Wellbeing: the challenge of ‘operationalising’ an holistic concept within a reductionist public health programme

Introduction

A concept of contemporary interest locally, nationally and globally, ¹ wellbeing remains highly contested. ² Traditionally, two contrasting perspectives, hedonic and eudaemonic, have been identified – the former concerned with pleasure, avoidance of pain and subjective happiness; the latter focused on human flourishing and realisation of potential.^3,4 Walker reflects that, ⁵ whereas the Romans equated concepts of health and wellbeing, the ancient Greeks distinguished between them – understanding good health to be a necessary, but not in itself sufficient, component of eudaemonic wellbeing. Similar perspectives emerged from discourses within 19^th century utilitarianism and 20^th century liberalism and socialism, which profiled an emphasis on wellbeing alongside and arguably beyond economic and material needs of individuals. ⁶

In 1946, the World Health Organisation defined health as a ‘complete state of physical, social and mental wellbeing’ (p. 1), ⁷ thus catalysing a closely intertwined relationship between the two concepts. Seventy years later, wellbeing can be described as an emergent, though ascendant, concept in public health – one that focuses not only on individual lifestyle, but also on wider contextual determinants.^5,8,9,10 Arguing that health is only one component of wellbeing, McNaught proposes a definitional framework comprising individual, ¹¹ family, community and society levels in dynamic relationship with people’s circumstances, activities and resources. He also positions wellbeing as a ‘macro concept concerned with the objective and subjective assessment of how human beings survive, thrive and function’ (p. 11). There is a growing critical discourse on the relationship between individual, collective and ecological wellbeing. This questions the degree to which the pursuit of personal wellbeing (particularly when defined in hedonic terms) threatens wellbeing of communities, societies and the ecosystems on which we depend. ⁴ Jones-Devitt extends this critique, questioning whether a commitment to wellbeing can be meaningfully realised within the context of a globalised neo-liberal ideology, ¹² which she suggests prioritises individual self-interest. Within England, the increasing use of wellbeing as a core concept within public health is related to a number of factors: the growing appreciation of mental health as a key focus, ¹³ an understanding of the importance of objective and subjective elements, ⁵ and the shift of public health to local authorities, which already have a ‘Power to Promote Wellbeing’, ¹⁴ alongside the establishment of health and wellbeing boards. ¹⁵

In the context of this study, it is relevant to introduce notions of reductionism and holism and consider their application to wellbeing. Reductionism can be defined as ‘the practice of analysing and describing a complex phenomenon in terms of its simple or fundamental constituents’, while holism is understood as

the theory that parts of a whole are in intimate interconnection, such that they cannot exist independently of the whole, or cannot be understood without reference to the whole, which is thus regarded as greater than the sum of its parts. ¹⁶

Although Carlisle et al. contend that the concept of wellbeing can counter reductionist tendencies inherent in modernity, ⁴ it is also clear that programmes may superficially appear to be holistic by addressing multiple health-related issues, but in reality operate in a disconnected and essentially reductionist way.

Target: Wellbeing (TWB) was a public health programme in North West England that ran from 2007 to 2015, funded by the Big Lottery Fund’s Wellbeing Programme. This article focuses on its first phase (2007–2012), which comprised a portfolio of 12 programmes. Reflecting the Wellbeing Programme’s three stated outcomes, each programme consisted of a diversity of projects focused on healthy eating (e.g. food growing, cooking), increasing physical activity (e.g. walking, cycling) and mental wellbeing (e.g. drama activities, tailored support for refugees).^17,18 There were 95 projects in total, benefiting over 110,000 people. Alongside a largely quantitative impact evaluation,^17,18 a process evaluation of TWB was commissioned as a freestanding study.

While impact evaluation is essential to establish whether or not interventions, projects and programmes have worked, it does not address the questions of ‘why’ and ‘how’. The process evaluation thus complemented the impact evaluation by conducting qualitative research to understand how the portfolio was delivered, by focusing on implementation, mechanisms of effect and context. ¹⁹ Its aim was to explore the design and delivery of TWB and increase understanding of how and why different approaches worked well or not so well in achieving desired outcomes. This article focuses on one particular area explored through the evaluation – the concept of wellbeing, examining perceptions of multiple stakeholders, including project participants, project staff and others involved at programme and portfolio management levels.

Study Design and Methods

Drawing on emergent models of wellbeing, ¹¹ the study was informed by a psychosocial perspective. This appreciates that individuals’ experiences are influenced by interpersonal relationships, organisational contexts and wider social, political and economic systems and highlights the interaction between people, ²⁰ settings and environments and seeks to understand multiple layers of determinants.

A qualitative approach was chosen, valuable for complementing quantitative research into wellbeing and appropriate for studying people within the context of organisations and communities and exploring meanings that people bring to their experiences and interactions.^21,22, ²³ Appreciating the resource constraints involved in evaluating a large-scale portfolio, the process evaluation focused on a sample of 13 projects, chosen to ensure representation from the three focus themes and from three programmes (one each from the three sub-regions making up the TWB geographical footprint). Semi-structured interviews and focus groups were conducted, as was determined to be appropriate for the context (e.g. in projects that included participants with mild to moderate mental health issues, we gave the option to take part in a focus group or a one-to-one interview), revealing individual perspectives alongside insights informed by interaction. ²⁴

A total of 142 stakeholders took part in 20 interviews and 29 focus groups, including 90 community members participating in projects, 40 staff involved in project and programme co-ordination and leadership and 12 individuals responsible for portfolio-level governance. Data collection with project participants largely took place ‘in situ’, with researchers attending project sessions to help contextualise and strengthen the authenticity of the process. Interview and focus group schedules were tailored to ensure applicability to each stakeholder group and covered a range of issues including project/programme initiation, development and sustainability; evaluation and administration; benefits of participation; and concepts of wellbeing. Questions pertaining to the latter, and therefore of particular pertinence to this paper, concerned use of models/frameworks, individual perceptions and the relationship between the three TWB outcome areas in the context of wellbeing. Interviews and focus groups were recorded and transcribed. Data were then subjected to manual thematic analysis, cross-check and refining, to build understanding through a process of discovering themes within the raw data, and by interpreting their implications in relation to the aims of the research. ²⁵ A University Ethics Committee granted approval for the evaluation. Key ethical issues were ensuring secure storage of confidential data (using password-protected and/or encrypted folders), and gaining informed consent to use selected quotations from interviews and focus groups (securing agreement to attribute quotations by generic role/title).

Findings

Findings are structured under three themes: meanings of wellbeing, relationship between health and wellbeing, and dissonance between the holistic concept of wellbeing and the reductionist design of the programme.

Discussion

Reflecting on limitations, it could be argued that the study would have been stronger if those commissioning the process evaluation had integrated it with the impact evaluation. However, working within this constraint and with available resources, it used interviews and focus groups with a sample of projects and programmes from the TWB portfolio to generate a wealth of rich data concerning perceptions and understandings of multiple stakeholders.

Findings support wider literature in suggesting that wellbeing remains ill-defined, overlaid with diverse and subjective understandings.^8,12,27 Some staff members felt that the concept was well-understood; however, others expressed concern that the diversity of understandings made the term challenging to use coherently. They also questioned why the model presented in a Wellbeing Programme report was not articulated more widely. ²¹ However, alongside this, the study revealed a strong belief that the language of wellbeing was enormously valuable in distancing TWB from narrow medicalised understandings of health and enabling project managers to engage participants effectively. This finding contrasts with the claim that wellbeing muddies rather than clarifies the concept of health. ²⁸ Importantly, though, it reflects a shift towards salutogenesis: this involves focusing not only on wider determinants of illness, but also on fostering health potentials and supporting human flourishing. ²⁹ , ³⁰ It also echoes a vision of wellbeing as a new driver for public health policy and action, and as a unifying framework for disparate social policy, able to move beyond the traditional disease focus attached to the term ‘health’ and engage with the breadth of local government functions. ³¹ In the English context, characterised by public health relocating to local authorities and health and wellbeing boards being established, ¹⁵ the perceived resonance of wellbeing with local government becomes particularly salient. ³²

The data highlighted multiple levels, signalling an appreciation that wellbeing is not only an individual experience but also a social and societal phenomenon. This was accompanied by a concern to understand the concept in relation to wider contextual and environmental influences. While findings revealed both hedonic and eudaemonic perspectives, ³ the latter dominated discourses of both staff and project participants. Staff talked about the importance of how people feel and function and emphasised that by prioritising meaning and potential, TWB projects and programmes will have longer-lasting value. Although participants often mentioned pleasure gained from projects, they also revealed understandings that ranged from a focus on provision of basic needs – elsewhere understood as prerequisites for health – to a cross-cutting and eudaemonic focus on purpose and identity, ³³ referring to self-development, self-realisation and a renewed sense of direction. This echoes Ryan and Deci, ³ who suggest that feelings of happiness do not constitute wellbeing, and accords with the views of writers who contend that what matters is not only the experience of positive emotions, but effective and authentic functioning within the context of society.^4,34

There was widespread understanding that the concept of wellbeing is unruly and cross-cutting and essentially characterised by holism, supporting wider arguments. ²² This meant that despite the requirement from Big Lottery as funders for projects to prioritise one defined outcome, staff working on TWB projects largely rejected this reductionist approach and felt unable to adhere to this neat ‘compartmentalisation’. For example, ‘healthy eating’ cooking projects supported participants’ mental wellbeing through the development of friendships, ‘physical activity’ cycling projects developed a sense of camaraderie and increased participants’ awareness of their connection to their surroundings and ‘allotment-based’ projects primarily focused on mental wellbeing enhanced awareness of healthy food, increased physical activity and supported positive flourishing associated with social contact and connecting with nature. Reflecting on the requirement to allocate projects to one primary theme, staff critiqued the impact evaluation as too prescriptive and linear. They suggested that its design failed to appreciate the complexities and synergies associated with wellbeing, and therefore to capture the full ‘added value’ of participation in TWB. They thus echoed Crawshaw who cautions against assuming that wellbeing can have quantifiable measurable outcomes. ³⁵ There was consensus that the process evaluation went some way to addressing these concerns, enabling the more elusive elements of wellbeing to be articulated and revealing the programme’s transformative potential.

Conclusion

This study supported wider literature, highlighting that wellbeing is a contested, multi-dimensional and complex phenomenon. There was consensus that wellbeing is ‘more than health’, a broader-based concept comprising multiple facets of human experience. Despite the popular conflation of the notions, it was also understood to represent ‘more than happiness’, with stakeholders emphasising eudaemonic perspectives and ideas relating to human flourishing. The research revealed a belief that the concept of wellbeing is holistic and offers the power to transcend clinical and pathogenic conceptions of ‘health’ and more fully engage and resonate with individuals, communities and local authorities. Linked to this, the study raised concerns about the feasibility of ‘operationalising’ wellbeing without compromising the concept, and questioned the value of funders categorising projects according to discrete thematic outcome areas. It was suggested that this over-simplification represents a reductionist approach that conflicts with the essentially ‘whole’ nature of wellbeing. There was also a sense that it failed to ‘push the boundaries’ of public health; interviewees suggested that the programme could instead have encouraged cross-cutting projects that tackled underlying determinants of wellbeing in joined-up innovative ways. Furthermore, the resulting ‘linear’ approach to monitoring may jeopardise evaluation by failing to capture impacts that cut across different themes and thus reveal the transformational role of projects in promoting wellbeing.

Despite these critical perspectives, it is important to celebrate positive impacts achieved by TWB. Looking ahead, there are a number of important themes emerging from the wider literature that resonate with the research findings. First, public health can use wellbeing as a driver for policy and action by engaging with the breadth of local government functions. ³¹ Within England, this is facilitated by the relocation of public health to local authorities, but also made enormously challenging by the economic context and swingeing cuts to core budgets – estimated at £18 billion in real terms between 2010 and 2015. ³⁶ Second, wellbeing is essentially social as well as individual,^3,6 and it is therefore important that research, policy and practice move beyond personal psychological constructs, being informed by psychosocial perspectives and utilising models that incorporate individual, family, community and societal dimensions. ²⁰ , ¹¹ Those implementing such models must grapple with the challenge of making multi-level holistic wellbeing meaningful within a culture of growing self-interest propagated by pervasive neo-liberal ideology. ¹² Third, wellbeing is experienced in relation to and influenced by people’s contexts and surroundings, ¹¹ a finding particularly prominent for those participating in activities in natural settings and echoing the growing body of evidence concerning wellbeing and people’s relationship with nature. ³⁷ Finally, there is an emerging social and ecological critique of the personal wellbeing discourse and the policy focus on individual happiness within the context of an increasingly consumerist society. As Carlisle et al. highlight, ⁴ this may prevent the attainment of wellbeing by others and jeopardise the future wellbeing of humanity and the planet. This suggests that it will be important to connect psychosocial models with emerging eco-social frameworks that connect social with ecological determinants of health. ³⁸