Introduction
Do we all (researchers, policy and decision makers, those experiencing mental health issues, and those working with them) mean the same thing when we refer to wellbeing? Whilst in its broadest use through popular literature and media this may refer to feeling happy or positive, wellbeing is increasingly measured and reported as the outcome of choice in health, psychology, social research, and epidemiology research (Dalingwater 2019; Karimi et al. 2021; Patalay and Fitzsimons 2018; Stampini et al. 2021). In particular, it is used to evaluate interventions that aim to improve mental and physical health, ranging from psychological treatments to nature or heritage-based interventions (for example, Britton et al. 2020; Camic et al. 2021; Rogerson et al. 2020; van Agteren 2021). However, wellbeing is a broadly applied term across these research fields and disciplines and may be capturing different aspects of wellbeing and mental (ill)health. Some psychologists have also argued that wellbeing encompasses more than these, possibly transient, emotions, and also encompasses deeper experiences of purpose in life and the ability to live in accordance with your values (Seligman 2011; van Agteren and Iasiello 2020). Indeed, it is often unclear what definitions are being applied and operationalised in research and evaluations, and it is therefore difficult to truly understand the evidence produced. This is further complicated because the concept of wellbeing, and how it can be operationalised and measured, may also be influenced by the approach of the researchersā discipline(s), and what is perceived as important to capture. This has the further effect of making the results of this disparate literature and evidence base difficult to synthesise and draw conclusions from (Linton et al. 2016), and synthesising without this clarity and nuance provides too simplistic a view of wellbeing and claims made in terms of how it can be improved. For instance, systematic reviews exploring the impact of various interventions on wellbeing have found this field limited by the variation in use of measures, and use of unvalidated survey instruments (for example, Daykin et al. 2018; Gascon et al. 2017). Despite this, the findings from research or evaluations of interventions may still inform policy and practice in several fields, even though the evidence used to inform policy and services may be founded upon different definitions, concepts, and constructs, resulting in evidence that is considered comparable when this may not be the case (Carlquist et al. 2017). Therefore, it is important for researchers in any field to be very clear about what they mean by, or are measuring when they evaluate changes in, wellbeing, as this will also link to the theoretical concepts upon which their definition of wellbeing is based. Whilst these may be different depending upon the aims and focus of the intervention, it is important to be transparent about the definitions used, and what it is that is being measured and there should be coherence between the two. As the policy focus in the UK increasingly includes a focus on wellbeing (Dalingwater 2019) we need to understand and be able to clearly show what is being measured, why, and what the changes observed really mean in practice.
This chapter therefore explores definitions of wellbeing in more depth and provides an overview and explanation of the theoretical bases of wellbeing in psychology and allied professions and disciplines. We start with definitions within health research and we explore definitions of mental health here too, moving on to lay definitions, followed by psychological and sociological definitions. We then move on to demonstrate how we can operationalise and measure wellbeing in research, followed by what is involved in evaluation and the importance of transparency in our approaches. This will be useful to those who wish to assess the impact of their heritage and wellbeing projects or to critique the claims being made by evaluations; to be clear about what is actually being measured and reported in order to use evidence appropriately in developing interventions.
Definitions and theoretical foundations of wellbeing
Before we discuss mental health further, it is perhaps important to explain what we mean by āmental health problemsā here, otherwise referred to as mental health disorders, mental ill-health, and mental illness. We recognise issues around stigma and medicalisation that can arise through the use of these latter terms, particularly when used by mental health professionals and academics, rather than those with lived experience. However, we also recognise that labelling severe and enduring mental ill-health as problems may not acknowledge the severity of experience and the impact on individuals, and perhaps here the term may itself be inappropriate, and mental ill-health or illness becomes more appropriate. Language is imperfect in this area, and beyond the scope of this chapter, but is discussed with great skill and clarity by Foulkes (2021). For the most part, in this chapter we use the term mental health problems, in line with NICE terminology (NICE 2011).
Health research and services
As discussed above, there has been an increase in research considering wellbeing in terms of both its influencers and its measurement as an outcome in the health literature. From a theoretical perspective, there are two main conceptualisations that we discuss; wellbeing in the context of mental health as the absence of psychological distress and conflation with physical health.
Absence of psychological distress/symptoms
The traditional biomedical model of mental health conceptualises wellbeing akin to mental health, and from the same lens as physical health ā the opposite and absence of disease (Bourne 2010), without reference to the social and environmental determinants of health (Allen et al. 2014). The approach to mental health within the National Health Service in England and Wales has, at times, reflected this. Although policy imperatives have shifted in recent years, with growing emphasis on community and social influences, and responses to health (for example through the embedding of social prescribing link workers in primary care; Aughterson et al. 2020), dissonance remains between this policy and how it is enacted: āthe notion that the absence of mental illness symptoms is insufficient to achieve good mental health and wellbeing is readily accepted (yet not always acted upon) in scientific, professional, and lay settingsā (van Agteren and Iasiello 2020: 307). This is evidenced by the support for wellbeing offered online by the NHS, which appears to conflate wellbeing with mental health; specifically, low mood, depression, and anxiety (for example NHS 2021), when depression and anxiety are, in fact, separate clinical diagnoses. Therefore, decreasing or removing these symptoms of poor mental health, such as sleep problems or negative thoughts, is taken as analogous to improved wellbeing, which may be an inappropriate conclusion to make.
Indeed, research suggests that while wellbeing is arguably separate from mental health, wellbeing may influence mental health (Keyes et al. 2010) and that there is a possible protective relationship against developing symptoms of psychological distress (van Agteren and Iasiello 2020). It is therefore crucial that we develop our understanding of what the relationship is, what aspects of wellbeing are important in this relationship, and the ways in which this might interact with mental health overall. Two points are important here though: sometimes it is assumed that wellbeing and mental health exist on the same continuum when this need not be the case; and that mental health and wellbeing seem to be used interchangeably in the literature, while they are arguably different concepts.
How we define mental health is the focus of much research and debate; however, as influenced by medical approaches, mental health problems are referred to as mental disorders, and there are a number of sources of classification; such as the World Health Organisation's (WHO) ICD-11 Classification of Mental and Behavioural Disorders (ICD-11; World Health Organization 2021), and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Health Disorders (DSM 5; American Psychiatric Association 2013). These references provide lists of symptoms that aid diagnosis. For instance, DSM 5 provides diagnostic criteria (including definitions and symptoms) for 157 disorders grouped into 20 diagnostic chapters. Of these, NICE (2011) identify a group of Common Mental Health Disorders (CMD). These include depression and anxiety disorders (including generalised anxiety disorder, panic disorder, and specific phobias), obsessive-compulsive disorder (OCD), and Post Traumatic Stress Disorder (PTSD). They are considered common because they affect more people than other mental health disorders, and they may also be co-morbid (existing together). In the most recent Adult Psychiatric Morbidity Survey, 17% (1 in 6) of those surveyed in England met the criteria for a CMD (McManus et al. 2016). These CMDs may also be experienced as mild, moderate, or more severe depending on the number of symptoms experienced and the impact of these symptoms on daily life, and a person may experience different levels of severity at different times as symptoms and impact may fluctuate. As such, common does not mean insignificant.
Conflation with physical health
The health literature focusing on wellbeing more generally reflects the biomedical paradigm and again reflects assumptions of a widely shared meaning of wellbeing (Cameron et al. 2006; Cronin de Chavez et al. 2005). As such, given the assumptions made about wellbeing in the context of mental health from the biomedical perspective, there may be no surprise that wellbeing is often confused and conflated with physical health (Cameron et al. 2006; Cronin de Chavez et al. 2005; Wheeler et al. 2012). There is also often an emphasis on the impact of physical ill-health on psychological wellbeing, with a lack of attention to the social determinants of health such as employment, occupational status, or education level (Cronin de Chavez et al. 2005); however, this literature is starting to reflect the shift in policy focus, as discussed above, with an increasing focus upon the impact of other social interventions on wellbeing (Camic et al. 2021; Emerson et al. 2021; Rogerson et al. 2020).
Where wellbeing is used to encompass both physical and mental health and in turn the lack of symptoms of physical or mental ill-health, this is a challenge to measurement; to progression of our understanding of the influencers and determinants of mental wellbeing; and for evaluating projects with an anticipated range of impacts. The problem with an under-defined concept of wellbeing is not confined to how to measure it, but also for developing effective interventions if there is not clarity around what it is that is being improved. For example, Cameron and colleagues found that effectiveness of interventions for community groups might be compromised where āthey remain founded on assumed, conventional notions of health, and disconnected from the wider knowledge base identifying complexities of health conceptionsā (Cameron et al. 2006: 348i).
An aspect of this conflation with physical health is reflected in the use of generi...
