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Health and well-being
The World Health Organisation (WHO) defines health as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’ (WHO, 1948). This is consistent with the biopsychosocial model of health, which considers physiological, psychological and social factors in health and illness, and interactions between these factors. It differs from the traditional medical model, which defines health as the absence of illness or disease and emphasises the role of clinical diagnosis and intervention. The WHO definition links health explicitly with wellbeing, and conceptualises health as a human right requiring physical and social resources to achieve and maintain. ‘Wellbeing’ refers to a positive rather than neutral state, framing health as a positive aspiration. This definition was adapted by the 1986 Ottawa charter, which describes health as ‘a resource for everyday life, not the object of living’. From this perspective health is a means to living well, which highlights the link between health and participation in society.
A major criticism of this view of health is that it is unrealistic, because it ‘leaves most of us unhealthy most of the time’ (Smith, 2008); few, if any people will have complete physical, mental and social wellbeing all the time, which can make this approach unhelpful and counterproductive (see Godlee, 2011). It fails to take into account not just temporary spells of ill health, but also the growing number of people living with chronic illnesses and disabilities. Furthermore, it might be argued that focusing on ‘complete’ health as a goal contributes to the overmedicalisation of society by pathologising suboptimal health states (see Sections 7 & 8).
Huber et al. (2011) proposed a new definition of health as ‘the ability to adapt and to self-manage’, which includes the ability of people to adapt to their situation as key to health. It also acknowledges the subjective element of health; what health and wellbeing mean will differ from one person to the next, depending on the context and their needs. This is considered by many to be a limitation of broader definitions of health, on the grounds that wellbeing is neither objective nor measurable; this is discussed in more detail below (Mental health and wellbeing). A further limitation of this approach is that it is very individualistic and takes little account of the wider determinants of health (see Section 9). Responsibility for health is seen as individual rather than collective, with little scope to promote it as a human right.
2. Mental health and wellbeing
Broadening definitions of health has contributed to improving understanding of the mental dimension of health and wellbeing, and increasing recognition of public mental health as integral to public health. Since the publication of the Government strategy No Health Without Mental Health in 2011,[1] NHS England has been working towards parity of esteem between physical and mental health – in other words, ensuring that mental health is recognised as equally important to physical health in the development, delivery and provision of health and social care services. Public mental health policy aims to improve population mental health and wellbeing, prevent the onset of mental and emotional distress, and increase resilience.
Defining wellbeing is key to discussing and conceptualising mental health and public mental health, with much debate and some controversy over recent years. Wellbeing sits outside the medical model of health as its presence or absence is not a diagnosis. It is widely accepted that subjective wellbeing varies greatly between individuals, as do the factors that contribute to it. This does not mean to say however that it cannot be defined or measured, and there has been considerable progress in this area. This is discussed in the 2016 report Better Mental Health For All published by the Faculty of Public Health and Mental Health Foundation.[2] The report sets out the public health perspective on public mental health, and highlights examples of good practice to improve wellbeing in local populations.
The FPH’s definition of mental wellbeing is synonymous with the WHO’s holistic and positive definition of health, and with the positive psychology approach advocated by Seligman (2000). Positive psychology reflects the core public health principle of protecting and improving health, focusing on keeping people well rather than treating illness. More recently Seligman (2011) introduced the PERMA model of flourishing, which has five core elements of psychological well-being: positive emotions, engagement, relationships, meaning, and accomplishment. Consistent with these definitions is the approach taken by the Wellbeing Institute at the University of Cambridge, which defines wellbeing as ‘positive and sustainable characteristics which enable individuals and organisations to thrive and flourish’.[3] Others nevertheless argue that wellbeing is a social and cultural construct, questioning the value of approaches that attempt to quantify and categorise it.
However, a common theme that has emerged from the various definitions of wellbeing is that of ‘feeling good and functioning well’. This broad definition encompasses an individual’s own experience of their life, and a comparison of their life circumstances with social norms and values. Wellbeing may therefore be viewed as having two dimensions: objective and subjective wellbeing. Objective wellbeing is more of a proxy measure based on assumptions about basic human needs and rights, including aspects such as adequate food, physical health, education, and safety. Objective wellbeing can be measured through self-report (e.g. asking people whether they have a specific health condition), or through more objective measures (e.g. mortality rates and life expectancy). Subjective wellbeing (or personal wellbeing) is measured by asking people directly how they think and feel about their own wellbeing, and includes aspects such as life satisfaction (evaluation), positive emotions (hedonic), and whether their life is meaningful (eudemonic). The Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) is a validated tool for monitoring subjective mental wellbeing in the general population and the evaluation of projects, programmes and policies which aim to improve mental wellbeing (See Tennant et al., 2007).[4]
In 2008 the New Economics Foundation identified five evidence-based actions people can take in their daily lives to improve their wellbeing, known as the 5 Ways to Wellbeing: connect, be active, take notice, keep learning, and give.[5] These actions have been promoted and applied in a range of public health settings. Although it is recognised that these are very broad concepts that are open to subjective interpretation and cover any number of activities, the 5 Ways to Wellbeing is a useful tool for stimulating discussions about wellbeing and public mental health, and enabling individuals to think about ways in which to improve their own wellbeing.
The relationship between mental and physical health
Mental health and physical health are inextricably linked, with evidence for a strong relationship between the two accumulating over recent decades and challenging the historical notion of mind-body duality. Mechanisms for this association can be physiological, behavioural and social, as identified by the biopsychosocial model of health. The nature of this relationship is two-way, with mental health influencing physical health and vice versa.
Mammalian stress responses (i.e. fight, flight or freeze) are known to affect physiological processes regulated by the autonomic nervous system, including cardiovascular, respiratory, digestive, repair and defence functions (see Porges, 2011). A number of medical conditions have been linked to stress, such as irritable bowel syndrome (Blanchard, 2001), asthma (e.g. Lehrer et al., 2002) and migraine headaches (e.g. Robbins, 1994). Likewise, stronger immune function has been associated with high levels of social support (e.g. Esterling et al., 1996) and hardiness (Dolbier et al., 2001), both of which may modify experiences of stress (e.g. Cottington & House, 1987) and its physiological manifestations (Karlin, Brondolo & Schwartz, 2003). Whilst it is clear that physical ill-health can be accompanied by mental health problems such as anxiety and depression, the resulting psychological state may in turn impede the recovery or stabilisation of medical conditions, thus producing a vicious circle in which wellbeing is difficult to attain (Evans et al. 2000).
Behavioural and social risk factors for physical and mental health problems tend to overlap, which can make it difficult to determine whether mental illness precedes physical illness, or vice versa. The Kings Fund estimates that more than four million people in England with a long-term physical health problem also have a mental health problem (Naylor et al., 2012), and the physical health of people with severe and enduring mental illness is often poor (Barry et al., 2015). Unhealthy lifestyles as responses to stress often contribute to this association; for example, people with mental health problems consume almost half of all tobacco (see Better Mental Health For All), and are more likely to develop a substance use disorder than the reverse (Frisher et al., 2003). People with mental health problems may also have more difficulty accessing services, which exacerbates both mental and physical illness. Social determinants of health and illness are discussed in more detail in sections 9 and 10.
The relationship between mental health and wellbeing
The relationship between mental health and wellbeing is described from two main perspectives: the dual continnum model, and the single continuum model. The dual continuum model views mental health as strongly related to but separate from mental wellbeing, whereby an individual is either mentally well or ill (mental health), and either flourishing or not flourishing (mental wellbeing). This model may apply to situations where it is possible to have a mental illness diagnosis and still have a high level of wellbeing; for example, someone with bipolar disorder may have high wellbeing if their condition is being managed, e.g. with medication, or if they are not currently experiencing an episode of symptoms. It is consistent with definitions of health that emphasise the importance of adaptation, as described above (Defining health and wellbeing). However, it is based on the view that people never fully recover from mental illness, which has been debated as ‘recovery’ can be defined in a number of ways depending on the perspective and context. One framework applies the same concepts as with chronic physical illness, with three forms of recovery: clinical recovery, in which the person is cured or in remission; illness management, in which symptoms are controlled, monitored and managed by clinicians; and personal recovery, in which individuals who are still experiencing symptoms function as best as they can within the limitations of their illness (see Barber, 2012).
The single continuum model views mental wellbeing as integral to mental health. It places mental health and wellbeing on a single spectrum, with mental illness/low wellbeing at one extreme and mental wellness/high wellbeing at the other. According to this model, mental health and wellbeing are distributed continuously in populations, and it is also possible to move in and out of those states. Professor Geoffrey Rose proposed that where a health issue is continuously distributed in the population, the mean predicts the proportion of the population with a diagnosable illness. It should therefore be possible to reduce levels of mental illness in a population by improving overall levels of population wellbeing, i.e. ‘shifting the curve’. This has been demonstrated for common mental health disorders in both children (Goodman & Goodman, 2011) and adults (Veerman et al., 2009), but there is currently insufficient evidence in relation to severe and enduring mental illness. There has recently been some controversy over this approach in mental health promotion and the measurement of population wellbeing (see Annual Report of the Chief Medical Officer, 2013[6] and FPH Mental Health Committee response[7]).