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)