Toward a Framework for Positive Health
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Despite explicit reference to promoting health and wellbeing in policy, application and promotion of positive health is limited. In New Zealand, like most societies, the dominant and funded health system is deficit-based. Two disciplines that can contribute toward changing this are positive psychology and public health. From positive psychology, robust articulations of optimal wellbeing (or flourishing) have emerged and the importance of translating and promoting wellbeing is recognised. However, lifestyle behaviours have received little attention. Conversely, lifestyle behaviours are promoted in public health, but primarily to reduce health risk. To address a disconnect between positive health policy and deficit-based practice, positive psychology and public health are integrated in this thesis. The overarching thesis aim is to explore an approach for reorienting toward a framework for positive health. Biological plausibility, epidemiological evidence, and translational research are explored in this doctoral research. A review of the literature indicates the link between lifestyle behaviours and optimal wellbeing is biologically plausible. However, epidemiological research investigating associations between lifestyle behaviours and emerging measures of optimal wellbeing are limited. To address this gap, associations between lifestyle behaviours and optimal wellbeing are explored in a large, diverse sample of New Zealand adults (N=9,514). The findings show that compared with reference groups, higher levels of exercise (odds ratio: 1.61, 95% confidence interval: 1.22-2.13, p<0.01) and lower levels of sitting (OR 1.87, 1.01-3.29, p<0.01) were associated with an increased likelihood of achieving optimal wellbeing. Conversely, restless sleep (OR 0.24, 95% CI: 0.17-0.32 p<0.01) and consuming sugar drinks 5-6 times/week (OR 0.73, 95% CI: 0.53-0.95, p<0.05) were associated with a decreased likelihood of achieving optimal wellbeing. Extending these findings and using a novel combination of behaviours?sleep, physical activity, sedentary behaviour, sugar intake, and fruit and vegetable intake?the clustering of healthy (e.g., meets recommendations) and unhealthy (e.g., does not meet recommendations) dichotomies is explored (N=9,425). Outcomes show the five behaviours cluster (healthy: observed/expected 2.0, CI 1.8-2.2; unhealthy: O/E 2.1, CI 1.9-2.3); 5% of the sample endorse all five healthy behaviours; and endorsing 4-5 healthy behaviours is associated with increased odds of optimal wellbeing (OR 4.7, CI 3.8-5.7). These initial studies make a novel contribution to international wellbeing epidemiology and the findings provide the rationale for targeting lifestyle behaviours, concurrently, in a positive health intervention. The ensuing work focuses on translation of positive health into practice. The second series of studies employ formative research methods to develop in-depth insights of lifestyle behaviour messaging to laypersons? in a framework for positive health. Qualitative focus groups are used to document, for the first time in New Zealand, laypersons? perceptions of nutrition, physical activity, and sleep guidelines (N=16). Findings indicate preference for focusing on the concomitant role of the lifestyle behaviours, benefits beyond weight loss, less prescriptive physical activity and sleep messages, and individual variation. In the second formative study, adoption of a novel approach provides broader insights into lifestyle behaviour change messages that laypersons? might find appealing. The content and combinations of lifestyle and wellbeing behaviours promoted in popular lifestyle books (Amazon) and podcasts (iTunes) are systematically reviewed. This innovative approach was chosen as, similar to lifestyle behaviour interventions, the success of popular books and podcasts depends on their ability to engage laypersons. Outcomes from this study show nutrition, exercise, and sleep were promoted concurrently in 33% of books (N=21) and in 37% of podcasts (N=35). In addition, a further 33% of books and 26% of podcasts endorsed these three lifestyle behaviours and wellbeing, concurrently. Contrasting the emerging trend in popular books and podcasts, there is a paucity of public health initiatives integrating wellbeing and lifestyle behaviours to promote positive health. Based on the convergence of findings from the previous studies, the final series of studies explores the implementation of positive health. A novel audit tool (BE Well) comprising 21 wellbeing and lifestyle behaviours is developed and tested. The Be Well tool enables satisfaction across concurrent behaviours to be quickly assessed, making it ideal for identifying the most pertinent behaviours to target in a positive health intervention. Testing the utility of BE Well shows participants (N=27) were least satisfied with their consumption of sugar and processed food (89%), screen-time (85%), time spent outdoors (85%), and exercise (81%). However, test-retest reliability shows further refinement of some items in the tool is necessary. In the final study, the acceptability and feasibility of a four-week intervention integrating wellbeing and lifestyle behaviours in an innovative way is explored. Drawing together findings of the preceding studies, key components of the intervention include the BE Well tool, social support, non-prescriptive self-tailored challenges (one per week), and a penalty. Qualitative interviews (N=25) show strengths of the intervention include the BE Well audit tool and tailored challenges. Limitations include the penalty and limited interactive content. The social support component received polarising feedback. Of the 89 challenges, the majority (59%) focused on lifestyle behaviours including nutrition (22%), sleep (20%), and exercise (17%). Outcomes from the final series of studies indicate targeting lifestyle behaviours for positive health is a strategy that engages laypersons. In this thesis, positive psychology and public health were integrated to assess the biological plausibility, epidemiological evidence, and translation of positive health. In doing so, this doctoral research makes a substantial contribution to refining a framework for positive health. The challenge now is to continue to reorient the deficit-based health system toward promoting positive health. For this to occur, further evidence and testing of positive health initiatives will be required to gain financial, public, and political support.