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An Historical Perspective on Wellbeing

An Historical Perspective on Wellbeing

By Dr Joyce Whittington

The term wellbeing occurs frequently today in both the medical and the socio-economic literature. It is one of those concepts that everyone seems to understand but no-one seems able to define precisely. In some contexts it is used synonymously with quality of life (see Wikipedia), which is another such concept. In the literature each has been claimed to be a component of the other. Wellbeing is recognised as having multiple components, and it is essentially subjective although attempts have been made to measure some components objectively. Objective measures are useful for comparing groups or communities or countries on some aspects of wellbeing such as incidence of mental health problems, rates of disability, standard of living, but can say little about the individual person.
Some of the main components of wellbeing that would be assessed today in trying to measure an individual's overall wellbeing would include: the individual's assessment of physical and mental health, having basic needs met, financial status, work environment, job satisfaction, social environment and relationships. Today it is likely that the report of an investigation into one aspect of wellbeing would qualify 'wellbeing' with the aspect being investigated, for example 'mental wellbeing'. But this was not the case when I first became
interested in the subject; then one frequently had to infer the aspect being investigated from the context.

A literature search on wellbeing showed that in the UK the term was widely used in the 70s and 80s in the context of foetal development (physical health) with many articles on the assessment of foetal wellbeing. Later it began to be applied in the context of mental health (mental wellbeing). At the same time, wellbeing was used in the socio-economic literature in the context of deprivation associated with such things as: social class, housing and neighbourhood characteristics, gender, and poverty, the measures here being the meeting of basic needs, income and health. In all three cases, it seemed that wellbeing was being conceived as the absence of ill-being. In the case of foetal wellbeing, typically some measure of the foetus (e.g. heart rate) was related to poor outcome (e.g. foetal mortality, foetal distress in labour, low Apgar score). In the case of mental wellbeing, signs of mental illness (e.g. symptoms of depression) were measured. In the case of economic wellbeing, low income, poor housing and unemployment were considered.

In the mid 1990s I was working on the Health and Lifestyle Survey (HALS) as one of two psychologists in a multidisciplinary team. As its name implies, HALS [1] surveyed aspects of physical and mental health, measures of lifestyle such as diet, exercise, smoking and drinking, and life events via questionnaires and diaries. Participants were also visited by a nurse who measured blood pressure and lung function, administered simple cognitive tests and noted details of housing and neighbourhood. As well as cognitive tests and a personality test, the psychologists were using the General Health Questionnaire 30 item version (GHQ-30) [2], which omits somatic symptoms, to screen for possible mental health conditions in the survey population of about 9000 and follow-up population of about 6700. From a psychological point of view, it seemed clear that 'health and lifestyle' should also measure people's satisfaction with their lives or 'wellbeing'. Could this be done using the information already collected in questionnaires and interviews? It was certainly possible to measure various aspects of ill-being such as physical and mental health, poverty and poor residential neighbourhood, but was this enough? To answer this question, it was necessary to define what exactly is wellbeing. This gave rise to three further questions: is wellbeing just the absence of ill-being? How many kinds of ill-being need to be considered? If it is not just an absence of ill-being, what other aspects are there?

To investigate the first question, I used our data on mental ill-being. The GHQ-30 consists of 30 questions which are responded to on a five-point scale (much more than usual, more than usual, same as usual, less than usual, much less than usual). Half the statements are worded positively (e.g. Have you recently been feeling hopeful about your own future?) and half are worded negatively (e.g. Have you recently felt that life is entirely hopeless?). The reasoning was that if wellbeing is the opposite of ill-being, then positive answers to negatively worded questions should give the inverse distribution to positive answers to positively worded questions. What I found were the two distributions below [3].

Clearly, these are not inverses. Although most people seem to be free of mental ill -being (negative scale), they are not entirely happy (positive scale).

To try to answer the other questions, I decided to ask people what factors they felt contributed to their own sense of wellbeing. And to cover two of the prevailing aspects of wellbeing identified in the literature members of the psychiatry and economics departments in the University were asked for their views. They were simply asked to list up to six factors that they thought contributed most to their own feelings of
wellbeing. A tentative hypothesis was that the members of the psychiatry department would rate mental health (and possibly also physical health) more highly and that members of the economics department would rate basic needs and income more highly.

What was found supported this hypothesis in that, within each department, the percentages of people mentioning each of these factors were as follows:

Overall, from the entire sample it was possible to extract the following major factors of wellbeing as seen by the members of these departments:

There were many idiosyncratic responses as well as these more common themes. It was found that the whole range of responses could be grouped under three components:
Lack of adversity = basic needs met; 
good physical and mental health; no
major stress, no fear, no money worries
Positive factors = good close
relationships; mental stimulation; autonomy
Boosters = a good meal; a special outing; new clothes.

It seemed that what had been missing from the UK literature on wellbeing up to that point was attention to the positive factors, which in this piece of research were as important as the lack of adversity. It was concluded that, although there were various measures of
aspects of ill-being in the HALS data, there were no measures of wellbeing.

Moreover, it seemed obvious that it would be impossible to measure overall wellbeing because of the subjective nature of some of these factors and their salience to different individuals.

Today the literature on personal wellbeing covers more of the positive factors and most articles focus explicitly on the particular aspect of wellbeing that is being investigated. There has been a move away from trying to find objective measures (e.g. gradients of disability, actual income) towards subjective assessments (e.g. how does the individual rate their disability, how adequate does the individual regard their income) [e.g. 4]. The economic literature has also shown a shift away from simple measures of national wellbeing from income or gross domestic product (GDP) to include measures of individuals [5]. Thus my finding has subsequently been supported in so far as wellbeing is now regarded as depending largely on positive factors, rather than merely the absence of ill-being. The increasing reliance on subjective measures also confirms the view that objective global indices of an individual's wellbeing are unattainable.

[1] : BD Cox, FA Huppert & MJ Whichelow (eds) The Health and Lifestyle Survey: Seven Years On. Aldershot: Dartmouth
[2] Goldberg, D. P. and Williams, P. (1988) A User's Guide to the General Health Questionnaire. NFER-Nelson, Windsor.
[3] Whittington JE & Huppert FA (1998) Constructing Invariant Subscales of the GHQ-30.Social Science and Medicine, 46:1429-1440
[4] Jolliffe R1, Seers H1, Jackson S1, Caro E2, Weeks L3, Polley MJ4. The Responsiveness, Content Validity, and Convergent Validity of the Measure Yourself Concerns and Wellbeing (MYCaW) Patient-Reported Outcome Measure The Responsiveness, Content Validity, and Convergent Validity of the Measure Yourself Concerns and Wellbeing (MYCaW) Patient-Reported Outcome Measure Integr Cancer Ther. 2014 Nov 10. pii: 1534735414555809. [Epub ahead of print]

[5] Allin P. and Hand D.J.) The Wellbeing of Nations: Meaning, Motive and Measurement 2013, John Wiley & Sons Ltd, Chichester

Dr Joyce Whittington was a Senior Research Associate at the University of Cambridge prior to her retirement and is now a visitor to the Department of Psychiatry. Originally a mathematician with masters degrees from London and Cambridge, she later graduated in Psychology from the Open University followed by a PhD on the topic of dyscalculia from the university of Bath. Joyce worked on human-computer interaction in Cambridge, then as a psychologist on the Health and Lifestyle Survey at the University of Cambridge, before joining Professor Tony Holland in 1998 to work on Prader-Willi syndrome.


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