Wellbeing ESRC Funded by the Economic and Social Research Council and Manchester Metropolitan University
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Seminar 3

Health and Wellbeing

 

Speaker's Notes

Diana Kuh A Life course approach to health and wellbeing.
Mary Shaw

Landscapes of wellbeing: exploring the potential and pitfalls of a more positive outlook on the social geography of health

 

A Life course approach to health and wellbeing.

Diana Kuh

ESRC Seminar June 12th 2002

'Health must come first: the mere state of not being ill must be recognised as an unacceptable substitute, too often tolerated or even regarded as normal. We must, moreover, face the fact that while immense study has been lavished on disease no one has intensively studied and analysed health, and our ignorance of the subject is now so deep that we can hardly claim scientifically to know what health is.’
(Political and Economic Planning 1937)

Historical perspective

Since antiquity there have been two contrasting paths to health, symbolised by the Greek goddesses Hygeia (Hygiene) and Panakeia (Cure-all). Hygeia represents the preservation of health by way of life, emphasising prevention rather than cure. Health is seen as the natural order of things for those who govern their lives wisely and live in harmony with their environment (the 'social' model). Panakeia represents the restoration of health by treating disease (the 'medical' model) and underlies the Cartesian reductionist approach to understanding the workings of the body. This approach has been employed by medical scientists since the seventeenth century and was reinforced by the development of the germ theory of disease and the rise of the doctrine of specific aetiology from the middle of the nineteenth century.

During the 1930s there was considerable debate in public health and social medicine about the nature of health and its determinants. Prevention was seen as better than cure and child health was seen as the cornerstone of the preventive model of adult health. The importance of social and economic conditions for infant and child health was recognised. The growing interest in positive health was linked to the expansion of scientific knowledge about nutrition and about normal biological functioning. A prominent Medical Officer of Health, Dr M'Gonigle, argued that practitioners of preventive medicine, '…should give greater consideration....to the study of normal biology. The maintenance of normality is our business; let us therefore veer from a pathological to a biological conception of our science.' (M'Gonigle 1930, p.245)

The need for 'rigid and scientific standards of human normality' was increasingly recognised as well the problem of using the average as an ideal standard which was inevitably contaminated by those in poor health (Le Gros Clark 1938). It was argued by some that the state should provide health-creating services that included, for example, cheap and available healthy food, new accommodation to replace slums and relieve overcrowding, Green Belt schemes, job security and decent work conditions, and education in healthy living (Political and Economic Planning 1937)

While physical, mental and social wellbeing were fundamental concepts to the newly formed WHO in 1948, there was little agreement on how to define it. In contrast, the development of international classifications of disease made considerable headway. Health was generally defined negatively by survival or the absence of disease or longstanding limiting illness. Occasionally health was seen as multifaceted, including measures of function of the body and the performance of day to day activities, but the focus on dysfunction and activity limitations remained and there was little agreement on which components should be included and how they should be weighted to derive a summary measure. The first WHO classification of impairment, disability and handicap (WHO 1980) was a welcome conceptual development but was still rightly criticised for its focus on the negative aspects of health and lack of attention to the role of environmental factors. The latest WHO international classification of functioning, disability and health (WHO 2001) attempts to rectify this by providing a classification of contextual factors. It represents the best effort to date of a unified and standard language and framework for the description of health and health-related states and overall wellbeing, in individuals and populations. Likewise, EuroQol (Rabin and de Charro 2001) is an internationally agreed classification of health related quality of life.

Even in these more recent classifications, negative scales are still employed to qualify the level of functioning (complete impairment through to no impairment), activity (complete difficulty through to no difficulty) or quality of life (no problems through to extreme problems). Higher level functioning is not assessed. The level of functioning of body systems at each age that is optimal for other aspects of health is not considered. Nor is there any attention to how function is acquired during development, maintained at maturity, and lost during ageing. We need to develop a temporal perspective for these new frameworks and integrate them with recent knowledge about the lifetime precursors of disease, functional change and quality of life.

What is a life course approach to health and wellbeing?
A life course perspective has been actively promoted by many disciplines, including psychology, anthropology, sociology, demography, biology and epidemiology (Cairns et al 1996, Magnusson 1996, Panter-Brick and Worthman 1999, Henry and Ulijaszek 1996, Giele and Elder 1998, Kuh and Ben-Shlomo 1997, Kuh and Hardy 2002). Based on recent epidemiological frameworks, a life course approach studies the long-term effects on health and wellbeing of physical and social risk or protective factors during gestation, childhood, adolescence, young adulthood and later adult life. Investigating the independent, cumulative and interactive effects on health and wellbeing of factors at each life stage helps to elucidate underlying biological, behavioural and psychosocial pathways that operate across the life span, or across generations. The aetiological insights gained from the integration of biological and social processes are the essence of an epidemiological life course perspective. Life course studies have been particularly concerned with how socially patterned exposures across the life course accumulate and influence adult health and disease. Up until now more attention has been paid to chains of risk rather than to protective chains that promote long-term wellbeing but the approach can, and should, accommodate both.

Dynamic concepts are needed to study the health of an individual over the life course or the health of a population over time, including some assessment of health capital and health potential. Health capital is the accumulation of biological resources, inherited or acquired during earlier stages of life that shape current health and health potential. Health potential includes the chance of survival and also the chance of maintaining and improving positive health attributes and discarding or reducing negative ones. For those at the beginning of life it would include an assessment of the likelihood for full physical and mental development, for older persons the likelihood of delaying degenerative ageing processes. Health and disease are expressions of success and failure of an organism in its efforts to respond adaptively to ever-changing environmental challenges (Dubos 1965) in the social as well as the physical world. Thus changing individuals need to be studied in a changing world; contextual effects require a temporal perspective. The physiological response of an individual to earlier social and biological experiences provides clues to susceptibility, vulnerability and resilience and hence to future health potential. Generally assessments of response have been restricted to changes in rather gross indicators of growth and development (such as height or weight gain) or illness history. The recent theories of the early origins of adult health and disease (Barker 1998) suggest that more subtle changes (such as physical changes to fetal arteries or the rate of lung growth or changes in the stress response) should be assessed.

A life course approach needs to start with some understanding of the natural history and physiological trajectory of biological systems. Many functions (such as lung, cognitive or muscle function) display rapid growth and development in the first stages of life followed by a period of stability and then a gradual decline with age (Ben-Shlomo and Kuh 2002). Early factors may influence the development of this capacity or ‘reserve’ and, alongside adult factors, the timing and rate of decline. To study change over time better measures are needed that at least discriminate the mild end of dysfunction and, ideally, discriminate those at the higher end of functioning.

Challenging questions posed by a life course approach include (a) how does the level of functioning at one age affect the level of functioning at another age, (b) is a higher level of functioning always more optimal for current health and future health potential or is there some threshold effect, (c) how does the social and physical environment leave long-term imprints on the structure or function of body systems, or affect adult activity and participation, and (d) are there critical or sensitive time windows during development when environmental challenges have a greater effect and to what extent can these early effects be modified or reversed later?

The notion of resilience is an important concept in a life course approach to health and wellbeing. Resilience is a dynamic process of positive adaptation in the face of adversity. The focus of research on resiliency has been on the intrinsic and extrinsic factors associated with educational, emotional and behavioural resilience of children. There has been less focus on health outcomes and physiological resilience, and on long-term outcomes in general. Ryff and Singer (1996) have studied pathways to psychological resilience in middle aged women who score high on well being despite a history of depression.

An interesting question is whether resilience at one stage of life (and the protective factors associated with it) has long-term benefits or costs. For example, there could be long-term health costs for those who respond to adversity by being driven to succeed educationally and occupationally. Another example is where adaptations for survival made by the fetus in response to adversity may raise the risk of chronic disease risk in later life

The maturing British birth cohort studies are a valuable resource for studying life course effects on health and wellbeing. The oldest (the MRC National Survey of Health and Development, commonly called the 1946 cohort) has focused on biological function and shown, for example, how patterns of early growth and early socioeconomic circumstances are related to later cognitive, muscle and reproductive function. (Richards et al 2001, Kuh et al 2002, Hardy and Kuh 2002). So far good health has been defined as the absence of health problems or poor functioning (Kuh and Wadsworth 1993). Those in the best of health (about 10% of the cohort at age 36 years) were more likely to have been raised in better childhood socioeconomic conditions even after taking account of own adult socioeconomic circumstances and health behaviours. We are currently developing a programme of research on positive health, wellbeing, quality of life and resiliency in this cohort. Studies of life course predictors of adult psychological wellbeing, healthy behaviours, and positive affect, relations with others and body image are included. Influences on study members’ assessment of life satisfaction at different ages will also be explored. Preliminary findings suggest that some dimensions of psychological wellbeing such as the capacity for self determination may be higher in women who have successfully coped with prior adverse life experiences.

In conclusion, a life course approach to health and wellbeing should be an integral part of an interdisciplinary life course approach to the study of human variation and what constitutes meaningful difference (Panter-Brick and Worthman 1999). It includes the study of (a) higher level biological and psychological functioning and the identification of optimal levels for health and health potential, (b) intrinsic and extrinsic factors across the life course that develop resilience, (c) the life course development of protective factors such as emotional support and healthy behaviours (d) transitions into and out of positive health states and health protecting environments over the life course, and (e) the inter-relationships between healthy minds, healthy bodies, healthy lives and healthy societies.

References

Barker DJP. Mothers, babies and health in later life. Edinburgh: Churchill Livingstone, 1998.

Ben-Shlomo Y, Kuh D. A life course approach to chronic disease epidemiology: conceptual models, empirical challenges, and interdisciplinary perspectives. Int J Epidemiol 2002;in press.

Cairns RB, Elder GH, Costello EJ, eds. Developmental Science. Cambridge: Cambridge University Press, 1996.

Dubos R. Man adapting. Yale University Press, New Haven and London 1965.

Giele JZ, Elder GH, Jr. Life Course Research: Development of a Field. In Giele JZ, Elder GH, Jr., eds. Methods of life course research: Qualitiative and quantitative approaches. Thousand Oaks,CA: Sage Publications,Inc., 1998:5-27.

Hardy R, Kuh D. Does early growth influence timing of the menopause? Evidence from a British birth cohort. Human Reproduction 2002; 17 (no. 9).

Henry CJK, Ulijaszek, eds. Long-term consequences of early environment: growth, development and the lifespan perspective. Oxford: Oxford University Press, 1996.

Kuh D, Bassey J, Hardy R, Aihie Sayer A, Wadsworth MEJ, Cooper C. Birth weight, childhood size and muscle strength in adult life: evidence from a birth cohort study. Am J Epidemiol 2002;156 (no.7).

Kuh DL, Ben-Shlomo Y, eds. A life course approach to chronic disease epidemiology: tracing the origins of ill-health from early to adult life. Oxford: Oxford University Press, 1997.

Kuh D, Hardy R, eds. A life course approach to women’s health. Oxford University Press, Oxford 2002.

Kuh DJL,Wadsworth MEJ. Physical health status at 36 years in a British national birth cohort. Soc Sci Med 1993;37:905-16.

Le Gros Clark F. National fitness: a brief essay on contemporary Britain. MacMillan, London 1938.

Magnusson D (ed). The lifespan development of individuals: behavioral, neurobiological and psychosocial perspectives. Cambridge: Cambridge University Press, 1996.

M’Gonigle GCM. The biological concept of preventive medicine. Public Health 1930;43:239-45.

Panter-Brick C, Worthman CM, eds. Hormones, health and behavior. Cambridge: Cambridge University Press, 1999.

Political and Economic Planning. Report on the British Health Services. A survey of the existing health services of Great Britain with proposals for future development. Political and Economic Planning, 1937.

Rabin R, de Charro F. EQ-5D: a measure of health status from the EuroQol Group. The Finnish Medical Society Duodecim, Ann Med 2001;33:227-43.

Richards M, Hardy R, Kuh D, Wadsworth MEJ. Birth weight and cognitive function in the British 1946 birth cohort: longitudinal population based study. BMJ 2001;322:199-203.Ryff CD,

Singer B. Psychological well-being: meaning, measurement and implications for psychotherapy research. Psychother Psychosom 1996;65:14-23.

World Health Organization. International classification of impairments, disabilities, and Handicaps. World Health Organization, Geneva 1980.

World Health Organization. International classification of functioning, disability and health. World Health Organization, Geneva 2001.

Landscapes of wellbeing: exploring the potential and pitfalls of a more positive outlook on the social geography of health

Mary Shaw, Department of Social Medicine, University of Bristol

This summary presents key points from this presentation, where I used some of my own work as a springboard for some critical thinking about how we approach and conceptualise health in it’s social and spatial context – how we might turn towards thinking about wellbeing as our study outcome and policy goal, and potential problems such a change in direction may entail.

As social scientists we spend a disproportionate amount of our time studying those who are worse off in society. We constantly talk about health when we mean illness, disease and ultimately death. This is partly due to the dominance of the bio-medical paradigm, but may also be related to how we measure outcomes - death, after all, is a pretty definitive outcome - and what we are used to judging as a worthwhile story to tell. We talk endlessly of poverty, deprivation, and more recently social exclusion (and a little on inclusion); we are far more reticent to tackle issues of wealth, power and prosperity. And it’s not just academics – policy makers also have a tendency to do this (the media definitely do). The current government have a social exclusion unit, but not a fat cats unit!

Our book The Widening Gap (Shaw et al., 1999), for example, documented health inequalities in Britain over the last two decades and more. We looked at premature mortality by parliamentary constituencies in Britain. The book takes a ‘things are getting worse’ stance, as it was intended not only for an academic audience, but the aim was to make a contribution to changes in policy, and ultimately (rather optimistically) to reduce health inequalities. A ‘bad news’ message such as this certainly grabs attention, as this front page from a Scottish newspaper shows.

Newspaper

In other work a more positive stance was taken, as in What if Britain were more equal? (Mitchell et al., 2000). For this report for the Joseph Rowntree Foundation we looked again at widening inequalities, but also turned the statistics and the message on its head by calculating what the impact would be if three government policies were successfully achieved.

But how might we more concertedly focus our attention to wellbeing? Other aspects of wellbeing (other than survival) which we could study include:

Some of these are easier to measure than others (assuming that we are still planning to try to do this), such as religious involvement and perhaps some aspects of quality of life. However, seeing as we currently have problems getting many indicators at a spatial scale and coverage to use for looking at the geography of Britain, it is unlikely that some of these will be in the census or any large-scale survey in the near future. If we are to focus on wellbeing, won’t we still want robust, comparable measures?

Some potential problems with wellbeing:

Relativism creeps in here – is wellbeing so subjective that we can’t compare it across individuals? Do we all have our own interpretation of what wellbeing is? If each person decides what wellbeing means - one person’s wellbeing is another risk, danger and discomfort - how do we handle this methodologically? How can we make any meaningful comparisons between people and groups, across places and times?

Negative Affectivity: some people have a negative outlook on life, whatever their circumstances, how do we account for this? Should negative affectivity be something we control for, or an independent or outcome variable?

Negative signs and outcomes are more easily spotted than positive ones (or we are more used to spotting them, find them more persuasive in supporting our claims). E.g. housing.

Material poverty: When the environment is dire, it’s really difficult to ignore it’s material features and to turn to less tangible issues. Shouldn’t we sort out these problems of poverty first?

Supporting the underdog: As social scientists don’t we have a moral obligation to help those at the bottom of the heap? Can we focus on wellbeing and still do that? What if we find that (some) people living in the most difficult material circumstance that constitute a threat to their health, report positive wellbeing? How do we make sense of that?

‘Risky’ behaviours may lead to wellbeing: There are many positive sides to ‘unhealthy’ behaviours, eg: smoking, drinking, drugs, risk-taking. How do we balance these competing outcomes? Particularly as wellbeing implies a focus on mental health: “ wellbeing relates to aspects of mental health as much as physical condition” (Curtis, in press). ‘Social conditions’ that policy-makers define as negative (e.g. teenage parenthood) may also have a positive contribution to wellbeing.

A way forward for wellbeing?

I concluded by saying that it would be good for researchers to look at more positive outcomes, and while it would be challenging, a focus on wellbeing could benefit from/incorporate:

References

Shaw, M., Dorling, D., Gordon, D. and Davey Smith, G. (1999) The widening gap: health inequalities and policy in Britain. The Policy Press: Bristol.

Mitchell, R., Dorling, D. and Shaw, M. (2000) Inequalities in life and death: what if Britain were more equal? The Policy Press: Bristol.

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