Five winning ways to wellbeing: a review
By Steve Carter, Mental Health Promoter, Mental Health Foundation
Introduction
Background
Mental health for all
A conceptual framework
What is the primary purpose of the projects?
Focus on partnerships
What are the issues?
Enhancing existing projects with a national campaign
A New Zealand angle
Future work
References
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Introduction
This year - as in 2009 - the Mental Health Foundation promoted the Five Winning Ways to Wellbeing1 during Mental Health Awareness Week (MHAW). The Foundation saw increased traction around the messages for this campaign and how the core messages were used across the country.
Background
The Five Ways to Wellbeing was first developed in the United Kingdom (UK) by the New Economics Foundation - working as part of the UK Government's Foresight Project. It is a set of evidence-based messages to support the development of a 'mental health equivalent of Five-Plus-A-Day fruit and vegetables'.
A review, published as New Applications, New Ways Of Thinking2, has just been carried out in the UK by the National Health Service (NHS) Federation and the National Mental Health Development Unit, to assess just how the core messages are being used in various settings across the UK. It is a useful document that should inform the development of the use of Five Ways to Wellbeing in New Zealand and I offer a summary here...
Mental health for all
Firstly, the document sets out the case for a focus on mental health for all as an approach, as opposed to targeted help for vulnerable groups - balancing promotion and prevention with care and treatment.
Certainly it is a cost-effective approach - while the review acknowledges the naivety in thinking promotion will ever completely obviate the need for care and treatment, it states categorically that, at a population level, it is a more effective approach in the medium-to-long term. Focussing solely on deficit does not reduce overall prevalence in the population.
A study by Huppert3 has made the case for viewing the opposite of mental illness as not simply its absence but the presence of actual positive psychological states. Further, it stresses that shifting the whole population towards flourishing states should reduce the mean prevalence of mental illness or distress.
Importantly, the document reiterates the implications of psychological wellbeing. People with increased wellbeing are more involved in social and civic life; are more environmentally responsible; have better social and family relationships; and are more productive at work. Those with positive mental health, experience fewer lost workdays, a decreased likelihood of stroke, and a decrease in risk of cardio-vascular illness.
A conceptual framework
The review takes as the core of its methodology the development of a conceptual framework on which to matrix the various uses of Five Ways to Wellbeing. It looks firstly at the point of intersection of the project: importantly here, the framework allows for ‘downstream' interventions (those aimed primarily at individual behaviour change) but also for ‘upstream' interventions (aimed at changing the circumstances in which people operate).
This recognises that behaviour change theory assumes conscious motivation whereas in reality change is also prompted by external factors leading to unconscious motivation. Thus the individual is only one agent in the change process. While mental health is determined in part by factors over which individuals have control, this is not the sole factor in operation.
Community, organisational and policy changes might include removing barriers to participation, making social improvements, or changing interactions with clients through process changes. It identifies the complementarity of changing opportunities and educating individuals to make use of the opportunities opened up to them.
What is the primary purpose of the projects?
The second axis of the matrix looks at the primary purpose of the projects using Five Ways to Wellbeing. It allows the review to differentiate between direct wellbeing promotion and promotion that is incidental to other purposes, and to recognise that a holistic approach and wider understanding of wellbeing may be used to design an intervention whose broader aim is not actually mental wellbeing.
A survey was carried out across the UK of various projects that had used Five Ways to Wellbeing. On mapping the responses from survey participants it was clear that Five Ways to Wellbeing messages were used right across the matrix, some projects fitting into more than one spectrum.
More than half aimed at individual behaviour change, but policy level interventions were also relatively common. The direct approach was certainly more common, but interventions and initiatives were designed across a range of settings, and for a variety of target populations. The review saw examples of mass media communication to huge populations of potential ‘footfall', but it also drew out examples of targeted education work in very localized settings.
Importantly, the policy-level implications were very instructive. A number of local authorities in the UK have adopted Five Ways to Wellbeing indicators in community surveys or have taken wellbeing as key targets. One NHS Trust was using Five Ways to Wellbeing indicators in outcome measures, while another was working with a local council to create funding opportunities for projects supporting Five Ways to Wellbeing messages. One NHS Trust is connecting people leaving the service to community activities, while another is using Five Ways to Wellbeing as an assessment framework for entry to and exit from services.
Focus on partnerships
In terms of project characteristics, there was strong emphasis upon partnership work as an approach supporting success. Out of 40 examples where a local NHS Trust was leading the work, only two were not in partnership, and some had many partners delivering aspects of the project. The same is true for local authorities and the voluntary and community sector.
What are the issues
One issue highlighted continually in the review was that many projects, while assessing impact, did not use subjective wellbeing as an indicator. Generally projects were measuring ‘hits', recognition or progress against action plans but not actually measuring the development of subjective wellbeing in their target populations.
Anecdotally, this was found to be mainly due to a lack of confidence in measurement of subjective wellbeing and the review made the case strongly for the development of better research in this area to develop robust measurement tools for subjective wellbeing and to disseminate them amongst projects delivering this work.
Enhancing existing projects with a national campaign
Many projects reported using Five Ways to Wellbeing to enhance their own current work and of using the messages in combination with other messages - for instance in work to address social determinants of health, or to ensure that the messages were appropriate to different cultural settings.
Most projects considered that their work would be enhanced by a national campaign on Five Ways to Wellbeing. They were keen that a common currency was to develop around wellbeing and that this is strongly evidence-based. Further, they felt that better integration into local and regional strategies would ensure that mental health and wellbeing were seen as everybody's business.
A New Zealand angle
So what might we take from this review here in New Zealand? The work began in the UK, so it is fair to assume that it is a little more embedded in projects across that country, but New Zealand is not actually far behind.
Five Ways to Wellbeing was launched as part of the Foresight Project in 2008 and the Foundation was quick to adopt them as a useful framework. MHAW 2009, which focussed on the ‘Five Winning Ways to Wellbeing' and MHAW 2011, which focussed on the Five Winning Ways to Wellbeing as a tool to ‘Get in the Game: train for happiness' were the most successful we have had. Where might it go next year?
The UK review makes it clear that, while Five Ways to Wellbeing is a set of evidence-based tools relating to individual behaviour change, the focus of projects utilising the messages need not always be on the individual.
There is scope to improve collective wellbeing in strategic and indirect ways by affecting the circumstances in which people live, and the processes and ways of working that surround them.
There is scope to integrate Five Ways to Wellbeing messages into existing projects. This means beginning to think about wellbeing as an approach to doing things. Local authorities around New Zealand, for example, could integrate Five Ways to Wellbeing as outcomes into commissioning specifications for all kinds of services (not just mental health).
Future work
The review makes some suggestions that we would do well to consider as possibilities for future work in this country.
First it is clear that impact assessments are not accurately collecting data about the effectiveness of projects using Five Ways to Wellbeing. It is one thing to measure take-up or recognition, but another entirely to evaluate whether that leads to actual behaviour change and, consequently, increased reporting of levels of positive wellbeing.- It is also clear that there has only been an ad hoc, not systematic review of the acceptability of these messages for diverse target groups. In New Zealand, given that we have a strong imperative under Te Tiriti O Waitangi, it is important that work continues to assess suitability for Maori, and also to consider the impact on other populations.
- The review suggests, perhaps unsurprisingly, that the most effective use for target populations has resulted from the work being planned and led by representatives from the target group.
- Similarly, there has been little review (and there were very few examples in this report) of the suitability of Five Ways to Wellbeing at a community level. There is some scope for research into how well Five Ways to Wellbeing messages would work to develop flourishing communities, particularly as a complement to work already being done (through initiatives such as Transition Towns4, for example).
- And finally, I believe that it may be time for a similar review of the use of Five Ways to Wellbeing in New Zealand. If the success and take-up of these messages continues, we should see a similarly diverse range of projects using these messages.
The Mental Health Foundation takes a strategic view of the implications of wellbeing at population levels and has exciting work in hand developing FEAT (the Flourishing Environments Assessment Tool).
FEAT uses the Five Ways to Wellbeing as a framework to assess levels of wellbeing in certain environments and to work with organisations to introduce plans for increasing wellbeing across those populations.
Perhaps it is time to see how far we have come since the 5WWW arrived here?
References
- The Five Ways to Wellbeing
- New Applications, New Ways Of Thinking - New Economics Foundation 2011
- Huppert, F.A. (2009). A new approach to reducing disorder and improving wellbeing. Perspectives on Psychological Science, 4, 108-111
- Transition Towns Aotearoa
- For further information about FEAT, please email: grant.rix@mentalhealth.org.nz
