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
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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
FOR INTEGRATION:
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)
The three major models surrounding individual behaviour change are the
Health Belief Model, the Theory of Reasoned Action/Planned Behaviour
(TRA/TPB) and the Trans-Theoretical Model. The Health Belief model (HBM)
(Glanz, Rimer & Viswanath, 2008) proposes that a person’s willingness
to change is dependent on seven factors, these being perceived
susceptibility to and severity of a health behaviour, perceived benefits
and barriers to changing a health behaviour, cues to action and
self-efficacy regarding the change, along with overall modifying
variables which refers to individual characteristics. An overarching
value of ‘perceived threat’ of a behaviour is a key indicator of
behavioural change in this model. In a similar manner of perceived
threat dictating behaviours, the Protection Motivation Theory proposes
that people protect themselves against threats based on the threat
appraisal, referring to the perceived severity and probability of the
occurrence, and coping appraisal, referring to efficacy and
self-efficacy (Rogers, 1975). However, the evidence supporting the
application of the HBM is weak and its predictive capacity is limited
(Taylor et al., 2006). Despite this, methods to increase a ‘perceived
threat’ of a behaviour have been useful, though it has not been related
to the HBM. For example, pictorial warnings on cigarette packaging are
significantly more effective than text-only warnings in increasing
intentions to quit smoking (Noar et al., 2016).
The TRA (Fishbein & Ajzen, 1975) proposes that behaviour change depends
on an individual’s attitude towards the behaviour, which is determined
by the beliefs and evaluations about the outcome of the behaviour.
Behaviour change also depends on the subjective norms about the
behaviour in question, which is defined by beliefs about others’
opinions on the behaviour and motivations to comply with those opinions.
A third component of the TRA is that of volitional control; the extent
to which the behaviour can be applied consciously and become habitual
over time. The TPB is an extension of TRA, in that it includes the
aspect of perceived behavioural control, which refers to the beliefs
regarding how easy or difficult it is to perform the behaviour (Ajzen,
1991). The evidence supporting the predictive performance of both TRA
and TPB is stronger than that of the HBM, with TPB accounting for
between 20% and 30% of the variance in adult health behaviours in the
US and UK (Taylor et al., 2006). However, this is relatively low when
needing to devise health behaviour interventions.
The Trans-Theoretical Model (Prochaska et al., 1992; Prochaska &
Velicer, 1997) proposes behaviour change as a process of six stages;
precontemplation (not intending to change), contemplation (think about
change) preparation (intending to change a behaviour and begin with
little steps), action (changing the behaviour), maintenance (sustaining
the new behaviour), termination (when there is no temptation to reverse
back to the old behaviour). In addition to these six steps, people can
relapse and reverse back through the stages when they have not reached
termination. The benefit of this model is that it holds the capacity to
serve as a foundation for interventions aimed at both an individual and
a community level (Taylor et al., 2006), however, the evidence suggests
it is no more effective than alternative, rationally designed,
interventions.
Overall, despite these models inadequately accounting for the impact of
social, economic and/or environmental factors on health behaviours, they
have been widely used and applied within health services (Taylor et al.,
2006). Kelly and Barker (2016) highlight how behaviour change is not a
simple choice an individual makes. They highlight the fact that just
because it is common sense to adopt positive health behaviours, it
doesn’t necessarily mean people will, and by providing more information
that is straightforward to understand doesn’t equate to behaviour
change. For this reason, we need to look beyond providing information
and towards techniques that will facilitate behaviour change.
Other theories provide additional influencers in health behaviours, for
example, it has been proposed that self-efficacy plays a key role in
behaviour change; as a predictor, mediator or moderator, proposed in
Bandura’s Social Cognitive Theory (1997). People are more likely to
choose to undertake tasks which begin them on the path of behaviour
change if their self-efficacy is high, whereas this is less likely when
self-efficacy is low. In a similar manner, those with high self-efficacy
about a task are more motivated to complete the task and continue with
the behaviour for longer. The role of self-efficacy can be related back
to the TPB in relation to perceived behaviour control (Ajzen, 1991), and
is discussed in the TTM as playing a role in behaviour change across the
stages (Prochaska et al., 1992). The four factors influencing
self-efficacy are enactive attainment, vicarious experience, social
persuasion and physiological factors, and targeting these to effectively
increase self-efficacy can increase the likelihood of behaviour change
(Ashford, Edmunds & French, 2010). Self-efficacy both directly and
indirectly impacts health through decision making, including behaviours
such as smoking, physical exercise, dieting, condom use, dental hygiene,
seat belt use, and breast examination (Conner, 2005).
The above literature is a small focus amongst a larger area of work
surrounding behaviour change. Other theories provide additional
standpoints, including the Theory of Interpersonal Behaviour which
highlights the importance of habit formation (Triandis, 1977; 1980), the
Theory of Trying which focuses on the influencers upon the intention to
try (Bagozzi, 1992), and the Self-determination Theory which focuses on
innate psychological needs for competence, autonomy and relatedness
(Deci & Ryan, 1985; Ryan & Deci, 2000).
By understanding the theoretical background to health behaviour change,
interventions that target health behaviours can incorporate behaviour
change strategies into the programme. One route through which long-term
behaviour change can be achieved is by understanding past behaviour and
habits. Forming positive health behaviour habits has been a focus for
heath psychologists, with research published on diet (Adriaanse et al.,
2010), physical activity (Rhodes & de Bruijn, 2010), alcohol
consumption (Norman, 2011) and medication adherence \citep*{Bolman2011}. It is argued that a habit can be formed through
repetition of a behaviour within a specific context (Lally, van
Jaarsaveld, Potts & Wardle, 2010) and eventually this context will have
the potential to trigger the behaviour without awareness, conscious
control cognitive effort or deliberation (Bargh, 1994; Lally, van
Jaarsveld, Potts, & Wardle, 2010; Wood & Neal, 2009).
When devising interventions to build habitual behaviours, it is
important to consider the context in which an intervention is applied.
For example, when aiming to ameliorate unhealthy behaviours, disrupting
a cue exposure which triggers the behaviour could be a focus
(Verplanken, Walker, Davis & Jurasek, 2008), however, there is the
possibility of the behaviour returning when the necessary cue or context
returns. This serves as an explanation as to why positive results from
interventions may be short-lasting. Judah and colleagues (2018) aimed to
investigate the formation of habits to create positive health behaviour
changes. In line with the above discussion, they found that performing a
behaviour in a more stable context was associated with more frequent
repetition, which they attributed to context-specific cues being
effective reminders. They also reported behaviour pleasure and intrinsic
motivation to be two key factors in predicting whether a behaviour
becomes a habit. Conversely, they found perceived utility and behaviour
benefits to have no impact on habit formation, contradicting the HBM
which highlights a key focus on perceived threat of behaviour to one’s
health. Previous behaviours and habit formations are important factors
when devising intervention strategies for individuals, as these
behaviours have ingrained neural pathways that are easily activated
(Gerdeman, Partridge, Lupica, & Lovinger, 2003; Smith, 2016; Yin &
Knowlton, 2006). For this reason, strategies need to be employed that
will both combat the old health behaviour and encourage the formation of
neural pathways associated with the new health behaviour.
There are many BCTs that can be employed when providing interventions,
promoting self-affirmation, through reflection upon important values,
attributes or social relations, is one useful tool to facilitate
behaviour change. Self-affirmation has proven to be a useful
psychological technique regarding its ability to decrease defensiveness
and increase receptivity to interventions across different health
behaviours (Falk et al., 2015). By targeting self-affirmation, the
neural processes involved in the self-related processing and value in
response to an intervention can be altered (within the ventromedial
prefrontal cortex), allowing the individual to understand the relevance
and value in the intervention instead of viewing it as a threatening
health intervention. A meta-analysis of 144 studies reported a positive
impact of self-affirmation on message acceptance, intentions to change
and subsequent behaviour (Epton et al., 2015). In a review of BCTs aimed
to reduce sedentary behaviour, they reported the most effective
techniques to be education, environmental restructuring, persuasion and
training (Gardner et al., 2015). An example of environmental
restructuring would be to provide sit-stand desks (Alkhajah et al.,
2012). Studies that used techniques that focused on self-monitoring of
behaviour, problem solving and changing the social or physical
environment have shown promising results (Gardner et al., 2015). In a
systematic review of behaviour change aimed at reducing obesity,
mediators for longer-term weight control were autonomous motivation,
self-efficacy and use of self-regulation skills (Teixeira et al., 2015).
Overall, there are many BCTs that can be used in conjunction with
treatment plans to potentially improve adherence to the treatment or
suggested behaviour change.
However, whilst many interventions have been effective in eliciting
behaviour change, these are often short-term successes (Avenell et al.,
2004) and it is not feasible to upscale these interventions to access
large population groups as they require a substantial amount of time and
money (Forster, Veerman, Bardendregt & Vos, 2011). Nudge Theory
provides a basis for an alternative intervention method to subtly alter
health behaviours of those in the community. Thaler and Sunstein (2008)
argue that there is a “choice architecture” which refers to all the
external forces that guide people to make choices, and subtle
environmental changes (nudges) can make a desired choice more likely.
Bringing together libertarian paternalism (directing decision making
whilst maintaining freedom of choice) and nudge theory offers an
effective and feasible route to altering health behaviours among large
populations. However, this method of influencing health behaviours comes
with controversy, with the argument that it undermines the UK
government’s aims which promote empowerment, freedom and fairness
(Blumenthal-Barby & Burroughs, 2012; Goodwin, 2012). Nudging strategies
target the impulsive and automatic system, guiding individuals to
certain choices without conscious decision making (Gill & Boylan, 2012;
Marteau, Hollands & Fletcher, 2012; Strack & Deutsch, 2015). Despite
this, nudging is generally accepted by the public with few concerns
(Junghans, Cheung & De Ridder, 2015; Petrescu, Hollands, Couturier &
Marteau, 2016).
The evidence supporting the use of Nudge Theory with health behaviours
is promising. A meta-analysis on dietary choices, including 42 studies,
demonstrated that nudge interventions caused an average increase in
healthier consumption decisions by 15.3% (Arno & Thomas, 2016). As a
result of promising research, a project named ‘Supreme Nudge’ has been
developed to target dietary and physical activity behaviour changes in
low socioeconomic areas to reduce the burden of cardiometabolic health
problems (Lakerveld et al., 2018). The aim of the project is to
implement and evaluate the impact of environmental changes (nudges) on
lifestyle behaviours and cardiometabolic health in adults. The targeted
intervention will focus on food pricing, environmental nudging and
tailored feedback for physical activity. The researchers have developed
this project with the awareness that targeting individual-level factors,
such as educational strategies, are insufficient in eliciting behaviour
change, particularly for those in lower SES groups (Angermayr, Melchart
& Linde, 2010). Whereas targeting the environment can prove effective
in encouraging health behaviour changes. For example, adjusting the
pricing on food products causes subsequent changes in food purchases
(Niebylski, Redburn, Duhaney & Campbell, 2015; WHO, 2015), with
discounts on fruits and vegetables increasing purchase and consumption
on such items (Ball et al., 2015; Geliebter et al., 2013; Ni Mhurchu et
al., 2010; Waterlander et al., 2013).
There is a need to incorporate theory-driven, behaviour change
techniques (BCT) into care packages and interventions. It is not enough
to simply provide the information, given that the four leading
non-communicable diseases (cancer, cardiovascular disease, type 2
diabetes and respiratory disease) are mostly preventable through
positive health behaviours (Marteau, Hollands & Kelly, 2015). It is
argued that when devising techniques for behaviour change, a wider focus
is needed that does not solely focus on the individual, but also
incorporates social and economic pressures that act upon the individual
(Kelly & Barker, 2016). With this is mind, theories of behaviour change
and BCTs need to be a focus when targeting health behaviours, instead of
simply expecting people to adhere to the treatment programme.
BCTs are particularly important for people with chronic conditions given
that healthy behaviour changes after disease onset can lower the risk of
recurrence, reduce symptom severity, increase functioning and extend
longevity (Aldana et al., 2003; Jolliffe et al., 2001; Speck et al.,
2010; Williamson et al., 2000), highlighting the importance of
implementing BCTs to facilitate this is vital. In addition, data
highlights that despite the diagnosis of a chronic condition, the vast
majority of individuals do not adopt long-term positive health
behaviours (Newsom et al., 2011). This is surprising given that theories
of health behaviour would propose that a diagnosis of a health condition
would present as a serious threat and at least minimally lead to an
initial stage of change (Prochaska & Prochaska, 2005). However, past
behaviours and habits can provide an explanation for why many people do
not change to more positive health behaviours (Ajzen, 2002; Verplanken,
2006). However, health behaviour changes differ between conditions, for
example, those with heart disease or stroke were more likely to abstain
from smoking (Twardella et al., 2006) and increase exercise (Van Gool et
al., 2007) compared with individuals with diabetes.
Research highlights that those with chronic conditions are more likely
to track a health indicator or symptom and are more likely to benefit
from health tracking (Fox & Duggan, 2013). If health tracking was used
in conjunction with goal setting and other BCTs, this would be an
efficient clinical target to improve the health of those living with
chronic conditions. BCTs have proven to be effective among those living
with chronic conditions, with a review of eight RCTs aimed at improving
exercise adherence among individuals with persistent musculoskeletal
pain (PMSK) finding social support, goal setting, instruction of
behaviour, demonstration of behaviour and practise/rehearsal to be
effective in improving exercise adherence (Meade et al., 2019). Popular
wearable technology currently offers a number of BCTs, including goal
setting, social support, social comparison, prompts/cues and rewards
which can be used to facilitate behaviour change (Lyons, Lewis, Mayrsohn
& Rowland, 2014).
Discussion
Wellbeing involves 'connection'... connection to ourselves, to others and to the environment. We suggest that vagal function provides a key mediator of health and wellbeing attributable to activities to promote wellbeing across these domains. There is now good evidence that vagus nerve connects us to ourselves (i.e. 80% of vagal nerve fibres are afferent nerves providing a structural link between mental and physical health, [REF]), to others (the vagus promotes social connection, [REF]), and to nature (vagal function is impacted on by a host of environmental factors). Vagal function may be considered as an index of resilience - underpinned by psychological flexibility \cite{Kashdan_2010} - an important consideration when seeking to build the health and wellbeing of individuals with or without chronic conditions. We encourage psychological scientists to draw upon a combination of strategies that involve facilitating positive psychological moments in addition to positive health behaviours, mindful of the major theoretical frameworks that have been proposed previously. To date, the discipline of positive psychology has been restricted to enhancing wellbeing by focusing on strategies to promote positive psychological moments. We argue that the impact of positive psychological interventions could be improved by integrating interventions that also focus on physical health, which we now know to have important impacts on mental - in addition to physical - health [REF].
With regards to the impact of community on individual health and wellbeing, it is worth considering the impacts of culture when building resilience in populations. The extent to which different cultures promote individualism (most developed nations including Australia, UK and US) versus collectivism (most developing nations, e.g. Brazil and China) will have differential impacts on resilience. Individualistic cultures characterise the individual as an active, independent agent, detached from the physical and social environment in which they live. By contrast, in collectivist cultures, the individual is seen as a responsive agent connected to the physical and social environment; wellbeing becomes less subjective and more relevant to the objective standards of others \citep*{Ryff_2014a}. Wellbeing - and the various strategies that can employed to promote it - will therefore vary across cultures \cite{Eckersley2006}, dependent on people’s values and goals, and influenced by culture \citep*{DIENER_1997a}. Take for example, the cultural diversity in the expression of gratitude \cite{Floyd_2018}. Speakers of English and Italian are more likely to express gratitude in everyday situations than speakers of other languages including Polish and Russian. Other research has demonstrated that collectivist cultures - in this case, the Taiwanese - do not experience changes in state gratitude, positive affect or negative affect when practising gratitude \cite{chang}, perhaps because they are fulfilling expected role obligations. Finally, it is important to note that community values and subsequent behaviours can be influenced through sociostructural factors such as governmental policies, a consideration highlighted in our original GENIAL model \cite{Kemp_2017} and a topic we discussed in section \ref{225494}.
Finally, our updated model extends beyond the individual and community, to incorporate the broader impacts of the environment. Mindful of previously proposed social ecological theories [REF] and Glenn Albrecht's work on 'Earth Emotions' \cite{albrecht2019}, we emphasise that the individual is intimately connected to the community and environment in such a way that XXX