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\begin{document}

\title{Rethinking wellbeing: Toward a more ethical science of wellbeing that
considers current and future generations}



\author[1,2]{Jessica mead}%
\author[2,3,4]{Zoe Fisher }%
\author[5]{Lowri Wilkie}%
\author[1]{Katie Gibbs}%
\author[3]{Julia Pridmore}%
\author[1]{Jeremy Tree}%
\author[1]{Andrew Kemp}%
\affil[1]{Department of Psychology, College of Human and Health Sciences, Swansea University, United Kingdom}%
\affil[2]{Fieldbay, South Wales, United Kingdom}%
\affil[3]{Health and Wellbeing Academy, College of Human and Health Sciences, Swansea University, United Kingdom}%
\affil[4]{Traumatic Brain Injury Service, Morriston Hospital, Swansea United Kingdom}%
\affil[5]{School of Psychology, Cardiff University}%


\vspace{-1em}



  
  \date{May 29, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
The construct of wellbeing has been criticised as a neoliberal
construction of western individualism that ignores wider systemic issues
including increasing burden of chronic disease, widening inequality,
concerns over environmental degradation and anthropogenic climate
change. While these criticisms overlook recent developments, there
remains a need for biopsychosocial models that extend theoretical
grounding beyond individual wellbeing, incorporating overlapping
contextual issues relating to community and environment. Our first
GENIAL model~\hyperref[csl:1]{(Kemp et al., 2017)} provided a more expansive view of
pathways to longevity in the context of individual health and wellbeing,
emphasising bidirectional links to positive social ties and the impact
of sociocultural factors. In this paper, we build on these ideas and
propose GENIAL 2.0, focusing on intersecting
individual-community-environmental contributions to health and
wellbeing, and laying an evidence-based, theoretical framework on which
future research and innovative therapeutic innovations could be based.
We suggest that our transdisciplinary model of wellbeing - focusing on
individual, community and environmental contributions to personal
wellbeing - will help to move the research field forward. In
reconceptualising wellbeing, GENIAL 2.0 bridges the gap between
psychological science and population health health systems, and presents
opportunities for enhancing the health and wellbeing of people living
with chronic conditions. Implications for future generations including
the very survival of our species are discussed.~~%
\end{abstract}%

\newpage

\sloppy


*Correspondence to be sent to: Associate Professor Andrew Kemp,
Department of Psychology, Vivian Tower, College of Human and Health
Sciences, Swansea University, United Kingdom; Email:
\href{mailto:a.h.kemp@swansea.ac.uk}{\nolinkurl{a.h.kemp@swansea.ac.uk}}

\par\null

\pagebreak



\tableofcontents
\listoffigures
\listoftables
\newpage

\par\null

\section{Introduction and Context}

{\label{852648}}\par\null

\begin{quote}
\emph{`But no time or nation will produce genius if there is a steady
decline away from the integral unity of man and the earth. The break in
this unity is swiftly apparent in the lack of ``wholeness'' in the
individual person. Divorced from his roots, man loses his psychic
stability.'}

\par\null

-- Elyne Mitchell, Soil and Civilization (1946)~
\end{quote}

There is now considerable research interest in the topic of `wellbeing'
and its relationship to `health', yet there has also been much debate
and criticism. The Oxford English Dictionary (OED) defines `wellbeing'
as `the state of being comfortable, healthy, and happy', suggesting that
the term relates to aspects of emotions and feelings, as well as
`health'. By contrast, the OED defines `health' as `the state of being
free from illness or injury', a definition that does not fully capture
the meaning of `health' as understood by researchers in population
health: `there is no health without mental health'~\hyperref[csl:2]{(Prince et al., 2007)}.
We further note that absence of illness is not necessarily `healthy'. It
is possible for instance, to be unhealthy without having illness, as one
can be~\emph{on course for an illness} through having poor diet, lack of
sleep, being overweight and physically inactive. Similarly, `not being
depressed' is not the same thing as `being happy'. The World Health
Organisation~\hyperref[csl:3]{({World Health Organisation}, n.d.)} defines `health' as complete mental,
physical and social wellbeing, thus - according to this definition -
wellbeing is subsumed by an overarching concept of `health', which
differs from the OED definition. Although superficially appealing, the
WHO definition has been criticised as being unrealistic. Petr Skrabanek,
a Professor of Medicine and sceptic reportedly joked that according to
this definition, health is only achievable at `the moment of mutual
orgasm'~\hyperref[csl:4]{(Smith, 2008)}. A critical observer might even query whether
it is possible for people living with long-term disabling conditions
such as common mental disorders, diabetes, obesity and cardiovascular
disease to have opportunities for experiencing wellbeing. We suggest
that they do have such opportunity, and that enhancing wellbeing in such
people may also improve physical health. This is an important
consideration as chronic conditions and disease now outstrip the
societal burden imposed by acute conditions~\hyperref[csl:5]{({GBD Collaborators}, 2015)}. In 2017,
as much as 79\% percent of the years lived with disability (YLDs)
globally are attribtuable to chronic conditions~\hyperref[csl:6]{(\textit{{GBD Compare | IHME Viz Hub}}, n.d.)}.
Prominent conditions including depression and anxiety are associated
with 5.05\% and 3.18\% of total global YLDs in 2017, respectively
(Fig~{\ref{535015}}).~Critically, our work is now
focused on building wellbeing in people living with chronic conditions
(see section~{\ref{223145}} for further discussion).\selectlanguage{english}
\begin{figure}[h!]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/screenshot-(1)/screenshot-(1)}
\caption{{The global burden of disease (GBD) with respects to years lived with
disability (YLDs) for all ages and both sexes in the year 2017. The
entire figure represents 100\% of YLDs; those conditions with increasing
\% annual change are highlighted in blue (non-communicable disease), red
(communicable disease) and green (injuries)~\protect\hyperref[csl:6]{(\textit{{GBD Compare | IHME Viz Hub}}, n.d.)}.
{\label{535015}}%
}}
\end{center}
\end{figure}

Positive psychologists have approached the construct of wellbeing from a
different perspective, emphasising life satisfaction~\hyperref[csl:7]{(Pavot \& Diener, 2008}; \hyperref[csl:8]{Diener, 1984)},
psychological wellbeing~\hyperref[csl:9]{(Ryff \& Keyes, 1995}; \hyperref[csl:10]{Ryff, 2014)} and
flourishing~\hyperref[csl:11]{(Diener et al., 2009}; \hyperref[csl:12]{Seligman, 2011}; \hyperref[csl:13]{Seligman, 2018)}.~`Resilience' is another associated
concept ~\hyperref[csl:14]{({American Psychological Association}, Accessed Monday 17th June 2019)}, which emphasises the process of adapting
well in the face of adversity or tragedy, and `bouncing back' from
difficult experiences. It is interesting to observe that this
psychological definition conflicts with those from other disciplines
(e.g. engineering), which highlight `stability' and
`efficiency'~\hyperref[csl:15]{(Quinlan et al., 2015)}. One need only think of a `stable
bridge' or an `efficient production line' to appreciate the distinction
between psychological science and engineering here. Others have
introduced the concept of `salutogenesis'~\hyperref[csl:16]{(Antonovsky, 1996)}, a word
based on the Latin term `salus' (health, well-being) and the Greek word
`genesis' meaning emergence or creation. The salutogenic concept
counters the tendency of medicine to focus on `pathogenesis', and
emphasises a role for a `sense of coherence' for managing and overcoming
stress reflecting feelings of confidence that the environment is
comprehensible, manageable and meaningful. However, psychological
theories of wellbeing have also been criticised for ignoring wider
systemic issues such as loneliness, inequality, environmental
degradation and climate change~\hyperref[csl:17]{(Carlisle et al., 2009}; \hyperref[csl:18]{Ehrenreich, 2010}; \hyperref[csl:19]{Frawley, 2015)}. These criticisms are
being tackled, in part, by developments in conservation and
environmental psychology, which explicitly link psychological science to
some of these challenges. Developments include for instance, the
positive psychology of sustainability~\hyperref[csl:20]{(Corral-Verdugo \& Fr{\'{\i}}as-Armenta, 2015}; \hyperref[csl:21]{Verdugo, 2012)}, sustainable
happiness~\hyperref[csl:22]{(O’Brien, 2010}; \hyperref[csl:23]{O'Brien, 2012}; \hyperref[csl:24]{O'Brien, 2016)} and sustainable
wellbeing~\hyperref[csl:25]{(Kjell, 2011)}. However, others have argued that the
concepts of `resilience' and `sustainability' have become so corrupted
by neoliberalism, the fossil fuel industry and the Trump administration,
that these concepts are no longer useful~\hyperref[csl:26]{(Albrecht, 2019)}.~

\par\null

Here we define the word `wellbeing' to refer to positive psychological
experience, which can be impacted on by positive health behaviours, and
is promoted through a sense of connectedness to ourselves as
individuals, as well as to the communities and environment within which
we live. Our GENIAL model provides and evidence-based and life-course
framework for appreciating how wellbeing (or illbeing) may arise. Our
paper is organised as follows: Section~{\ref{605389}}
briefly reviews our previously proposed model of wellbeing, the GENIAL
model. The word GENIAL is an acronym
encompassing~\emph{G}enomics,~\emph{E}nvironment, vagus~\emph{N}erve,
social~\emph{I}nteraction,~\emph{A}llostatic regulation,
and~\emph{L}ongevity, providing a life course framework within which to
understand the pathways to health and wellbeing versus premature
mortality. GENIAL provides a theoretical context with which to
understand key components which determine pathways to health and
wellbeing for individuals, for example, psychological experiences,
health behaviours, vagal function. However, a plethora of evidence shows
that health and wellbeing are influenced by individual factors but by
the systems and environment that surround people.
Accordingly,~Section~{\ref{806067}} expands the focus
of the GENIAL model to explicitly encompass individual, community and
environmental wellbeing ~(see Fig~{\ref{881013}}),
highlighting a key role for individual wellbeing as a foundation to
build community and environmental wellbeing in line with social ecology
theory, and their respective bidirectional impacts on the wellbeing of
individuals. Section~{\ref{170385}} provides a succinct
summary of our updated model. Section~{\ref{933427}}
considers the implications of our updated model (GENIAL 2.0) for people
living with chronic conditions, and
section~{\ref{223145}} draws some conclusions and
provides some examples relating to our own work that we are doing in
this regard.

\par\null\selectlanguage{english}
\begin{figure}[h!]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Fig-1---Venn/Fig-1---Venn}
\caption{{Venn diagram of key wellbeing domains: the individual, community and
environment.~These domains are placed within the
`symbioment'~\protect\hyperref[csl:26]{(Albrecht, 2019)} to emphasise symbiotic coexistence of
all life at various scales.
{\label{881013}}%
}}
\end{center}
\end{figure}

\section{The Original GENIAL Model~}

{\label{605389}}

Our original GENIAL model~\hyperref[csl:1]{(Kemp et al., 2017)}
(Fig~{\ref{div-134290}}) emphasised the pathways to
health and wellbeing versus ill-health and premature mortality,
highlighting key roles for vagal function and social interaction along
these pathways. The role for the vagus nerve -- indexed by heart rate
variability (HRV) -- built on well-established theoretical models
including polyvagal theory~\hyperref[csl:27]{(Porges, 2011}; \hyperref[csl:28]{Porges, 1995}; \hyperref[csl:29]{Porges, 2001}; \hyperref[csl:30]{Porges, 2003}; \hyperref[csl:31]{Porges, 2007)}, which emphasises a role
for the myelinated vagus nerve -- in particular -- in social engagement,
and the neurovisceral integration model~\hyperref[csl:32]{(Thayer \& Lane, 2000}; \hyperref[csl:33]{Thayer \& Fischer, 2009}; \hyperref[csl:34]{Thayer \& Lane, 2009)}, which lays a
neurophysiological foundation for understanding mind-brain-body linkage.
The recent extension of the neurovisceral integration model named the
`Neurovisceral Integration Across a Continuum of Time' or
`NIACT'~\hyperref[csl:35]{(Kemp et al., 2017)} laid a temporal framework for understanding
linkage between emotion and - over time - mortality, bridging the gap
between psychological science and epidemiology. This model was motivated
by research~\hyperref[csl:36]{(Tracey, 2002}; \hyperref[csl:37]{Jarczok et al., 2014}; \hyperref[csl:38]{Jandackova et al., 2016}; \hyperref[csl:39]{Kemp et al., 2016)}~highlighting a mediating role of the
vagus nerve over downstream health-relevant outcomes. NIACT provides a
theoretical framework within which these disparate findings can be
understood. Kevin Tracey, an American neurosurgeon identified
the~`cholinergic anti-inflammatory reflex'~\hyperref[csl:36]{(Tracey, 2002)}, regulated
by the vagus nerve, which if impaired may contribute to a host of
conditions including poor metabolic outcomes, cardiovascular disease~and
associated mortality~\hyperref[csl:40]{(Hillebrand et al., 2013}; \hyperref[csl:41]{Wulsin et al., 2015)}. The efferent vagus nerve
achieves this through interaction with the
peripheral~\(\alpha\)7 subunit-containing nicotinic
acetylcholine receptors expressed on macrophages. See~\hyperref[csl:42]{(Pavlov et al., 2003)}
for a detailed review of the cholinergic anti-inflammatory pathway.
Jarczok and colleagues~\hyperref[csl:37]{(Jarczok et al., 2014)}~demonstrated that reduced
vagal function (indexed by lower heart rate variability) predicts
increased levels of C-reactive protein four years later,
providing~\emph{in vivo} support for this cholinergic anti-inflammatory
pathway in humans. Kemp and colleagues employed modern mediation
modelling on the ELSA-Brasil cohort~\hyperref[csl:39]{(Kemp et al., 2016)},~demonstrating
that vagal function lies upstream of insulin resistance and
carotid-intima media thickness, an early marker of atherosclerosis,
which together leads to cognitive dysfunction. Jandackova and colleagues
applied cross-lagged analysis to the Whitehall Stress and Health Study
cohort~\hyperref[csl:38]{(Jandackova et al., 2016)}~and observed that vagal function precedes
development of depression over a ten-year follow-up period. These
studies are part of a larger body of work summarised
previously~\hyperref[csl:1]{(Kemp et al., 2017}; \hyperref[csl:35]{Kemp et al., 2017}; \hyperref[csl:43]{Kemp, 2018)}~that demonstrate how early changes in
vagal functioning may contribute to downstream changes in wellbeing. The
GENIAL model~\hyperref[csl:1]{(Kemp et al., 2017)}~further developed
NIACT~\hyperref[csl:35]{(Kemp et al., 2017)} by highlighting the role of social
relationships along the pathways to health and wellbeing, in addition to
the moderating role of health behaviours (e.g. diet, physical activity,
sleep, smoking and alcohol consumption) and sociostructural factors
(e.g. inequality, collective efficacy). The GENIAL model draws and
builds on research which highlights: 1) the role of social identity in
the development of meaning and purpose in life and its impacts on health
and wellbeing~\hyperref[csl:44]{(Haslam et al., 2008)}; 2) that positive social ties reduce
risk of early death to a degree that is equivalent to the effects of
smoking cessation~\hyperref[csl:45]{(Holt-Lunstad et al., 2010)}, and 3) the impact of
sociostructural factors such as inequality~\hyperref[csl:46]{(Kondo et al., 2009)} and
collective efficacy~\hyperref[csl:47]{(Bandura, 2004)} on individuals' capacity to
achieve health-related goals. These ideas are further developed in the
following sections.~

\par\null\selectlanguage{english}
\begin{figure}[h!]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}
\caption{{The original GENIAL model reprinted from \protect\hyperref[csl:1]{(Kemp et al., 2017)} with kind
permission from Springer Nature. (License number: 4652451214375).
{\label{div-134290}}%
}}
\end{center}
\end{figure}

\section{}

{\label{806067}}

\section{Expanding the focus of
wellbeing}

{\label{806067}}

In this section, we emphasise a role for individual, community and
environmental contributors to personal wellbeing, their overlap and
impacts. Table~{\ref{348217}} provides a summary of
major theories and models in individual, social and environmental
domains, which has helped to further develop our GENIAL model, as
described in section~{\ref{170385}}. These models and
supporting evidence are briefly described in the following sections.\selectlanguage{english}
\begin{table}[h!]
\centering
\normalsize\begin{tabulary}{1.0\textwidth}{CCC}
Domain & Theory & Description \\
Individual & Tripartite model of subjective wellbeing (Diener) & Life satisfaction, positive and negative affect. Typically characterised as tapping into hedonic wellbeing. Diener has argued that subjective wellbeing does not involve making value judgments by 'experts' on what a good life entails (Kesebir \& Diener, 2008), such as proponents of 'eudaimonic wellbeing'. \\
 & Six-factor model of psychological wellbeing (Ryff) & Argues that wellbeing cannot be reduced to hedonic wellbeing. Spans positive relationships with others, personal mastery, autonomy, a feeling of purpose and meaning in life, and personal growth and development. This model is characterised as tapping into 'eudaimonic wellbeing'. \\
 & PERMA model (Seligman) & Positive emotion, engagement, social relationships, meaning and achievement all contribute to wellbeing. Spans both hedonic (affect) and eudaimonic (psychological wellbeing) aspects of wellbeing. \\
 & Salutogenesis theory (Antonovsky) & 'Salutogenesis' is based on the Latin term 'salus' (health, well-being) and the Greek word 'genesis' meaning emergence or creation. The salutogenic concept emphasises a role for a 'sense of coherence' in managing and overcoming stress.  \\
 & Neurovisceral Integration Across the Continuum of Time (NIACT) model (Kemp) & A life-course theoretical framework for wellbeing, characterising pathways to ill-being versus wellbeing, highlighting a key role for the vagus nerve. NIACT is complimentary to the GENIAL model of wellbeing (see below).  \\
Community & Social identity theory (Haslam) & Groups provide individuals with a sense of meaning, purpose and meaning with positive psychological consequences. This theory has led to the publication of a book titled 'The New Psychology of Health', which emphasises the importance of positive social ties. \\
 & Conceptual models on the social determinants of health (SDOH) & Multiple models have been proposed, however a recent review  by Lucyk and McLaren (2017) emphasised the role of health equity and social gradients as major concepts. \\
 & GENIAL 1.0 [genomics-environment-vagus nerve-social interaction-allostatic regulation-longevity] model (Kemp) & Builds on the NIACT model, again emphasising a role for the vagus nerve in a host of psychological and physiological processes. Novel aspects include the role of social ties and sociostructural factors. \\
Environmental & Biophilia hypothesis (Wilson) & Core assumption is that human beings have a strong, innate affiliation with the biological world.  \\
 & Psycho-evolutionary theory (Ulrich) & Restorative influences of nature involve a shift toward more positive emotions, parasympathetic dominated responses (heart rate deceleration) and sustained -- yet non-taxing -- attention.  \\
 & Topophilia hypothesis (Sampson) & A broadening of the 'biophilia' hypothesis to encompass non-living, physical elements, emphasising human affiliation with the local environment ('place') and a role for cultural experience. \\
 & Positive psychology of sustainability (Corral-Verdugo) & Sustainable behaviour is characterised as a positive behaviour aimed at protecting the socio-physical environment involving pro-ecological, altruistic, frugal and equitable behaviors, which have positive psychological consequences.  \\
 & Model of sustainable happiness (O'Brien) & 'Sustainable happiness' is defined as individual, community, and/or global well-being that does not involved exploitation of other people, the environment, or future generations. Critically, it is distinguished from 'sustaining happiness' or 'sustainable increases in happiness'. \\
 & Model of sustainable wellbeing (Kjell) & Places the construct of wellbeing within the framework of sustainability, highlighting interdependencies between the individual, others and nature. \\
 & Social-ecological theory (Cohen) & Emphasises dynamic relationships among individuals, groups and their environments. Complementary to this is Glenn Albrecht's concept of the 'symbioment', which has particular relevance to the present review paper given the direct link between the environment and human emotions. The symbioment refers symbiotic coexistence in which 'all life exists within living systems at various scales.' \\
\end{tabulary}
\caption{{Summary of major theories and models of wellbeing
{\label{348217}}%
}}
\end{table}\par\null\par\null

\textbf{3.1: Focus on the individual~}

\par\null

In terms of~ individual factors contributing to health and wellbeing,
our original GENIAL framework highlighted the critical role of positive
psychological experiences as well as positive health behaviours. We use
the term `psychological experiences' to refer to an individual's
interpretation of life events and the temporal narrative relating to the
events over one's life course via cognitive and emotional processes.
Although there is a wealth of evidence demonstrating a
reciprocal~relationship between health behaviours and psychological
experiences, reviews on one typically do not discuss the other. There
are two potential reasons for this: 1) the distinction between mind and
body remains an issue of great philosophical debate, with consequences
for mental and physical health, and, 2) researchers tend to work in
disciplinary silos, a phenomenon reinforced by higher education, focused
research areas and targeted funding initiatives. In this section we
discuss both~positive psychological experiences and positive health
behaviours, laying the foundation for improving individual wellbeing
with an eye towards applying this information to improving wellbeing in
people living with chronic conditions in future research.~

\par\null

\subsubsection{\texorpdfstring{\emph{Psychological
experience~~}~}{Psychological experience~~~}}

{\label{407732}}

Major theories relating to the wellbeing of individuals
(Table~{\ref{348217}}) can be categorised according to
two contrasting philosophical positions: hedonic and eudaimonic
wellbeing. According to the hedonic standpoint, wellbeing is achieved by
focusing on pleasurable experiences in order to enhance positive affect.
A major theory is the `tripartite model of subjective wellbeing',
proposed by~\hyperref[csl:8]{(Diener, 1984)}, highlighting a role for life
satisfaction, decreases in negative affect and increases in~positive
affect. Another key model is the `broaden and build' theory by Barbara
Fredrickson~\hyperref[csl:48]{(Fredrickson, 2001)}, which emphasises a role for positive
emotions such as joy, interest, contentment, pride and love in
broadening individual thought-action tendencies that subsequently build
personal resources for individual growth, social connection and
psychological resilience. Research has shown that positive emotions
increase the perception of social connectedness, enhance vagal function,
and facilitate the adoption of positive health behaviours, among other
factors~\hyperref[csl:49]{(Kok \& Fredrickson, 2010}; \hyperref[csl:50]{Sin et al., 2015}; \hyperref[csl:51]{Kok et al., 2013)}.~Recent longitudinal
research~\hyperref[csl:52]{(Petrie et al., 2018)} observed that participants in a low positive
affect grouping have a twofold increased risk for mortality, compared to
those in the more favourable grouping over a 16.5 year follow-up period.
Positive affect has been shown to affect health via inflammation, such
that greater trait positive affect is associated with reduced
pro-inflammatory cytokines~\hyperref[csl:53]{(Stellar et al., 2015)}. Interested readers are
also referred to major reviews on this topic~\hyperref[csl:54]{(Chida \& Steptoe, 2008}; \hyperref[csl:55]{DuBois et al., 2012}; \hyperref[csl:56]{Boehm \& Kubzansky, 2012)}. Our own
work emphasises the role of vagal function over these allostatic systems
\hyperref[csl:1]{(Kemp et al., 2017}; \hyperref[csl:57]{Kemp et al., 2017}; \hyperref[csl:43]{Kemp, 2018}; \hyperref[csl:58]{Kemp \& Quintana, 2013}; \hyperref[csl:59]{Kemp, 2016)}.

\par\null

In contrast to a focus on hedonia, eudaimonic theories of wellbeing look
beyond momentary happiness, focusing on purpose, meaning in life, and
flourishing. According to this perspective, Carol Ryff's Psychological
Wellbeing theory~\hyperref[csl:9]{(Ryff \& Keyes, 1995}; \hyperref[csl:10]{Ryff, 2014}; \hyperref[csl:60]{Ryff, 1989)} emphasises six elements that
contribute to psychological wellbeing including self-acceptance,
personal growth, purpose in life, positive relations with others,
environmental mastery, and autonomy. As with hedonic wellbeing,
psychological wellbeing has also been associated with improved health,
including subjective health, chronic conditions, symptoms and functional
impairment~\hyperref[csl:10]{(Ryff, 2014)}. Purpose in life reduces risk of
developing Alzheimer's disease and mild cognitive
impairment~\hyperref[csl:61]{(Boyle et al., 2010)} along with reducing risk of
death~\hyperref[csl:62]{(Boyle et al., 2009)}. Postmortem results have even revealed that -
among those with high levels of brain pathology - those with greater
purpose in life presented with better cognitive functioning whilst they
were still alive, highlighting a moderating role of purpose in life on
the relationship between brain-based pathology and cognitive
functioning~\hyperref[csl:63]{(Boyle et al., 2012)}.~A more recent study reported that a
stronger sense of purpose is associated with decreased
mortality~\hyperref[csl:64]{(Alimujiang et al., 2019)}, an effect associated with a hazard ratio
of 2.43 (95\% CI, 1.57-3.75) when comparing those in the lowest life
purpose category with those in the highest life purpose category.

\par\null

However, these theoretical models - especially those focusing on hedonia
- have faced criticism. As alluded to above, the focus on `happiology'
has been criticised as lacking in nuance. Positive affect alone is not
sufficient for improving wellbeing and over-valuing the need to be happy
can actually lead one to feel less happy~\hyperref[csl:65]{(Mauss et al., 2011)}, and may
even be associated with the symptoms and diagnosis of unipolar
depression~\hyperref[csl:66]{(Ford et al., 2014)} and bipolar
depression~\hyperref[csl:67]{(Ford et al., 2015)}. Other writers have criticised the
individualistic focus, which ignores the impact of community and wider
environmental factors~\hyperref[csl:68]{(Davies, 2015}; \hyperref[csl:19]{Frawley, 2015}; \hyperref[csl:17]{Carlisle et al., 2009)}. E{udaimonic theories have
also attracted criticism for not recognising the importance of positive
emotions, leading to proposals such as Seligman's PERMA
model~\hyperref[csl:12]{(Seligman, 2011}; \hyperref[csl:13]{Seligman, 2018)}, which incorporates aspects of both hedonic
and eudaimonic theory. The PERMA model argues for a five-pronged model
of wellbeing including~}\emph{p}ositive emotions,~\emph{e}ngagement,
positive~\emph{r}elationships,~\emph{m}eaning, and~\emph{a}ccomplishment
(i.e. PERMA). According to this model, all five pillars of wellbeing
contribute to flourishing in life. While theories relate to concepts of
hedonia and eudaimonia as well as their combination, recent research has
shown a large overlap between them. For instance, research by Todd
Kashdan and colleagues~\hyperref[csl:69]{(Disabato et al., 2016)}~reported a high latent
correlation of .96 between Diener's subjective wellbeing model of
hedonia~\hyperref[csl:8]{(Diener, 1984)} and Ryff's psychological wellbeing model of
eudaimonia~\hyperref[csl:60]{(Ryff, 1989)} indicating that the discriminant validity
of these constructs is negligible. Critically, analyses across seven
geographical world regions revealed similar results. The authors
however, noted three exceptions to this trend, which were `hope',
`meaning orientation' and `grit', which differentially related to
hedonia and eudaimonia, giving some support to the discriminant validity
of the two constructs. In another study by the same
authors~\hyperref[csl:70]{(Goodman et al., 2017)}, PERMA was observed to measure the same type
of wellbeing as Diener's model of subjective wellbeing with confirmatory
factor analysis yielding a latent correlation as high as .98. The
authors subsequently criticised PERMA for not offering any further
insights into wellbeing beyond the former theory of SWB. In response to
this, Seligman has argued that PERMA is not ``redundant'' simply because
different models correlate; instead, PERMA presents a model that
constitutes the critical elements of wellbeing~\hyperref[csl:13]{(Seligman, 2018)} and
one what that we draw and build on in our own applied research (see
section {\ref{223145}}).~

\par\null

Building on strong theoretical foundations and an extensive body of
research, our previously published models~\hyperref[csl:35]{(Kemp et al., 2017}; \hyperref[csl:1]{Kemp et al., 2017)}~argue that
healthy vagal nerve function,~underpin and are impacted on by positive
psychological moments, facilitating longer-term improvements in health
and wellbeing. These insights are based on a strong body of evidence.
For instance, Todd Kashdan and Jonathan
Rotenberg~\hyperref[csl:71]{(Kashdan \& Rottenberg, 2010)}~argued that vagal function is an index of
psychological flexibility (PF) that is fundamental for psychological
health. Psychological flexibility is an important component of
resilience, facilitating ones capacity to assess and adapt to demands,
alter mindset and behaviour when necessary, and for commitment to
behaviours that are congruent with deeply held
values~\hyperref[csl:72]{(Kashdan \& Rottenberg, 2010)}. Conversely, psychological inflexibility has
been associated with worsened mental health and an exacerbated
stress~\hyperref[csl:73]{(Masuda \& Tully, 2011}; \hyperref[csl:74]{Kato, 2016}; \hyperref[csl:75]{Chawla \& Ostafin, 2007}; \hyperref[csl:76]{White et al., 2013}; \hyperref[csl:77]{Smeekens et al., 2007)}. An inflexible response style - characterised
by withdrawal of the vagal brake - plays a key role in the development
of and symptomatology of depression~\hyperref[csl:78]{(Nolen-Hoeksema et al., 2008)}, along with
explanatory inflexibility (applying the same attribution style cross
different situations) and inflexible coping
behaviours~\hyperref[csl:79]{(Fresco et al., 2006}; \hyperref[csl:80]{Moore \& Fresco, 2007)}. According to~\hyperref[csl:71]{(Kashdan \& Rottenberg, 2010)}, vagal
function underpins the capacity for psychological flexibility.
Intriguingly, Bethany Kok and Barbara
Fredrickson~\hyperref[csl:81]{(Kok \& Fredrickson, 2010}; \hyperref[csl:82]{Kok et al., 2013)}~demonstrated that change in vagal
function - following training in loving kindness meditation - is
associated with increases in positive emotions and enhanced perception
of social connectedness, suggesting that positive emotions facilitate
physical health via the vagus nerve. The link between individual and
community is a topic that we turn to following our~discussion of
positive health behaviours.

\par\null

\subsubsection{\texorpdfstring{\emph{Health
behaviours~}}{Health behaviours~}}

{\label{138512}}

Whilst health behaviours are typically thought of with respect to their
impact on physical health, there is now compelling evidence that health
behaviours impact on both physical~and mental health. Accordingly, and
in contrast to many other models of wellbeing~\hyperref[csl:60]{(Ryff, 1989}; \hyperref[csl:8]{Diener, 1984}; \hyperref[csl:83]{Seligman, 2011)}, we
have proposed a key role for health behaviours in facilitating
individual pathways to health, wellbeing and
longevity~\hyperref[csl:1]{(Kemp et al., 2017)}. Moreover, we propose the vagal nerve acts
as the structural link between physical and mental health and plays a
critical role in reciprocal relationship between positive health
behaviours, and physical and mental health. In this section, we present
some key studies highlighting the importance of health behaviours in
physical and mental health outcomes. An exhaustive review is beyond the
scope of this paper however, and interested readers are referred
to~\hyperref[csl:1]{(Kemp et al., 2017)}. Given the number of health behaviours, for
brevity, we focus specifically on physical activity, diet and sleep.~~

\par\null

\emph{Impact of health behaviours on physical health:}

\par\null

A summary of public health guidelines and associated evidence-base
relating to physical activity, diet and sleep is provided in Table 2.~

\par\null\selectlanguage{english}
\begin{table}[h!]
\centering
\normalsize\begin{tabulary}{1.0\textwidth}{CCCC}
Health Behaviours & UK Government Guidelines (Adults 18+) & Peer-reviewed literature & Comparison: Guidelines vs Research \\
Diet: Fruit and Vegetable Intake & Consume at least five portions a day (or 400g) (Public Health England, 2016) & Dutch guidelines based on 29 systematic reviews of meta-analyses comprising RCTs and the risk of chronic disease based on diet choices - 200g of fruit and 200g of vegetables daily (Kromhout et al., 2016). Although research highlights benefits in increasing fruit and vegetable intake up to 800g per day in regards to reducing risk for heart disease, cardiovascular disease and all-cause mortality (Aune et al., 2017). In addition to these physical health benefits, increasing fruit and vegetable portions has been shown to be beneficial in improving wellbeing (Mujcic \& Oswald, 2016): 8 portions a day increases life satisfaction by 0.24 points, equivalent to the psychological gain of moving from unemployed to employed. & UK guidelines may be an underestimate of the ideal amount of fruit and vegetable consumption given the health benefits of eating more than 5 a day for both physical and mental health.  \\
Diet: Other food items & Consume at least two portions of fish (2x 140g) weekly (one of which is oily fish), consume some beans, pulses, eggs, meat and other proteins, and limit unsaturated oils and spreads (Public Health England, 2016) & Dutch guidelines - Limit consumption of red meat, a few dairy portions daily, eat legumes weekly, consume at least 15g of unsalted nuts daily, consume oily fish weekly, zero alcohol (or less than one glass daily), less than 6g salt daily (Kromhout et al., 2016). Dietary interventions have also been shown to improve mental health (symptoms of depression and anxiety) (Firth et al., 2019) - examples include adherence to a Mediterranean diet, coaching in healthy eating, and calorie-restricted diets. & Guidelines do not specify recommended amounts of more general food items, such as legumes and red meat. It would be beneficial to provide evidence-based recommendations on these foods. \\
Diet: Alcohol Consumption & Less than 14 units per week (Public Health England, 2016) & There is a J-shaped curve with alcohol consumption and cardiovascular health (O'Keefe et al., 2014), the benefits of drinking peaks around 2 nonheavy occasions per week (Plunk et al., 2014), with mortality risk increasing thereon after. Drinking more than 60g on one occasion increases risk of CHD (Kromhout et al., 2016). The J-shaped curve between alcohol and health is not present for risk of cancer; even light drinkers display increased risk compared to non-drinkers (Cao et al., 2015). & Limiting alcohol consumption to less tan 14 units per week is reasonable given the evidence; given that research highlights a J-shaped curve for alcohol consumption and many health outcomes it would unreasonable to recommend a zero-alcohol diet. However, a recommended restriction is beneficial given the severe health outcomes of drinking heavily.  \\
Physical Activity & At least 150 minutes of moderate aerobic exercise a week, in addition to a minimum of two strength exercise sessions weekly (Public Health England, 2019)  & 15 minutes of exercise a day reduces all-cause mortality risk by 14\% (Wen et al., 2011); exercise also improves mental health, with specific exercises (such as team sports and cycling) being more effective (Chekroud et al., 2018) & Guidelines could be more focused in the types of exercise that is recommended, given that the evidence base highlights certain sports to be more efficacious in health outcomes.  \\
Sleep & Between 6-9 hours each night (NHS, 2019) & No less than 7 hours per night to promote optimal health, with less than 7 hours per night on a regular basis being associated with adverse health outcomes, including obesity, diabetes, heart disease, stroke and depression (Watson et al., 2015). Daytime napping shown to be beneficial for healthy adult populations - improving cognition and wellbeing (Milner \& Cote, 2009). However, emotional reasons for napping are associated with reduced wellbeing, while restorative reasons for napping improves the health outcomes (Duggan et al., 2018). & A discrepancy arises among sleep guidelines, with the UK recommending between 6-9 hours a night, despite the evidence base recommending no less than 7 hours to avoid adverse health outcomes.  \\
\end{tabulary}
\caption{{Summary of public health guidelines and associated evidence-base
relating to physical activity, diet and sleep. Key references include
\protect\hyperref[csl:84]{(Kromhout et al., 2016}; \hyperref[csl:85]{Aune et al., 2017}; \hyperref[csl:86]{Mujcic \& J.Oswald, 2016}; \hyperref[csl:87]{Firth et al., 2019}; \hyperref[csl:88]{O'Keefe et al., 2014}; \hyperref[csl:89]{Plunk et al., 2013}; \hyperref[csl:90]{Cao et al., 2015}; \hyperref[csl:91]{Wen et al., 2011}; \hyperref[csl:92]{Chekroud et al., 2018}; \hyperref[csl:93]{Watson et al., 2015}; \hyperref[csl:94]{MILNER \& COTE, 2009}; \hyperref[csl:95]{Duggan et al., 2016)}%
}}
\end{table}\par\null

Research on over 20,000 participants analysed the impact of key positive
health behaviours on mortality risk - non-smoking, physical activity,
consumption of less than 14 units of alcohol per week and a diet rich in
fruit and vegetables. Participants who adopted all four health
behaviours at baseline had a mortality risk that was equivalent to being
14-years younger at follow-up (average of 11-years later), compared to
those who adopted none of the positive health
behaviours~\protect\hyperlink{Khaw2008}{(Khaw et al., 2008)}. A more
recent study focused on six health behaviours: non-smoking, physical
activity, healthy diet, sleeping seven to eight hours a night,
inactivity less than eight hours a day, and daily social
contact~\protect\selectlanguage{ngerman}\hyperlink{Martux5cux25C3ux5cux25ADnez__minus__Gux5cux25C3ux5cux25B3mez2013}{(Martínez-Gómez
et al., 2013)}. Results again highlighted a mortality risk that was
equivalent to being 14-years younger for those who adopted these
behaviours relative to those who adopted none of
them.~\protect\hyperlink{Wen2011}{Wen et al. (2011)} conducted a
prospective cohort study with over 400,000 individuals between
1996-2008. Surprisingly, even those individuals in a low physical
activity group (average of 15 mins a day or 92 mins per week) had a 14\%
reduced risk of all-cause mortality. Moreover, every additional 15
minutes of daily exercise beyond this minimum amount, reduced all-cause
mortality by further 4\%.~The authors argued that less exercise is
easier to achieve for those who do not engage in any physical activity
at all, and yet it may still be sufficient to achieve health benefits.
Moreover,~\protect\hyperlink{Lee2014}{Lee, Pate, Lavie, Sui, Church, and
Blair (2014)} concluded that running 5-10 minutes a day at slow speeds
(less than 6mph) is even associated with reduced all-cause risk of
mortality, providing further evidence that exercising below current
minimum guidelines is sufficient for mortality benefit. Once a routine
is established individuals may then be able to be motivated to exercise
at higher levels.~

\par\null

The relationship between diet and physical health has been widely
reported in the literature. For example, the vegetarian diet has been
associated with a reduced risk for disease development, including
coronary heart disease and type 2 diabetes, compared with a diet
containing red and processed
meat~\protect\hyperlink{McEvoy2012}{(McEvoy, Temple, and Woodside,
2012)}. Insufficient fibre has been associated with colon cancer, high
blood cholesterol, diabetes, coronary heart disease and
obesity~\protect\hyperlink{cowbrough2005}{(Jefferson and Cowbrough,
2005)}. Diet is also associated with all-cause mortality, with one study
reporting findings based on a sample of 2000 individuals, finding that
those adhering to a Mediterranean diet had an all-cause mortality risk
that was 34\% lower than those who did not adhere to the
diet~\protect\hyperlink{Limongi2017}{(Limongi et al.,
2017)}.~~\hyperref[csl:96]{(Watson et al., 2015)} concluded that 7 hours or more sleep per
night produces optimal health in adults. Sleeping less than 7 hours a
night is associated with obesity diabetes, hypertension, heart disease,
stroke, depression and increased mortality. Moreover, a recent
prospective twin
study~\protect\hyperlink{ux5cux25C3ux5cux2585kerstedt2017}{(Åkerstedt
2017)} found that both short (defined as \textless{}6.5 hours) and long
(defined as \selectlanguage{english}[?]9.5 hours) sleep were linked to increased
mortality.~However, it is important to note that these statistics are
generalisations and that other research has shown that~ small groups of
people are able to function healthily on shorter periods of
sleep~\protect\hyperlink{Pellegrino2014}{(Pellegrino et al.,
2014;}~\protect\hyperlink{He2009}{He et al., 2009)}.~~

~

\emph{Impact of health behaviours on physical and mental health:~}
Focusing on health behaviours - including exercise, diet and sleep -
typically involves consideration of one's physical health, however there
is now convincing evidence that demonstrates the impact of positive
health behaviours on mental wellbeing, supporting declarations that
there is `no health without mental health'~\hyperref[csl:2]{(Prince et al., 2007)}. In a
study which included over 4,500 adolescents, health behaviours were
measured across several domains; diet, specifically consumption of
carbonated soft drinks and fast food, tobacco use and physical activity.
Participants were then allocated a number ranging from zero to ``four or
more'' depending on the number of unhealthy behaviours they engaged
in~\protect\hyperlink{Rao2015}{(Rao et al., 2015)}. Results highlighted
that participants with a score of four or more were significantly more
likely to be anxious, experience suicidal ideation and have been
involved in a physical fight, compared to those who scored
zero.~Analysis of over 2,400 Chinese college students found those who
frequently consumed alcohol, had disturbed sleep, poor dietary behaviour
and internet addiction disorder. This was associated with significant
increased risk of depression and anxiety~\protect\hyperlink{Ye2016}{(Ye
et al., 2016)}. ~

\par\null

With respects to physical activity and mental health, research on a
sample of 49 unique prospective studies (N=266,939), showed that
physical activity protected against depression, irrespective of age and
geographic region~\hyperref[csl:97]{(Schuch et al., 2018)}. In a cross-sectional study of more
than 1 million individuals in the U.S.~\hyperref[csl:92]{(Chekroud et al., 2018)}, exercisers
displayed 43\% fewer days of poor mental health than non-exercisers. The
authors further reported that all exercise types were associated with a
lower mental health burden (from 11.8\% to 22.3\% reduction), and the
activities identified with the largest associations included popular
team sports (22.3\% lower), cycling (21.6\%~ lower),~and~aerobic~and
gym~activities (20.1\% lower).~Exercise duration of~45~minutes and
frequencies of~ three to five times per week were associated with the
lowest mental health burden.~

\par\null

With respects to diet and mental health, combined data from four
longitudinal studies found a risk estimate of highest vs. lowest
adherence to the Mediterranean diet of 0.67 (95\% CI 0.55-.82) for
incident depression~\hyperref[csl:98]{(Lassale et al., 2018)}. The Mediterranean diet has also
been implicated in slowing age-related deterioration, including
improvements in cognitive function and reducing risk of cognitive
impairment and dementia~\protect\hyperlink{Petersson2016}{(Petersson
2016,}~\protect\hyperlink{Aridi2017}{Aridi 2017)}, with B-vitamins and
antioxidants playing a key role~\protect\hyperlink{Moore2018}{(Moore et
al., 2018;}~\protect\hyperlink{Castelli2018}{Castelli et al., 2018)}.
Several randomised controlled studies, showed that a modified version of
the Mediterranean diet reduced depression
symptomology~\hyperref[csl:99]{(Parletta et al., 2017)} and~\hyperref[csl:100]{(Opie et al., 2017)}. Based on the
evidence, dietary recommendations for the prevention of depression have
been proposed; adopting ``traditional'' diets, such as the Mediterranean
diet, increasing consumption of fruits, vegetables, legumes, wholegrain
cereals, nuts, seeds, foods rich in omega-3 polyunsaturated fatty acids
and limit consumption of processed
foods~\protect\hyperlink{Opie2017}{(Opie et al., 2017)}. We note here
that socio-structural factors (e.g. inequality and poverty) will impact
on individuals capacity to follow such advice \hyperref[csl:101]{(Darnton-Hill et al., 2004)}.

~

With regards to sleep, a systematic review and meta-analysis of 14
studies found sleep disturbances significantly predicted the risk of
suicidal ideation; an effect not moderated by
depression~\hyperref[csl:102]{(Liu et al., 2019)}. Poor sleep is also associated with common
mental disorders, while improving sleep in these patients can lead to
mental health improvements~\protect\hyperlink{Freeman2017}{(Freeman et
al., 2017)}. Analyses on nearly 100,000 adolescents in Japan found a
U-shaped association between mental health status and sleep
duration~\protect\hyperlink{Kaneita2007}{(Kaneita et al., 2007)}. The
authors also reported a positive correlation between mental health
status and subjective sleep assessment. Similarly, among an elderly
population, sleep problems were associated with worsened mental and
physical health-related quality of
life~\protect\hyperlink{Reid2006}{(Reid et al., 2006)}.

\par\null

Critically, each of these health behaviours - physical activity, diet
and sleep - have a powerful impact on vagal
function~\hyperref[csl:57]{(Kemp et al., 2017)}. Thus, improving positive health behaviours
is a powerful means to promote health~and wellbeing. As with physical
activity~\hyperref[csl:103]{(Sandercock et al., 2005}; \hyperref[csl:104]{Raffin et al., 2019)} and diet~\hyperref[csl:105]{(Young \& Benton, 2018)}, changes in
sleep are associated with changes in vagal function, such that reduced
vagal function (combined baseline and reactivity measures) is associated
with sleep
disruption~\protect\hyperlink{El__minus__Sheikh2013}{(El-Sheikh, Erath,
and Bagley, 2013)}. Intriguingly, increases in resting state vagal
function have been shown to predict better subjective and objective
sleep quality~\protect\hyperlink{Werner2015}{(Werner et al.,
2015;}~\protect\hyperlink{Grimaldi2016}{Grimaldi et al., 2016)}. By
contrast, reduced heart rate variability (HRV) - an index of vagal
functioning - has also been detected during early stages of
sleep-related breathing
disorders~\protect\hyperlink{Aeschbacher2016}{(Aeschbacher et al.,
2016)}.~

~

In summary, we highlight a role for positive psychological experience
and positive health behaviours in facilitating individual pathways to
health and wellbeing. We argue that this effect is moderated by vagal
function which triggers a cascade of downstream physiological processes
(Kemp et al, 2017). Accordingly, in order to facilitate pathways to
health and wellbeing, interventions should be considered that both
enhance psychological experiences and positive health behaviours.
Nonetheless, individual factors are not the only determinants of health
and wellbeing and so in the next section we explore community or
societal determinants.~Before doing so however, it is instructive to
point out the importance of building individual wellbeing in order to
achieve community and environmental wellbeing. For instance, it has been
argued that~community resilience is underpinned by the individuals
within it. This work highlighted the role of a positive outlook and
individual strengths, which underpin a community's capacity for
resilience and agency~\hyperref[csl:106]{(Berkes \& Ross, 2013)}. A greater appreciation of the
interconnectedness between individuals, and the communities and
environment in which they reside is important for considerations
relating to how we might improve the wellbeing of current and future
generations.~

\par\null

\subsection{\texorpdfstring{{Focus on
Community}}{Focus on Community}}

{\label{417151}}

In this section we focus on the relevance of community to individual
wellbeing, a major focus of our original GENIAL
model~\hyperref[csl:1]{(Kemp et al., 2017)}. Unfortunately, there is much evidence to
suggest that community is deteriorating \hyperref[csl:107]{(Kushlev et al., 2017}; \hyperref[csl:108]{Twenge, 2013}; \hyperref[csl:109]{Twenge, 2014}; \hyperref[csl:110]{Putnam, 2001)}. The reasons
for this are complicated, but may involve a host of interconnected
societal issues including~generational shifts in
narcissism~\hyperref[csl:108]{(Twenge, 2013}; \hyperref[csl:109]{Twenge, 2014)}, declines in perspective taking and
empathic concern~\hyperref[csl:111]{(Konrath et al., 2010)}, increasing individualism (versus
collectivism) in western society~\hyperref[csl:112]{(Heu et al., 2018}; \hyperref[csl:113]{Brewer \& Chen, 2007)}, and
inequalities~\hyperref[csl:114]{(Scheffer et al., 2017}; \hyperref[csl:115]{Scheidel, 2017}; \hyperref[csl:116]{\textit{{The Spirit Level: Why Equality is Better for Everyone}}, 2010}; \hyperref[csl:117]{Nolan \& Valenzuela, 2019)}. It is is worth noting here that
others~\hyperref[csl:118]{(Beery et al., 2015}; \hyperref[csl:119]{Nurse et al., 2010)} have argued that the boundaries of
`community' should be extended to the environment
(section~{\ref{479675}}) including soil, water, plants
and animals (to facilitate love and respect, and a commitment to
environmental sustainability). Considering the climate crisis as issue
we turn to in section {\ref{479675}}, it is apparent
that `community' in its broadest sense is under threat.~

\par\null

Although we would not describe ourselves as luddites, it is worth noting
that despite technological advancements and online connectedness, the
use and engagement of social media - including Facebook, Twitter and
WhatsApp - is negatively associated with eudaimonic wellbeing (as
defined by the extent to which respondents felt their life to be
worthwhile)~\hyperref[csl:120]{(``{Subjective Well-being and Social Media Use in Emerging Adulthood: Findings from two UK University Millennial Cohorts.}'', 2019)}. Interestingly, decreases in sleep
quality and self-esteem were also observed~\hyperref[csl:120]{(``{Subjective Well-being and Social Media Use in Emerging Adulthood: Findings from two UK University Millennial Cohorts.}'', 2019)}. Young
adults are increasingly connected, however their online activities are
adversely affecting their wellbeing: these findings were associated with
a medium effect size (observed correlations for two cohorts, r=-.32 and
r=-.29). In fact, research has demonstrated that use of Facebook is
associated with ill-being such that ``links clicked'' or ``status
updates'' are associated with a decrease of 5\% to 8\% of a standard
deviation in self-reported mental health~\hyperref[csl:121]{(Shakya \& Christakis, 2017)}.
Importantly, this longitudinal research demonstrated that while those
with compromised wellbeing may be more likely to use Facebook, use of
the Facebook platform is associated with reduced \emph{future
wellbeing}, even when controlling for initial wellbeing. Research by the
same authors has also shown that loneliness occurs in clusters, extends
up to three degrees of separation and may spread through a contagious
process~\hyperref[csl:122]{(Cacioppo et al., 2008)}, a finding leading to social contagion
theory~\hyperref[csl:123]{(Christakis \& Fowler, 2012)}. On this background and in light of the
'\href{https://www.netflix.com/gb/title/80117542}{The Great Hack}' it is
clear that social media companies have much to learn about promoting
wellbeing and social cohesion as well as the ethical management of their
platforms.

\par\null

Critically, loneliness has important impacts on health and wellbeing. A
meta-analysis of studies on more than 300,000 participants reported that
a lack of social ties are associated with a 50\% increased risk of
premature mortality over a 7.5 year~follow-up period, an effect that was
stronger than physical activity, smoking (15 cigarettes daily) and body
mass index~\hyperref[csl:45]{(Holt-Lunstad et al., 2010)}. In a more recent study on 48,673
participants, the same researchers~\hyperref[csl:124]{(Holt-Lunstad et al., 2015)}~observed that
social isolation (29\%), loneliness (26\%), and living alone (32\%)
increase risk for premature mortality, reporting no differences for
objective and subjective measures. Furthermore, greater impacts on
mortality were observed among those under the age of 65 years.~The
Japanese even have a word to describe ``lonely death'': `kodokushi', a
phenomenon that refers to people dying without friends or family.
Sometimes these individuals are not found for many weeks\ldots{} or
months. (``Dead people don't pay their bills''). Tragically, these
experiences characterise the modern world,~and especially
individualistic cultures.~

\par\null

Social isolation and loneliness impact on a host of behavioural,
psychological and physiological factors. Behavioural factors include
physical~{inactivity and smoking~\hyperref[csl:125]{(Shankar et al., 2011)}, substance use and
hazardous drinking~\hyperref[csl:126]{(Stickley et al., 2014)}, while psychological factors
include decreases in self-esteem, increased risk of depression, and
feelings of hopelessness~\hyperref[csl:127]{(Steptoe et al., 2004)}, both of which subsequently
contribute to dysregulation of cardiovascular, metabolic, and
neuroendocrine processes~\hyperref[csl:128]{(Grant et al., 2009)}, higher systolic blood
pressure, independent of several factors such as age, gender,
cardiovascular risk factors, medications, social support and perceived
stress~\hyperref[csl:129]{(Hawkley et al., 2010)}.~}The NIACT~\hyperref[csl:35]{(Kemp et al., 2017)} and
GENIAL~\hyperref[csl:1]{(Kemp et al., 2017)} models integrate these behavioural,
psychological and physiological factors into innovative frameworks
within which pathways to health and ill-health may be understood,
bridging the gap between psychological moments and mortality.~

\par\null

{Further to our original GENIAL model~\hyperref[csl:1]{(Kemp et al., 2017)}, the
relationship between social ties and health was recently comprehensively
reviewed in a book titled `The New Psychology of Health: Unlocking the
Social Cure'~\hyperref[csl:130]{(Haslam, 2018)}. Social identity theory helped to
contextualise this research which refers to people conforming to the
norms of the group to which they identify. Actions and thoughts of the
group become the reference point for the individual, thus, if an
individual's perception of others in a representative~group is positive,
individuals of that group will think and behave similarly. Peer
modelling has proven to be an effective intervention to increase fruit
and vegetable intake~\hyperref[csl:131]{(Horne et al., 2008)},~although only when modelled by
someone that shares the same group identity~\hyperref[csl:132]{(Cruwys et al., 2012)}.~By
contrast, if an individual was to identify with a group whose health
behaviours are risky, they are more likely to participate in negative
health behaviours. Research has shown there is a relationship~between
strength of group identification and smoking status when smoking is a
normal group behaviour~\hyperref[csl:133]{(Schofffild et al., 2001)}. Intriguingly, the more group
identities an individual has, the less likely they are to engage in
negative health behaviours, such as cigarette smoking, alcohol
consumption, and use of illicit drugs~\hyperref[csl:134]{(Miller et al., 2016)}.~ ~ ~ ~ ~ ~~}

\par\null

{Social identity theory provides a useful context within which to
understand the influence of community on the health and wellbeing of the
individual. For example, social identity provides meaning, purpose and
worth to an individuals life~\hyperref[csl:135]{(de Vroome \& Hooghe, 2013}; \hyperref[csl:136]{Nakamura, 2013}; \hyperref[csl:137]{Peterson et al., 2005)}, the importance of
which was highlighted above in our discussion of positive psychological
experiences. Social identities also facilitate the extent to which
others are likely to provide social support~\hyperref[csl:138]{(Cohen, 2004}; \hyperref[csl:139]{Levine et al., 2002}; \hyperref[csl:140]{Levine et al., 2005}; \hyperref[csl:141]{Platow et al., 2006)}, and
provide a sense of efficacy, agency and power to an individual,
contributing to the sense that `the whole is greater than the sum of its
parts'~\hyperref[csl:142]{(Haslam et al., 2018)}. Strikingly, research has demonstrated that
cardiac and respiratory patterns synchronise when members of a choir
sing in unison, compared to when singing
independently~\hyperref[csl:143]{(Timmons et al., 2015)}. This phenomenon of `physiological
linkage' may help to explain relationship
connectedness~\hyperref[csl:143]{(Timmons et al., 2015)} and the vagus nerve underpins ones
capacity for connecting with others, regulating downstream allostatic
systems that are also involved (e.g. the hypothalamic-pituitary-adrenal
axis) \hyperref[csl:27]{(Porges, 2011}; \hyperref[csl:1]{Kemp et al., 2017}; \hyperref[csl:35]{Kemp et al., 2017)}.~}

\par\null

To conclude, community is important for individual health and wellbeing
as it provides the environment in which individual health and wellbeing
may be achieved. A supportive community will therefore contribute to the
health and wellbeing of individuals within that community, and this
relationship will be a bidirectional one such that improved health and
wellbeing of the individual will help to foster community wellbeing. It
is helpful to consider the inter-connectedness of individual, community
and environmental wellbeing, consistent with social ecological
theory.~In this regard, research not only highlights the importance of
eating less meat for individual health and
wellbeing~\hyperref[csl:144]{(Pan et al., 2011)},~\hyperref[csl:145]{(Micha et al., 2010)},~\hyperref[csl:146]{(Demeyer et al., 2016)},
it also highlights the impacts of eating less meat to reduce adverse
impacts on the environment~\hyperref[csl:147]{(Poore \& Nemecek, 2018)}, reinforcing this concept
of the `symbioment' (Fig~{\ref{881013}}) which
emphasises symbiotic coexistence of all life at various scales. It is
perhaps prudent to note however, that although these
findings~\hyperref[csl:147]{(Poore \& Nemecek, 2018)} led to much fanfare in the media on the
need to `go vegan'~\hyperref[csl:148]{(\textit{{Avoiding meat and dairy is ‘single biggest way’ to reduce your impact on Earth}}, n.d.)}, other
research~\hyperref[csl:149]{(Peters et al., 2016)} reports on findings from modelling that
shows that the diets with low to modest amounts of meat (the `omnivore
diet') actually outperform a vegan diet in regards to the ``carrying
capacity'' of an agricultural land base. The authors noted that the
carrying capacity of the vegan diet fell between the 60\% and 40\%
omnivore diet options, which reflect the percentage of vegetarian food
consumed. These findings highlight - as always - that one should always
be mindful of evidence-based nuance. Finally, and in closing this
section, we would like to highlight the relationship between individuals
and community. For instance, among Western cultures, positive feelings
are associated with individual success, high self-esteem, and good
health~\hyperref[csl:150]{(Heine et al., 1999}; \hyperref[csl:151]{Kitayama et al., 2000}; \hyperref[csl:152]{Taylor \& Brown, 1988)}. In Japan however, individuals are more
likely to associate happiness with negative social consequences, such as
jealousy and disharmony among relationships~\hyperref[csl:153]{(Uchida et al., 2004)}. We now
turn our attention to the wider environment in which individuals live
and work, focusing on a major societal challenge to human health and
wellbeing: the climate crisis.

\par\null

\subsection{Focus on the Environment}

{\label{479675}}

Psychological science has been criticised for a blinkered focus on the
individual while ignoring wider, systemic
issues~issues~\hyperref[csl:17]{(Carlisle et al., 2009}; \hyperref[csl:19]{Frawley, 2015)}. Critics have argued that the
construct of wellbeing is a socio-cultural construction of western
individualism that places importance on wealth, fame and materialistic
pursuits, while neglecting neglecting our shared
environment~\hyperref[csl:17]{(Carlisle et al., 2009)}. These criticisms in combination with an
ever-increasing body of peer-reviewed literature on `happiness' and
`wellbeing' were, in part, reason for proposing our original GENIAL
framework~\hyperref[csl:1]{(Kemp et al., 2017)}, which extended theoretical frameworks of
individual wellbeing to community wellbeing. Here we focus on the
contributions from the wider environment to individual wellbeing, and on
the implications for tackling the greatest societal challenge facing
mankind: the climate. We use the term `environment' in a very general
sense in this paper, encompassing natural as well as human-built
environments, although we place emphasis on the relationship between
individual wellbeing and the natural environment given the sheer scale
of the challenge associated with the climate crisis.

\par\null

It is now accepted in scientific circles~\hyperref[csl:154]{({Intergovernmental Panel on Climate Change}, 2007}; \hyperref[csl:155]{{Intergovernmental Panel on Climate Change}, 2014)} that
humanity will face catastrophic climate change should we fail to commit
to climate action. An increase in the frequency, duration and intensity
of extreme weather events increases risk of population distress and
psychiatric disorders through disruption to food supply and damage to
community wellbeing~\hyperref[csl:156]{(Berry et al., 2009}; \hyperref[csl:157]{Hayes et al., 2018)}. Extreme weather events have
even been shown to influence the future health and wellbeing of an
unborn child with implications for brain development and metabolic
outcomes~\hyperref[csl:158]{(Dancause et al., 2015}; \hyperref[csl:159]{Dufoix et al., 2015)}. Other research has also shown that climate
change has increased global economic inequality by \textasciitilde{}25\%
over the last 50 years, with wealthy countries benefiting
disproportionally~\hyperref[csl:160]{(Diffenbaugh \& Burke, 2019)}. Rising inequality has been linked
to the middle-class squeeze, intergenerational immobility, erosion of
trust, more divided societies, rising populism, poverty, crime,
ill-health and ill-being. Interested readers are referred to the
excellent recent review by Brian Nolan and Luis Alenzuela in this regard
\hyperref[csl:117]{(Nolan \& Valenzuela, 2019)}. Critically, ratings of peer-reviewed
climate-science and self-ratings by climate change scientists themselves
has indicated that there is 97\% endorsement that humans are
contributing to the warming climate (i.e. anthropogenic climate
change)~\hyperref[csl:161]{(Cook et al., 2013}; \hyperref[csl:162]{Cook et al., 2016)}. Unfortunately, this finding remains under
appreciated in a brave new world of alternative facts and
disinformation~\hyperref[csl:163]{(Lewandowsky et al., 2013}; \hyperref[csl:164]{Lewandowsky et al., 2017)}.

\par\null

Human beings have a strong, innate affiliation with the biological
world, a phenomenon captured by the `biophilia hypothesis'. Recent
research indicates that people who spend at least two hours a week in
nature are more likely to report good health and high levels of
wellbeing than those who spend no time in nature~\hyperref[csl:165]{(White et al., 2019)}.
Furthermore, these findings were consistent across a variety of
demographic variables including sex, age-group, occupational social
grade, presence of chronic illness and whether or not individuals met
physical activity guidelines. Prior research had indicated that spending
time in nature over a two-week period boosts hedonic as well as
eudaimonic wellbeing~\hyperref[csl:166]{(Howell, 2014)}, and that effect sizes are
larger (\emph{d}s from .37 to .63) than those reported for other
positive psychology interventions (\emph{d}s from .20 to
.34)~\hyperref[csl:167]{(Bolier et al., 2013)}.~Exposure to nature can lead to transcendent
emotions~\hyperref[csl:168]{(Bethelmy \& Corraliza, 2019)}, peak experience~\hyperref[csl:169]{(Maslow, 1964)} and
psychological flow~\hyperref[csl:170]{(Csikszentmihalyi, 2014)}. Interestingly, transcendent
emotions - including compassion, gratitude and awe - foster healthy
social relationships~\hyperref[csl:171]{(Stellar et al., 2017)} and such relationships are
facilitated by spending time in nature~\hyperref[csl:172]{(Mayer et al., 2008}; \hyperref[csl:173]{Richardson et al., 2016)}, further
highlighting the inter-connectedness between individual, community and
environmental domains.~Research also reports that exposure to nature is
associated with stress reduction~\hyperref[csl:174]{(Hansmann et al., 2007}; \hyperref[csl:175]{Ulrich et al., 1991)}, feelings of
restoration~\hyperref[csl:176]{(White et al., 2013}; \hyperref[csl:177]{Wyles et al., 2017)}, subjective
wellbeing~\hyperref[csl:178]{(Johansson et al., 2011}; \hyperref[csl:179]{LUCK et al., 2011}; \hyperref[csl:180]{White et al., 2017)}, and improved cognitive
functioning~\hyperref[csl:181]{(Berman et al., 2008}; \hyperref[csl:182]{Berto, 2005)}. Human beings also have a strong
affiliation with the local environment (`place'), driven by cultural
experience~\hyperref[csl:118]{(Beery et al., 2015}; \hyperref[csl:183]{Sampson, 2012)}. This is known as the `topophilia
hypothesis'; the word topophilia combines~\emph{topos~}(place)
with~\emph{philia~}(love).~These biophilia and topophilia hypotheses
provide a foundation on which to understand the distress, pain or
sickness associated with environmental degradation of home or territory.
Glenn~\hyperref[csl:26]{(Albrecht, 2019)}, an Australian environmental philosopher
coined the term `solastalgia' after reflecting on the environmental
impacts of open cut coal mining and pollution of local power stations on
the residents of the Upper Hunter Region of NSW in Australia. He wrote
that `solastalgia' reflects a:~

\par\null

\begin{quote}
``specific form of melancholia connected to a lack of solace and intense
desolation'' associated with place-based distress~\hyperref[csl:184]{(Albrecht, 2005)}.~
\end{quote}

Feelings of guilt, shame, fear, emotional discomfort and solastalgia
have been associated with motivation to engage in environmental
sustainability behaviours~\hyperref[csl:185]{(Albrecht et al., 2007}; \hyperref[csl:186]{Dickerson et al., 1992}; \hyperref[csl:187]{Kaiser et al., 2008}; \hyperref[csl:188]{Malott, 2010)}. In order to encourage
such behaviours, scholars have proposed an `aesthetics of elsewhere',
which involves encouraging a double aesthetic judgment of `here' and
`elsewhere' to induce an aesthetic melancholia to influence consumption
decisions~\hyperref[csl:189]{(Maskit, 2011)}. However, researchers have also begun to
investigate the value of positive psychology in encouraging
pro-environmental behaviours. Positive psychology refers to the
scientific study of human flourishing and an applied approach to
enabling individuals, communities and organisations to
thrive~~\hyperref[csl:190]{(Gable \& Haidt, 2005)},~\hyperref[csl:191]{(Sheldon \& King, 2001)}.~ The positive
psychology of sustainability~\hyperref[csl:192]{(Corral-Verdugo et al., 2014}; \hyperref[csl:21]{Verdugo, 2012}; \hyperref[csl:24]{O'Brien, 2016)} is a strategy that may
help to foster what has been described as sustainable
wellbeing~\hyperref[csl:25]{(Kjell, 2011)}. In a study on 606 undergraduate students
in Mexico~\hyperref[csl:193]{(``{Happiness as Correlate of Sustainable Behavior}'', 2011)}, researchers reported that pro-ecological,
altruistic, frugal and equitable behaviours reflect the
sustainably-oriented person, and that these behaviours have positive
psychological consequences (i.e. greater happiness). A major goal of
positive psychology should now be focused on developing interventions
that promote pro-environmental behaviours, an effort that would have
substantial benefits for the wellbeing of current and future of
generations as well as the environment. In this regard, prior research
has shown that individuals engaging in pro-ecological behaviours -- such
as resource conservation -- report greater
happiness~\hyperref[csl:194]{(Brown \& Kasser, 2005)}, that altruism leads to greater long-term
happiness~\hyperref[csl:195]{(\textit{{The psychology of helping and altruism: Problems and puzzles}}, 1995)}, and that frugality predicts greater
psychological wellbeing, satisfaction and
motivation~\hyperref[csl:194]{(Brown \& Kasser, 2005)}. Notably however, equitable individuals
have been reported to be less happy due to the `negative hedonic impact
of inequality in society' as climate change exacerbates existing
inequities~\hyperref[csl:157]{(Hayes et al., 2018)}, highlighting a need for sociostructural
reforms that combat various types of inequality.
Importantly,~\hyperref[csl:117]{(Nolan \& Valenzuela, 2019)} concluded that we now have a window of
opportunity for designing and implementing sociostructural changes
through strategies and policies to halt and reverse rising income and
wealth inequality.

\par\null

The grave threat of anthropogenic climate change - referring to the
production of greenhouse gases emitted by human activity - may help to
inspire a variety of positive feelings such as altruism, compassion,
optimism as well as a sense of purpose ``as people band together to
salvage, rebuild, and console amongst the chaos and loss of a changing
climate''~\hyperref[csl:157]{(Hayes et al., 2018)}, feelings that reflect `active
hope'~\hyperref[csl:196]{(Macy J, 2012)}. The concept of `sustainable
happiness'~\hyperref[csl:197]{(O'Brien, 2016)} has been defined as ``happiness that
contributes to individual, community, and/or global well-being without
exploiting other people, the environment, or future
generations''\hyperref[csl:198]{(O'Brien, 2010)}.~

\par\null

A central concept within the field of Positive Psychology is that of
`character strengths'. In their book `Character strengths and virtues: A
handbook and classification',~\hyperref[csl:199]{(\textit{{Character strengths and virtues: A hand-book and classification}}, 2004)} describes a framework
for the identification of individual cognitive,~ emotional, social and
community strengths, protective strengths, and spiritual strengths. In
total~\hyperref[csl:199]{(\textit{{Character strengths and virtues: A hand-book and classification}}, 2004)} describe 24 character strengths which
individuals possess to more or less of a degree. A structural model of
the relationships between character strengths, virtues and sustainable
behaviours (i.e. altruistic, frugal, equitable and pro-ecological
behaviours) has been presented such that all 24 character strengths are
associated with all four sustainable behaviours~\hyperref[csl:20]{(Corral-Verdugo \& Fr{\'{\i}}as-Armenta, 2015)}. The
knowledge that pro-environmental behaviours provide opportunities to
promote happiness and build resources for resilience, in addition to
much-needed environmental benefits provides a useful foundation on which
psychological scientists could address environmental challenges through
targeted interventions focusing on the individual~\hyperref[csl:200]{(Clayton et al., 2016}; \hyperref[csl:193]{``{Happiness as Correlate of Sustainable Behavior}'', 2011}; \hyperref[csl:21]{Verdugo, 2012)}.
Recommendations included the need for psychological scientists to
incorporate a contextualised or `place-based' approach - including
aspects of the built environment and different cultures - into
initiatives designed to facilitate pro-environmental behaviours and to
engage in more interdisciplinary research.

\par\null

Unfortunately, the vast majority of people do not engage in
pro-environmental behaviours, a result of helplessness and low
self-efficacy~\hyperref[csl:201]{(Salomon et al., 2017)}. The difficulty in comprehending
problems associated with climate change, and the intangibility and
invisibility of such change may lead individuals to `sit on their hands
and do nothing', a phenomenon known as `Giddens
Paradox'~\hyperref[csl:202]{(Giddens, 2009)}. Recent qualitative
research~\hyperref[csl:203]{(``{Learning from Co-Founders of Grassroots Initiatives: Personal Resilience, Transition, and Behavioral Change – a Salutogenic Approach}'', 2017)} has investigated the psychological
processes that foster pro-environmental behaviours. Findings were
interpreted in the context of `salutogenesis'~\hyperref[csl:16]{(Antonovsky, 1996)},
which emphasises a role for a `sense of coherence' for managing and
overcoming stress. This `sense of coherence' reflect feelings of
confidence that stimuli in the (internal and external) environment are
comprehensible, manageable and meaningful. The researchers reported that
grassroots activists relied on values and attitudes, emphasising that
the problems are so vast that limits are imposed on knowledge (i.e.
comprehensibility), arguing that emotions are a key mediator between the
appraisal of a situation and motivation to take action. A sense of
personal responsibility for change was associated with an improved
perceived quality of life, attributable to empowerment and social
cohesion, which provides a sense of meaning and purpose in life.
Concrete and collective action was also observed to enhance positive
emotions and mastery experiences subsequently enhancing beliefs about
self-efficacy (i.e. manageability) \hyperref[csl:203]{(``{Learning from Co-Founders of Grassroots Initiatives: Personal Resilience, Transition, and Behavioral Change – a Salutogenic Approach}'', 2017)}.

\par\null

In summary, we have observed emerging research interest in the concepts
of sustainable happiness and wellbeing, directly linking positive
psychology to concepts relating to sustainability and pro-environmental
behaviours. Although much work remains to be done, these efforts serve
to combat criticisms of psychological science relating to a blinkered
focus on personal happiness that ignores important societal challenges.
Spending time in and caring for for the natural environment may also
provide an under-appreciated means to promote~ wellbeing that is over
and above the beneficial impacts of outdoor physical
activity~\hyperref[csl:204]{(Franco et al., 2017}; \hyperref[csl:205]{Capaldi et al., 2015}; \hyperref[csl:206]{Bowler et al., 2010)} and may even promote commitment to
pro-environmental behaviours, supporting efforts to combat the climate
crisis.~

\par\null

\section{The Updated GENIAL model: GENIAL
2.0}

{\label{170385}}\par\null

\begin{quote}
''Models, of course, are never true, but fortunately it is only
necessary that they be useful''.

-- George Box, 1979, Journal of the American Statistical Association,
74:365, 1-4
\end{quote}

The GENIAL framework illustrates common pathways to ill-health and
ill-being versus health and wellbeing. The evidence-base for these
pathways - including a key regulatory role for vagal function - have
been described~previously~\hyperref[csl:1]{(Kemp et al., 2017}; \hyperref[csl:57]{Kemp et al., 2017}; \hyperref[csl:43]{Kemp, 2018)}. While our original
GENIAL model highlighted the importance of positive social ties for
individual health and wellbeing~\hyperref[csl:1]{(Kemp et al., 2017)}, our updated model
(see Fig~{\ref{div-162276}})~ provides an important
update to our original GENIAL model, emphasising individual, community
and environmental contributors to personal wellbeing. In doing so, our
model characterises the relationships between individuals, communities
and their environments, as well as the impacts of sociostructural
factors (e.g. inequality) and their impact on the health and wellbeing
of the individual. Key features of the individual, community and
environmental domains are now briefly described with a particular focus
on vagal function.

\par\null

Our original GENIAL and NIACT models suggest that enhancing positive
psychological experiences and positive health behaviours can facilitate
individual pathways to health and wellbeing~\hyperref[csl:1]{(Kemp et al., 2017}; \hyperref[csl:35]{Kemp et al., 2017)}. In
terms of enhancing psychological experiences, broadly speaking, there
have been~two approaches; the reduction of impairment or the promotion
of wellbeing. Historically psychological interventions have typically
been weighted towards interventions that seek to reduce
impairment~\hyperref[csl:207]{(Ryff \& Singer, 1996)}. This approach assumes that health and
wellbeing are synonymous with the absence of illness, as opposed to the
presence of wellness. However,~\hyperref[csl:207]{(Ryff \& Singer, 1996)} suggest that the
`absence of wellbeing' facilitates pathways to ill-health and ill-being,
and they argue that the route to recovery will not come from only
attempting to ameliorate negative symptoms associated with ill-health.
We also advocate interventions that create a platform for the experience
of `positive psychological experiences' because environments that
promote positive emotions may help people learn to better short circuit
downward spirals to illness. In this regard, interventions from the feld
of Positive Psychology~have much to offer. Meta-analyses have
demonstrated that positive psychological interventions (PPIs) are
effective for people with or without diagnosed
disorders~\hyperref[csl:167]{(Bolier et al., 2013}; \hyperref[csl:208]{Hendriks et al., 2019}; \hyperref[csl:209]{Chakhssi et al., 2018}; \hyperref[csl:210]{Sin \& Lyubomirsky, 2009}; \hyperref[csl:211]{White et al., 2019)}, with effect sizes ranging from small to
large. Meta-analyses have further demonstrated the effectiveness of
specific positive psychological interventions (PPIs) on increasing SWB,
PWB, optimism, positive affect and life satisfaction, including the
practicing of gratitude~\hyperref[csl:212]{(Davis et al., 2016)}, the `best possible self'
intervention~\hyperref[csl:213]{(Malouff \& Schutte, 2016)}, savouring positive
emotions~\hyperref[csl:214]{(Smith et al., 2014)}, mindfulness-based
interventions~\hyperref[csl:215]{(Simpson et al., 2019)}, and performing acts of
kindness~\hyperref[csl:216]{(Curry et al., 2018)}. The three main models of
wellbeing~\hyperref[csl:13]{(Seligman, 2018}; \hyperref[csl:8]{Diener, 1984}; \hyperref[csl:9]{Ryff \& Keyes, 1995)}~provide a theoretical foundation for
developing new and novel interventions for enhancing positive
psychological experience. Importantly, research demonstrates that
despite the different theories that have been proposed for wellbeing,
each of these contributes to the same higher order construct of
wellbeing~\hyperref[csl:70]{(Goodman et al., 2017}; \hyperref[csl:69]{Disabato et al., 2016)}.~In other words, there are many
strategies through which positive psychological experience may be
enhanced.~

\par\null

Other meta-analyses on health behaviours have emphasised the role of
physical activity~\hyperref[csl:92]{(Chekroud et al., 2018)}, diet~\hyperref[csl:87]{(Firth et al., 2019)} and
sleep~\hyperref[csl:217]{(Baglioni et al., 2016)} on our mental lives. Our recent review on
vagal function~\hyperref[csl:35]{(Kemp et al., 2017)} concluded that higher resting state
vagal function is associated with positive mood states, highlighting the
utility of PPIs for enhancing a critical regulator of health and
wellbeing. Our work further emphasises the structural link between the
vagus nerve, and physical and mental health~\hyperref[csl:1]{(Kemp et al., 2017}; \hyperref[csl:57]{Kemp et al., 2017}; \hyperref[csl:43]{Kemp, 2018}; \hyperref[csl:58]{Kemp \& Quintana, 2013}; \hyperref[csl:59]{Kemp, 2016)}. It is
interesting to note here that purpose in life has been shown to predict
allostatic load ten years later~\hyperref[csl:218]{(Zilioli et al., 2015)} as measured by~the
sum of seven scores across multiple physiological systems including
cardiovascular, lipid, glucose metabolism, inflammation, autonomic
function, and hypothalmic-pituitary-adrenal risk scores. Unfortunately
however, this study did not distinguish between upstream and downstream
systems driving increases in metabolic risk as we do here. Critically,
vagal function plays a known regulatory role over inflammatory
processes, as demonstrated previously:~\hyperref[csl:36]{(Tracey, 2002)}.~

\par\null

In addition to focusing on positive psychological experience and health
behaviours, recent developments in psychological science have
highlighted a key role for social relationships for the health and
wellbeing of the individual. Therefore, individual wellbeing may also be
promoted by focusing on community, the focus of our original GENIAL
model~\hyperref[csl:1]{(Kemp et al., 2017)}. The implications of social relationships for
the health and wellbeing of the individual were recently summarised
by~\hyperref[csl:130]{(Haslam, 2018)}.~\hyperref[csl:219]{(Haslam et al., 2016)} evaluated a new
intervention that targets social isolation and disconnection, ``Groups 4
Health'' (G4H). Results highlighted the intervention to improve mental
health, wellbeing, and social connectedness up to 6-months post
intervention. In addition to this, improvements in depression, anxiety,
stress, loneliness, and life satisfaction correlated with heightened
identification with the G4H group and with multiple groups. The work by
Barbara Fredrickson and colleagues is especially relevant here,
emphasising the upward spiral of positive emotions, social connectedness
and vagal function~\hyperref[csl:81]{(Kok \& Fredrickson, 2010}; \hyperref[csl:82]{Kok et al., 2013)}. Other well established theories
of vagal function, such as the polyvagal theory~\hyperref[csl:27]{(Porges, 2011}; \hyperref[csl:28]{Porges, 1995}; \hyperref[csl:29]{Porges, 2001}; \hyperref[csl:30]{Porges, 2003}; \hyperref[csl:31]{Porges, 2007)}
highlight a role for the vagus in promoting capacity to engage with
others and regulating our emotions during such encounters.~

\par\null

Finally, our updated model emphasises the environmental context within
which individual health and wellbeing is promoted and communities
reside. Glenn~\hyperref[csl:26]{(Albrecht, 2019)} provides a solid foundation for
understanding the link between human emotion and the environment,
coining numerous words to emphasise the negative and positive
`psychoterratic' states that have important implications for the health
and wellbeing of individuals, communities and nations now and into the
future. Environmental contributors include negative and positive
psychoterratic states such as solastalgia (chronic place-based distress)
and soliphila (a neutral political term for combatting
solastalgia)~\hyperref[csl:26]{(Albrecht, 2019)}.~A review of the literature on
potential mechanisms linking nature to health identified 21 potential
pathways empirically linked to nature~\hyperref[csl:220]{(Kuo, 2015)}. These
pathways included environmental factors including phytoncides -
antimicrobial volatile organic compounds with physiological effects -
and vegetation filtering of pollutants, physiological factors such as
elevation of vagal function and immune function, psychological factors
involving positive emotions and attention restoration, and behavioural
factors including positive health behaviours such as the promotion of
physical activity and social ties. Interestingly, this paper suggested
that enhanced immune functioning might reflect a central pathway for
mediating the beneficial effects of nature on health. It is apparent
however, that vagal function plays a regulatory role over immune
function via the cholinergic anti-inflammatory
response~\hyperref[csl:42]{(Pavlov et al., 2003)}.~ Other research has shown that vagal
function may be facilitated by spending time in nature. For instance, a
recent review of the literature~\hyperref[csl:221]{(Kondo et al., 2018)}~on the impacts of
spending time outdoors on stress reported that of 17 studies reporting
on measures of HRV, 14 reported significant findings. Measures of the
high frequency (HF) component - a commonly reported measure of vagal
function - increased for participants spending time outdoors. It is
relevant to note here that measures of HF HRV are generally negatively
correlated with meaures of heart rate. That is, high levels of vagal
function - as is typically indexed by high HF HRV - are associated with
a low heart rate. Interested readers are referred to recently published
reference values for short-term resting-state HRV \hyperref[csl:222]{(Dantas et al., 2018)}.
Thus, it is against this background of findings that we suggest that
vagal function both affects and are affected by the effects of
psychological experience, health behaviours, social ties, as well as the
environment.

\par\null

In conclusion, our updated GENIAL model
(fig~{\ref{div-162276}}) summarises individual,
community and environmental contributors to human health and wellbeing.
Our model also characterises the major targets for potentially improving
wellbeing in the community including, potentially, those people living
with chronic conditions and disorders. Clinical targets include
psychological experience, health behaviour, social connections and
outdoor nature-based activities to which the tools from positive
psychology and behaviour change may be applied.~

\par\null\selectlanguage{english}
\begin{figure}[h!]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/GENIAL-2.0}
\caption{{GENIAL 2.0: Illustrates pathways to premature mortality versus longevity
within the context of community and environmental contributors to health
and wellbeing. Our original paper \protect\hyperref[csl:1]{(Kemp et al., 2017)} provides a detailed
review on which our life-course model was based.
{\label{div-162276}}%
}}
\end{center}
\end{figure}

\section{Implications for Chronic Conditions and Non-Communicable
Disease}

{\label{933427}}

Chronic conditions include diabetes, obesity, cardiovascular disease,
cancer, chronic respiratory diseases, some neurological conditions and
mental health conditions. Chronic conditions are also referred to as
non-communicable disease (NCDs)~\protect\hyperlink{diseases}{(Non
communicable dise\ldots{})}. The global burden of disease attributable
to NCDs has now outstripped the burden of communicable conditions
(Fig~\protect\hyperlink{author-label-535015}{1}), a phenomenon known as
the `epidemiological transition'. The worldwide increasing burden of
chronic conditions (Fig 1), treatment gaps and treatment
lag~\hyperref[csl:223]{(Wang et al., 2004}; \hyperref[csl:224]{PATEL et al., 2010)} are major obstacles to be overcome. The treatment
gap refers to the numbers of people who need treatment that are not
receiving it. As an example, the treatment gap for mental health
disorders has been estimated to exceed 50\% in all countries of the
world, and to reach 90\% in those with less
resources~\hyperref[csl:224]{(PATEL et al., 2010)}. The amount of time taken to receive mental
health treatment when it does exist---treatment lag--- has been
estimated to be longer than a decade~\hyperref[csl:223]{(Wang et al., 2004)}.

~

As a function of this epidemiological transition, healthcare systems are
struggling to meet increasing
demand~\protect\hyperlink{Guzman__minus__Castillo2017}{(Guzman-Castillo
et al., 2017)}. In the United Kingdom (UK), it is estimated that
approximately 30\% of the UK population have one or more chronic
conditions and that this 30\% accounts for 70\% of the spend~(Department
of Health, 2012). People living with chronic conditions are the biggest
users of the National Health Service (NHS). They are more likely to see
their general practitioner (accounting for approximately 50\% of
consultations), to be admitted as inpatients and to use more inpatient
days than those without such conditions (70\% of all inpatient bed
days), and account for 64\% more outpatient appointments~(Department of
Health, 2012).~ Our theoretical models of health and wellbeing allow
several inferences to be drawn regarding health care for people with
chronic conditions.~

~

\emph{Models of health care:} Despite the epidemiological transition,
healthcare models have not adapted to the changed landscape. The
dominant model of health care, `the acute medical model' was designed to
treat acute conditions. Inherent in the medical model are several
assumptions that are `not a good fit' when applied to people with
chronic conditions. For example, the acute model is underpinned by the
assumption that a person's `acute problem' can be fixed and that they
can be returned to a `pre-injury state'. However, chronic conditions
cannot be fixed and whereas impairment may be reduced to some extent, a
healthcare approach that attempts only to reduce symptoms misses
opportunities to promote wellbeing. The absence of illness or impairment
does not equate to wellbeing, and interventions which focus only on
reducing impairment are insufficient to tackle the challenge of chronic
conditions. With reference to our framework we argue that by building
positive psychological experiences (e.g. individual strengths, optimism
and resilience) within a supportive social network and environment,
pathways to self-sustaining cycles of positive health and wellbeing may
be triggered and maintained, supporting and facilitating wellbeing
despite the limitations imposed by the condition. Accordingly, the
management of people with chronic conditions requires a holistic
approach both within the health service and beyond -- an approach that
extends beyond a) medicine which by definition is the science and
practice of establishing diagnosis, treatment and prevention of disease;
and b) the health service given major determinants of health are
influenced by the communities and the environment we live in. Another
assumption of the medical model is that patients are `passive recipient
of care'. However, treatment outcomes for people with chronic conditions
are contingent on active collaboration between clinician and patient.
For example, adherence to treatment regimens, and adoption of
recommended lifestyle changes etc. With respect to interventions to
promote psychological experiences, interventions cannot be `done to the
patient' and successful outcomes depend on an active and collaborative
approach.~

\emph{~}

\emph{Organisational and institutional barriers within health services
and beyond:} Epidemiological studies have shown that common mental
health disorders~and physical diseases are strongly inter-connected,
highly co-morbid and share critical pathways to ill health and disease
({Druss, Walker, 2011}~),~\protect\hyperlink{O_Neil_2015}{(O'Neil
2015)}. This evidence has been captured by the tagline: `there is no
health without mental health'~\protect\hyperlink{Prince_2007}{(Prince
2007)}. As an example, the senior author on the current review (AHK)
investigated the relationship between the mood and anxiety disorders and
coronary heart disease (CHD) in
Brazil~\protect\hyperlink{Kemp_2015}{(Kemp 2015)}, observing that these
common mental disorders are associated with a threefold increase in CHD,
after full adjustment for potentially confounding factors. Common mood
disorders share an underlying diathesis whereby mechanisms that
predispose individuals to depression and anxiety for example, contribute
to the development of a range of chronic physical health conditions
across the life span, and vice versa. While the mechanisms for such a
relationship are complex, our work on this
topic~\protect\hyperlink{Kemp_2017}{(Kemp
2017,}~\protect\hyperlink{Kemp2017}{Kemp
2017a,}~\protect\hyperlink{ah2018}{Kemp
2018,}~\protect\hyperlink{Kemp_2013}{Kemp
2013,}~\protect\hyperlink{Kemp_2016a}{Kemp 2016)} - including our GENIAL
model~\protect\hyperlink{Kemp_2017}{(Kemp 2017)} - have emphasised a
role for vagal function as a mediating link between mental and physical
health~\protect\hyperlink{Kemp_2017}{(Kemp
2017,}~\protect\hyperlink{Kemp2017}{Kemp
2017a,}~\protect\hyperlink{ah2018}{Kemp
2018,}~\protect\hyperlink{Kemp_2013}{Kemp
2013,}~\protect\hyperlink{Kemp_2016a}{Kemp 2016)}. A greater
appreciation - and understanding - of the relationships between mental
and physical illnesses and their underlying mechanisms are needed so
that improved interventions and treatments may be developed which bridge
the gap between physical and mental health services. Accordingly, this
tight interconnection between physical~ and mental health needs to be
reflected in the models, infrastructure and commissioning of health
services that support people with chronic conditions.~ For
example,~relative to physical health conditions, mental disorders are
much less likely to receive treatment and this holds true across the
world~\hyperref[csl:225]{({Book Authors}, 2009)}. However, if one considers the global burden of
chronic conditions in terms of disability rather than mortality, major
depression is the second leading cause of disability~\hyperref[csl:226]{(O'Neil et al., 2015)}
preceded only by cardiovascular disease. Moreover, there is a high
degree of co-morbidity with mental and physical health conditions and we
know that mental ill health affects adherence to treatments and
prognosis~\hyperref[csl:227]{(DiMatteo et al., 2002)}. Accordingly, the commissioning bias in
favour of physical health services actually disadvantages the majority
of people with chronic conditions given the tight linkage between
physical and mental health and serves to exacerbate the challenges for
the prevention and amelioration of chronic conditions.

\par\null

There are also biases in the types of interventions offered by mental
and physical health services (with the exception of pharmacological
treatment). People with physical health difficulties are typically
prescribed physical health treatments. For example, people with
cardiovascular disease (CVD) are typically advised to partake in
healthier diets and physical activity. However, we know that there is a
strong reciprocal relationship between CVD and
depression~\hyperref[csl:228]{(Gasse et al., 2012}; \hyperref[csl:229]{Kemp et al., 2015)}. This bias misses several opportunities to
enhance health and wellbeing for people with CVD. For example, positive
psychological experiences have been associated with decreased risk of
secondary cardiovascular events and
mortality~\hyperref[csl:230]{(Boehm \& Kubzansky, 2012)};~\hyperref[csl:231]{(DuBois et al., 2015)}. It has been argued
that psychological wellbeing is a modifiable protective factor that
could decrease the impact of CVD through its potential influences on
health behaviours and CVD-related
biomarkers~\hyperref[csl:55]{(DuBois et al., 2012)};~\hyperref[csl:232]{(Sin et al., 2015)}. Conversely, mental
health services typically focus on offering psychological therapies in
addition to medication whereas much research has shown that people with
mental health conditions have poor diets~\hyperref[csl:233]{(Storlien et al., 1996)}, disturbed
sleep~\href{https://www.authorea.com/users/9886/articles/378536-rethinking-wellbeing-an-examination-of-individual-community-and-environmental-contributions-to-personal-wellbeing-with-application-to-chronic-conditions\#Lee2012}{(Lee
2012,}~\href{https://www.authorea.com/users/9886/articles/378536-rethinking-wellbeing-an-examination-of-individual-community-and-environmental-contributions-to-personal-wellbeing-with-application-to-chronic-conditions\#Ancoli__minus__Israel2006}{Ancoli-Israel
2006)}, lower levels of physical activity \hyperref[csl:234]{(Goodwin, 2003)} and social
isolation \hyperref[csl:235]{(Dom{\`{e}}nech-Abella et al., 2019)}. Moreover, interventions that target these
health behaviours significantly ameliorate
symptoms~\protect\hyperlink{Trauer_2015}{(Trauer et al.,
2015)},~~\hyperref[csl:236]{(Stathopoulou et al., 2006)},~\href{https://www.authorea.com/users/9886/articles/378536-rethinking-wellbeing-an-examination-of-individual-community-and-environmental-contributions-to-personal-wellbeing-with-application-to-chronic-conditions\#Opie2015}{(Opie
et al.,
2015;}~\href{https://www.authorea.com/users/9886/articles/378536-rethinking-wellbeing-an-examination-of-individual-community-and-environmental-contributions-to-personal-wellbeing-with-application-to-chronic-conditions\#Parletta2019}{Parletta
et al., 2019)}.~ Given that undesirable health behaviours contribute to
the aetiology and amelioration of chronic conditions; a plethora of
guidelines and recommendations regarding optimal diet, physical activity
etc. have been developed (for a summary, see Table 2). Often treatment
approaches for people with chronic conditions includes educating them
about healthier life choices.~Despite such education, the majority of
individuals fall short of pursuing a healthier lifestyle
\hyperref[csl:237]{(Newsom et al., 2011)}.

\par\null

Evidence shows that such strategies have minimal impact upon inducing
sustained change, especially in individuals of a lower socio-economic
status~\hyperref[csl:238]{(Angermayr et al., 2010)}.~~That is, `common knowledge is not common
action'. There is an inherent disconnect between what people know and
what they do - often referred to as the intention-behaviour gap
(\href{https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682236/\#R84}{Sheeran,
2002}). It is this intention-behaviour gap that creates a barrier to the
uptake of evidence surrounding well-being activities into healthcare
practice~\hyperref[csl:239]{(Francis et al., 2012)}. This is because successful change requires
more than education or communication of personalised risk
information~\hyperref[csl:240]{(French et al., 2017)}. Accordingly, in order to better
understand how to effectively target health behaviours we must move
beyond giving information and attempt to better understand how to
facilitate behavioural change. Moreover, our GENIAL framework
demonstrates that social relationships offer a target for intervention
that is typically not exploited by the health service despite research
showing that a) people with chronic conditions are often socially
isolated and, b) a lack of social ties predicts premature mortality to a
greater degree than physical activity, smoking (15 cigarettes daily) and
body mass index~\hyperref[csl:45]{(Holt-Lunstad et al., 2010)}.~ Accordingly, interventions which
seek to foster positive social ties may have much to contribute to
tackling the challenge of chronic conditions. This may be achieved by
creating networks based on collaborations between the health service and
community organisations, with both parties having a theoretical and
applied understanding of how to create environments that promote social
connectivity and wellbeing - we describe an example of this from our own
clinical practice below.~

\par\null

The original GENIAL framework highlights individual pathways to illness
and premature death and health, wellbeing and longevity. When negative,
health behaviours, psychological experiences and social ties (social
relationships, integration and cohesion) contribute to the aetiology of
chronic conditions and exacerbate the condition when present.
Accordingly, we have argued that they should be targeted in the
prevention and amelioration of chronic conditions. Given that the health
service is typically organised by `disease specific' services as
discussed above, and given that health behaviours, psychological
experiences and social ties offer a common target for intervention
across a range of diseases,~we advocate for a transdiagnostic approach
to management. That is, creating a balance between the need for disease
specific `specialisms', but also for transdiagnostic approaches that
treat some of the common diathesis that many people with chronic
conditions share (undesirable health behaviours, negative psychological
experiences, social isolation and exclusion). This approach would mean
that people with chronic conditions would be able to access
interventions based on need and efficacy not diagnosis. Transdiagnostic
services would hold expertise in; a) interventions for optimal sleep,
nutrition and~ adapted physical activity interventions couple with an
understanding of promoting behavioural change; b) links with the
community to facilitate community integration and positive relationships
with others; c) psychological interventions to both reduce impairment,
but also to improve wellbeing; d) links with academic institutions to
promote urgently needed cross disciplinary research into effective
management strategies. With a mind to the financial difficulties facing
the health service, the addition of transdiagnostic services would
negate the need to resource and skill-up all diagnostic specific
services to deliver interventions targeting heath behaviours,
psychological experiences and social connectivity. Moreover, in relation
to bridging the gap between the health service and the community, this
would be difficult for diagnostic services to do in reality.~

\par\null

Finally, our extended GENIAL 2.0 framework makes it clear that in order
to promote the health and wellbeing of entire populations, the
healthcare cannot and should not shoulder the burden alone. We present a
range of compelling evidence that the health and wellbeing of
individuals are not just determined by individual factors alone, and
that community and environmental determinants of health must also be
targeted to reduce the burden imposed by chronic conditions. This
requires a shared understanding of the problems and solutions and joined
up working between the healthcare services, community organisations and
academia. Our own work in the National Health Service has focused on
re-developing our services for people living with acquired brain
injury.~ In addition to traditional impairment focused services, we are
developing interventions to improve wellbeing, social relationships,
community integration and social identity in addition to some
interventions that involve environmental sustainability. We are doing so
in collaboration with academic institutions as well as community, third
sector and industry organisations. This service development, based on
our GENIAL framework, has application across chronic conditions.~We
discuss our work further in the following section and draw some
conclusions.

\par\null

\section{Discussion}

{\label{223145}}

Here we have presented a modern understanding of wellbeing; one that
involves `connection'\ldots{} connection to ourselves, to others and to
the environment. We suggest that vagal function provides an important
mediator of wellbeing that affects and is affected by activities to
promote wellbeing across these multiple domains. The vagus nerve
connects us to ourselves (i.e.~80\% of vagal nerve fibres are afferent
nerves~\hyperref[csl:241]{(Agostoni et al., 1957)} providing a structural link between mental
and physical health), to others (increases in vagal function facilitate
a `calm and connect' response promoting social
connectedness,~\hyperref[csl:27]{(Porges, 2011}; \hyperref[csl:1]{Kemp et al., 2017}; \hyperref[csl:82]{Kok et al., 2013)}), and to nature (vagal function is
impacted on by a host of environmental factors, as discussed in
section~{\ref{170385}}, that will subsequently promote
individual health and wellbeing). Vagal function may be considered as an
index of resilience, underpinned by psychological
flexibility~\hyperref[csl:71]{(Kashdan \& Rottenberg, 2010)} that can be enhanced through a variety
of interventions within individual, community and environmental domains,
providing a target for focused interventions.~We suggest that benefits
to vagal function could be maximised by drawing upon multiple
interventions that span these multiple domains of wellbeing. While we
have been greatly influenced by the maturing discipline of positive
psychology, we argue that the field has been limited by a restricted
focus on strategies that promote positive psychological moments and
experience. As recent research has argued that the impacts of positive
psychological interventions are smaller in size than previously
reported~\hyperref[csl:211]{(White et al., 2019)}, we argue that their impact could be
improved by integrating interventions that also focus on physical
health, which we now know to have important impacts on mental - in
addition to physical - health~\hyperref[csl:92]{(Chekroud et al., 2018)}. Integrating
interventions within community and environmental domains will likely
improve the impact of interventions further. I{t is also important to
note that wellbeing can be influenced through sociostructural factors
such as governmental policy, a consideration highlighted in our original
GENIAL model~}\hyperref[csl:1]{(Kemp et al., 2017)}{ (see
section~}{\ref{605389}}). Our updated GENIAL model
(section~{\ref{170385}}) further extends beyond the
individual and community, to incorporate the broader impacts of the
environment. Mindful of previously proposed social ecological theories
such as Glenn Albrecht's work on `Earth Emotions'~\hyperref[csl:26]{(Albrecht, 2019)},
which emphasise the connectedness between human emotions and the state
of our natural environment, we emphasise that the individual is
intimately connected to the community and environment within which they
live, in a `symbioment'. In this regard it is interesting to observe
calls~\hyperref[csl:242]{(Bratman et al., 2019)} for the modification of the~{natural
environment in ways that will promote the mental health of communities,
with research even demonstrating relationships between urban tree
density and numbers of antidepressant medications
prescribed~\hyperref[csl:243]{(Taylor et al., 2015)}. Researchers have also argued that
sociostructural changes aimed at improving the natural environment will
further contribute to improvements in wellbeing through the reduction of
inequalities~\hyperref[csl:242]{(Bratman et al., 2019)}. As noted earlier, income and welath
inequalities have~substantial impacts on societal wellbeing, and this
topic is now the subject of major international and interdisciplinary
reviews on the subject (e.g. the 5-year Deaton
Review:~\href{https://www.ifs.org.uk/}{https://www.ifs.org.uk}~funded by
the Nuffield Foundation).~~}

\par\null

Over the last few years, we have developed a novel 8-week positive
psychotherapy intervention (see table~{\ref{544962}}
for a summary of individual components) built on our innovative GENIAL
framework, incorporating interventions that focus on the individual,
community and environmental domains. Presently, we are working with
university undergraduate students and people living with acquired brain
injury, although we are seeking to broaden our focus to patients with a
variety of chronic conditions including for example, diabetes, obesity,
cardiovascular disease, common mental disorders and their comorbidity.
Interventions focusing on the individual include activities from
positive psychology (section~{\ref{407732}}) as well as
education relating to positive health behaviours
(section~{\ref{138512}}). Interventions involving the
community domain focus on building positive relationships with others in
line with social identity theory~\hyperref[csl:130]{(Haslam, 2018)}, supported by
partnership working with community organisations, such as
``Surfability'' (\url{https://surfabilityukcic.org/}) and
``Bikeability'' (\url{https://bikeability.org.uk/}), which serve to
encourage community integration
(section~{\ref{417151}}). Finally, interventions
focusing on the environment include activities such as mindful
photography, as well as partnership working with the community
organisation, `Down to Earth'
(\url{https://www.downtoearthproject.org.uk/}). This organisation
promotes wellbeing in disadvantaged populations through engagement with
the environment, especially in regards to environmental sustainability
and social ecology. For instance, our patients with acquired brain
injury were recently involved in the construction of a `community
building' using sustainable and locally sourced raw materials on the
Gower Peninsula, the first place in Britain to be named an Area of
Outstanding Natural Beauty. These are just some selected examples to
illustrate the potential to promote wellbeing in each of the domains,
and we are always seeking to engage with other academic groups, health
boards and community organisations to improve health and wellbeing in
the community, based on strong theoretical foundations.\selectlanguage{english}
\begin{table}[h!]
\centering
\normalsize\begin{tabulary}{1.0\textwidth}{CCC}
Week & Focus & Comment \\
1 & Character strengths & Identifying one's character strengths is the foundation to 'building on what is strong, rather than fixing what is wrong'. Ryan Niemiec's work in this regard provides a solid foundation in this regard. \\
2 & Emotions & Positive emotions are fundamental to theories of hedonic wellbeing. While Barbara Fredrickson's 'Broaden and Build Model' is the major focus of this section - as is Martin Seligman's 'learned optimism' and Ed Diener's tripartite model - we also emphasise the utility negative emotions, as described by Todd Kashdan \& Robert Biswas-Diener in their 'Upside of Your Darkside'. \\
3 & Engagement and 'Flow' & A core feature of positive psychology is to promote task engagement by facilitating 'psychological flow' as coined by Mih\selectlanguage{ngerman}ály Csíkszentmihályi. Flow is facilitated through activities that involve both a high level of skill and challenge. \\
4 & Positive health behaviours & Recent research highlights that positive psychological interventions may be associated with smaller effect sizes than prior studies suggested. We emphasise here the importance of building positive health behaviours to facilitate vagal function that will have positive impacts on psychological experience. We further draw upon behaviour change theory to reinforce sustain positive change. \\
5 & Positive social relationships & Our original GENIAL model emphasised the need to move beyond a focus on the individual given recent findings highlighting the impacts of social ties on health and wellbeing. We emphasise here the need to focus on positive social relationships to facilitate individual wellbeing in line with Alex Haslam's 'social identity theory'. \\
6 & Reconnecting with nature & A more moral and ethical science of wellbeing is needed that tackles criticisms of positive psychology relating to western neoliberalism and rampant individualism. We emphasise a need for reconnecting with nature and in doing so, suggest that a modern science of wellbeing could be applied to tackle major societal challenges including the climate crisis. \\
7 & Meaning and purpose & Meaning and purpose in life are major component to eudaimonic wellbeing. The work by Viktor Frankl and Paul Wong are particularly influential in this regard. We argue that meaning and purpose in life might be enhanced and facilitated through a combination of interventions that focus on the individual, community and environment.  \\
8 & Achievement & Achievement orientation is also considered to be a fundamental component to the promotion of wellbeing. Influencers include Angela Duckworth and Carol Dweck. \\
\end{tabulary}
\caption{{Overview of our 8-week positive psychotherapy intervention. Astute
readers will note that our intervention has been built around Martin
Seligman's PERMA model~\protect\hyperref[csl:12]{(Seligman, 2011}; \hyperref[csl:13]{Seligman, 2018)} and positive
psychotherapy~\protect\hyperref[csl:244]{(Rashid \& Seligman, 2018)}, which combines models of `hedonic' and
`eudaimonic' wellbeing, supplemented by a focus on positive health
behaviours, behavior change and connections to the natural environment.
{\label{544962}}%
}}
\end{table}In conclusion, we have presented a novel approach to understanding and
improving wellbeing, connecting psychological science with a social
ecological approach that considers the individual in the context of
community and the wider environment (Fig
{\ref{535015}}). Our GENIAL framework bridges the gap
between psychological science and
\href{https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/population-health-systems-kingsfund-feb15.pdf}{population
health health systems}, and provides a solid foundation for future
research on the wellbeing of the individual as well as the communities
and environments within which individuals live. In doing so, we hope
that this framework and updated theoretical review helps to move the
science of wellbeing forward to a more ethical and moral science that
considers the wellbeing of current as well as future generations,
providing an evidence base for groundbreaking national polices such as
the
\href{https://futuregenerations.wales/about-us/future-generations-act/}{`Well-being
of Future Generations (Wales) Act' (2015)}, and alerting researchers to
consider the implications and context of human wellbeing in relation to
major societal challenges such as the climate crisis.~Wellbeing
researchers ignore this context at their peril, and it is time that
funding bodies take a more supportive stance of the transdisciplinary
science that is urgently needed to achieve this goal, let alone, better
understand relationships and inter-dependencies between individual,
community and environmental wellbeing. We look forward to a future -
well-funded - scientific effort that embraces the science of behavioural
change to improve the wellbeing of not just the individual, but also of
communities,and the wider environment, bearing in mind the potential
positive impacts that improved community and environmental wellbeing
will also have at the individual level.

\par\null

\section{Acknowledgements}

{\label{788550}}

We would like to acknowledge the support of Swansea University and the
National Health Service in recognising and promoting our work through
various awards including the University Research and Innovation Award
for Outstanding Impact on Health and wellbeing (2018) and the Swansea
Bay University Health Board Chairman's VIP Award for Commitment to
Research and Learning (2018). We also acknowledge the partial funding
that we have received from our partner, Fieldbay, which has been used to
co-fund a PhD studentship that was awarded to the first author of this
manuscript (JM). Finally, we would like to express our heartfelt thanks
for the support of our service users, with whom we have built and
implemented our novel and innovative positive psychotherapy intervention
that is based on the GENIAL theoretical framework. This intervention is
now being supported by grant funding from Health and Care Research Wales
through the Research for Public Patient Benefit Scheme.

\selectlanguage{english}
\FloatBarrier
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