a growing concern for societies, with an estimated
3.6 million older people in the UK living alone; 2 million of which are
over the age of 75 years (Age UK, 2018). It has become a modern
epidemic, with the term ‘kodokushi’ coined in Japan to describe lonely
deaths where people are not discovered to be dead for some time (The
Straits Times, 2017). Despite the increasing awareness surrounding the
importance of social connectivity, single-person households and
home-based careers continue to rise in the UK (Office for National
statistics, 2017; Trades Union Congress, 2016). The impact of loneliness
and the lack of a strong, supportive social network can be fatal. A
meta-analysis consisting of 300,000 participants found that those who
had stronger relationships had a 50% greater likelihood of survival on
an average of 7.5 years later, which was a stronger predictor for
survival than physical activity, smoking (15 cigarettes daily), alcohol
consumption, and BMI (Holt-Lundstad, Smith & Layton, 2010). Following
this, the researchers investigated the impact of social isolation,
loneliness and living alone as risk factors for mortality (Holt-Lundstad
et al., 2015) . Among a total of 48,673 participants, social isolation,
loneliness, and living alone increased risk for mortality by 29%, 26%,
and 32%, respectively. Results were consistent between both objective
and subjective measures of social isolation. Interestingly, the social
deficits had a greater impact on mortality among those below 65 years of
age.
Three pathways that link social relationships and health have been
identified. Behavioural pathways have been proposed in which negative
health-risk behaviours are associated with loneliness and social
isolation. For example, social isolation and loneliness are
independently associated with increased risk of inactivity and smoking
(Shanker et al., 2011). Loneliness has also been associated with an
increased risk of substance use among adolescents (Stickley et al.,
2014), along with hazardous drinking and smoking (Stickley et al.,
2013). Psychological pathways have been proposed with loneliness being
associated with decreased self-esteem, increased risk for depression and
feelings of hopelessness, along with an increase in reported sleep
problems (Steptoe et al., 2004). Hypothesis within the psychological
pathways help highlight the barriers that individuals can develop to
build resilience (Haslam et al., 2018). These include the meaning
hypothesis, which argues sharing a social identity with others brings
meaning, purpose and worth to an individual’s life. The support
hypothesis proposes that people receive support from those they share a
social identity with. The agency hypothesis suggests a social identity
brings a sense of efficacy, agency and power to an individual’s life.
Among many other hypotheses, these are useful to highlight the
importance of social connections with others in terms of the identity
they help develop and the pathways through which a poor social network
impacts on health. Physiological pathways are another link, with social
isolation and/or loneliness being associated with a dysregulation of
cardiovascular, metabolic, and neuroendocrine processes (Grant, Hamer &
Steptoe, 2009), along with higher systolic blood pressure, independent
of several factors such as age, gender, cardiovascular risk factors,
medications, social support and perceived stress (Hawkley et al., 2010).
A good example of the physiological effects of social engagement is
presented by Muller and Lindenberger (2011). Among choir members,
cardiac and respiratory patterns synchronised with this effect being
stronger when the members sang in unison as opposed to solo. The term
“physiological linkage” has been coined to describe this process
(Timmons, Margolin & Saxbe, 2015). The emotional context in which the
physiological linkage occurs is important, for example negative effects
have reported when the sympathetic nervous system or HPA axis
synchronises between individuals as this results in reduced relationship
satisfaction (Timmons, Margolin & Saxbe, 2015).
Taking a social identity standpoint, it is argued that the groups that
an individual identifies with impacts on their health behaviours
(Oyserman, Fryberg, & Yoder, 2007) in accordance with the
self-categorisation theory (Turner, 1991). The reason for this is
because people conform to the norms of the group to which they identify
themselves as part of (the norm enactment hypothesis), because it is
expected that others in the group share similar views and opinions of
the world, particularly those most representative of themselves
(prototypicality hypothesis). Therefore, the actions and thoughts of the
group become the reference point to which the individual uses for how
they conduct themselves (influence hypothesis) (Haslam et al., 2018). If
the thoughts and actions of the group are positive, an individual that
strongly identifies with the group will experience these same positive
thoughts and actions. For example, the greater a nurse identifies
themselves with other nurses, the more likely that nurse is to seek flu
vaccinations (Falomir-Pichastor, Toscani, & Despointes, 2009). This was
because highly identified nurses were likely to perceive vaccinations as
a professional duty, as they protect both the nurse and the patients. In
terms of diet, peer modelling has proven to be an effective intervention
to increase fruit and vegetable intake (Horne et al., 2009; Thordike,
Riis, & Levy, 2016). Modelling of food intake is ineffective however,
when modelled by someone that does not share the same group identity
(out-group member) (Cruwus et al., 2012). This highlights the importance
of group identities in health behaviours, as opposed to strangers
encouraging better health behaviours. Whilst the direction of the health
behaviour (positive or negative) depends on the group norms, generally
it has been found that the more group identities an individual has, the
less likely they are to engage in negative health behaviours, such as
cigarette smoking, alcohol consumption, and use of illicit drugs
(Miller, Wakefield, & Sani, 2016). However, if an individual was to
identify as a group member with a group whose health behaviours are
risky, they are more likely to participate in those negative health
behaviours. For example, research on 3300 young adults found that among
a group in which smoking was the norm, there was a strength-dependent
relationship between how strongly an individual identified with the
group and their smoking status. Those who weakly identified with the
group were also more likely to exhibit behaviour that was not the group
norm and eventually change to a group in which they identified with to a
greater amount (Schofield et al., 2000).
Positive emotion plays a key role in an upward spiral dynamic involving
social engagement and the vagus nerve. The vagus nerve is vital in the
facilitation of social engagement through eliciting positive emotions
(Kok & Fredrickson, 2010; Kok et al., 2013), facilitating positive
facial expressions (Porges, 2011), prosocial traits and emotions (Kogan
et al., 2014), better emotion recognition (Quintana et al., 2012),
positive social interactions (Kok & Fredrickson, 2010; Kok et al.,
2013), social-support seeking (Geisler et al., 2013) and positive
behaviours, including altruistic behaviour (Bornemann et al., 2016).
Individuals with increased vagal tone upon baseline measures increased
in levels of social connectedness and positive emotions at a greater
rate over a 9-week assessment period compared to those with lower vagal
tone. Increases in connectedness and positive emotions predicted final
vagal tone measures, independent of vagal tone at baseline. Geisler and
colleagues (2013) found cardiac vagal tone, indexed by respiratory sinus
arrhythmia (RSA), to be positively correlated with engagement coping and
aspects of social wellbeing. Increased RSA also correlated with reduced
disengagement strategies for regulating negative emotions and increased
use of social emotion-regulation strategies. Individuals who reported
zero episodes of anger presented with higher RSA, compared to those who
had one or more episodes of anger during the study. This study
highlights the importance of vagal function in self-regulatory behaviour
and subsequent ability to engage socially. Conversely, low resting-state
HRV is associated with prefrontal hypoactivity and amygdala
hyperactivity, which facilitates threat perception and increases
negativity bias, subsequently impacting on the ability to build
connections with others (Kemp, Koenig, & Thayer, 2017). It is therefore
important to include vagal function and emotion regulation as factors
that impact on an individual’s ability to build a supportive social
network.
Social Connectedness/Loneliness
Social connectedness needs to become a focus for people living with
chronic conditions as this population are more vulnerable to social
isolation, through factors such as receiving care, attending physician
visits and hospitalisations, being physically disabled and unemployed
(Meek et al., 2018). This is important as social engagement can help
prevent a person’s condition from becoming disabling (De Leon, Glass &
Berkman, 2003). Participation in social activities is associated with a
lower risk of suffering from chronic diseases, and the reverse effect is
observed for people who live alone (Cantarero-Prieto, Pascual-Saez &
Blazquez-Fernandez, 2018). A meta-analysis found poor social
relationships to increase the risk of coronary heart disease by 29% and
increase the risk of stroke by 32% (Valtorta et al., 2016).
with and without chronic conditions, results highlighted emotional
wellbeing and family connectedness to be positively correlated across
all individuals (Wolman et al., 1994). However, emotional wellbeing was
lower among those with chronic conditions. This raises the question as
to why people with chronic conditions are experiencing lower levels of
wellbeing, and whether social connectedness plays a key regulatory role.
It is argued that social engagement promotes the resources which people
can use to manage their condition (Arcury et al., 2012; Bath & Deeg,
2005). As previously mentioned, social connections can have an adverse
effect on health when these connections are not positive, for example,
having to support family members of receive unhelpful advice, which can
subsequently impact on the management of health conditions (Gallant,
2003).
A community-based study evaluated the work of Reclink; an Australian
community agency that works with individuals with chronic mental health
conditions (Dingle et al., 2014). Examples of the activities Reclink
organise include choirs, bowling, yoga, and football. Among the 49
individuals surveyed at the Reclink activities, 80% reported an
improvement in their life, 61% reported improvements in physical health
and fitness, and 82% reported improvements in their mental health and
wellbeing. There was also an overall decrease in social isolation and
number of reported visits to a general practitioner. Again, focusing on
chronic mental health conditions in the Reclink choir group, 21
individuals were interviewed when they joined the choir, along with a 6-
and 12-month follow-up (Dingle et al., 2013). Qualitative analysis
revealed three areas in which they benefited from the choir. The first
area that begun to develop were the personal benefits, which includes
positive emotions, emotion regulation, spiritual experience,
self-understanding, and the sense of ‘finding a voice’. Expanding beyond
from the benefits to the self, these outcomes lead to improved social
functioning and connectedness. Lastly, functional benefits were also
reported including improved health and employment prospects, along with
improving structure and routine in day-to-day life. A similar study was
completed which found that those who were receiving more social support
from their Reclink group reported greater improvement in mental
wellbeing, highlighting the fundamental role of the social aspect of
these groups (Williams et al., 2017). However, social connectedness is
not a certain predictor of good health as social ties may also lead to
adverse health outcomes, especially when social ties are not health
promoting. For example, in line with the self-categorisation theory, if
the norms of the group of which someone identifies with are negative,
they too are more likely to engage in this negative behaviour, with
smoking being a good example (Schofield et al., 2000). Also, marriage is
a source of both support and stress, with poor marriage quality reducing
immune and endocrine function along with increasing depressive symptoms,
with this association between marriage quality and health becoming
stronger as age increases (Kiecolt-Glaser & Newton, 2001; Umberson et
al., 2006; Walen & Lachman, 2000). There is also the health cost of
providing care for a loved one, which has been associated with an
elevated risk for the care provider (Christakis & Allison, 2006), with
increased physical and psychiatric morbidity and impaired immune
function (Schulz & Sherwood, 2008).
Based off the social identity theory, using social identity as a
clinical target may prove beneficial. This was investigated among
participants with clinical depression (Cruwys et al., 2014).
Participants at risk of depression joined a community recreation group
whereas those with diagnosed depression joined a clinical psychotherapy
group. Results highlighted that the extent to which the individuals
identified with the group predicted the reductions in their depressive
symptoms, irrespective of the group to which they were assigned to. This
is useful in raising awareness for the effectiveness of group-based
interventions. Manipulating clinical interventions to be run as a group
activity is also another route in order to derive a sense of shared
social identification among service users. For example, adults living in
care settings were allocated to either group reminiscence, individual
reminiscence or a control group activity for 6 weeks (Haslam et al.,
2010). Results highlighted that the group reminiscence and control group
activity was effective improving memory performance and wellbeing, which
the researchers arguing this effect is due to the shared social identity
among both groups. Group-based therapies can also be useful to
facilitate peer modelling. For example, a wellness recovery group was
devised in which service users in stable recovery from mental illness
run the groups, acting as models and using personal examples from both
the group facilitators and new attendees (Lawn & Schoo, 2010). These
weekly sessions ran for 8-weeks and was more effective in reducing
symptoms, improving feelings of hopefulness and quality of life up to
6-month post-intervention, compared with a treatment as usual control
group.
Social connectedness can be particularly important for those with a
chronic condition as becoming a group member provides social identity
(e.g. choir member). Through this process, the individual becomes more
than the condition they have. The social identity theory proposes that
the more social identities an individual possesses the more
psychological resources they have access to, which protects them from a
decline in health (Haslam et al., 2018). Among frequent attenders of the
health service who have a chronic physical health condition, social
isolation was the most reliable predictor of attendance, more so than
physical or mental health issues (Cruwys et al., 2018). Researchers also
found that by joining a social gro
up, primary care attendance reduced.
This reduction was associated with the extent to which individuals
subjectively experienced social connectedness.
Directly influencing the degree to which individuals experience social
connection with others is another route through which health and
wellbeing can be improved. With an evolutionary-based theoretical
background (Dunbar, 2012; McNeill, 1997; Phillips-Silver et al., 2010),
interventions that target synchrony between people in a group can go
above and beyond simply providing a context for the potential of
developing social connections and ensure a feeling of connectedness with
others. For example, virtual reality gaming which is designed to
synchronise movements between players significantly increases social
closeness with their virtual co-participants compared to players in the
non-synchrony condition (Tarr, Slater & Cohen, 2018). Synchronised
behaviour also improves self-esteem, social rapport and group
cooperation (Hove & Risen, 2009; Lakens & Stel, 2011; Lumsden, Miles
& Macrae, 2014; Wiltermuth & Heath, 2009). Physical synchrony during
large-scale gatherings also fosters community connectedness or
“collective effervescence” (Durkheim, 1915; Ehrenreich, 2007;
Olaveson, 2004).
Interventions aimed at increasing positive emotion is one pathway
through which individuals are better able to build social connections
and subsequently improve their health and wellbeing. In a longitudinal
study, experimental participants were required to participate in a
loving-kindness meditation to elicit positive emotion, the control group
did not participate (Kok & Fredrickson, 2010; Kok & Fredrickson, 2015;
Kok et al., 2013). Results indicated an increase in positive emotions
among the experimental group relative to the controls, which was
moderated by vagal tone. This increase in positive emotion lead to
subsequent increases in vagal tone, which was mediated by an increase in
perceived social connections. Also, higher HRV predicts greater social
engagement upon follow-up assessments, and higher social engagement
predicts higher HRV upon follow up (Kok & Fredrickson, 2010). This
highlights the self-sustaining upward spiral between vagal function,
emotion and social connections. Acute nasal administration of oxytocin
may be another method to trigger cycles to improve health and wellbeing
as it increases capacity for social engagement (Kemp et al., 2012).
Conversely, decreased vagal activation results in increased sympathetic
activity, associated with the fight-flight-or-freeze responses, which
causes withdrawal behaviours (e.g. anxiety) not conducive with social
environments (Porges, 2011).
Overall, is it important to understand the norms of the group in which
individuals gain their social identity in order to analyse the effect
that social ties have on the individual’s health and wellbeing. Despite
this, increasing social connectedness among users of the health care
system is vital in order to provide better health care, taking into
account broader aspects of a service user’s life that may impact on
their health and wellbeing outside of the condition they manage. Health
care services would benefit from moving away the biomedical model and
towards a new model of health that encompasses not only the physical and
mental needs of the service user, but also the social needs. It would be
a cost-efficient and more effective way of delivery treatment by using
group interventions, allowing for not only the treatment, but also
social connectedness and group identity. An alternative route to
encompass social connectedness as a pathway through which service users
can increase health and wellbeing is by targeting both the service user
and their partner within the intervention. For example, a qualitative
review of 33 studies and meta-analyses for a subset of 25 studies was
conducted consisting of participant groups with a range of chronic
conditions, including arthritis, cardiovascular disease and chronic pain
(Martire et al., 2010). Results found couple-based interventions
produced greater improvements with depressive symptoms, marital
functioning and pain compared to both patient psychosocial intervention
or treatment as usual.
Given the above evidence for the importance of social engagement for
health and wellbeing, it is unsurprising that social prescribing is now
being adopted as a form of treatment. Arts on prescription is one
example, in which participants and referrers reported psychological,
social and occupational benefits (Stickley & Hui, 2012a; Stickley &
Hui, 2012b). A review of 15 social prescribing programmes found mostly
positive results (Bickerdike et al., 2017). Whilst all the studies
involved possessed a high risk of bias, it provides a starting point
which future researchers can build on and further the evidence in this
field.
ROLE OF CUTURAL FACTORS:
It has been argued that wellbeing is a westernised construct with a sole
focus on the individual. A key difference when considering culture is
the differences between Western (individualistic) and Eastern
(collectivist) culture. With the West considering individuals as an
active, independent agent who is separate from the physical and social
environment in which they live. Wellbeing in this sense is focused
solely on the individual. Conversely, in the East the individual is seen
as a responsive agent who is connected to the physical and social
environment, and wellbeing becomes less of a subjective concept and more
about meeting objective standards and gaining the respect of others
(Ryff, Love, Miyamoto & Markus, 2014). Due to these differences,
subjective wellbeing will vary as a construct between cultures, with
culture moderating which variables most impact subjective wellbeing
(Eckersley, 2006). The reason for which is because the central elements
of wellbeing are dependent on people’s values and goals, which are
influenced by culture (Diener & Suh, 1997
The exposure of Western culture to people unfamiliar with the culture is
useful in highlighting the impact it can have on health and wellbeing.
For example, over 3,000 Japanese men who had moved to California
participated in a study which explored the prevalence of coronary heart
disease (Marmot & Syme, 1976). Results highlighted the group of
Japanese-Americans which were more acculturated to Western culture had a
three- to five-fold excess in the prevalence of coronary heart disease.
Whereas those who most held the traditional Japanese culture had the
lowest prevalence of coronary heart disease. However, more recently the
term ‘hikikomori’ (severe social withdrawal) has been coined in Japan
and is referred to as a “modern-type depression” due to the shift away
from collectivistic values and towards individualistic values with a
reluctance to accept prevailing norms (Kato et al., 2011).
The individualistic culture has also been associated with increased
malignant neoplasms, circulatory disease, and heart disease, compared
with those living in a collectivist culture (Matsumoto & Fletcher,
1996). More recent research highlights an association between wellbeing
and cardiovascular disease to be stronger in more individualistic
countries (Okely, Weiss & Gale, 2018), suggesting the importance placed
on wellbeing and the subsequent impact on health is greater among
individualistic cultures compared with collectivist cultures. Similar
research has found that there is a greater emphasis on positive emotions
among individualistic cultures, with positive emotions being associated
with depression symptoms, whereas this association is not present among
collectivist cultures (Leu, Wang & Koo, 2011). However, negative
emotions were found to be associated with depression symptoms across
both cultures. Although, research highlights this association between
negative affect and health to be stronger among individualistic cultures
compared to collectivist cultures (Curhan et al., 2014; Miyamoto et al.,
2013). The authors concluded that the appraisals of affect influence the
subsequent impact, with individualistic cultures viewing negative affect
as harmful, which may cause additional distress when faced with negative
affect resulting in poorer health (Collins et al., 2009; Rugulies, 2002;
Saz & Dewey, 2001). This has serious implications for positive
psychology-based interventions given that the aim is to increase
positive affect, which may not be as applicable in Eastern countries.
Researchers have proposed several reasons for why the individualistic
culture can impact health and wellbeing adversely compared with
collectivist cultures. For example, the Western qualities of materialism
and individualism are detrimental to health and wellbeing through their
influence on values (Eckersley, 2006). Materialistic values have found
to lower self-actualisation, vitality, happiness and wellbeing, along
with increase anxiety, physical symptomatology, and unhappiness (Kasser
& Ahuvia, 2001; Tatzel, 2002). Individualistic cultures also place an
importance on striving for happiness with the avoidance of negative
emotions (Ahuvia, 2002; Diener & Suh, 2000; Steptoe et al., 2007;
Veenhoven, 1999; Wierzbicka, 1994), whereas this is not always possible.
Among collectivist cultures, the focus is on emotional stability,
including the presence of both positive and negative affect (Lu, 2001;
Ng et al., 2003). An important factor is the difference between the
building of social ties between the cultures, with individualistic
cultures focused on the self over connections between people, compared
with the collectivist cultures whose happiness is more dependent on
being part of a cohesive network. The research previously discussed on
the associations between social connectedness and health becomes a key
factor here.
As personality is known to influence wellbeing, it is important to
discuss the role society and culture has in influencing personality.
Longitudinal research highlights large changes in personality trait
scores over a 60-year period (Twenge, 2002). There have been increases
in neuroticism and self-esteem, as well as decreases in a sense of
control, meaning an increase in an external locus of control. Among
women particularly there has been an increase in assertiveness. These
changes have been linked to the rise in individualism and freedom
through social change. Given that certain personality traits have been
associated with mental health (positive and negative), it is important
to include this when designing interventions, as previously discussed.
Resilience is an important factor in building health and wellbeing,
which is discussed later in the article, and factors that influence
resilience differ between cultures. The extent to which the culture
provides culturally meaningful support, identity, power and control,
social justice and a sense of belongingness, among other factors,
impacts on resilience development (Ungar, 2006). For example,
egalitarian culture between men and women helps build resilience (Hou,
Ko, & Shu, 2013), and this culture is affected by the policies that are
implemented. It is important to consider the culture when designing
resilience-building programmes given that one factor that contributes
towards resilience in a collectivist culture may present as a risk
factor in an individualist culture, an example being social orientation
(Strand, Pula & Downs, 2015). Interventions such as foster care,
adoption and parental training can help build resilience in children
(Sapienza & Masten, 2011). Training can include teaching the parents to
employ warm and sensitive parenting practices to promote characteristics
among their children that build resilience, including better emotion
regulation abilities (Khosla, 2017). In a similar manner, the extent to
which a culture fosters or opposes racism impacts on individual health
and wellbeing. For example, discrimination, harassment and assault is
associated with reduced HRV among African Americans (Hill et al., 2017).
Discrimination has also been found to mediate the relationship between
race and HRV (Kemp et al., 2016b). Associations have
also been found between self-reported racism and poor mental and
physical health outcomes, including cancer-related health behaviours
(Jackson et al., 1996; Paradies, 2006; Shariff-Marco et al., 2010;
Williams & Mohammed, 2013). Again, community values and subsequent
behaviours can be influenced through governmental policies, therefore,
the responsibility of changing racial attitudes is both on an individual
and organisational/governmental level.
Human-Animal Interactions
Relationships with animals can provide a pathway to wellbeing,
particularly for those who have difficulty socialising. For example, for
individuals with autism an animal-assisted intervention was effective in
increasing social interaction and communication, along with decreasing
problem behaviours, autistic severity, and stress (O’Haire, 2013). Other
research supports the social benefits of a dog for individuals with
autism (Bass et al., 2009; Martin & Farnum, 2002; Prothmann et al.,
2009; Sams et al., 2006). The presence of a dog has also proven to be
effective in promoting social engagement among psychiatric populations
(Haughie et al., 1992; Marr et al., 2000). Wheelchair-bound individuals
found that when they had shopping trips with their service dog they
reported a significant increase in the number of social greetings from
others compared with trips before they had the dog, trips when they did
not take the dog with them, or a control group without dogs (Hart, Hart,
& Bergin, 1987). They also reported increasing their evening outings
after having the dog. When applied to nursing homes, animal-assisted
therapy was found to significantly increase social interaction and
decrease agitated behaviours among 15 older adults with dementia
(Richeson, 2003). A review of animal-assisted therapy for people with
dementia concludes that the presence of a dog can reduce aggression and
agitation, along with facilitating social behaviour (Filan &
Llewellyn-Jones, 2006). Therapy dogs have also been effective in
improving pain and emotional distress among outpatients compared with a
waiting room control, along with having a positive impact on the
accompanying adults and clinic staff (Marcus et al., 2012). This
reduction in pain was clinically meaningful in 23% of patients after a
visit from the therapy dog, compared to 4% in the waiting room control.
Animal-assisted therapy or activities have also proven to be effective
in reducing mental health symptoms, including depressive symptoms
(Scouter & Miller, 2007), anxiety and fear (Barker et al., 2003; Cole
et al., 2007). However, other studies have found no significant effect
(Barker & Dawson, 1998; Wilson, 1991). Research has also highlighted a
correlation between pet ownership and improved physical health. For
example, pet owners had lower levels of risk factors for cardiovascular
disease (Anderson, Reid, & Jennings, 1992). A review of pet therapy
research concluded there is consistent evidence supporting pet ownership
as a protector against cardiovascular risk (Giaquinto & Valentini,
2009). This could be due to the anti-stress effects of animals, as the
presence of a dog can reduce cortisol levels (Barker et al., 2005; Beetz
et al., 2011; Odendaal, 2000; Odendaal & Meintjes, 2003; Viau et al.,
2010) and reduce epinephrine and norepinephrine levels (Cole et al.,
2007). The presence of a dog has also found to lower blood pressure
(Friedmann et al., 1983; Grossberg & Alf, 1985; Jenkins, 1986;
Nagengast et al., 1997; Vormbrock & Grossberg, 1988) and increase heart
rate variability (Motooka et al., 2006). Animal-assisted therapy has
proven to be effective in improving symptoms in a variety of areas,
including but not limited to autism-spectrum symptoms, medical
difficulties, behavioural problems and emotional well-being (Nimer &
Lundahl, 2007).
Whilst most of the research focuses on dog-based interventions, there is
promise that an aquarium can have beneficial effects. For example, an
aquarium in a dining room can be an effective way to stimulate residents
to eat more, as well as the possibility of using robotic pets to
increase pleasure and interest among the individual with dementia. Other
research has highlighted the benefits of an aquarium, as patients about
to undergo oral surgery found watching fish in an aquarium as equally
relaxing as hypnosis (Katcher et al., 1983; Katcher, Segal, & Beck,
1984). The studies included in the Filan and Llewellyn-Jones review are
small but are useful in providing potential areas of future research in
improving wellbeing among individuals, particularly for those who are
unsuitable for dog-based interventions.
An explanation as to why the presence of an animal can elicit social
interactions could be that having an animal can make an individual
appear more trustworthy. For example, students report a greater general
satisfaction and greater willingness to disclose personal information to
a psychotherapist with a dog compared to a psychotherapist alone
(Schneider & Harkey, 2006). Also, strangers helping behaviour increased
when the individual they were helping had a dog (Gueguen & Cicotti,
2008), supporting the theory that dogs can alter the perception of
someone in terms of their trustworthiness. Beetz and colleagues (2012)
argue that the oxytocin system plays a key role in the psychological and
psychophysiological effects that human-animal interactions can have.
Human-animal interaction has proven to increase oxytocin levels in both
the human and the animal (Handlin et al., 2011; Odendaal, 2000; Odendaal
& Meintjes, 2003). Increases in oxytocin facilitates social interaction
and improves health through several methods, including increasing trust
(Kosfeld et al., 2005; Zak et al., 2005; 2007) and reducing stress
(Kirsch et al., 2005; Legros et al., 1988) and anxiety (Guastella et
al., 2009; Jonas et al., 2008).
Overall, animal-assisted interventions have a clear positive impact on
health and wellbeing and should be a consideration for people who lack
strong social relationships. For example, there are correlations that
owning a pet can stabilise a marriage (Na & Richang, 2003) and increase
leisure activities among a family (Paul & Serpell, 1996). With this
respect, a service user who reports family problems or a disconnect
within the family may benefit from this kind of intervention alongside
their treatment as usual. This highlights the importance of encompassing
all aspects of an individual’s life when considering treatment options
for them because whilst the “traditional” treatment may help their
condition, it does not help with building a mentally and physically
supportive lifestyle which can serve as a protector to worsening health.
Environmental
Wellbeing
But no time or nation will produce genius if there is a steady decline away from the integral unity of man and the earth. The break in this unity is swiftly apparent in the lack of "wholeness" in the individual person. Divorced from his roots, man loses his psychic stability.
– Elyne Mitchell, Soil and Civilization (1946)