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].
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}.
Promoting Wellbeing by Focusing on the Environment
We have previously discussed the impact of nature
on general health and wellbeing, drawing upon the biophilia hypothesis as a theoretical background \cite{wilson1990}. 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, accessibility issues being one example \citep{Meek_2018}. The link between nature and disease prevalence is outstanding, with a systematic review with study populations ranging from the thousands to the
millions \citep{Gascon_2016} finding a negative correlation
between cardiovascular disease mortality and residential greenness, the pathways through which this relationship
occurs can be explained by \citet*{Kuo_2015}. Other research highlights the positive impact of natural environments on
brain activity, the cardiovascular system, endocrine system, immune
function and mental health outcomes \citep{Haluza2014,Bratman_2019}, along with increasing social capital for individuals \citep{Braubach_2017}, the benefits of which have been previously highlighted. The benefits of contact with nature has been found to be independent of cultural and climatic contexts \citep{van_den_Berg_2016}.
Introducing green spaces into communities and care homes is one route
through which those with chronic illness and/or disabilities can easily
access nature when living in an urban environment. Research
on 126 care facilities across 17 European cities found
green spaces within the facility grounds had a significant impact on the
quality of life for the residents, with increased physical activity, recreation and social engagement, benefits were also reported among staff and
visitors \citep{Artmann_2017}.
Traditionally, care homes were designed for the safety of
residents, neglecting what potentially improve their health and wellbeing, but this
is beginning to change \citep{Ausserhofer_2016}. Simple additions,
such as indoor plants, have reportedly reduced stress for patients in
hospital \citep*{Dijkstra2008}.
In order to fully assess the impact of nature, \citet{Shanahan_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.
Facilitating
Behavioural Change
Positive health behaviours can assist in the management of many chronic conditions (Marteau, Hollands & Kelly, 2015), lowering the risk of recurrence, reducing symptom severity, improving functioning and, in some cases, even extending longevity (Aldana et al., 2003; Jolliffe et al., 2001; Speck et al., 2010; Williamson et al., 2000). Still, a majority of individuals fall short of pursuing a healthier lifestyle (Newsom et al., 2011)
\citep*{Van_Cappellen_2017} despite conscious intent. Behaviour change may comprise the key to addressing the intention-behaviour gap (
Sheeran, 2002) and to increasing the uptake of evidence surrounding well-being activities into healthcare practice
\citep*{Francis_2012}. However, successful change requires more than education or communication of personalised risk information
\citep*{French_2017}; strategies which have minimal impact upon inducing sustained change, especially in individuals of a lower socio-economic status (Angermayr, Melchart & Linde, 2010). Accordingly, behaviour change must be understood through comprehensive models and facilitated through guiding framework's and appropriate change-inducing strategies.