Flourishing and the scope of medicine and public health.

A framework is put forward for the proper scope of considerations concerning flourishing within medicine, psychiatry, clinical counselling, public health and public policy. Each of these disciplines and associated institutional practices have distinctive contributions to make in advancing flourishing within society. In each case, there are also various aspects of flourishing that extend beyond each practice's purview; and yet to restrict attention only to health, narrowly conceived, limits what each of these practices can in fact accomplish. A clearer understanding of what aspects of flourishing do, and do not, lie within the bounds of each discipline and practice has the potential to better enable the pursuit of societal well-being.

Positive affect during adolescence and health and well-being in adulthood: An outcome-wide longitudinal approach.

BACKGROUND: Several intergovernmental organizations, including the World Health Organization and United Nations, are urging countries to use well-being indicators for policymaking. This trend, coupled with increasing recognition that positive affect is beneficial for health/well-being, opens new avenues for intervening on positive affect to improve outcomes. However, it remains unclear if positive affect in adolescence shapes health/well-being in adulthood. We examined if increases in positive affect during adolescence were associated with better health/well-being in adulthood across 41 outcomes. METHODS AND FINDINGS: We conducted a longitudinal cohort study using data from Add Health-a prospective and nationally representative cohort of community-dwelling U.S. adolescents. Using regression models, we evaluated if increases in positive affect over 1 year (between Wave I; 1994 to 1995 and Wave II; 1995 to 1996) were associated with better health/well-being 11.37 years later (in Wave IV; 2008; N = 11,040) or 20.64 years later (in Wave V; 2016 to 2018; N = 9,003). Participants were aged 15.28 years at study onset, and aged 28.17 or 37.20 years-during the final assessment. Participants with the highest (versus lowest) positive affect had better outcomes on 3 (of 13) physical health outcomes (e.g., higher cognition (ß = 0·12, 95% CI = 0·05, 0·19, p = 0.002)), 3 (of 9) health behavior outcomes (e.g., lower physical inactivity (RR = 0·80, CI = 0·66, 0·98, p = 0.029)), 6 (of 7) mental health outcomes (e.g., lower anxiety (RR = 0·81, CI = 0·71, 0·93, p = 0.003)), 2 (of 3) psychological well-being (e.g., higher optimism (ß = 0·20, 95% CI = 0·12, 0·28, p < 0.001)), 4 (of 7) social outcomes (e.g., lower loneliness (ß = -0·09, 95% CI = -0·16, -0·02, p = 0.015)), and 1 (of 2) civic/prosocial outcomes (e.g., more voting (RR = 1·25, 95% CI = 1·16, 1·36, p < 0.001)). Study limitations include potential unmeasured confounding and reverse causality. CONCLUSIONS: Enhanced positive affect during adolescence is linked with a range of improved health/well-being outcomes in adulthood. These findings suggest the promise of testing scalable positive affect interventions and policies to more definitively assess their impact on outcomes.

Hope in adolescence and subsequent health and well-being in adulthood: An outcome-wide longitudinal study.

BACKGROUND: A sense of hopelessness is rising at alarming levels among adolescents in the United States. There is urgent need to understand the potential implications of being hopeful on adolescents' future health and wellbeing. METHODS: This study utilized data from the National Longitudinal Study of Adolescent to Adult Health (N = 11,038, mean age at baseline = 15 years) to prospectively examine the relationship between baseline hope and a wide range of outcomes 12 years later. Thirty-eight outcomes were examined in the domains of physical health, health behavior, mental health, psychological well-being, social factors, and civic and prosocial behavior. Regression models were used to regress each outcome on baseline hope separately. Models controlled for a wide range of factors as well as prior values of the exposure (hope) and outcomes. RESULTS: Having hope for the future in adolescence was associated with improvements in 11 subsequent outcomes after Bonferonni correction, including higher cognition and self-rated health, less physical inactivity, fewer depressive symptoms, lower perceived stress, and improvement on a number of psychological and social factors including greater happiness, more satisfaction with parenting, and increased voting and volunteering in adulthood. There were also a number of associations that were close to the null, which are equally important to explore and understand. IMPLICATIONS: The results of the study may have important implications for hope-based efforts and programs aimed at improving the lives of young people and promoting their current and future well-being.

The silent epidemic of loneliness: identifying the antecedents of loneliness using a lagged exposure-wide approach.

BACKGROUND: A large and accumulating body of evidence shows that loneliness is detrimental for various health and well-being outcomes. However, less is known about potentially modifiable factors that lead to decreased loneliness. METHODS: We used data from the Health and Retirement Study to prospectively evaluate a wide array of candidate predictors of subsequent loneliness. Importantly, we examined if changes in 69 physical-, behavioral-, and psychosocial-health factors (from t0;2006/2008 to t1;2010/2012) were associated with subsequent loneliness 4 years later (t2;2014/2016). RESULTS: Adjusting for a large range of covariates, changes in certain health behaviors (e.g. increased physical activity), physical health factors (e.g. fewer functioning limitations), psychological factors (e.g. increased purpose in life, decreased depression), and social factors (e.g. greater number of close friends) were associated with less subsequent loneliness. CONCLUSIONS: Our findings suggest that subjective ratings of physical and psychological health and perceived social environment (e.g. chronic pain, self-rated health, purpose in life, anxiety, neighborhood cohesion) are more strongly associated with subsequent loneliness. Yet, objective ratings (e.g. specific chronic health conditions, living status) show less evidence of associations with subsequent loneliness. The current study identified potentially modifiable predictors of subsequent loneliness that may be important targets for interventions aimed at reducing loneliness.

Do Forgiveness Campaign Activities Improve Forgiveness, Mental Health, and Flourishing?

Objectives: To evaluate the effectiveness of a forgiveness public health intervention at promoting forgiveness, mental health, and flourishing. Methods: Colombian students (N = 2,878) at a private, nonreligious university were exposed to a 4-week forgiveness community campaign and were assessed pre- and post-campaign. Results: Forgiveness, mental health, and flourishing outcomes showed improvements after the campaign. On average, participants reported engaging in 7.18 (SD = 3.99) of the 16 types of campaign activities. The number of types of campaign activities that participants engaged in evidenced a positive linear association with forgiveness, although some activities were more popular than others and some activities were more strongly associated with increased forgiveness. For depression, anxiety, and flourishing, engaging in more activities was generally associated with greater improvements, but the patterns were less consistent relative to forgiveness. Conclusion: This forgiveness public health intervention effectively promoted forgiveness, mental health, and flourishing. Effective campaigns in diverse communities involve promoting mental and physical health through forgiveness. However, recent conflict may hinder acceptance, necessitating political capital for leadership advocating forgiveness initiatives.

Childhood maltreatment and health in the UK Biobank: triangulation of outcome-wide and polygenic risk score analyses.

BACKGROUND: Childhood maltreatment is common globally and impacts morbidity, mortality, and well-being. Our understanding of its impact is constrained by key substantive and methodological limitations of extant research, including understudied physical health outcomes and bias due to unmeasured confounding. We address these limitations through a large-scale outcome-wide triangulation study. METHODS: We performed two outcome-wide analyses (OWAs) in the UK Biobank. First, we examined the relationship between self-reported maltreatment exposure (number of maltreatment types, via Childhood Trauma Screener) and 414 outcomes in a sub-sample of 157,316 individuals using generalized linear models ("observational OWA"). Outcomes covered a broad range of health themes including health behaviors, cardiovascular disease, digestive health, socioeconomic status, and pain. Second, we examined the relationship between a polygenic risk score for maltreatment and 298 outcomes in a non-overlapping sample of 243,006 individuals ("genetic OWA"). We triangulated results across OWAs based on differing sources of bias. RESULTS: Overall, 23.8% of the analytic sample for the observational OWA reported at least one maltreatment type. Of 298 outcomes examined in both OWAs, 25% were significant in both OWAs and concordant in the direction of association. Most of these were considered robust in the observational OWA according to sensitivity analyses and included outcomes such as marital separation (OR from observational OWA, ORo = 1.25 (95% CI: 1.21, 1.29); OR from genetic OWA, ORg = 1.06 (1.03, 1.08)), major diet changes due to illness (ORo = 1.27 (1.24, 1.29); ORg = 1.01 (1.00, 1.03)), certain intestinal diseases (ORo = 1.14 (1.10, 1.18); ORg = 1.03 (1.01, 1.06)), hearing difficulty with background noise (ORo = 1.11 (1.11, 1.12); ORg = 1.01 (1.00, 1.01)), knee arthrosis (ORo = 1.13 (1.09, 1.18); ORg = 1.03 (1.01, 1.05)), frequent sleeplessness (ORo = 1.21 (1.20, 1.23); ORg = 1.02 (1.01, 1.03)), and low household income (ORo = 1.28 (1.26, 1.31); ORg = 1.02 (1.01, 1.03)). Approximately 62% of results were significant in the observational OWA but not the genetic OWA, including numerous cardiovascular outcomes. Only 6 outcomes were significant in the genetic OWA and null in the observational OWA; these included diastolic blood pressure and glaucoma. No outcomes were statistically significant in opposite directions in the two analyses, and 11% were not significant in either OWA. CONCLUSIONS: Our findings underscore the far-reaching negative effects of childhood maltreatment in later life and the utility of an outcome-wide triangulation design with sensitivity analyses for improving causal inference.

Prospective associations of multidimensional well-being with work distraction and job satisfaction: a two-wave study of US employees.

Previous studies on the associations between well-being and work outcomes, such as work distraction and job satisfaction, have largely been cross-sectional and typically focused on only one or two aspects of well-being. Using two waves of data from a sample of employees at a United States health insurance company (n = 1,234), the present brief research report examines prospective associations between six domains of well-being (emotional health, physical health, meaning & purpose, character strengths, social connectedness, and financial security) and two work outcomes (work distraction and job satisfaction). Lagged regression analyses provided some evidence indicating that higher-level well-being in several domains was associated with subsequent reduced work distraction and increased job satisfaction assessed approximately 1 year later, but the magnitude of associations with each outcome did vary by specific domain. Emotional health and social connectedness were most strongly associated with work distraction and job satisfaction. We discuss some implications of the findings, including the importance of applying a multidimensional approach to studying employee well-being and potential opportunities for organizations to support the well-being of their employees.

Reliability and Validity of a Multidimensional Measure of Subjective Community Well-Being.

An individual's flourishing is sustained by and dependent on their community's well-being. We provide one of the first studies of a measure of communal subjective well-being, focusing on individuals' relationships with their community. Using two samples from the Greater Columbus, Ohio region, we provide evidence of the reliability and validity of the Subjective Community Well-being (SCWB) assessment. The five domains of the SCWB are Good Relationships (α = .92), Proficient Leadership (α = .93), Healthy Practices (α = .92), Satisfying Community (α = .88), and Strong Mission (α = .81). A community-based sample (N = 1,435) and an online sample of Columbus residents (N = 692) were scored on the SCWB and compared across domains. We found evidence that the SCWB scores differentiate between active and less active community members. We discuss the appropriate uses of the SCWB as a measure of well-being and provide recommendations for research that could profitably utilize the SCWB measure to examine community well-being.

Moral controversies and academic public health: Notes on navigating and surviving academic freedom challenges.

Schools of public health often serve both as public health advocacy organizations and as academic units within a university. These two roles, however, can sometimes come into conflict. I experienced this conflict directly at the Harvard T. H. Chan School of Public Health in holding and expressing unpopular minority viewpoints on certain moral controversies. In this essay I describe my experiences and their relation to questions of academic freedom, population health promotion, and efforts at working together across differing moral systems.

Viewpoint diversity in public health.

Schools of public health are often situated within universities but not infrequently also function as public health advocacy organizations. Viewpoint diversity on many issues is often limited within schools of public health and does not reflect the diversity one finds in society more generally. It is argued that welcoming, and even seeking out, viewpoint diversity within public health would contribute to understanding and knowledge, to the training public health leaders and academics who can serve the whole of society, and to working together across ideological lines to better contribute to population health.

Who Benefits From Helping? Moderators of the Association Between Informal Helping and Mortality.

BACKGROUND: While informal helping has been linked to a reduced risk of mortality, it remains unclear if this association persists across different levels of key social structural moderators. PURPOSE: To examine whether the longitudinal association between informal helping and all-cause mortality differs by specific social structural moderators (including age, gender, race/ethnicity, wealth, income, and education) in a large, prospective, national, and diverse sample of older U.S. adults. METHODS: We analyzed data from the Health and Retirement Study, a national sample of U.S. adults aged >50 (N = 9,662). Using multivariable Poisson regression, we assessed effect modification by six social structural moderators (age, gender, race/ethnicity, wealth, income, and education) for the informal helping (2006/2008) to mortality (2010-2016/2012-2018) association on the additive and multiplicative scales. RESULTS: Participants who reported ≥100 hr/year of informal helping (vs. 0 hr/year), had a lower mortality risk. Those who engaged in 1-49 hr/year most consistently displayed lower mortality risk across moderators, while those who engaged in 50-99 and ≥100 hr/year only showed decreased mortality risk across some moderators. When formally testing effect modification, there was evidence that the informal helping-mortality associations were stronger among women and the wealthiest. CONCLUSIONS: Informal helping is associated with decreased mortality. Yet, there appear to be key differences in who benefits from higher amounts of informal helping across social structural moderators. Further research is needed to evaluate how the associations between informal helping and health and well-being are patterned across key social structural moderators.

Informal helping has been associated with a decreased mortality risk, but it remains unclear if this association persists across different levels of key social structural moderators. We examined whether the longitudinal association between informal helping and all-cause mortality differs across age, gender, race/ethnicity, wealth, income, and education, in a large sample of older U.S. adults from the Health and Retirement Study (N = 9,662). Participants who reported ≥100 hr/year of informal helping (vs. 0 hr/year), had a lower mortality risk. Those who engaged in 1­49 hr/year most consistently displayed lower mortality risk across moderators, while those who engaged in 50­99 and ≥100 hr/year only showed decreased mortality risk across some moderators. There was evidence that the informal helping­mortality associations were stronger among women and the wealthiest when testing effect modification. While informal helping was associated with decreased mortality, there appear to be key differences in who benefits from higher amounts of informal helping across social structural moderators. Further research is needed to evaluate how the associations between informal helping and health and well-being differ across important social structural factors.

Are loneliness and social isolation equal threats to health and well-being? An outcome-wide longitudinal approach.

The detrimental effects of loneliness and social isolation on health and well-being outcomes are well documented. In response, governments, corporations, and community-based organizations have begun leveraging tools to create interventions and policies aimed at reducing loneliness and social isolation at scale. However, these efforts are frequently hampered by a key knowledge gap: when attempting to improve specific health and well-being outcomes, decision-makers are often unsure whether to target loneliness, social isolation, or both. Filling this knowledge gap will inform the development and refinement of effective interventions. Using data from the Health and Retirement Study (13,752 participants (59% women and 41% men, mean [SD] age = 67 [10] years)), we examined how changes in loneliness and social isolation over a 4-year follow-up period (from t0:2008/2010 to t1:2012/2014) were associated with 32 indicators of physical-, behavioral-, and psychosocial-health outcomes 4-years later (t2:2016/2018). We used multiple logistic-, linear-, and generalized-linear regression models, and adjusted for sociodemographic, personality traits, pre-baseline levels of both exposures (loneliness and social isolation), and all outcomes (t0:2008/2010). We incorporated data from all participants into the overall estimate, regardless of whether their levels of loneliness and social isolation changed from the pre-baseline to baseline waves. After adjusting for a wide range of covariates, we observed that both loneliness and social isolation were associated with several physical health outcomes and health behaviors. However, social isolation was more predictive of mortality risk and loneliness was a stronger predictor of psychological outcomes. Loneliness and social isolation have independent effects on various health and well-being outcomes and thus constitute distinct targets for interventions aimed at improving population health and well-being.

Marital transitions during earlier adulthood and subsequent health and well-being in mid- to late-life among female nurses: An outcome-wide analysis.

Comparing outcomes for individuals remaining married to those for single or divorced individuals might overstate the positive effects of the decision to marry, since marriage carries an inherent risk of divorce and its associated negative outcomes. While a growing literature has examined marital transitions, confounding by past marital history remains a concern and only a limited set of outcomes have been examined. To address these issues, this study examined incident first-time marriage and incident divorce/separation in relation to multiple subsequent physical health, health behavior, psychological distress, and psychosocial well-being outcomes in a large sample of female nurses in the U.S.. Data from the Nurses' Health Study II were studied (1993 to 2015/2017 questionnaire wave, Nmarriage analyses = 11,830, Ndivorce/separation analyses = 73,018, interquartile range of baseline age = 35 to 42 years). A set of regression models were used to regress each outcome on marital transition status, adjusting for a wide range of initial health and wellbeing status in addition to other covariates. Bonferroni correction was performed to account for multiple testing. Among the initially never married, those who became married had lower mortality (RR = 0.65, 95%CI = 0.50, 0.84), lower risks of cardiovascular diseases (e.g., RRstroke = 0.64, 95%CI = 0.50, 0.82), greater psychological wellbeing and less psychological distress (e.g., ßdepressive symptoms = -0.10, 95%CI = -0.15, -0.06). Among the initially married, those who became divorced/separated had lower social integration (ß = -0.15, 95%CI = -0.19, -0.11), greater psychosocial distress (e.g., RRdepression = 1.23, 95%CI = 1.10, 1.37), and possibly greater risks of mortality, cardiovascular diseases, and smoking. Future research could study similar questions using data from more recent cohorts, examine potential mechanisms and heterogeneity, and also examine alternative social relationship types.

Differences in Multi-Dimensional Well-Being Among Factory Workers: Evidence from Six Countries.

This paper presents cross-cultural comparisons of well-being among factory workers, as measured by the six well-being domains of happiness and life satisfaction, physical and mental health, meaning and purpose, character and virtue, close social relationships, and financial and material stability. Relative ranks of well-being domains across examined groups of workers are also compared. Results are based on survey data from factory workers in Cambodia, China, Mexico, Poland, Sri Lanka, and the United States. Average well-being scores are higher among factory workers in Mexico, China, and Cambodia than in the U.S., Poland, and Sri Lanka across all domains except financial and material stability. Close social relationships were the highest ranked domain in Cambodia and China but ranked much lower (5th) in the U.S. Meaning and purpose, as well as character and virtue were highly ranked across the board. Strong social relationships seem to thrive in contexts where financial insecurity is high.

Informal Helping and Subsequent Health and Well-Being in Older U.S. Adults.

BACKGROUND: Growing evidence suggests that informal helping (unpaid volunteering not coordinated by an organization or institution) is associated with improved health and well-being outcomes. However, studies have not investigated whether changes in informal helping are associated with subsequent health and well-being. METHODS: This study evaluated if changes in informal helping (between t0;2006/2008 and t1;2010/2012) were associated with 35 indicators of physical, behavioral, and psychosocial health and well-being (at t2;2014/2016) using data from 12,998 participants in the Health and Retirement study - a national cohort of US adults aged > 50. RESULTS: Over the four-year follow-up period, informal helping ≥ 100 (versus 0) hours/year was associated with a 32% lower mortality risk (95% CI [0.54, 0.86]), and improved physical health (e.g., 20% reduced risk of stroke (95% CI [0.65, 0.98])), health behaviors (e.g., 11% increased likelihood of frequent physical activity (95% CI [1.04, 1.20])), and psychosocial outcomes (e.g., higher purpose in life (ß = 0.15, 95% CI [0.07, 0.22])). However, there was little evidence of associations with various other outcomes. In secondary analyses, this study adjusted for formal volunteering and a variety of social factors (e.g., social network factors, receiving social support, and social participation) and results were largely unchanged. CONCLUSIONS: Encouraging informal helping may improve various aspects of individuals' health and well-being and also promote societal well-being.

Spiritual needs in Denmark: a population-based cross-sectional survey linked to Danish national registers.

Background: Spiritual aspects of the human condition may give rise to spiritual pain and suffering, especially in the face of illness or difficult life situations. A growing volume of research documents the effects of religiosity, spirituality, meaning, and purpose on health. In supposedly secular societies, however, spiritual matters are rarely addressed in healthcare. This is the first large scale study to examine spiritual needs in Danish culture, and the largest study on spiritual needs to date. Methods: A population-based sample of 104,137 adult (≥18 yrs) Danes were surveyed cross-sectionally (the EXICODE study) and responses were linked to data from Danish national registers. The primary outcome was spiritual needs in four dimensions: religious, existential, generativity, and inner peace. Logistic regression models were fitted to examine the relationship between participant characteristics and spiritual needs. Findings: A total of 26,678 participants responded to the survey (25.6%). Of included participants 19,507 (81.9%) reported at least one strong or very strong spiritual need in the past month. The Danes scored highest on inner peace needs, followed by generativity, then existential, and lastly, religious needs. Affiliating as religious or spiritual, regularly meditating or praying, or reporting low health, low life satisfaction, or low well-being increased the odds of having spiritual needs. Interpretation: This study demonstrated that spiritual needs are common among Danes. These findings have important implications for public health policies and clinical care. Care for the spiritual dimension of health is warranted as part of holistic, person-centered care in what we term 'post-secular' societies. Future research should inform how spiritual needs might be addressed in healthy and diseased populations in Denmark and other European countries and the clinical effectiveness of such interventions. Funding: The paper was supported by the Danish Cancer Society (R247-A14755), The Jascha Foundation (ID 3610), The Danish Lung Foundation, AgeCare, and the University of Southern Denmark.

Interventions to Modify Psychological Well-Being: Progress, Promises, and an Agenda for Future Research.

Psychological well-being, characterized by feelings, cognitions, and strategies that are associated with positive functioning (including hedonic and eudaimonic well-being), has been linked with better physical health and greater longevity. Importantly, psychological well-being can be strengthened with interventions, providing a strategy for improving population health. But are the effects of well-being interventions meaningful, durable, and scalable enough to improve health at a population-level? To assess this possibility, a cross-disciplinary group of scholars convened to review current knowledge and develop a research agenda. Here we summarize and build on the key insights from this convening, which were: (1) existing interventions should continue to be adapted to achieve a large-enough effect to result in downstream improvements in psychological functioning and health, (2) research should determine the durability of interventions needed to drive population-level and lasting changes, (3) a shift from individual-level care and treatment to a public-health model of population-level prevention is needed and will require new infrastructure that can deliver interventions at scale, (4) interventions should be accessible and effective in racially, ethnically, and geographically diverse samples. A discussion examining the key future research questions follows.

Terminology and the Well-being Literature.

In this commentary, we offer some remarks concerning distinctions that might be drawn between psychological well-being, emotional well-being, well-being more generally, and flourishing. We put forward a flexible map of flourishing to help understand the relative place of these and other terms, and their respective nestings. We discuss some of the challenges concerning terminology related to the use of ordinary language, as well as practices of branding ordinary language expressions that potentially threaten understanding, and we offer some suggestions as to how to navigate some of these terminological challenges in the well-being literature.