Emerging research suggests that insomnia, a disorder of arousal [
9,
10], contributes to the development of cardiovascular conditions [
11,
12,
13,
14] independent of traditional risk factors [
15]. Although data are mixed [
16,
17], insomnia and short or long sleep duration [
18,
19,
20] and insomnia with arousal were associated with hypertension [
21]. Insomnia also predicted use of anti-hypertensive and other cardiovascular medications [
22], coronary heart disease [
23], and myocardial infarction [
24,
25]. Insomnia had a dose-related effect on incident HF and death [
26], and may contribute to death from other cardiovascular conditions [
14,
27], but data are conflicting [
15,
28]. This evidence points to importance of identification of sleep disturbances in people with chronic conditions and also suggests the important of treatment of either the sleep disorder its self or its moderating factors (e.g weight gain, pain). Next we explore the evidence such intervention in people with chronic conditions.
Cognitive Behavioural Therapy has been shown to be an effective treatment for adults with insomina with clinically meaningful effect sizes
\citep{Trauer_2015}.
Music therapy has proved effective for both acute and chronic sleep disorders
(Wang, Sun, and Zang, 2014), with massage, acupuncture, natural sounds and music videos being reported to be effective in health care settings
(Hellström and Willman, 2011). As discussed above physical activity is often recommended for obesity. Given the reciprocal interaction between obesity and sleep physical activity has also been explored for the treatment of sleep disorders. Interestingly, in several cross sectional studies physical inactivity has been shown to be a risk factor for poor sleep and insomnia
\citep{Chasens2012},
\citep{Paparrigopoulos2010},
\cite{Foley2004},
\citep{Morgan2003}. With respect to insomnia, physical activity has been shown benefit people with sleep disorders but this was dependent but this was dependent on the type and intensity of the physical activity, with moderate-intensity aerobic exercise proving beneficial as opposed to high intensity aerobic and moderate-intensity resistance training
\citep{Passos2010}. A plethora of studies have also shown amelioration of OSA and associated symptoms such as excessive daytime sleepiness as a function of increased physical activity and/or diet
\citep{Tuomilehto_2009},
\citep{Tuomilehto_2013},
\citep{Kuna2013},
\citep{Foster2009}.
Conclusion - overall re health behaviours as they pertain to chronic conditions
It is noted however, that simply providing information on modifications to health behaviours is not sufficient to elicit behaviour change. The use of behaviour change theory or behaviour change techniques is needed
(Michie, Fixsen, Grimshaw, and Eccles, 2009), such as self-monitoring, goal setting, goal review and feedback; proving to increase the likelihood of behaviour change
(Michie et al., 2009). Based on the upward spiral theory of lifestyle change, increasing positive affect will encourage adherence to a new behaviour change
(Van, Rice, Catalino, and Fredrickson, 2018), mediated by increasing HRV and social connectedness
(Kok and Fredrickson, 2010). There is a need to build positive psychological experiences in parallel with the ongoing medical treatment to both increase treatment adherence and improve health and wellbeing through other routes.
5.1.2: Positive Psychological Moments/experiences :
There is a strong relationship between chronic disease and mental health conditions
Rutledge T, Reis SE, Olson M, et al. Depression is associated with cardiac symptoms, mortality risk, and hospitalization among women with suspected coronary disease: the NHLBI-sponsored WISE study. Psychosom Med. 2006;68(2):217–23.
PubMedCrossRefGoogle ScholarFinally, in persons with obesity, complaints of chronic emotional stress or sleep disturbance have been reported to be predictors for short sleep duration, rather than voluntary sleep curtailment as previously thought.21 Chapman DP, Perry GS, Strine TW. The vital link between chronic disease and depressive disorders. Prev Chronic Dis [serial online] 2005; 2(1).
http://www.cdc.gov/pcd/issues/2005/jan/04_0066.htm. Accessed September 20, 2012. 3. Mayo Clinic. Mental Health Risk Factors Web Site.
http://www.mayoclinic.com/health/mental-illness/DS01104/DSECTION=risk-factors. Accessed September 20, 2012. 4. World Health Organization. Facing the Facts #1: Chronic Diseases and Their Common Risk Factors
http://www.who.int/chp/chronic_disease_report/media/Factsheet1.pdf. Accessed October 4, 2012. 5. Anderson G. Chronic Care: Making the Case for Ongoing Care. Princeton, NJ: Robert Wood Johnson Foundation; 2010.
http://www.rwjf.org/content/dam/web-assets/2010/01/chronic-care. Accessed October 4, 2012. 6. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psych. 2005;62:617-27. 7. 7.American Epilepsy Society; Centers for Disease Control and Prevention; Chronic Disease Directors; Epilepsy Foundation; National Association of Epilepsy Centers. Living Well with Epilepsy II: Priorities for a Public Health Agenda on Epilepsy. Report of the National Conference on Public Health and Epilepsy, 2003. Landover: Epilepsy Foundation; 2003.
http://www.cdc.gov/epilepsy/pdfs/living_well_2003.pdf. Accessed September 20, 2012. 8. Daniels, EC. ABCD Community Health Worker Training Program. Presented at: Society for Public Health Education Meeting: November, 2009: Washington, DC.
Relationship between mental health, chronic disease, and injury Both mental health disorders and chronic diseases are common and disabling. These conditions can affect anyone, regardless of age, culture, race/ethnicity, gender, or income. In 2009, 145 million people— almost half of all Americans— were living with a chronic condition.5 Approximately 26% of American adults aged 18 years and older suffer from a diagnosable mental disorder in a given year.6 Arthritis, as a chronic condition, and depression, as a mental health illness, are both leading causes of disability worldwide. Many other associations exist between mental illness and cardiovascular disease, diabetes, obesity, asthma, and arthritis to name a few.2,8 For example, the chart to the right shows the prevalence of major depressive disorder and other common chronic diseases. Depression is found to co-occur in 17% of cardiovascular cases, 23% of cerebrovascular cases, and with 27% of diabetes patients and more than 40% of individuals with cancer.9,10 The relationship between mental health, chronic disease and injury is significant. Many examples exist of individuals with a chronic condition or risk factor and an increased risk for mental illness such as the risk for tobacco use is about twice as high for those with mental illness compared to the general population.7 Injuries, both intentional such as homicide and suicide and unintentional such as motor vehicle accidents, are 2—6 times higher for persons with a history of mental illness than those without a history.11,12
In addition to positive health behaviours, the promotion of individual
strengths such as acceptance, optimism, resilience, sense of coherence and psychological flexibility are likely to
promote health and wellbeing in people living with chronic conditions.
These strengths are developed through many psychological t cognitive-behavioural therapy, person-centred therapy, acceptance and commitment therapy and positive psychotherapy \citep{Hughes2017,Joyce2018,Bond_2006,Luoma2013,2012,Lin2018,von_Humboldt_2013}. Resilience, which can be described as the ability to adapt well in the face of adversity \citep*{Southwick2012}, is influenced by a multitude of factors, including but not limited to genetics, age, life experiences (quantity and quality), and culture. Resilience levels are lower among people living with chronic conditions compared to healthy individuals, although notably,
increased resilience among those living with a chronic condition is
associated with reduced psychological distress, and reduced symptoms of
anxiety and depression \citep{Keil2017,Winger2016}. Higher resilience levels have been associated with improved mental and physical health, such as symptoms of depression and chronic pain \citep{Mehta2008,Schure2013}, arguably due to more efficient strategies being employed to cope with life stressors \citep*{Bonanno_2015}. Resilience-building techniques based off the principles of positive psychology are now being recognised as a viable strategy to prevent ill-health \citep*{Davydov_2010}, an example being optimism training \citep*{seligman2007}, proving to be effective in improving wellbeing and coping styles \citep*{Scheier_1992}, even among those with chronic conditions \citep{Mohammadi_2018,Kraai_2017} . Common resilience-related protective factors that are employed by this
population include self-efficacy and adaptive coping \citep{Ghanei2016}. Combinations of mindfulness
and CBT techniques have proven useful in building resilience among individuals living with
chronic physical conditions including heart disease and diabetes \citep*{Robinson2019}, resulting in improvements in positive experiences, condition
management, and social engagement. Other mindfulness-based interventions have proven effective in increasing resilience among people living with chronic conditions \citep{Shim_2017}.
Strikingly, a strong sense of coherence (or SOC) (a contributor to resilience) is associated with a 30% reduction in mortality rate from cardiovascular disease, cancer and all cause-related death \citep{Surtees2003}. SOC reflects feelings of confidence that stimuli in the (internal and external) environment are comprehensible, manageable and meaningful \cite{1987}, as a result, people with higher SOC are better capable of dealing with stressors and subsequently are more resilient to negative physical and mental health outcomes, with SOC levels predicting mental health outcomes \citep{Pallant_2002,Sairenchi_2011,Hart_1991}.
In summary, there is tremendous opportunity for improving the health and wellbeing of people living with chronic conditions by focusing on the individual. Traditional routes for improving physical health, such as physical activity, diet and sleep may now be considered as opportunities to support mental wellbeing, when combined with strategies for behaviour change. Treatments that build strengths, resilience, optimism and positive psychological attributes will provide useful strategies to promote health and wellbeing, as has been discussed previously [REF].
5.2: Promoting Wellbeing by Focusing on the Community
Social connectedness needs to become a key focus for people living with
chronic conditions as this population are more vulnerable to social
isolation due to barriers such as receiving care, attending physician
visits and hospitalisations, being physically disabled and/or being unemployed
\citep{Meek2018}. This subsequently influences their health, with one study finding social isolation to be the most reliable predictor of attendance to a health service, more so than physical or mental health issues \citep{Cruwys2018}. Among the participants in this study, increased subjective social connectedness after joining a group, correlated with a reduction in primary care attendance. It is argued that social engagement promotes the resources which people can use to manage their condition \citep{Arcury2012}. The term "social capital" has been termed to describe the social connections and network that influence individuals and their output into the social structure in which they live, with research highlighting social capital to serve as a protective factor against common mental disorders \cite{Ehsan2015}.
Further highlighting this importance, social engagement can help
prevent a health condition from worsening \citep*{Mendes_de_Leon_2003}, and even prevent the development of a chronic disease in the first place; the reverse effect is
observed for people who live alone \citep*{Cantarero-Prieto2018}. However, the quality of the social connections is important \citep*{Gallant2003}, with poor social relationships increasing the risk of disease development \citep{Valtorta2016}; poor marriage quality being one example in which this can occur \citep{Kiecolt-Glaser2001,Umberson2006,Walen_2000}. The self-categorisation theory illustrates one pathway through which this relationship occurs; 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 \citep{Schofffild_2001}. An additional pathway in which social relationships negatively impact on health and wellbeing is when one of the pair becomes a care provider for the other \citep{Christakis_2006,Schulz_2008}.
Reclink is an example of utilising communities to benefit the health and wellbeing of the members; an Australian
community agency that works with individuals with chronic mental health
conditions through the organisation of groups such as choirs, bowling, yoga, and football. Results from the choir group evaluation reported improvements in three areas; personal improvements, including positive emotions and emotion regulation, social improvements, including social connectedness and social functioning, and functional outcomes, including health improvements \citep*{Dingle_2012}. A similar study was
completed which highlighted that those who received greater social support
from their Reclink group reported greater improvement in mental
wellbeing, highlighting the fundamental role of the social aspect of
these groups \citep*{Williams_2018}.
Group interventions allow for peer modelling and peer mentoring, both of which have proven to be effective utilities, especially for hard to reach groups such as those with chronic conditions \citep{Lawn_2010,Sokol2016,Fisher2015,Merianos_2015}. Utilising members of the community in this way will help provide longer-term support for those living with chronic conditions in a currently under-resourced health care system. In addition to this, it allows for the building of a greater social network subsequently influencing one's social identity, the importance of which is highlighted by the social identity theory; the more social identities an individual possesses the more psychological resources they have access to, which protects them from a decline in health \citep{haslam2018}. This is arguably more important for those living with chronic conditions as this population face more discrimination than the general population, which subsequently impacts their health and wellbeing \citep*{Cockerham_2017}. Using social identity as a
clinical target has proven beneficial \citep{Haslam2010,Cruwys_2014} in improving wellbeing and reducing illbeing, therefore manipulating clinical
interventions to be run as a group activity should be considered in
order to derive a sense of shared social identification among service
users.
Another pathway through which social connections improves health and wellbeing is the upward spiral dynamic between social connectedness, positive emotions and vagal function. Using a loving-kindness meditation study as an example, positive emotions can be increased (moderated by vagal function), subsequently increasing vagal tone, an effect mediated by perceived social connections
\citep{Kok_2010,Kok2015,Kok_2013}. Also, higher HRV predicts greater social
engagement upon follow-up assessments, and higher social engagement
predicts higher HRV upon follow up \citep*{Kok_2010}. This
highlights the self-sustaining upward spiral between vagal function,
emotion and social connections, emphasising the need to build on both positive affect and social connections. Whilst building social connections has it's benefits, as previously discussed, positive emotions too has it's own benefits, with positive affect being associated with reduced negative affect, pain and
stress \citep*{Zautra2005}, along with increased physical activity,
sleep quality, and medication adherence \citep*{Sin2015}, among people living with chronic conditions.
Expanding beyond the relationships previously discussed is that of human-animal relationships which can be utilised to enhance an individual's health \citep*{Friedmann_2015}, with general pet ownership being associated with improved physical health, an example being protection against cardiovascular risk \citep*{Giaquinto_2009}. Pet ownership reduces mortality risk after discharge from a coronary care unit, independent of disease severity and sources of social support \citep{FRIEDMANN_1995,Friedmann1980}.
This may be attributable to the anti-stress effects of animals; reducing cortisol \citep{Barker_2005,Beetz_2011,Odendaal_2000,Odendaal_2003,Viau_2010}, epinephrine and norepinephrine levels \citep*{Cole2007}, along with reducing blood pressure \citep{FRIEDMANN_1983,Nagengast_1997,Vormbrock_1988} and increasing heart rate variability \citep*{Motooka2006}.
Animal-assisted interventions have proven effective when working with clients with autism, dementia and psychiatric populations in terms of improving stress levels and problem behaviours, and in increasing social interaction and communication \citep{O_Haire_2012,Bass_2009,Martin_2002,Prothmann_2009,Sams_2006,Richeson_2003,Filan_2006,Haughie_1992,Marr_2000}. Animal-assisted therapy or activities have also proven effective in reducing symptomology of mental illness \citep{Souter_2007,Jones_2019,Peluso_2018} although some research has reported no significant effect \cite{Barker_1998,WILSON_1991}.
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 \citep*{Nimer_2007}. \citet{Beetz_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 \citep{Handlin_2011,Odendaal_2000,Odendaal_2003}. Increases in oxytocin facilitates social interaction and improves health through several methods, including increasing trust \citep{Kosfeld_2005,Zak_2007,ZAK_2005} and reducing stress \citep{Kirsch_2005,Legros_1988} and anxiety \cite{Guastella_2009}.
Overall, targeting the social network is vitally important for
increasing health and wellbeing. One reason being that it is an
opportunity to build more social identities, providing individuals with
more psychological resources in times of need \citep{haslam2018}.
Another reason is that social engagement improves positive affect and
emotion regulation \citep{Dingle_2012}, which is part of the
self-sustaining upward spiral of positive emotion, social connection and
vagal function \citep*{Kok_2010}. It is unsurprising that
social prescribing is now being adopted as a form of treatment, with a
review of 15 social prescribing programmes reporting mostly positive
results \citep{Bickerdike2017}. 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. Incorporating a focus on the social aspect of a client's life 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; incorporating loved ones into the intervention is a key example \citep*{Martire2010} . 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 has been argued that a broader method of tackling of health and wellbeing that focuses on developing healthy and sustainable communities is necessary for targeting disadvantaged populations; asset-based community development is one route through which this can be achieved,whereby communities utilise the assets they have to address the problems within \citep{Blickem_2018}.
Health behaviours