Common resilience-related protective factors that are employed by this
population include self-efficacy and adaptive coping \citep{Ghanei2016}. Combinations of mindfulness
and CBT techniques have proven useful in building resilience among individuals living with
chronic physical conditions including heart disease and diabetes \citep*{Robinson2019}, resulting in improvements in positive experiences, condition
management, and social engagement. Other mindfulness-based interventions have proven effective in increasing resilience among people living with chronic conditions \citep{Shim_2017}, along with reducing pain (Hilton et al., 2017; Veehof, Trompetter, Bohlmeijer & Schreurs, 2016; Zeidan & Vago, 2016). Optimism training has also proven effective among people with heart disease in increasing life satisfaction and hope, along with reducing anxiety (Mohammadi et al., 2018), with optimism being positively correlated with higher quality of life among people with heart failure (Kraai et al., 2018).
Strikingly, a strong sense of coherence (or SOC) (a contributor to resilience) is associated with a 30% reduction in mortality rate from cardiovascular disease, cancer and all cause-related death \citep{Surtees2003}. SOC reflects feelings of confidence that stimuli in the (internal and external) environment are comprehensible, manageable and meaningful [REF], as a result, people with higher SOC are better capable of dealing with stressors and subsequently are more resilient to negative physical and mental health outcomes, with SOC levels predicting mental health outcomes \citep{Pallant_2002,Sairenchi_2011,Hart_1991}.
In summary, there is tremendous opportunity for improving the health and wellbeing of people living with chronic conditions by focusing on the individual. Traditional routes for improving physical health, such as physical activity, diet and sleep may now be considered as opportunities to support mental wellbeing, when combined with strategies for behaviour change. Treatments that build strengths, resilience, optimism and positive psychological attributes will provide useful strategies to promote health and wellbeing, as has been discussed previously [REF].
INTEGRATE THE FOLLOWING FROM ABOVE: Targeting Resilience & Sense of Coherence
Resilience has been defined by the American Psychological Association as “the process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of threat” (Southwick and Charney, 2012). However, is it unclear what is meant by ‘adapting well’. A paper that examined the definitions of resilience claimed that no operationalised definition truly exists, but the central question surrounding resilience concerns how some people are able to withstand adversity without developing adverse physical or mental health outcomes (Herman et al, 2011). Factors that influence resiliency fall under three categories; individual, context and life events (Lindstrom & Eriksson, 2010). Examples of individual factors include genetics, age and life experience. The context refers to social class, support and culture. Whereas life events concern the quantity and quality of such events, examples surrounding the controllability, desirability, magnitude etc. Some researchers have adopted a salutogenic approach, meaning that they focus on the factors that assist in one’s individual level of resilience. One key factor within this approach is a ‘sense of coherence’, which refers to the capability to organise the resources and social context of one’s life and manage themselves, and that the demands that one faces are meaningful and comprehensible (Allardt et al., 1980; Antonovsky, 1987). It has been argued that people with a strong sense of coherence are cognitively and emotionally more capable of managing problems and stressors and are thus more resilient to negative physical and mental health outcomes (Pallant and Lae, 2002). Low SOC has been found to be a significant predictor of depression (Sairenchi et al, 2011) and anxiety traits (Hart, Hittner and Paras, 1991). Successful interventions to increase SOC surround a focus on the individual, such as person-centred therapy (von Humboldt and Leal, 2013) or a pycho-drama intervention (using role play, imagination, writing, music, drawing etc. to investigate something of importance to an individual) (Kähönen et al, 2012).
There is an abundance of research highlighting the relationship between resilience and health, with resilience moderating the relationship between stress with trait anxiety and depressive symptoms (Gloria & Steinhardt, 2014). Higher levels of resilience have also been associated with reduced symptoms of depression subsequently influencing both mental and physical health, along with reduced chronic pain (Mehta et al., 2008; Schure, Odden & Goins, 2013). It is argued that people with greater resilience view life stressors as challenges and employ strategies to actively cope with them (Bonanno et al., 2015).
Comprehensive training programmes have been developed to specifically target building resilience, including stress inoculation training (Meichenbaum & Deffenbacher, 1988), hardiness training (Maddi, 2008), the Psychoeducational Resilience Training Programme (Steinhardt & Dolbier, 2008), and the military’s Comprehensive Solider Fitness Programme (Cornum, Matthews & Seligman, 2011). There is a clear interest in resilience building, however many of these programmes lack supporting evidence regarding their efficacy (Southwick et a., 2015). Researchers have also argued that resilience training does not differ substantially from other forms of psychological training, and the impact of such training depends on the chosen outcome measures and training setting (Forbes & Fikretoglu, 2018).
Resilience-focused research in the 1980s predominantly concerned the ability to bounce back from adversity, known as recovery as resilience (Garmezy, 1991). Whereas resilience-building techniques based off the principles of positive psychology are now being recognised as a viable strategy to prevent ill-health (Davydov et al., 2010). An example of which focuses on optimism (Seligman, 2007), proving to be effective in improving wellbeing and coping styles (Khosla & Hangal, 2004; Scheier & Carver, 1992). The Penn Resilience Programme (PRP) and PERMA workshops have been developed to build resilience, wellbeing and optimism. These programmes have been applied to children, proving beneficial in reducing mental health symptoms among 11- to 12-year-olds (Gillham et a., 2006), as well as preventing symptoms of depression in adolescents (Cutuli et al., 2007), and increasing resilience and positive emotion among medical students (Peng et al., 2014)
Promoting Wellbeing by Focusing on the Community
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
\citep*{Meek2018}. This is important as social engagement can help
prevent a person’s condition from becoming disabling \citep*{Mendes_de_Leon_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 \citep*{Cantarero-Prieto2018}. 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% \citep*{Valtorta2016}. It is
argued that social engagement promotes the resources which people can
use to manage their condition \citep{Arcury2012,Bath2005}.
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 led to improved social
functioning and connectedness. Lastly, functional benefits were
reported, such as 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 \citep*{Williams_2018}.
Based off the social identity theory, using social identity as a
clinical target may prove beneficial, and as such, manipulating clinical
interventions to be run as a group activity should be considered 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 \citep*{Haslam2010}. Results highlighted that the
group reminiscence and control group activity effectively improved
memory performance and wellbeing, with the researchers arguing this
effect was due to the shared social identity among both groups.
Building a social identity is particularly important for those with a
chronic condition as they can become more than the condition they have.
Especially given that this population may face more discrimination than
the general population, which subsequently impacts their health and
wellbeing (Cockerham, Hamby & Oates, 2017). 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 \citep*{Cruwys2018}. Researchers also found that by joining a social group,
primary care attendance reduced. This reduction was associated with the
extent to which individuals subjectively experienced social
connectedness.
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 \citep{Kok_2010,Kok2015,Kok_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 \citep*{Kok_2010}. This
highlights the self-sustaining upward spiral between vagal function,
emotion and social connections. Regarding people living with chronic
conditions, their symptoms can be alleviated through positive affect.
Positive affect is associated with reduced negative affect, pain and
stress among women with chronic pain \citep*{Zautra2005}.
Among patients with coronary heart disease, greater positive affect was
associated with better health behaviours, including physical activity,
sleep quality, medication adherence and non-smoking at baseline \citep*{Sin2015}. Also, increases in positive affect over the
five years was associated with improvements in physical activity, sleep
quality and medication adherence, highlighting a need to target positive
emotion when providing interventions.
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 \citep*{Martire2010}. Results found couple-based interventions produced greater
improvements with depressive symptoms, marital functioning and pain
compared to both patient psycho-social intervention and treatment as
usual.
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. A review of animal-assisted therapy for people
with dementia concluded that the presence of a dog can reduce aggression
and agitation, along with facilitating social behaviour (Filan &
Llewellyn-Jones, 2006).
Research has also highlighted a correlation between pet ownership and
improved physical health. For example, a review of pet therapy research
concluded there is consistent evidence supporting pet ownership as a
protector against cardiovascular risk \citep*{Giaquinto_2009}.
This could be due to the anti-stress effects of animals, as the presence
of a dog can reduce cortisol levels \citep{Barker_2005,Beetz_2011,Odendaal_2000,Odendaal_2003,Viau_2010} and
reduce epinephrine and norepinephrine levels \citep*{Cole2007}. 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
\citep*{Motooka2006}. 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 \citep*{Nimer_2007}.
Overall, targeting the social network is vitally important for
increasing health and wellbeing. One reason being that it is an
opportunity to build more social identities, providing individuals with
more psychological resources in times of need (Haslam et al., 2018).
Another reason is that social engagement improves positive affect and
emotion regulation (Dingle et al., 2013), which is part of the
self-sustaining upward spiral of positive emotion, social connection and
vagal function \citep*{Kok_2010}. It is unsurprising that
social prescribing is now being adopted as a form of treatment, with a
review of 15 social prescribing programmes reporting mostly positive
results \citep*{Bickerdike2017}. 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.
INTEGRATE THE FOLLOWING [THIS TEXT IS FROM SECTION 3, BUT DISCUSSES CHRONIC CONDITIONS AND IS THUS RELEVANT TO THIS SECTION]
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 group, primary care attendance reduced. This reduction was associated with the extent to which individuals subjectively experienced social connectedness.
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.
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
XXX INTEGRATE:
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.
Promoting Wellbeing by Focusing on the Environment
When discussing the impact of the environment on people living with
chronic conditions specifically, contact with nature and environmental
modifications are key areas. The biophilia hypothesis provides a
theoretical background for the importance of being immersed in the
natural environment, with our innate need for contact with nature and
life (Wilson, 1984). We have previously discussed the impact of nature
on general health and wellbeing, and whilst these benefits are useful
for the general population, a greater focus needs to be placed on
contact with nature for those with chronic conditions as they face
health issues on a daily basis, and have additional barriers in their
life which may prevent them from easily accessing opportunities such as
green spaces \citep*{Meek_2018}. These potential barriers include a
lack of time due to physician visits and/or hospitalisations, and
accessibility due to a physical disability. Along with this, research
has highlighted an association between contact with nature and
prevalence of disease. For example, a systematic review analysed the
evidence linking green spaces with mortality, in which 12 studies were
included with study populations ranging from the thousands to the
millions (Gascon et al., 2016). Results found a negative correlation
between cardiovascular disease mortality and residential greenness in
the majority of studies, the pathways through which this relationship
occurs can be explained by Kuo (2015). A review on 17 studies based in
Japan concluded there is a positive impact of natural environments on
brain activity, the cardiovascular system, endocrine system and immune
function \citep*{Haluza2014}. However, when going in
to more detail the results are mixed. For example, the review concluded
beneficial impacts of nature on cardiovascular functions, however, when
concerning blood pressure, only two out of nine studies reported clear
positive effects (a decrease), with six reporting mixed effects and
three reporting no significant effects. A similar pattern arises with
heart rate, with four studies reporting positive effects (a decrease),
three reporting mixed results and two reporting no significant effects.
When focusing on heart rate variability, two studies reported a positive
effect (an increase) with four studies reporting mixed effects. Similar
patterns arise with data linking nature with the endocrine system and
immune function. Despite these mixed results, the review concluded an
overall health benefit of contact with nature, with a clear potential to
target at-risk people or those living with cardiovascular problems.
Introducing green spaces into communities and care homes is one route
through which those with chronic illness and/or disabilities can easily
access contact with nature when living in an urban environment. Research
on 126 care facilities for the elderly across 17 European cities found
green spaces within the facility grounds had a significant impact on the
quality of life for the residents, along with benefits for the staff and
visitors (Artmann et al., 2017). The green spaces facilitated physical
activities, recreation and social engagement, which provide subsequent
health benefits associated with such factors. It is important to
consider contact with nature when designing care packages for service
users with chronic conditions as they are more vulnerable to losing
contact with nature as day-to-day living is more difficult. Care homes
would benefit from designing a timetable which guarantees all residents
access to nature for a certain period every day or by including green
spaces on their property.
Traditionally, care homes were designed for the health and safety of
residents, neglecting what is important to the people that live there
and what could potentially improve their health and wellbeing, but this
is beginning to change (Ausserhofer et al., 2016). Modifying the
environment for residents or patients in care facilities should be a
focal point, taking into account their condition and which modifications
will facilitate health and wellbeing improvements. Simple additions,
such as indoor plants, have reportedly reduced stress for patients in
hospital \citep*{Dijkstra2008}. A review of 30 studies
found positive effects for sunlight, windows, odour and seating
arrangements \citep*{Dijkstra2006}. Whilst evidence for
sound, nature, spatial layout, television and stimuli interventions was
inconsistent. The impact of the modifications was dependent on patient
population characteristics and the context, highlighting the need for a
person-centred approach when designing the building and rooms for
service users. This is highlighted in a qualitative study which reported
both positive and negative outcomes from home modifications; the
researchers concluded that the negative impact to be attributable to a
lack of understanding about the individual client \citep*{Aplin2015}. It would be useful for health facilities to modify
their design to accommodate the service users, particularly care homes
where residents live for the remainder of their lives. For example,
individuals with dementia would benefit from modifications that
normalise their circadian rhythms, including lighting and ambient
temperature, along with modifying walkways and exits to make it clearer
and safer (Luxenberg, 1997). A review of 57 articles focusing on
environmental design or changes for people with dementia concluded that
there is sufficient evidence for the effectiveness of varying ambience,
size and shape of spaces in a home, unobtrusive safety measures and
controlling levels of stimulation \citep*{Fleming2010}.
- Include research linking design and colour schemes
Overall, the evidence linking nature and health continues to grow, but
with mixed results. Reasons for such could be attributed to a lack of
concrete recommendations concerning what level of exposure to nature
would be sufficient to elicit health changes and what type of nature
environment has a greater benefit. Shanahan and colleagues (2015) have
propose using dose-response modelling when providing nature-based
interventions to identify a cost-effective level of urban nature. They
argue that manipulating the type and amount of nature exposure will
subsequently impact differently on health outcomes. By applying this
method in future research, it will allow researchers to better identify
what types of nature-based interventions are effective and at what dose.
With sufficient research, recommendations can then be made for future
generations to utilise nature, and particularly green spaces for urban
environments, to build health and wellbeing among all populations. The
introduction of green spaces should be a focal point for urban areas,
which will moderate the climate change impact, help prevent disease over
a life course model, improve health and wellbeing and subsequently
lessen the burden on the health care services. Feasibility research has
been carried out to investigate the impact of urban green spaces on
health \citep*{Pearce2016} and further development
in this area may provide substantial health-related data associated with
green spaces across a life course model.
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Facilitating
Behavioural Change
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Beyond models of hedonic and eudaimonic wellbeing, the theory of synergistic change \citep*{Rusk_2017} describes the pathways through which positive psychological interventions facilitate sustained changes in behaviour and wellbeing. Building on prior theory on positive psychological change, including the Hedonic Adaptation Model \citep*{Sheldon_2013}, the Positive-Activity Model \citep*{Layous_2013}, and the emotion regulation theory \citep*{Quoidbach_2015}, this theory emphasises the interplay of many dynamic elements that facilitate successful and sustained positive change. The model is based on the' Domains of Positive Functioning' (DPF-5) framework \citep*{Rusk_2014}, which emphasises five domains of psycho-social functioning including: (1) attention and awareness, (2) comprehension and coping, (3) emotions, (4) goals and habits, and (5) relationships and virtues. The influence of biological/physiological and environmental factors are also recognised, although not characterised. \citet{Rusk_2017} argue that the inter-dependent and synergistic components of DPF-5 underpin the 'complex dynamics' of psycho-social functioning, emphasising multiple pathways for positive psychological change. Three types of processes are characterised: relapse, spill-over and synergy. According to the model, relapse occurs when the intervention ceases and changes that have been made within one domain are undermined by a lack of change within other domains. Spill-over occurs when the change within one domain "spills over" and influences another domain, whereas synergy arises when the intervention creates interactions between multiple domains that are mutually reinforcing, creating a stable change in behaviour. The model therefore suggests that enduring positive change will be facilitated by (1) targeting single elements, (2) using exiting strengths, and (3) harnessing mutually reinforcing elements.
AND THIS: Interventions aimed at increasing positive emotion facilitate the building of social connections. For instance, training in loving-kindness meditation \citep{Kok_2010,Kok2015,Kok2013} elicits positive emotion and this is dependent (moderated by) baseline vagal tone. Increases in positive emotion lead to subsequent increases in vagal tone, mediated by an increase in the perception of social connectedness. Higher vagal tone predicts greater social engagement at follow-up, and higher social engagement due to the intervention predicts further increases in vagal tone \citep*{Kok_2010}. These findings highlight a 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)
ALSO: INFORMATION ON SCM FRAMEWORK -
Positive psychology interventions have the potential to facilitate wellbeing in vulnerable populations (Sin & Lyubomirsky, 2009). However, in many instances, PPI outcomes are short-lived and participants often revert to pre-intervention levels of functioning at follow-up assessment (Seligman, Steen, Park, & Peterson, 2005; Tricarico, 2012). In order to truly facilitate well-being, intervention strategies must induce change that is both enduring and sustainable, and the mechanisms by which positive psychology interventions can cultivate lasting positive change must be addressed (Rusk, Vella-Brodrick & Waters, 2017).
Some theorists propose that individuals need to continue to engage in activities that promote wellbeing before any resultant positive changes in functioning can be sustained beyond the initial intervention period (Lyubomirsky, Sheldon, & Schkade, 2005). Supporting evidence to this view has been demonstrated, for example, by Morgan, Graham, Hayes-Skelton, Orsillo, and Roemer (2014) who report a clear link between continued mindfulness practice and sustained benefits; existing beyond the initial mindfulness intervention. Such findings imply that sustained increases in well-being require sustained changes in how a person functions, which may include an ongoing variety of activities to combat hedonic adaptation (Rusk et al., 2017).
Rusk, Vella-Brodrick and Waters (2017) provide a guiding model and theoretical perspective of positive psychological change to understand why intervention-induced changes in positive psycho-social functioning are not sustained. The Synergistic Change Model (Rusk, Vella-Brodrick & Waters, 2017) is based in complex dynamics systems theory (Thelen, 2005); recognising that psychological change is a fundamentally complex process and involves interaction between many dynamic elements. An extensive review of the literature relating to positive psychological and social functioning (Rusk & Waters, 2015) has highlighted five major elements which are central to positive functioning; including attention and awareness, comprehension and coping, emotions, goals and habits, and relationships and virtues. Together, these five domains of positive functioning (DPF-5), in addition to environmental and biological/physiological influences (Rickard & Vella-Brodrick, 2014) represent the elements of a complex dynamic system of psycho-social functioning and comprise the framework through which sustained positive change can be achieved. Particularly, the psychological and social processes, states, and tendencies in these domains represent what changes as a result of an effective intervention. This empirical framework is the basis through which the Synergistic Change Model (Rusk, Vella-Brodrick & Waters, 2017) operates.
The fundamental principle in the SCM is that whilst each individual domain operates independently (Rusk & Waters, 2015), each domain may also interact and influence psycho-social functioning in all other domains; thus demonstrating moderation effects. Therefore, alterations in psycho-social functioning in one domain can affect how an individual functions in multiple other domains; and the effects of change on the targeted domain may also be enhanced or weakened through the influence of other elements (Lopes & Cunha, 2008). To articulate this; Rusk et al., (2017) indicated that changes in one’s mindset (i.e. the Comprehension and Coping domain) can affect, for instance, the person’s social relationships in the Relationships and Virtues domain; their goals and perseverance in the Goals and Habits domain, their tendency toward rumination in the Attention and Awareness domain, and, lastly, their affective experiences, as represented in the Emotions domain. The environmental and biological/physiological domains also influence functioning in the five domains and may also be influenced by them. Thus, the outcome of an intervention targeting one domain may influence and be influenced by the functioning of another. However, relationships between domains are dynamic, time-dependent, and non-linear, and true to complex systems principles, the effects of changing one element depend on the current state of the system. Regarding applying these principles to induce sustained behaviour change then, it would be important to note that the sequences in which changes occur to create new stable behaviours may vary greatly between individuals. The interactions between domains may either reinforce or undermine the changes in a given domain and affect whether change - particularly sustained positive change, is achieved.
According to the SCM, well-being interventions may result in one of three distinguishable types of dynamic processes of change in patients: relapse, spill-over, and synergy. ‘Relapse’ may occur when changes made are inadequate, unstable and are made to one or two domains in isolation. From an initial state of undesired functioning, an intervention may cultivate desired functioning in one domain, but when the intervention ends, the individual may relapse and revert to their original state of undesired functioning. Isolated changes are less likely to change the overall dynamic stability of the psycho-social system and instead results in between-domain interactions which undermine and prohibit initiated change within a given domain. For example, an intervention could train individuals to adopt an optimistic explanatory style. If it were to do this by targeting only the Comprehension and Coping domain, the functioning in the other domains may undermine the attempted change in explanatory style. For example, an individual may not make a habit of using an optimistic explanatory style (Goals and Habits domain), or may be overwhelmed by negative emotions that counter optimism (Emotions domain), or may socialise with pessimistic friends (Relationships and Virtues domain). The model suggests that relapse to old patterns of thought and behaviour could occur in this scenario as a consequence of interactions between domains, which tend to restore the dynamic stability of the system.
In contrast, an intervention may elicit positive change and improve functioning in one domain and these effects may ‘spill over’ to enhance functioning in other domains. Spill over effects from enhancements in one domain on to another are often reported in qualitative investigations of patient experiences (Landsman-Dijkstra, van Wijck, & Groothoff, 2006) and may be evidenced as mediation effects (Toussaint & Friedman, 2009). Rusk et al., (2017) use the strategy of gratuity activities (a component commonly used in PPI’s) to articulate the process through which spill over can occur. The researchers propose that gratitude may operate by increasing one’s attention to positive aspects of one’s life (Attention and Awareness) and this in turn has a spill-over effect on one’s explanatory style and expectations for positive events in the future, thus assisting a person’s ability to cope (Comprehension and Coping). Indeed, gratitude has been shown to correlate with positive reinterpretation, coping and planning (Wood, Joseph, & Linley, 2007). Meanwhile, Froh, Yurkewicz, and Kashdan (2009) found gratitude is associated with positive affect, optimism, social support, and prosocial behaviour, with most associations remaining significant even after controlling for positive affect. Spill-over effects demonstrate that cognitive functions do not operate independently and offer insight as to how different interventions may result in similar changes being accomplished through multiple pathways of pursuit (Oman, Richards, Hedberg, & Thoresen, 2008). However, these residual effects are often temporary and offer no promise of sustainable change.
To induce stable and enduring change, synergy is necessary. Synergy is the primary insight of the SCM and occurs when different domains of psycho-social functioning interact in ways that are mutually reinforcing and sufficiently strong to create a new dynamically stable pattern of behaviour. For example, an intervention encouraging acts of kindness (Relationships and Virtues) could be reinforced by experiencing positive emotions from kindness (Emotions), beliefs about kindness (Comprehension and Coping), planning regular acts of kindness (Goals and Habits), and becoming mindful of opportunities for kindness (Attention and Awareness). These synergistic interactions have been typically referred to as upward positive spirals within the PP literature (Ryff & Singer, 1998; Crawford & Caltabiano, 2011; Gudan, 2010; Lyubomirsky & Layous, 2013; Wood, Maltby, Gillett, Linley, & Joseph, 2008) and identified as mechanisms through which PPI’s may enhance well-being (Cohn & Fredrickson, 2010). According to the SCM, the formation of these synergistic spirals is a powerful means by which the effect of a PPI can be made enduring; and that PPI’s will be more effective if they are designed to produce synergistic change. Moreover, the SCM explains why different therapies may target different aspects of psycho-social functioning, but through interaction effects, more widespread changes occur. The SCM suggests an important principle: lasting change will be more likely when reinforcing changes occur within most or all DPF-5 domains. Moreover, different therapies may target different aspects of psycho-social functioning, but through interaction effects, more widespread changes occur.