As the population live longer
As the population live longer, current life expectancy is 72.04 years of age (WHO 2018), the many factors which are influencing the increase in life longevity, ranging from better access to quality health care to better socioeconomic conditions, are leading to improved health and wellbeing (WHO 2018). This shows the importance of these concepts, but what are health and wellbeing and what factors can impact on them. This essay will look at concepts of health and wellbeing by considering definitions from sources such as, the World Health Organization, UK Government Policy, and the Care Act legislation. Factors that can affect health and wellbeing will then be looked at briefly, these including, socioeconomic influence, and biological determinates. The experience of loss and its impact on health and wellbeing will then be explored looking at theories of loss, including Attachment theory and the Five Stages of Grief model (Bowlby, cited in Holmes 2013, Kubler-Ross 1969). Then specifically looking at loss around bereavement, exploring Prolonged Grief Disorder and how it can impact on health and wellbeing, from psychological symptoms affecting wellbeing to physical implications for health and mortality (Shear 2015, LeBlanc 2016), whilst also acknowledging that there are some positive aspects to grief and loss such as an increased social network and positive, post loss, achievements (Frantz et, al 1998, Waugh, et al 2018).
Over the past decade global life expectancy has continued an upward trend of growth, improving from 69.48 at birth to currently 72.04 years of age (WHO 2018). With health and wellbeing an integral part of global policies (WHO 2018). The UK government (2010) introduced the National wellbeing programme to monitor the country’s life improvement, and not just growth economically, including opening a national debate about what is important to the people of the UK with an aim to try improving wellbeing. There are also policies around local authority’s responsibility to implement health and wellbeing in their planning to aim to reduce health inequalities and promote healthy living (Gov.UK, 2014). As Health and Wellbeing are of National and Global interest, they are terms which are often heard of through various platforms such as websites and blogs offering advice on how to achieve optimum health and wellbeing (Age UK 2018, Mind UK 2018, Betterhealth 2018, Selbie et al., 2018), but what exactly are health and wellbeing and what factors can impact on them.
The world Health Organization set out definitions of what health and wellbeing are as:
“A state of complete, physical, mental wellbeing and not merely the absence of disease or infirmity” (WHO 2014, p1.).
“Well-being exists in two dimensions, subjective and objective. It comprises an individual’s experience of their life as well as a comparison of life circumstances with social norms and values” (WHO 2013, p21.).
Criticisms of the World Health Organization’s health definition have centred around its outdatedness. More people are living longer with chronic illness and the requirement that to be healthy is to have complete physical and mental wellbeing is not achievable and would leave much of the population unhealthy (BMJ 2011). Health can be defined as an individual being able to self-regulate and change, adapting to their health and situations (BMJ 2011, Dulaney, et al 2017). It is also important to acknowledge the subjective experience of health, what one person may deem good health, could be another person’s idea of poor health. (BMJ 2011).
The Care Act (2014) has defined wellbeing as including, social, economic, societal, and individual aspects, alongside; physical and mental health and emotional wellbeing.
According to the Department of Health (2014), there is a reciprocal relationship between wellbeing and health. Health affects wellbeing and wellbeing in turn affects health. Health is determined as the important factor for wellbeing, with both physical and mental health impacting on wellbeing, but have given no clear definition of what health and wellbeing are, however do acknowledge that health and wellbeing are more than living longer and living without illness or disease.
These definitions of health and wellbeing show the difficulty in pinpointing a true definition of what the concepts are, as there are many determinates of health, and also due to the subjective and objective nature of what constitutes wellbeing (WHO 2018) Influencing factors of health Include – conditions and diseases which have a biological basis, such as some cancers, Parkinson’s disease, cystic fibrosis, which are hereditary and determine the individual’s health at birth (National Human Genome Research Institute (NHGRI), 2018). There are also social determinants of health as well as biological determinants according to the World Health Organisation (2018), these include the conditions an individual is born into. Individual’s living in poverty have poor health outcomes compared to individual’s in better financial situations (Gov UK. 2017).
Life experiences, such as romantic relationships, family relationships, financial worries and bereavement can impact on health and wellbeing, often causing depression and anxiety (Low et, al 2012, Boyes, et al 2015). The concept of loss is an important factor of different, often complex, life events (Murray 2001).
Attachment theory explains loss in terms of an individual’s attachment to their loss. Attachment styles and attachment behaviour are formed through an internal working model, this way of thinking is influenced by past experiences and past relationships (Bowlby, cited in Holmes. 2013 p54). Individual’s attachment to caregivers can be securely attached, whereby the individual feels safe and loved, or insecurely attached. Insecure attachment styles are divided into 3 substyles; Avoidant, ambivalent and disorganised attachments (Bowlby, cited in Holmes. 2013 p53). Insecurely attached individuals will have a range of emotions and feelings connected to their attachment figure these include; strong feelings of love, an overwhelming need to be loved, anxiety and worry at not being loved and anger (Bowlby, cited in Holmes. 2013 p53). These often complex emotions in reaction to perceived loss have consequences for an insecurely attached individual’s mental health and future relationships. Individuals suffering from maternal deprivation are more at risk of developing mental health problems, such as depression (Bowlby 1951). An insecure attachment style also has negative implications for the individual’s future relationships due to the impact on their behaviour and personality, such as psychological instability (Bowlby 1951). Attachment behaviours, such as separation protest, can be grief like in its symptoms and is an immediate response to children being separated by their caregivers, crying and bad behaviours are a natural response to an anticipated threat or trauma. (Bowlby, cited in Holmes. 2013 p53). Attachment behaviours are the natural response to a presumed threat or loss and mourning is the usual reaction to the actual loss of a loved one (Bowlby 1982).
Individuals facing terminal illness experience loss and grief connected to their impending loss of life. Terminally ill patients have been seen to go through a Five Stage Grief process in relation to their illness (Kubler-Ross 1969). The Five Stage Grief model comprises of, Stage 1: Denial, whereby the individual is unable to comprehend their diagnosis. Stage 2: Anger, the individual experiences feelings of anger or indignation at their situation. Stage 3: Bargaining, individuals experience the ‘what if’ moments where they question what they could have done differently to prevent their terminal illness. Stage 4: Depression, individuals experience sorrow and regret. Stage 5: Acceptance, individuals reach a place where they have come to terms with their diagnosis (Kubler-Ross 1969). The stages within the Five Stage Grief model are not always experienced in a logical order, and some individuals may not experience all the five stages (Kubler-Ross 1969). Stroebe, et al (2017), whilst acknowledging the usefulness of the Five Stages of Grief model as a tool to better understand grief, criticised its potential harmfulness in creating an expectation of a bereaved individual’s grief pattern and duration.
Loss is not confined to the loss of maternal care (Bowlby 1951), or individuals facing a terminal diagnosis (Kubler-Ross 1969). Loss can be the bereavement of a loved one, this can be a mother, or father or can be a spouse or child. Losing a loved one can be one of the most traumatic experiences an individual can face (Bowlby 1982). Bereavement and the subsequent grief, that is associated with the loss, are a normal process of the experience of losing something or someone (Murray 2001).
The grieving of a loved one can bring with it implications for physical and mental health, particularly in the early stages of grief when the loss is felt more acutely (Stroebe et, al 2007). Bereaved individuals are at increased risk of developing ill health, ranging from headaches, increased risk of high blood pressure, changes in the immune system, cardiovascular disease and diabetes and are also at risk of spending more time seeking medical help than non-bereaved individuals (Stroebe et, al 2007, Shear 2015, Spillane, et al 2017). Grief can also influence the mortality rate of bereaved individuals, this is seen in widowers particularly in the early months of loss and then decreases over time (Bowling 1994, Stroebe et, al 2007).
According to Kubler-Ross and Kessler (2005) grief needs to be externalised, when grief is internalized the full extent of sadness can be acknowledged. When bereaved individuals are in denial of their loss they become stuck in the emotions of their loss and find it difficult to return to a healthy way of living (Kubler-Ross and Kessler 2005). When grief becomes complicated individuals experience a continual yearning for their loved one, frequent emotional pain, they are unable to accept the loss becoming stuck in a cycle of grief, and they feel they are unable to move on without the person they have lost. (Shear 2015). Health implications when grief become complicated are extensive, these range from sleep problems, substance abuse, abnormal Immune function, problematic emotional regulation, and increased risk of cancer (Shear 2015, LeBlanc 2016).
Prolonged Grief Disorder is now a recognised mental health disorder with its inclusion into the Diagnostic and Statistical Manual for Mental Health Disorders, with an estimated one out of ten adults risk developing the disorder (Lundorff et, al 2016, Arzimendi et, al 2017, Maciejewski and Prigerson 2017). For bereaved individuals with Prolonged Grief Disorder their symptoms of intense grief do not improve over time as with ordered grief, instead their grief symptoms become dis-ordered, persistent, intense and impairs normal, everyday functioning – this can last for a considerable amount of time, months to even years (Hall 2011, Lundorff et, al 2016). Predictors for grief to become complicated suggest that attachments play a major role. Experiencing childhood anxiety, and a negative childhood environment was connected to a higher risk of problematic grief. Dependency was also connected to a higher chance of grief complications (Lobb et, al 2010).
Access to treatment and therapy are vital in reducing the symptoms of Prolonged Grief Disorder and Complicated Grief and enabling bereaved individuals normal everyday functioning (Wittouck et, al 2010, Shear 2015, Rosner et, al 2015). This is supported with an increase in awareness, skills and knowledge of complications with grief amongst medical staff (Dodd et, al 2017). There can even be positive aspects to grief health and wellbeing. Post traumatic growth included individuals being more compassionate toward others, a renewed appreciation of their loved ones, an increase in social networks, and a realisation that the individual is more resilient than they realised (Thomas et, al 1998, Waugh et, al 2018). However, individuals with Prolonged Grief disorder have shown lower levels of functioning in research for post traumatic growth, hi-lighting the difficulties of a more complicated grief and its disturbance of the grief process (Ningning et, al 2018).
Health and wellbeing, which have many determinates, are integral to living a longer life (WHO 2018). Bereavement, and the ensuing grief that follows can be life changing in its effects on health and wellbeing (LeBlanc 2016, Lundorff et, al 2016). Grief does not necessarily follow a structured path, but can include some, if not all, of the 5 Stages of Grief (Kubler-Ross 1969). Prolonged Grief Disorder, which is now recognised as a mental health disorder, and connected to the individual’s attachment to the deceased, can become complex and prolonged in its symptoms often impairing bereaved individual’s daily function (Lobb et, al 2010, Maciejewski and Prigerson 2017). There can be positive post traumatic growth after grief. Some bereaved individuals reported having a different outlook on life after the loss of their loved one and a renewed appreciation for their remaining loved ones (Waugh et, al 2018). Grief is subjective and unique to the individual experiencing it, with many influencing factors (Lobb et, al 2010). There is no one size fits all when it comes to the grief process (Stroebe, et al 2017). The inclusion of Prolonged Grief Disorder into the Diagnostic and Statistical Manual for Mental Health Disorders shows the progress that is being been made in the understanding of how unique and individualized grief can be (Maciejewski and Prigerson 2017.