Promoting Wellbeing by Focusing on the Community

Social connectedness needs to become a focus for people living with chronic conditions as this population are more vulnerable to social isolation, through factors such as receiving care, attending physician visits and hospitalisations, being physically disabled and unemployed \citep*{Meek2018}. This is important as social engagement can help prevent a person’s condition from becoming disabling \citep*{Mendes_de_Leon_2003}. Participation in social activities is associated with a lower risk of suffering from chronic diseases, and the reverse effect is observed for people who live alone \citep*{Cantarero-Prieto2018}. A meta-analysis found poor social relationships to increase the risk of coronary heart disease by 29% and increase the risk of stroke by 32% \citep*{Valtorta2016}. It is argued that social engagement promotes the resources which people can use to manage their condition \citep{Arcury2012,Bath2005}.
A community-based study evaluated the work of Reclink; an Australian community agency that works with individuals with chronic mental health conditions (Dingle et al., 2014). Examples of the activities Reclink organise include choirs, bowling, yoga, and football. Among the 49 individuals surveyed at the Reclink activities, 80% reported an improvement in their life, 61% reported improvements in physical health and fitness, and 82% reported improvements in their mental health and wellbeing. There was also an overall decrease in social isolation and number of reported visits to a general practitioner. Again, focusing on chronic mental health conditions in the Reclink choir group, 21 individuals were interviewed when they joined the choir, along with a 6- and 12-month follow-up (Dingle et al., 2013). Qualitative analysis revealed three areas in which they benefited from the choir. The first area that begun to develop were the personal benefits, which includes positive emotions, emotion regulation, spiritual experience, self-understanding, and the sense of ‘finding a voice’. Expanding beyond from the benefits to the self, these outcomes led to improved social functioning and connectedness. Lastly, functional benefits were reported, such as improved health and employment prospects, along with improving structure and routine in day-to-day life. A similar study was completed which found that those who were receiving more social support from their Reclink group reported greater improvement in mental wellbeing, highlighting the fundamental role of the social aspect of these groups \citep*{Williams_2018}.
Based off the social identity theory, using social identity as a clinical target may prove beneficial, and as such, manipulating clinical interventions to be run as a group activity should be considered in order to derive a sense of shared social identification among service users. For example, adults living in care settings were allocated to either group reminiscence, individual reminiscence or a control group activity for 6 weeks \citep*{Haslam2010}. Results highlighted that the group reminiscence and control group activity effectively improved memory performance and wellbeing, with the researchers arguing this effect was due to the shared social identity among both groups.
Building a social identity is particularly important for those with a chronic condition as they can become more than the condition they have. Especially given that this population may face more discrimination than the general population, which subsequently impacts their health and wellbeing (Cockerham, Hamby & Oates, 2017). The social identity theory proposes that the more social identities an individual possesses the more psychological resources they have access to, which protects them from a decline in health (Haslam et al., 2018). Among frequent attenders of the health service who have a chronic physical health condition, social isolation was the most reliable predictor of attendance, more so than physical or mental health issues \citep*{Cruwys2018}. Researchers also found that by joining a social group, primary care attendance reduced. This reduction was associated with the extent to which individuals subjectively experienced social connectedness.
Interventions aimed at increasing positive emotion is one pathway through which individuals are better able to build social connections and subsequently improve their health and wellbeing. In a longitudinal study, experimental participants were required to participate in a loving-kindness meditation to elicit positive emotion, the control group did not participate \citep{Kok_2010,Kok2015,Kok_2013}. Results indicated an increase in positive emotions among the experimental group relative to the controls, which was moderated by vagal tone. This increase in positive emotion lead to subsequent increases in vagal tone, which was mediated by an increase in perceived social connections. Also, higher HRV predicts greater social engagement upon follow-up assessments, and higher social engagement predicts higher HRV upon follow up \citep*{Kok_2010}. This highlights the self-sustaining upward spiral between vagal function, emotion and social connections. Regarding people living with chronic conditions, their symptoms can be alleviated through positive affect. Positive affect is associated with reduced negative affect, pain and stress among women with chronic pain \citep*{Zautra2005}. Among patients with coronary heart disease, greater positive affect was associated with better health behaviours, including physical activity, sleep quality, medication adherence and non-smoking at baseline \citep*{Sin2015}. Also, increases in positive affect over the five years was associated with improvements in physical activity, sleep quality and medication adherence, highlighting a need to target positive emotion when providing interventions.
An alternative route to encompass social connectedness as a pathway through which service users can increase health and wellbeing is by targeting both the service user and their partner within the intervention. For example, a qualitative review of 33 studies and meta-analyses for a subset of 25 studies was conducted consisting of participant groups with a range of chronic conditions, including arthritis, cardiovascular disease and chronic pain \citep*{Martire2010}. Results found couple-based interventions produced greater improvements with depressive symptoms, marital functioning and pain compared to both patient psycho-social intervention and treatment as usual.
Relationships with animals can provide a pathway to wellbeing, particularly for those who have difficulty socialising. For example, for individuals with autism an animal-assisted intervention was effective in increasing social interaction and communication, along with decreasing problem behaviours, autistic severity, and stress (O’Haire, 2013). Other research supports the social benefits of a dog for individuals with autism (Bass et al., 2009; Martin & Farnum, 2002; Prothmann et al., 2009; Sams et al., 2006). The presence of a dog has also proven to be effective in promoting social engagement among psychiatric populations (Haughie et al., 1992; Marr et al., 2000). Wheelchair-bound individuals found that when they had shopping trips with their service dog they reported a significant increase in the number of social greetings from others compared with trips before they had the dog, trips when they did not take the dog with them, or a control group without dogs (Hart, Hart, & Bergin, 1987). They also reported increasing their evening outings after having the dog. A review of animal-assisted therapy for people with dementia concluded that the presence of a dog can reduce aggression and agitation, along with facilitating social behaviour (Filan & Llewellyn-Jones, 2006).
Research has also highlighted a correlation between pet ownership and improved physical health. For example, a review of pet therapy research concluded there is consistent evidence supporting pet ownership as a protector against cardiovascular risk \citep*{Giaquinto_2009}. This could be due to the anti-stress effects of animals, as the presence of a dog can reduce cortisol levels \citep{Barker_2005,Beetz_2011,Odendaal_2000,Odendaal_2003,Viau_2010} and reduce epinephrine and norepinephrine levels \citep*{Cole2007}. The presence of a dog has also found to lower blood pressure (Friedmann et al., 1983; Grossberg & Alf, 1985; Jenkins, 1986; Nagengast et al., 1997; Vormbrock & Grossberg, 1988) and increase heart rate variability \citep*{Motooka2006}. Animal-assisted therapy has proven to be effective in improving symptoms in a variety of areas, including but not limited to autism-spectrum symptoms, medical difficulties, behavioural problems and emotional well-being \citep*{Nimer_2007}.
Overall, targeting the social network is vitally important for increasing health and wellbeing. One reason being that it is an opportunity to build more social identities, providing individuals with more psychological resources in times of need (Haslam et al., 2018). Another reason is that social engagement improves positive affect and emotion regulation (Dingle et al., 2013), which is part of the self-sustaining upward spiral of positive emotion, social connection and vagal function \citep*{Kok_2010}. It is unsurprising that social prescribing is now being adopted as a form of treatment, with a review of 15 social prescribing programmes reporting mostly positive results \citep*{Bickerdike2017}. Whilst all the studies involved possessed a high risk of bias, it provides a starting point which future researchers can build on and further the evidence in this field.
INTEGRATE THE FOLLOWING [THIS TEXT IS FROM SECTION 3, BUT DISCUSSES CHRONIC CONDITIONS AND IS THUS RELEVANT TO THIS SECTION]
Social Connectedness/Loneliness
Social connectedness needs to become a focus for people living with chronic conditions as this population are more vulnerable to social isolation, through factors such as receiving care, attending physician visits and hospitalisations, being physically disabled and unemployed (Meek et al., 2018). This is important as social engagement can help prevent a person’s condition from becoming disabling (De Leon, Glass & Berkman, 2003). Participation in social activities is associated with a lower risk of suffering from chronic diseases, and the reverse effect is observed for people who live alone (Cantarero-Prieto, Pascual-Saez & Blazquez-Fernandez, 2018). A meta-analysis found poor social relationships to increase the risk of coronary heart disease by 29% and increase the risk of stroke by 32% (Valtorta et al., 2016). with and without chronic conditions, results highlighted emotional wellbeing and family connectedness to be positively correlated across all individuals (Wolman et al., 1994). However, emotional wellbeing was lower among those with chronic conditions. This raises the question as to why people with chronic conditions are experiencing lower levels of wellbeing, and whether social connectedness plays a key regulatory role. It is argued that social engagement promotes the resources which people can use to manage their condition (Arcury et al., 2012; Bath & Deeg, 2005). As previously mentioned, social connections can have an adverse effect on health when these connections are not positive, for example, having to support family members of receive unhelpful advice, which can subsequently impact on the management of health conditions (Gallant, 2003).
A community-based study evaluated the work of Reclink; an Australian community agency that works with individuals with chronic mental health conditions (Dingle et al., 2014). Examples of the activities Reclink organise include choirs, bowling, yoga, and football. Among the 49 individuals surveyed at the Reclink activities, 80% reported an improvement in their life, 61% reported improvements in physical health and fitness, and 82% reported improvements in their mental health and wellbeing. There was also an overall decrease in social isolation and number of reported visits to a general practitioner. Again, focusing on chronic mental health conditions in the Reclink choir group, 21 individuals were interviewed when they joined the choir, along with a 6- and 12-month follow-up (Dingle et al., 2013). Qualitative analysis revealed three areas in which they benefited from the choir. The first area that begun to develop were the personal benefits, which includes positive emotions, emotion regulation, spiritual experience, self-understanding, and the sense of ‘finding a voice’. Expanding beyond from the benefits to the self, these outcomes lead to improved social functioning and connectedness. Lastly, functional benefits were also reported including improved health and employment prospects, along with improving structure and routine in day-to-day life. A similar study was completed which found that those who were receiving more social support from their Reclink group reported greater improvement in mental wellbeing, highlighting the fundamental role of the social aspect of these groups (Williams et al., 2017). However, social connectedness is not a certain predictor of good health as social ties may also lead to adverse health outcomes, especially when social ties are not health promoting. For example, in line with the self-categorisation theory, if the norms of the group of which someone identifies with are negative, they too are more likely to engage in this negative behaviour, with smoking being a good example (Schofield et al., 2000). Also, marriage is a source of both support and stress, with poor marriage quality reducing immune and endocrine function along with increasing depressive symptoms, with this association between marriage quality and health becoming stronger as age increases (Kiecolt-Glaser & Newton, 2001; Umberson et al., 2006; Walen & Lachman, 2000). There is also the health cost of providing care for a loved one, which has been associated with an elevated risk for the care provider (Christakis & Allison, 2006), with increased physical and psychiatric morbidity and impaired immune function (Schulz & Sherwood, 2008).
Based off the social identity theory, using social identity as a clinical target may prove beneficial. This was investigated among participants with clinical depression (Cruwys et al., 2014). Participants at risk of depression joined a community recreation group whereas those with diagnosed depression joined a clinical psychotherapy group. Results highlighted that the extent to which the individuals identified with the group predicted the reductions in their depressive symptoms, irrespective of the group to which they were assigned to. This is useful in raising awareness for the effectiveness of group-based interventions. Manipulating clinical interventions to be run as a group activity is also another route in order to derive a sense of shared social identification among service users. For example, adults living in care settings were allocated to either group reminiscence, individual reminiscence or a control group activity for 6 weeks (Haslam et al., 2010). Results highlighted that the group reminiscence and control group activity was effective improving memory performance and wellbeing, which the researchers arguing this effect is due to the shared social identity among both groups. Group-based therapies can also be useful to facilitate peer modelling. For example, a wellness recovery group was devised in which service users in stable recovery from mental illness run the groups, acting as models and using personal examples from both the group facilitators and new attendees (Lawn & Schoo, 2010). These weekly sessions ran for 8-weeks and was more effective in reducing symptoms, improving feelings of hopefulness and quality of life up to 6-month post-intervention, compared with a treatment as usual control group.
Social connectedness can be particularly important for those with a chronic condition as becoming a group member provides social identity (e.g. choir member). Through this process, the individual becomes more than the condition they have. The social identity theory proposes that the more social identities an individual possesses the more psychological resources they have access to, which protects them from a decline in health (Haslam et al., 2018). Among frequent attenders of the health service who have a chronic physical health condition, social isolation was the most reliable predictor of attendance, more so than physical or mental health issues (Cruwys et al., 2018). Researchers also found that by joining a social group, primary care attendance reduced. This reduction was associated with the extent to which individuals subjectively experienced social connectedness.
Given the above evidence for the importance of social engagement for health and wellbeing, it is unsurprising that social prescribing is now being adopted as a form of treatment. Arts on prescription is one example, in which participants and referrers reported psychological, social and occupational benefits (Stickley & Hui, 2012a; Stickley & Hui, 2012b). A review of 15 social prescribing programmes found mostly positive results (Bickerdike et al., 2017). Whilst all the studies involved possessed a high risk of bias, it provides a starting point which future researchers can build on and further the evidence in this field.
Human-Animal Interactions
Relationships with animals can provide a pathway to wellbeing, particularly for those who have difficulty socialising. For example, for individuals with autism an animal-assisted intervention was effective in increasing social interaction and communication, along with decreasing problem behaviours, autistic severity, and stress (O’Haire, 2013). Other research supports the social benefits of a dog for individuals with autism (Bass et al., 2009; Martin & Farnum, 2002; Prothmann et al., 2009; Sams et al., 2006). The presence of a dog has also proven to be effective in promoting social engagement among psychiatric populations (Haughie et al., 1992; Marr et al., 2000). Wheelchair-bound individuals found that when they had shopping trips with their service dog they reported a significant increase in the number of social greetings from others compared with trips before they had the dog, trips when they did not take the dog with them, or a control group without dogs (Hart, Hart, & Bergin, 1987). They also reported increasing their evening outings after having the dog. When applied to nursing homes, animal-assisted therapy was found to significantly increase social interaction and decrease agitated behaviours among 15 older adults with dementia (Richeson, 2003). A review of animal-assisted therapy for people with dementia concludes that the presence of a dog can reduce aggression and agitation, along with facilitating social behaviour (Filan & Llewellyn-Jones, 2006). Therapy dogs have also been effective in improving pain and emotional distress among outpatients compared with a waiting room control, along with having a positive impact on the accompanying adults and clinic staff (Marcus et al., 2012). This reduction in pain was clinically meaningful in 23% of patients after a visit from the therapy dog, compared to 4% in the waiting room control.
Animal-assisted therapy or activities have also proven to be effective in reducing mental health symptoms, including depressive symptoms (Scouter & Miller, 2007), anxiety and fear (Barker et al., 2003; Cole et al., 2007). However, other studies have found no significant effect (Barker & Dawson, 1998; Wilson, 1991). Research has also highlighted a correlation between pet ownership and improved physical health. For example, pet owners had lower levels of risk factors for cardiovascular disease (Anderson, Reid, & Jennings, 1992). A review of pet therapy research concluded there is consistent evidence supporting pet ownership as a protector against cardiovascular risk (Giaquinto & Valentini, 2009). This could be due to the anti-stress effects of animals, as the presence of a dog can reduce cortisol levels (Barker et al., 2005; Beetz et al., 2011; Odendaal, 2000; Odendaal & Meintjes, 2003; Viau et al., 2010) and reduce epinephrine and norepinephrine levels (Cole et al., 2007). The presence of a dog has also found to lower blood pressure (Friedmann et al., 1983; Grossberg & Alf, 1985; Jenkins, 1986; Nagengast et al., 1997; Vormbrock & Grossberg, 1988) and increase heart rate variability (Motooka et al., 2006). Animal-assisted therapy has proven to be effective in improving symptoms in a variety of areas, including but not limited to autism-spectrum symptoms, medical difficulties, behavioural problems and emotional well-being (Nimer & Lundahl, 2007).
Whilst most of the research focuses on dog-based interventions, there is promise that an aquarium can have beneficial effects. For example, an aquarium in a dining room can be an effective way to stimulate residents to eat more, as well as the possibility of using robotic pets to increase pleasure and interest among the individual with dementia. Other research has highlighted the benefits of an aquarium, as patients about to undergo oral surgery found watching fish in an aquarium as equally relaxing as hypnosis (Katcher et al., 1983; Katcher, Segal, & Beck, 1984). The studies included in the Filan and Llewellyn-Jones review are small but are useful in providing potential areas of future research in improving wellbeing among individuals, particularly for those who are unsuitable for dog-based interventions. 
An explanation as to why the presence of an animal can elicit social interactions could be that having an animal can make an individual appear more trustworthy. For example, students report a greater general satisfaction and greater willingness to disclose personal information to a psychotherapist with a dog compared to a psychotherapist alone (Schneider & Harkey, 2006). Also, strangers helping behaviour increased when the individual they were helping had a dog (Gueguen & Cicotti, 2008), supporting the theory that dogs can alter the perception of someone in terms of their trustworthiness. Beetz and colleagues (2012) argue that the oxytocin system plays a key role in the psychological and psychophysiological effects that human-animal interactions can have. Human-animal interaction has proven to increase oxytocin levels in both the human and the animal (Handlin et al., 2011; Odendaal, 2000; Odendaal & Meintjes, 2003). Increases in oxytocin facilitates social interaction and improves health through several methods, including increasing trust (Kosfeld et al., 2005; Zak et al., 2005; 2007) and reducing stress (Kirsch et al., 2005; Legros et al., 1988) and anxiety (Guastella et al., 2009; Jonas et al., 2008). 
Overall, animal-assisted interventions have a clear positive impact on health and wellbeing and should be a consideration for people who lack strong social relationships. For example, there are correlations that owning a pet can stabilise a marriage (Na & Richang, 2003) and increase leisure activities among a family (Paul & Serpell, 1996). With this respect, a service user who reports family problems or a disconnect within the family may benefit from this kind of intervention alongside their treatment as usual. This highlights the importance of encompassing all aspects of an individual’s life when considering treatment options for them because whilst the “traditional” treatment may help their condition, it does not help with building a mentally and physically supportive lifestyle which can serve as a protector to worsening health
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Overall, is it important to understand the norms of the group in which individuals gain their social identity in order to analyse the effect that social ties have on the individual’s health and wellbeing. Despite this, increasing social connectedness among users of the health care system is vital in order to provide better health care, taking into account broader aspects of a service user’s life that may impact on their health and wellbeing outside of the condition they manage. Health care services would benefit from moving away the biomedical model and towards a new model of health that encompasses not only the physical and mental needs of the service user, but also the social needs. It would be a cost-efficient and more effective way of delivery treatment by using group interventions, allowing for not only the treatment, but also social connectedness and group identity. An alternative route to encompass social connectedness as a pathway through which service users can increase health and wellbeing is by targeting both the service user and their partner within the intervention. For example, a qualitative review of 33 studies and meta-analyses for a subset of 25 studies was conducted consisting of participant groups with a range of chronic conditions, including arthritis, cardiovascular disease and chronic pain (Martire et al., 2010). Results found couple-based interventions produced greater improvements with depressive symptoms, marital functioning and pain compared to both patient psychosocial intervention or treatment as usual.

Promoting Wellbeing by Focusing on the Environment

When discussing the impact of the environment on people living with chronic conditions specifically, contact with nature and environmental modifications are key areas. The biophilia hypothesis provides a theoretical background for the importance of being immersed in the natural environment, with our innate need for contact with nature and life (Wilson, 1984). We have previously discussed the impact of nature on general health and wellbeing, and whilst these benefits are useful for the general population, a greater focus needs to be placed on contact with nature for those with chronic conditions as they face health issues on a daily basis, and have additional barriers in their life which may prevent them from easily accessing opportunities such as green spaces \citep*{Meek_2018}. These potential barriers include a lack of time due to physician visits and/or hospitalisations, and accessibility due to a physical disability. Along with this, research has highlighted an association between contact with nature and prevalence of disease. For example, a systematic review analysed the evidence linking green spaces with mortality, in which 12 studies were included with study populations ranging from the thousands to the millions (Gascon et al., 2016). Results found a negative correlation between cardiovascular disease mortality and residential greenness in the majority of studies, the pathways through which this relationship occurs can be explained by Kuo (2015). A review on 17 studies based in Japan concluded there is a positive impact of natural environments on brain activity, the cardiovascular system, endocrine system and immune function \citep*{Haluza2014}. However, when going in to more detail the results are mixed. For example, the review concluded beneficial impacts of nature on cardiovascular functions, however, when concerning blood pressure, only two out of nine studies reported clear positive effects (a decrease), with six reporting mixed effects and three reporting no significant effects. A similar pattern arises with heart rate, with four studies reporting positive effects (a decrease), three reporting mixed results and two reporting no significant effects. When focusing on heart rate variability, two studies reported a positive effect (an increase) with four studies reporting mixed effects. Similar patterns arise with data linking nature with the endocrine system and immune function. Despite these mixed results, the review concluded an overall health benefit of contact with nature, with a clear potential to target at-risk people or those living with cardiovascular problems.
Introducing green spaces into communities and care homes is one route through which those with chronic illness and/or disabilities can easily access contact with nature when living in an urban environment. Research on 126 care facilities for the elderly across 17 European cities found green spaces within the facility grounds had a significant impact on the quality of life for the residents, along with benefits for the staff and visitors (Artmann et al., 2017). The green spaces facilitated physical activities, recreation and social engagement, which provide subsequent health benefits associated with such factors. It is important to consider contact with nature when designing care packages for service users with chronic conditions as they are more vulnerable to losing contact with nature as day-to-day living is more difficult. Care homes would benefit from designing a timetable which guarantees all residents access to nature for a certain period every day or by including green spaces on their property.
Traditionally, care homes were designed for the health and safety of residents, neglecting what is important to the people that live there and what could potentially improve their health and wellbeing, but this is beginning to change (Ausserhofer et al., 2016). Modifying the environment for residents or patients in care facilities should be a focal point, taking into account their condition and which modifications will facilitate health and wellbeing improvements. Simple additions, such as indoor plants, have reportedly reduced stress for patients in hospital \citep*{Dijkstra2008}. A review of 30 studies found positive effects for sunlight, windows, odour and seating arrangements \citep*{Dijkstra2006}. Whilst evidence for sound, nature, spatial layout, television and stimuli interventions was inconsistent. The impact of the modifications was dependent on patient population characteristics and the context, highlighting the need for a person-centred approach when designing the building and rooms for service users. This is highlighted in a qualitative study which reported both positive and negative outcomes from home modifications; the researchers concluded that the negative impact to be attributable to a lack of understanding about the individual client \citep*{Aplin2015}. It would be useful for health facilities to modify their design to accommodate the service users, particularly care homes where residents live for the remainder of their lives. For example, individuals with dementia would benefit from modifications that normalise their circadian rhythms, including lighting and ambient temperature, along with modifying walkways and exits to make it clearer and safer (Luxenberg, 1997). A review of 57 articles focusing on environmental design or changes for people with dementia concluded that there is sufficient evidence for the effectiveness of varying ambience, size and shape of spaces in a home, unobtrusive safety measures and controlling levels of stimulation \citep*{Fleming2010}.
Overall, the evidence linking nature and health continues to grow, but with mixed results. Reasons for such could be attributed to a lack of concrete recommendations concerning what level of exposure to nature would be sufficient to elicit health changes and what type of nature environment has a greater benefit. Shanahan and colleagues (2015) have propose using dose-response modelling when providing nature-based interventions to identify a cost-effective level of urban nature. They argue that manipulating the type and amount of nature exposure will subsequently impact differently on health outcomes. By applying this method in future research, it will allow researchers to better identify what types of nature-based interventions are effective and at what dose. With sufficient research, recommendations can then be made for future generations to utilise nature, and particularly green spaces for urban environments, to build health and wellbeing among all populations. The introduction of green spaces should be a focal point for urban areas, which will moderate the climate change impact, help prevent disease over a life course model, improve health and wellbeing and subsequently lessen the burden on the health care services. Feasibility research has been carried out to investigate the impact of urban green spaces on health \citep*{Pearce2016} and further development in this area may provide substantial health-related data associated with green spaces across a life course model.
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Facilitating Behavioural Change 

FOR INTEGRATION:
Beyond models of hedonic and eudaimonic wellbeing, the theory of synergistic change \citep*{Rusk_2017} describes the pathways through which positive psychological interventions facilitate sustained changes in behaviour and wellbeing. Building on prior theory on positive psychological change, including the Hedonic Adaptation Model \citep*{Sheldon_2013}, the Positive-Activity Model \citep*{Layous_2013}, and the emotion regulation theory \citep*{Quoidbach_2015}, this theory emphasises the interplay of many dynamic elements that facilitate successful and sustained positive change. The model is based on the' Domains of Positive Functioning' (DPF-5) framework \citep*{Rusk_2014}, which emphasises five domains of psycho-social functioning including: (1) attention and awareness, (2) comprehension and coping, (3) emotions, (4) goals and habits, and (5) relationships and virtues. The influence of biological/physiological and environmental factors are also recognised, although not characterised. \citet{Rusk_2017} argue that the inter-dependent and synergistic components of DPF-5 underpin the 'complex dynamics' of psycho-social functioning, emphasising multiple pathways for positive psychological change. Three types of processes are characterised: relapse, spill-over and synergy. According to the model, relapse occurs when the intervention ceases and changes that have been made within one domain are undermined by a lack of change within other domains. Spill-over occurs when the change within one domain "spills over" and influences another domain, whereas synergy arises when the intervention creates interactions between multiple domains that are mutually reinforcing, creating a stable change in behaviour. The model therefore suggests that enduring positive change will be facilitated by (1) targeting single elements, (2) using exiting strengths, and (3) harnessing mutually reinforcing elements. 
AND THIS: Interventions aimed at increasing positive emotion facilitate the building of social connections. For instance, training in loving-kindness meditation \citep{Kok_2010,Kok2015,Kok2013} elicits positive emotion and this is dependent (moderated by) baseline vagal tone. Increases in positive emotion lead to subsequent increases in vagal tone, mediated by an increase in the perception of social connectedness. Higher vagal tone predicts greater social engagement at follow-up, and higher social engagement due to the intervention predicts further increases in vagal tone \citep*{Kok_2010}. These findings highlight a self-sustaining upward spiral between vagal function, emotion and social connections. Acute nasal administration of oxytocin may be another method to trigger cycles to improve health and wellbeing as it increases capacity for social engagement (Kemp et al., 2012). Conversely, decreased vagal activation results in increased sympathetic activity, associated with the fight-flight-or-freeze responses, which causes withdrawal behaviours (e.g. anxiety) not conducive with social environments (Porges, 2011)
The three major models surrounding individual behaviour change are the Health Belief Model, the Theory of Reasoned Action/Planned Behaviour (TRA/TPB) and the Trans-Theoretical Model. The Health Belief model (HBM) (Glanz, Rimer & Viswanath, 2008) proposes that a person’s willingness to change is dependent on seven factors, these being perceived susceptibility to and severity of a health behaviour, perceived benefits and barriers to changing a health behaviour, cues to action and self-efficacy regarding the change, along with overall modifying variables which refers to individual characteristics. An overarching value of ‘perceived threat’ of a behaviour is a key indicator of behavioural change in this model. In a similar manner of perceived threat dictating behaviours, the Protection Motivation Theory proposes that people protect themselves against threats based on the threat appraisal, referring to the perceived severity and probability of the occurrence, and coping appraisal, referring to efficacy and self-efficacy (Rogers, 1975). However, the evidence supporting the application of the HBM is weak and its predictive capacity is limited (Taylor et al., 2006). Despite this, methods to increase a ‘perceived threat’ of a behaviour have been useful, though it has not been related to the HBM. For example, pictorial warnings on cigarette packaging are significantly more effective than text-only warnings in increasing intentions to quit smoking (Noar et al., 2016).
The TRA (Fishbein & Ajzen, 1975) proposes that behaviour change depends on an individual’s attitude towards the behaviour, which is determined by the beliefs and evaluations about the outcome of the behaviour. Behaviour change also depends on the subjective norms about the behaviour in question, which is defined by beliefs about others’ opinions on the behaviour and motivations to comply with those opinions. A third component of the TRA is that of volitional control; the extent to which the behaviour can be applied consciously and become habitual over time. The TPB is an extension of TRA, in that it includes the aspect of perceived behavioural control, which refers to the beliefs regarding how easy or difficult it is to perform the behaviour (Ajzen, 1991). The evidence supporting the predictive performance of both TRA and TPB is stronger than that of the HBM, with TPB accounting for between 20% and 30% of the variance in adult health behaviours in the US and UK (Taylor et al., 2006). However, this is relatively low when needing to devise health behaviour interventions.
The Trans-Theoretical Model (Prochaska et al., 1992; Prochaska & Velicer, 1997) proposes behaviour change as a process of six stages; precontemplation (not intending to change), contemplation (think about change) preparation (intending to change a behaviour and begin with little steps), action (changing the behaviour), maintenance (sustaining the new behaviour), termination (when there is no temptation to reverse back to the old behaviour). In addition to these six steps, people can relapse and reverse back through the stages when they have not reached termination. The benefit of this model is that it holds the capacity to serve as a foundation for interventions aimed at both an individual and a community level (Taylor et al., 2006), however, the evidence suggests it is no more effective than alternative, rationally designed, interventions.
Overall, despite these models inadequately accounting for the impact of social, economic and/or environmental factors on health behaviours, they have been widely used and applied within health services (Taylor et al., 2006). Kelly and Barker (2016) highlight how behaviour change is not a simple choice an individual makes. They highlight the fact that just because it is common sense to adopt positive health behaviours, it doesn’t necessarily mean people will, and by providing more information that is straightforward to understand doesn’t equate to behaviour change. For this reason, we need to look beyond providing information and towards techniques that will facilitate behaviour change.
Other theories provide additional influencers in health behaviours, for example, it has been proposed that self-efficacy plays a key role in behaviour change; as a predictor, mediator or moderator, proposed in Bandura’s Social Cognitive Theory (1997). People are more likely to choose to undertake tasks which begin them on the path of behaviour change if their self-efficacy is high, whereas this is less likely when self-efficacy is low. In a similar manner, those with high self-efficacy about a task are more motivated to complete the task and continue with the behaviour for longer. The role of self-efficacy can be related back to the TPB in relation to perceived behaviour control (Ajzen, 1991), and is discussed in the TTM as playing a role in behaviour change across the stages (Prochaska et al., 1992). The four factors influencing self-efficacy are enactive attainment, vicarious experience, social persuasion and physiological factors, and targeting these to effectively increase self-efficacy can increase the likelihood of behaviour change (Ashford, Edmunds & French, 2010). Self-efficacy both directly and indirectly impacts health through decision making, including behaviours such as smoking, physical exercise, dieting, condom use, dental hygiene, seat belt use, and breast examination (Conner, 2005).
The above literature is a small focus amongst a larger area of work surrounding behaviour change. Other theories provide additional standpoints, including the Theory of Interpersonal Behaviour which highlights the importance of habit formation (Triandis, 1977; 1980), the Theory of Trying which focuses on the influencers upon the intention to try (Bagozzi, 1992), and the Self-determination Theory which focuses on innate psychological needs for competence, autonomy and relatedness (Deci & Ryan, 1985; Ryan & Deci, 2000).
By understanding the theoretical background to health behaviour change, interventions that target health behaviours can incorporate behaviour change strategies into the programme. One route through which long-term behaviour change can be achieved is by understanding past behaviour and habits. Forming positive health behaviour habits has been a focus for heath psychologists, with research published on diet (Adriaanse et al., 2010), physical activity (Rhodes & de Bruijn, 2010), alcohol consumption (Norman, 2011) and medication adherence \citep*{Bolman2011}. It is argued that a habit can be formed through repetition of a behaviour within a specific context (Lally, van Jaarsaveld, Potts & Wardle, 2010) and eventually this context will have the potential to trigger the behaviour without awareness, conscious control cognitive effort or deliberation (Bargh, 1994; Lally, van Jaarsveld, Potts, & Wardle, 2010; Wood & Neal, 2009).
When devising interventions to build habitual behaviours, it is important to consider the context in which an intervention is applied. For example, when aiming to ameliorate unhealthy behaviours, disrupting a cue exposure which triggers the behaviour could be a focus (Verplanken, Walker, Davis & Jurasek, 2008), however, there is the possibility of the behaviour returning when the necessary cue or context returns. This serves as an explanation as to why positive results from interventions may be short-lasting. Judah and colleagues (2018) aimed to investigate the formation of habits to create positive health behaviour changes. In line with the above discussion, they found that performing a behaviour in a more stable context was associated with more frequent repetition, which they attributed to context-specific cues being effective reminders. They also reported behaviour pleasure and intrinsic motivation to be two key factors in predicting whether a behaviour becomes a habit. Conversely, they found perceived utility and behaviour benefits to have no impact on habit formation, contradicting the HBM which highlights a key focus on perceived threat of behaviour to one’s health. Previous behaviours and habit formations are important factors when devising intervention strategies for individuals, as these behaviours have ingrained neural pathways that are easily activated (Gerdeman, Partridge, Lupica, & Lovinger, 2003; Smith, 2016; Yin & Knowlton, 2006). For this reason, strategies need to be employed that will both combat the old health behaviour and encourage the formation of neural pathways associated with the new health behaviour.
There are many BCTs that can be employed when providing interventions, promoting self-affirmation, through reflection upon important values, attributes or social relations, is one useful tool to facilitate behaviour change. Self-affirmation has proven to be a useful psychological technique regarding its ability to decrease defensiveness and increase receptivity to interventions across different health behaviours (Falk et al., 2015). By targeting self-affirmation, the neural processes involved in the self-related processing and value in response to an intervention can be altered (within the ventromedial prefrontal cortex), allowing the individual to understand the relevance and value in the intervention instead of viewing it as a threatening health intervention. A meta-analysis of 144 studies reported a positive impact of self-affirmation on message acceptance, intentions to change and subsequent behaviour (Epton et al., 2015). In a review of BCTs aimed to reduce sedentary behaviour, they reported the most effective techniques to be education, environmental restructuring, persuasion and training (Gardner et al., 2015). An example of environmental restructuring would be to provide sit-stand desks (Alkhajah et al., 2012). Studies that used techniques that focused on self-monitoring of behaviour, problem solving and changing the social or physical environment have shown promising results (Gardner et al., 2015). In a systematic review of behaviour change aimed at reducing obesity, mediators for longer-term weight control were autonomous motivation, self-efficacy and use of self-regulation skills (Teixeira et al., 2015). Overall, there are many BCTs that can be used in conjunction with treatment plans to potentially improve adherence to the treatment or suggested behaviour change.
However, whilst many interventions have been effective in eliciting behaviour change, these are often short-term successes (Avenell et al., 2004) and it is not feasible to upscale these interventions to access large population groups as they require a substantial amount of time and money (Forster, Veerman, Bardendregt & Vos, 2011). Nudge Theory provides a basis for an alternative intervention method to subtly alter health behaviours of those in the community. Thaler and Sunstein (2008) argue that there is a “choice architecture” which refers to all the external forces that guide people to make choices, and subtle environmental changes (nudges) can make a desired choice more likely. Bringing together libertarian paternalism (directing decision making whilst maintaining freedom of choice) and nudge theory offers an effective and feasible route to altering health behaviours among large populations. However, this method of influencing health behaviours comes with controversy, with the argument that it undermines the UK government’s aims which promote empowerment, freedom and fairness (Blumenthal-Barby & Burroughs, 2012; Goodwin, 2012). Nudging strategies target the impulsive and automatic system, guiding individuals to certain choices without conscious decision making (Gill & Boylan, 2012; Marteau, Hollands & Fletcher, 2012; Strack & Deutsch, 2015). Despite this, nudging is generally accepted by the public with few concerns (Junghans, Cheung & De Ridder, 2015; Petrescu, Hollands, Couturier & Marteau, 2016).
The evidence supporting the use of Nudge Theory with health behaviours is promising. A meta-analysis on dietary choices, including 42 studies, demonstrated that nudge interventions caused an average increase in healthier consumption decisions by 15.3% (Arno & Thomas, 2016). As a result of promising research, a project named ‘Supreme Nudge’ has been developed to target dietary and physical activity behaviour changes in low socioeconomic areas to reduce the burden of cardiometabolic health problems (Lakerveld et al., 2018). The aim of the project is to implement and evaluate the impact of environmental changes (nudges) on lifestyle behaviours and cardiometabolic health in adults. The targeted intervention will focus on food pricing, environmental nudging and tailored feedback for physical activity. The researchers have developed this project with the awareness that targeting individual-level factors, such as educational strategies, are insufficient in eliciting behaviour change, particularly for those in lower SES groups (Angermayr, Melchart & Linde, 2010). Whereas targeting the environment can prove effective in encouraging health behaviour changes. For example, adjusting the pricing on food products causes subsequent changes in food purchases (Niebylski, Redburn, Duhaney & Campbell, 2015; WHO, 2015), with discounts on fruits and vegetables increasing purchase and consumption on such items (Ball et al., 2015; Geliebter et al., 2013; Ni Mhurchu et al., 2010; Waterlander et al., 2013).
There is a need to incorporate theory-driven, behaviour change techniques (BCT) into care packages and interventions. It is not enough to simply provide the information, given that the four leading non-communicable diseases (cancer, cardiovascular disease, type 2 diabetes and respiratory disease) are mostly preventable through positive health behaviours (Marteau, Hollands & Kelly, 2015). It is argued that when devising techniques for behaviour change, a wider focus is needed that does not solely focus on the individual, but also incorporates social and economic pressures that act upon the individual (Kelly & Barker, 2016). With this is mind, theories of behaviour change and BCTs need to be a focus when targeting health behaviours, instead of simply expecting people to adhere to the treatment programme.
BCTs are particularly important for people with chronic conditions given that healthy behaviour changes after disease onset can lower the risk of recurrence, reduce symptom severity, increase functioning and extend longevity (Aldana et al., 2003; Jolliffe et al., 2001; Speck et al., 2010; Williamson et al., 2000), highlighting the importance of implementing BCTs to facilitate this is vital. In addition, data highlights that despite the diagnosis of a chronic condition, the vast majority of individuals do not adopt long-term positive health behaviours (Newsom et al., 2011). This is surprising given that theories of health behaviour would propose that a diagnosis of a health condition would present as a serious threat and at least minimally lead to an initial stage of change (Prochaska & Prochaska, 2005). However, past behaviours and habits can provide an explanation for why many people do not change to more positive health behaviours (Ajzen, 2002; Verplanken, 2006). However, health behaviour changes differ between conditions, for example, those with heart disease or stroke were more likely to abstain from smoking (Twardella et al., 2006) and increase exercise (Van Gool et al., 2007) compared with individuals with diabetes.
Research highlights that those with chronic conditions are more likely to track a health indicator or symptom and are more likely to benefit from health tracking (Fox & Duggan, 2013). If health tracking was used in conjunction with goal setting and other BCTs, this would be an efficient clinical target to improve the health of those living with chronic conditions. BCTs have proven to be effective among those living with chronic conditions, with a review of eight RCTs aimed at improving exercise adherence among individuals with persistent musculoskeletal pain (PMSK) finding social support, goal setting, instruction of behaviour, demonstration of behaviour and practise/rehearsal to be effective in improving exercise adherence (Meade et al., 2019). Popular wearable technology currently offers a number of BCTs, including goal setting, social support, social comparison, prompts/cues and rewards which can be used to facilitate behaviour change (Lyons, Lewis, Mayrsohn & Rowland, 2014).

Discussion

Wellbeing involves 'connection'... connection to ourselves, to others and to the environment. We suggest that vagal function provides a key mediator of health and wellbeing attributable to activities to promote wellbeing across these domains. There is now good evidence that vagus nerve connects us to ourselves (i.e. 80% of vagal nerve fibres are afferent nerves providing a structural link between mental and physical health, [REF]), to others (the vagus promotes social connection, [REF]), and to nature (vagal function is impacted on by a host of environmental factors). Vagal function may be considered as an index of resilience - underpinned by psychological flexibility \cite{Kashdan_2010} - an important consideration when seeking to build the health and wellbeing of individuals with or without chronic conditions. We encourage psychological scientists to draw upon a combination of strategies that involve facilitating positive psychological moments in addition to positive health behaviours, mindful of the major theoretical frameworks that have been proposed previously. To date, the discipline of positive psychology has been restricted to enhancing wellbeing by focusing on strategies to promote positive psychological moments. We argue that the impact of positive psychological interventions 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 [REF]. 
With regards to the impact of community on individual health and wellbeing, it is worth considering the impacts of culture when building resilience in populations. The extent to which different cultures promote individualism (most developed nations including Australia, UK and US) versus collectivism (most developing nations, e.g. Brazil and China) will have differential impacts on resilience. Individualistic cultures characterise the individual as an active, independent agent, detached from the physical and social environment in which they live. By contrast, in collectivist cultures, the individual is seen as a responsive agent connected to the physical and social environment; wellbeing becomes less subjective and more relevant to the objective standards of others  \citep*{Ryff_2014a}. Wellbeing - and the various strategies that can employed to promote it - will therefore vary across cultures \cite{Eckersley2006}, dependent on people’s values and goals, and influenced by culture \citep*{DIENER_1997a}. Take for example, the cultural diversity in the expression of gratitude \cite{Floyd_2018}. Speakers of English and Italian are more likely to express gratitude in everyday situations than speakers of other languages including Polish and Russian. Other research has demonstrated that collectivist cultures - in this case,  the Taiwanese - do not experience changes in state gratitude, positive affect or negative affect when practising gratitude \cite{chang}, perhaps because they are fulfilling expected role obligations. Finally, it is important to note that community values and subsequent behaviours can be influenced through sociostructural factors such as governmental policies, a consideration highlighted in our original GENIAL model \cite{Kemp_2017} and a topic we discussed in section \ref{225494}.
Finally, our updated model extends beyond the individual and community, to incorporate the broader impacts of the environment. Mindful of previously proposed social ecological theories [REF] and Glenn Albrecht's work on 'Earth Emotions' \cite{albrecht2019}, we emphasise that the individual is intimately connected to the community and environment in such a way that XXX