OMG Digital Magazine OMG Issue 336 20th December 2018 | Page 28

OMG Digital Magazine | 336 | Thursday 20 December 2018 • PAGE 28
Concepts of health and wellbeing
1.  Defining health and wellbeing
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).