Environmental |
Forest bathing |
Barriers include transport to location
(could be combatted by VR and changing immediate environment), weather,
client mobility, availability of supporting staff and risk
assessment |
|
Gardening; responsibility to look after a plant |
Relevant to the
biophilia hypothesis, ‘positive psychology of sustainability’ and
‘sustainable happiness’ |
|
Environmental changes, e.g. lighting, greenery, nature-based
wallpaper, temperature changes, nature sounds |
Potential barrier
includes available funding |
5.1: Promoting Health and Wellbeing in Individuals
Our theoretical models emphasise a cycle of mutually causal factors including healthy vagal function, positive psychological moments, health behaviours and social relationships that trigger a cascade of downstream physiological processes that will facilitate pathways to individual health and wellbeing (Kemp et al, 2017). Accordingly, in this section we provide evidence linking each of the factors identified as being critical in facilitating pathways to individual health and wellbeing, in the aetiology of chronic conditions as well as highlighting their potential to be targets for prevention and treatment.
5.1.1: Health Behaviours
The health and wellbeing of people living with chronic conditions may be supported and improved by focusing on interventions to facilitate changes in positive health behaviours
(Lassale et al., 2019; Dinu et al., 2018; Lee et al., 2012). Interventions targeting health behaviours are of course, not novel however, they tend to centre around providing education and information about the importance of health behaviours to people with chronic conditions despite evidence that ‘information is not transformation’. To this end, it is critical that interventions designed to facilitate positive health behaviours consider how to most effectively do this, with reference to theories of behavioural change. This is one of the aims of the following section. For the sake of brevity, given the number of health behaviours, we focus predominantly on physical exercise, diet and sleep. Moreover, in the clinical setting the focus on health behaviours for people with chronic conditions tends to be biased towards people with physical rather than with cognitive or mental health symptoms. However, recent large-scale epidemiological research and meta-analysis has shown that physical activity may favourably impact on mental health, decreasing risk for common mental disorders
(Chekroud 2018,Schuch 2018, Hearing 2016), being as effective as medication and psychotherapy in some cases
(Knapen, Vancampfort, Moriën, and Marchal, 2015). Moreover, several studies have shown the potential of physical activity to facilitate plasticity, increased pre-frontal cortex volume and reduced cognitive difficulties in people with dementia and brain injury.
SAY SOMETHING ABOUT THE INTERACTION BETWEEN SLEEP, DIET AND PHYSICAL ACTIVITY IN TERMS OF THEIR CONTRIBUTION TO CHRONIC CONDITIONS AND MENTAL HEALTH AND THEIR INTERACTION IN TERMS OF TREATMENT APPROACHES
Physical Activity: It is estimated that physical inactivity is responsible for between 10-11% of the burden of chronic disease
(Carlson et al., 2015)., including diabetes, colon cancer and coronary heart disease, and that inactivity causes 9% of premature mortality
(Lee et al., 2012a). Physical activity favourably impacts on a variety of physical health outcomes including improved autonomic function
(Adamopoulos et al., 1992), reduced abdominal adiposity
(Tremblay et al., 1990) and reduced systemic inflammation
(Adamopoulos et al., 1992). This has been shown to result in decreased risk of all-cause and cardiovascular-related death, diabetes mellitus and cancer
(Warburton et al., 2006), providing a basis on which its prescription may be used as a treatment for many chronic diseases to improve symptoms. Regular physical activity can be an effective primary and secondary preventative measure for at least 25 chronic conditions
(Rhodes et al., 2017), along with improving cognitive function, an especially important consideration given that chronic conditions are associated with declining cognitive ability
(Lautenschlager et al., 2008), an important contributing factor to ill-health and illbeing
(Brosschot 2017, Beauchaine 2015, Friedman 2007). Physical activity has proven effective in symptom reduction as part of treatment for many chronic conditions or mental health conditions which often co-occur with, with, and exacerbate the impact of, chronic conditions, including anxiety
(Aylett et al., 2018; Oeland et al., 2010), depression
(Rimer et al., 2012; Weyerer, 1992), schizophrenia
(Girdler et al., 2019; Vancampfort et al., 2012), panic disorder
(Hovland et al., 2013), PTSD
(Liedl et al., 2011), bipolar disorder
(Kucyi et al., 2010), binge eating disorder
(Pendleton et al., 2002), bulimia nervosa
(Sundgot-Borgen et al., 2002), anorexia nervosa
(Zunker, Mitchell, and Wonderlich, 2011), and substance use disorders
(Ussher et al., 2014; Smith et al., 2011)[zf2] .
Diet:
We have to say something obesity - now classified as a chronic condition!! I will come back to this.
In an extensive review Kromhout (2016) concluded that consumption of vegetables and fruit convincingly reduced the risk of coronary heart disease (CHD) and stroke, and on this basis the Dutch food-based dietary guidelines recommended at least 200g of vegetables and 200g of fruit per day.
(Kromhout 2016). This is in keeping with the NHS guidelines which recommends 'five-a-day' (or 400 grams)
(UKGOV, 2019), as well as guidance from the World Health Organisation
(WHO | Promoting fruit...). Kromhout (2016) also concluded that the consumption of nuts convincingly reduces CHD risk and recommended that one eats at least 15 grams of unsalted nuts per day, although this is not currently recommended in UK guidelines. Also recommended was the consumption of 90 grams of brown or whole-grain products daily, as whole-grain products has been shown to reduce risk of CHD. In contrast to the recommendations by
Kromhout et al. (2016), other research suggests that as many as 'ten-a-day' may be required for long-term health benefit
(Aune 2017). Recent studies have demonstrated that the Mediterranean diet may protect against chronic disease including common mental disorders
(Lassale et al., 2019; Dinu et al., 2018).
Sofi et al. (2010) concluded from a systematic review and meta-analysis that a greater adherence to a Mediterranean diet leads to a significant reduction in cardiovascular incidence, cancer incidence or mortality and neurodegenerative diseases. Importantly, randomised controlled trials now demonstrate that adopting a Mediterranean diet independently reduces cognitive decline associated with chronic conditions
(Martínez-Lapiscina et al., 2013; Valls-Pedret et al., 2015). Dietary changes have shown to be effective in triggering changes in the intestinal microbiome (a modulator in the risk of disease development) within 24 hours, highlighting the importance of diet as a pathway through which health can be improved
(Singh et al., 2017). It is argued that targeting diet would be an effective opportunity to relieve the growing burden of mental and neurological disease
(Owen and Corfe, 2017). This may seem common knowledge, but it has been well established that ‘
common knowledge is not common action’ (Swan 2014). For example, a study by Bell et al. (2015) showed that 20% of nursing home residents have been reported to be malnourished internationally, although depending on the definition of malnutrition prevalence ranges from 1.5% to 66.5%
(Bell, Lee, and Tamura, 2015). Studies have also shown that improved diet can be effective in improving depression symptomology
(Opie et al., 2015; Parletta et al., 2019). An important dietary contributor to risk of future chronic illness is alcohol consumption, which has been causally related to 60 medical conditions, including certain cancers (breast, mouth and liver), epilepsy and haemorrhagic stroke
(Room, Babor, and Rehm, 2005).
Alcohol[zf4] is also an important aspect of diet in terms of health. In ‘The 2015 Dutch food-based dietary guidelines’
(Kromhout 2016) claimed that alcohol convincingly increases the risk of stroke and that binge drinking 60 g or more significantly increases the risk of CHD and thus recommends that individuals abstain from alcohol all together or do not drink more than one glass daily. This is roughly in line with the NHS guideline
(NHS, 2019)which recommends no more than 2 units a day (this is roughly one pint of beer or a glass of wine). There is mixed evidence as to whether there is a ‘J’ shaped relationship between alcohol and all-cause mortality such that drinking a low amount of alcohol may be more beneficial for health than abstaining from alcohol all together. However, a meta-analysis of 87 studies
(Stockwell 2016) adjusted results to account for abstainer bias towards ill health and found no significant reduction in mortality risk for low volume drinkers compared to those who abstain from alcohol. Including former drinkers in the abstainer reference group has biased the drinking risk estimates in many studies. Thus according to these findings, it is best to abstain from alcohol all together as we should not assume there are health benefits to low level drinking. It is acknowledged however, there are other reasons people consume alcohol (e.g. social drinking) and that risk increases with amount drunk
Sleep: Sleep is an important factor influencing the health and wellbeing of people living with chronic conditions. The International Classification of Sleep Disorders includes more than 80 sleep disorders. Sleep disorders are associated with increased risk of all-cause mortality and serious adverse health consequences
\citep{Alvarez_2004}. Epidemiological studies have shown that people with chronic conditions (eg. heart disease, arthritis, diabetes, stroke and lung diseases) had a significantly higher incidences of sleep disturbances than those without such conditions
\citep{Foley1999},
\citep{Maggi1998},
\cite{Vitiello1997},
\citep{Foley1995},
\citep{Ancoli-Israel1991},
\cite{Foley1999a},
\citep{Whitney1998},
\citep{Newman1997} and
\citep{Enright1996}. The relationship between many chronic conditions and sleep has been shown to be bidirectional; the worsening of one can influence the other
(Lee 2012, Ancoli-Israel 2006). Overall there is compelling evidence of the contribution of sleep disorders to the pathogenesis and exacerbation of chronic conditions. In this section we illustrate this point with several examples for the purpose of brevity. We then present evidence exploring the treatment of sleep disorders or they underpinning moderators, which may have the potential to ameliorate the impact of chronic conditions.
Two of the most prevalent sleep disorders, Insomnia and OSA have been shown to contribute to an increased risk of several chronic health conditions (\citep*{Hargens2013} including, but not restricted to, diabetes mellitus \citep{Punjabi2004} and cardiovascular disease \cite{Somers2008}, asthma \citep{Janson1996}, systemic lupus erythematosus \citep{Gudbjörnsson2001}, rheumatoid arthritis \citep{Luyster2011} and inflammatory bowel disease \citep{Keefer2006}. The mechanisms which underpin this relationship are complex and many. However, it is thought that most common sleep disorders result in a reduction of sleep quality and duration which has been associated with increased body weight and adiposity and can lead to obesity \citep{López-García2008}\citep{Patel2008}. Although obesity has not yet be classified as a chronic condition in its own right in the UK, it has been formally recognised as such in the United States (references). Nonetheless, it has been well established that obesity significantly contributes to the pathogenesis of many chronic conditions. Consequently it has been argued that relationship between chronic conditions and sleep disorders are likely mediated by the relationship between sleep disorders and obesity. For example, with respect to insomnia, \citet{Taheri2004} showed that shorter sleep durations were associated with 15% lower lepin levels and 14.9% higher ghrelin levels which were independent of Body Mass Index (BMI). They conclude that chronically shortened sleep duration could increase appetite leading to overeating and eventually obesity. The neuro-cognitive theory of insomnia suggests that insomnia is associated with increased levels of cortisol \citep{Perlis1997}. \citet{Dallman2003}, proposed that chronic evaluation of gluocorticoids, such as cortisol may be implicated in the overconsumption of high fat and sugary foods and the propensity to store fat around the abdominal area. They argue that chronically elevated levels of glucocortical hormones increase corticotropin-releasing factor activity in the central nucleus of the amygdala which increases stimulus salience and abdominal obesity. This mechanism then moderates metabolic inhibitory feedback on the catecholamines in the brain and the expression of corticotropin-releasing factor. Accordingly, the authors propose that, in an attempt to dampen activity in the brain, the same mechanisms which mediates hyperactivity in insomnia facilitates overconsumption of high fat and sugary foods as well as promoting abdominal obesity.
Population studies have also demonstrated a strong associated between OSA and chronic diseases including cardiovascular disease, hypertension, diabetes mellitus and stroke (Somer et al, 2008) \citep{Kato2009}. Moreover, as with insomnia, a strong relationship has also been shown between OSA and obesity and emerging evidence suggests a reciprocal interaction \citep{Passos2010}. \citep{Malhotra2002}. \citet{Ong2013} propose that obesity causes changes to the upper airway structure and function, causes 'reductions in resting load volume and negative effects on respiratory drive and load compensation' compensation' \citep{Hargens_2013}.
Several studies \cite{Marshall_2002}\cite{Bryant_2004} have highlighted the reciprocal relationship between sleep and the immune system whereby sleep disturbances affect immune function \citep{Born1997} \citep{Everson1993} and activation of the immune system disturbs sleep patterns \citep{Sp_th_Schwalbe_1998}, \citep{Takahashi1999}. Thus sleep disturbance may be linked directly to the pathogenesis of chronic inflammatory conditions such as asthma, rheumatoid arthritis and inflammatory bowel disease. For example, sleep disturbances are one of the major modifiers of asthma and can directly affect its course and severity. Specifically, sleep disturbances have been shown to negatively affect respiration, arousal responses and airway clearance \citep{D_Ambrosio_1998}. This effect is thought to be underpinned by prolonged supine posture, intrapulmonary pooling of blood, alterations in balance between the parasympathetic and sympathetic nervous system, sleep induced reduction in lung volumes \citep{Ballard_1999}.
Another significant factor which may mediate the relationship between chronic conditions and sleep disorder is pain. It has been shown that chronic conditions associated with pain are associated with a higher prevalence of sleep disorders than conditions that are not \citep{Benca2004}. Although the relationship between pain and sleep remains unclear \citep{Drewes2019} \citep{Roehrs2017,Roehrs2005}. Some have suggested that pain has an arousal-enhancing effect that prevents the initiation and/or maintenance of sleep. Others argue that pain and disturbed sleep are underpinned by common neurobiological pathways and that poor sleep negatively affects pain processing causing increased pain sensitivity \citep{Moldofsky_2001}\citep{Smith_2004} \citep{LAUTENBACHER_2006}. Again, there is evidence of a reciprocal interaction between sleep and pain with disturbed sleep increasing pain sensitivity and with pain sensitivity decreasing following deep, less fragmented sleep \citep{Bigatti_2008}.
In sum, the examples above illustrate how sleep disturbances may be implicated in the pathogenesis of a range of chronic conditions either by exerting their effects directly (e.g. via the immune system) or indirectly (eg. increase appetite leading to overeating of unhealthy food). Moreover, example also show how sleep disturbance can exacerbate the impact of chronic conditions (for example by increasing pain sensitivity). To further illustrate this point with cardiovascular diseases as an example, insomnia has been shown to reduce compliance with anti-hypertensive and other cardiovascular medications \citep{Haaramo_2013}. Moreover, the presence of insomnia also predicted coronary heart disease \citep{Sands-Lincoln2013} and myocardial infarction \citep{Laugsand_2013}.
Emerging research suggests that insomnia, a disorder of arousal [
9,
10], contributes to the development of cardiovascular conditions [
11,
12,
13,
14] independent of traditional risk factors [
15]. Although data are mixed [
16,
17], insomnia and short or long sleep duration [
18,
19,
20] and insomnia with arousal were associated with hypertension [
21]. Insomnia also predicted use of anti-hypertensive and other cardiovascular medications [
22], coronary heart disease [
23], and myocardial infarction [
24,
25]. Insomnia had a dose-related effect on incident HF and death [
26], and may contribute to death from other cardiovascular conditions [
14,
27], but data are conflicting [
15,
28]. This evidence points to importance of identification of sleep disturbances in people with chronic conditions and also suggests the important of treatment of either the sleep disorder its self or its moderating factors (e.g weight gain, pain). Next we explore the evidence such intervention in people with chronic conditions.
Cognitive Behavioural Therapy has been shown to be an effective treatment for adults with insomina with clinically meaningful effect sizes
\citep{Trauer_2015}.
Music therapy has proved effective for both acute and chronic sleep disorders
(Wang, Sun, and Zang, 2014), with massage, acupuncture, natural sounds and music videos being reported to be effective in health care settings
(Hellström and Willman, 2011). As discussed above physical activity is often recommended for obesity. Given the reciprocal interaction between obesity and sleep physical activity has also been explored for the treatment of sleep disorders. Interestingly, in several cross sectional studies physical inactivity has been shown to be a risk factor for poor sleep and insomnia
\citep{Chasens2012},
\citep{Paparrigopoulos2010},
\cite{Foley2004},
\citep{Morgan2003}. With respect to insomnia, physical activity has been shown benefit people with sleep disorders but this was dependent but this was dependent on the type and intensity of the physical activity, with moderate-intensity aerobic exercise proving beneficial as opposed to high intensity aerobic and moderate-intensity resistance training
\citep{Passos2010}. A plethora of studies have also shown amelioration of OSA and associated symptoms such as excessive daytime sleepiness as a function of increased physical activity and/or diet
\citep{Tuomilehto_2009},
\citep{Tuomilehto_2013},
\citep{Kuna2013},
\citep{Foster2009}.
Conclusion - overall re health behaviours as they pertain to chronic conditions
It is noted however, that simply providing information on modifications to health behaviours is not sufficient to elicit behaviour change. The use of behaviour change theory or behaviour change techniques is needed
(Michie, Fixsen, Grimshaw, and Eccles, 2009), such as self-monitoring, goal setting, goal review and feedback; proving to increase the likelihood of behaviour change
(Michie et al., 2009). Based on the upward spiral theory of lifestyle change, increasing positive affect will encourage adherence to a new behaviour change
(Van, Rice, Catalino, and Fredrickson, 2018), mediated by increasing HRV and social connectedness
(Kok and Fredrickson, 2010). There is a need to build positive psychological experiences in parallel with the ongoing medical treatment to both increase treatment adherence and improve health and wellbeing through other routes.
5.1.2: Positive Psychological Moments/experiences :
In a study of 245,404 participants from 60 countries across the world, an average of between 9.3-23% of participants with one or more chronic physical condition had co-morbid depression \citep{Moussavi_2007}. This is significantly higher than depression rates in people without a chronic physical disease (p>0.0001). Moreover, even after adjustment for health conditions and socioeconomic factors, depression had the largest effect on worsening mean health scores. The authors conclude that participants with one or more chronic condition and co-morbid depression had the worst health states of all of the disease states.
In addition to positive health behaviours, the promotion of individual
strengths such as acceptance, optimism, resilience, sense of coherence and psychological flexibility are likely to
promote health and wellbeing in people living with chronic conditions.
These strengths are developed through many psychological t cognitive-behavioural therapy, person-centred therapy, acceptance and commitment therapy and positive psychotherapy \citep{Hughes2017,Joyce2018,Bond_2006,Luoma2013,2012,Lin2018,von_Humboldt_2013}. Resilience, which can be described as the ability to adapt well in the face of adversity \citep*{Southwick2012}, is influenced by a multitude of factors, including but not limited to genetics, age, life experiences (quantity and quality), and culture. Resilience levels are lower among people living with chronic conditions compared to healthy individuals, although notably,
increased resilience among those living with a chronic condition is
associated with reduced psychological distress, and reduced symptoms of
anxiety and depression \citep{Keil2017,Winger2016}. Higher resilience levels have been associated with improved mental and physical health, such as symptoms of depression and chronic pain \citep{Mehta2008,Schure2013}, arguably due to more efficient strategies being employed to cope with life stressors \citep*{Bonanno_2015}. Resilience-building techniques based off the principles of positive psychology are now being recognised as a viable strategy to prevent ill-health \citep*{Davydov_2010}, an example being optimism training \citep*{seligman2007}, proving to be effective in improving wellbeing and coping styles \citep*{Scheier_1992}, even among those with chronic conditions \citep{Mohammadi_2018,Kraai_2017} . Common resilience-related protective factors that are employed by this
population include self-efficacy and adaptive coping \citep{Ghanei2016}. Combinations of mindfulness
and CBT techniques have proven useful in building resilience among individuals living with
chronic physical conditions including heart disease and diabetes \citep*{Robinson2019}, resulting in improvements in positive experiences, condition
management, and social engagement. Other mindfulness-based interventions have proven effective in increasing resilience among people living with chronic conditions \citep{Shim_2017}.
Strikingly, a strong sense of coherence (or SOC) (a contributor to resilience) is associated with a 30% reduction in mortality rate from cardiovascular disease, cancer and all cause-related death \citep{Surtees2003}. SOC reflects feelings of confidence that stimuli in the (internal and external) environment are comprehensible, manageable and meaningful \cite{1987}, as a result, people with higher SOC are better capable of dealing with stressors and subsequently are more resilient to negative physical and mental health outcomes, with SOC levels predicting mental health outcomes \citep{Pallant_2002,Sairenchi_2011,Hart_1991}.
In summary, there is tremendous opportunity for improving the health and wellbeing of people living with chronic conditions by focusing on the individual. Traditional routes for improving physical health, such as physical activity, diet and sleep may now be considered as opportunities to support mental wellbeing, when combined with strategies for behaviour change. Treatments that build strengths, resilience, optimism and positive psychological attributes will provide useful strategies to promote health and wellbeing, as has been discussed previously [REF].
5.2: Promoting Wellbeing by Focusing on the Community
Social connectedness needs to become a key focus for people living with
chronic conditions as this population are more vulnerable to social
isolation due to barriers such as receiving care, attending physician
visits and hospitalisations, being physically disabled and/or being unemployed
\citep{Meek2018}. This subsequently influences their health, with one study finding social isolation to be the most reliable predictor of attendance to a health service, more so than physical or mental health issues \citep{Cruwys2018}. Among the participants in this study, increased subjective social connectedness after joining a group, correlated with a reduction in primary care attendance. It is argued that social engagement promotes the resources which people can use to manage their condition \citep{Arcury2012}. The term "social capital" has been termed to describe the social connections and network that influence individuals and their output into the social structure in which they live, with research highlighting social capital to serve as a protective factor against common mental disorders \cite{Ehsan2015}.
Further highlighting this importance, social engagement can help
prevent a health condition from worsening \citep*{Mendes_de_Leon_2003}, and even prevent the development of a chronic disease in the first place; the reverse effect is
observed for people who live alone \citep*{Cantarero-Prieto2018}. However, the quality of the social connections is important \citep*{Gallant2003}, with poor social relationships increasing the risk of disease development \citep{Valtorta2016}; poor marriage quality being one example in which this can occur \citep{Kiecolt-Glaser2001,Umberson2006,Walen_2000}. The self-categorisation theory illustrates one pathway through which this relationship occurs; 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 \citep{Schofffild_2001}. An additional pathway in which social relationships negatively impact on health and wellbeing is when one of the pair becomes a care provider for the other \citep{Christakis_2006,Schulz_2008}.
Reclink is an example of utilising communities to benefit the health and wellbeing of the members; an Australian
community agency that works with individuals with chronic mental health
conditions through the organisation of groups such as choirs, bowling, yoga, and football. Results from the choir group evaluation reported improvements in three areas; personal improvements, including positive emotions and emotion regulation, social improvements, including social connectedness and social functioning, and functional outcomes, including health improvements \citep*{Dingle_2012}. A similar study was
completed which highlighted that those who received greater 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}.
Group interventions allow for peer modelling and peer mentoring, both of which have proven to be effective utilities, especially for hard to reach groups such as those with chronic conditions \citep{Lawn_2010,Sokol2016,Fisher2015,Merianos_2015}. Utilising members of the community in this way will help provide longer-term support for those living with chronic conditions in a currently under-resourced health care system. In addition to this, it allows for the building of a greater social network subsequently influencing one's social identity, the importance of which is highlighted by the social identity theory; the more social identities an individual possesses the more psychological resources they have access to, which protects them from a decline in health \citep{haslam2018}. This is arguably more important for those living with chronic conditions as this population face more discrimination than the general population, which subsequently impacts their health and wellbeing \citep*{Cockerham_2017}. Using social identity as a
clinical target has proven beneficial \citep{Haslam2010,Cruwys_2014} in improving wellbeing and reducing illbeing, therefore 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.
Another pathway through which social connections improves health and wellbeing is the upward spiral dynamic between social connectedness, positive emotions and vagal function. Using a loving-kindness meditation study as an example, positive emotions can be increased (moderated by vagal function), subsequently increasing vagal tone, an effect mediated by perceived social connections
\citep{Kok_2010,Kok2015,Kok_2013}. 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, emphasising the need to build on both positive affect and social connections. Whilst building social connections has it's benefits, as previously discussed, positive emotions too has it's own benefits, with positive affect being associated with reduced negative affect, pain and
stress \citep*{Zautra2005}, along with increased physical activity,
sleep quality, and medication adherence \citep*{Sin2015}, among people living with chronic conditions.
Expanding beyond the relationships previously discussed is that of human-animal relationships which can be utilised to enhance an individual's health \citep*{Friedmann_2015}, with general pet ownership being associated with improved physical health, an example being protection against cardiovascular risk \citep*{Giaquinto_2009}. Pet ownership reduces mortality risk after discharge from a coronary care unit, independent of disease severity and sources of social support \citep{FRIEDMANN_1995,Friedmann1980}. This may be attributable to the anti-stress effects of animals; reducing cortisol \citep{Barker_2005,Beetz_2011,Odendaal_2000,Odendaal_2003,Viau_2010}, epinephrine and norepinephrine levels \citep*{Cole2007}, along with reducing blood pressure \citep{FRIEDMANN_1983,Nagengast_1997,Vormbrock_1988} and increasing heart rate variability \citep*{Motooka2006}.
Animal-assisted interventions have proven effective when working with clients with autism, dementia and psychiatric populations in terms of improving stress levels and problem behaviours, and in increasing social interaction and communication \citep{O_Haire_2012,Bass_2009,Martin_2002,Prothmann_2009,Sams_2006,Richeson_2003,Filan_2006,Haughie_1992,Marr_2000}. Animal-assisted therapy or activities have also proven effective in reducing symptomology of mental illness \citep{Souter_2007,Jones_2019,Peluso_2018} although some research has reported no significant effect \cite{Barker_1998,WILSON_1991}. 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}. \citet{Beetz_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 \citep{Handlin_2011,Odendaal_2000,Odendaal_2003}. Increases in oxytocin facilitates social interaction and improves health through several methods, including increasing trust \citep{Kosfeld_2005,Zak_2007,ZAK_2005} and reducing stress \citep{Kirsch_2005,Legros_1988} and anxiety \cite{Guastella_2009}.
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 \citep{haslam2018}.
Another reason is that social engagement improves positive affect and
emotion regulation \citep{Dingle_2012}, 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. Incorporating a focus on the social aspect of a client's life 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; incorporating loved ones into the intervention is a key example \citep*{Martire2010} . 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 has been argued that a broader method of tackling of health and wellbeing that focuses on developing healthy and sustainable communities is necessary for targeting disadvantaged populations; asset-based community development is one route through which this can be achieved,whereby communities utilise the assets they have to address the problems within \citep{Blickem_2018}.
Health behaviours - I assume that community includes society and so notably missing from this section are social factors as they pertain to health behaviour - see below in relation to obesity