Pursuing Better Health Outcomes

9

Developing Conceptual Models of Psychosocial Wellbeing Pursuing Better Health Outcomes Lyn G. Courtney, Nerina J. Caltabiano, and Marie L. Caltabiano Subjective wellbeing (SWB), often referred to as quality of life (QOL) or satisfaction with life. is a predictor of better mental health, improved overalJ health, superior prognosis in times of illness, reduced mortality, and Încreased longevity (Diener & Chan, 2011; Seligman, 2008). For more than four d ecades, the theoretical structure of SWB has been su bjected to extensive empirical

investigation in order to determine the dimensions that comprise SWB (see review Diener et al., 2009). However, the study ofSWB is coosidered to be in i15 formative stages with little con sensus o n the theoretical structure, composition, conceptual characteristics, measurement, and consequences

ofSWB. This chapter has four objectives. Firs!, trus chapter will introduce SWB within a positive psychology fram ework (Seligm an 1998, 2003) and the emerging field ofpositive health (Seligman, 2008). Next, to provide the contex! from which the field of SWB has em erged, a brief review of QOLand wellbeing is presented. Third, we will compare and contrast four weU-established models and measures ofSWB in order to elucidate sorne of the challenges that neecl to be resolved by SWB researchers. Finally, this chapter will present an argum ent for viewing SBW from an integrative, holistic perspective that takes ioto account the differing life contexts, h istories, experiences, beliefs, values, perceptions, and expectations of sub populations (e.g., gender, age, personality, culture). A hoHstic perspective ofSWB woulcl incorpo rate factors that have reœntly been shown to cont ribute to SWB, such as spirituality/rcligiosity (c.g., McCullough et al., 2000; Strawbridge et al., 2001), generativity (e.g., An & Cooney, 2006; Cheng, 2009) . and autonomy (e.g., Deci & Ryan, 2008) . Precise, targeted conceptual models of SWB may facilitate the developrnent of interventio ns that promote and enhance physical and psychosocial health.

Positive Psychology and Positive Health ln 1946 the World Health Organization (WHO) introduced a revised definition ofhealth as "a state of complete physical, mental and social wellbeing and not merely the absence of disease or

Applied Topic$ in Hea/th Psychology, First Edi tion. Edi te
Conceptual Models of Psychosocial Wellbeing

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infirmity" (WHO, 1946, p. 100). However. the Iraditional"disease modeJ" ofhuman functioning, which focused primarily on pathology, weaknesses, and Ireating illness, persisted. By including psychological and social aspects ofind ividual health, concerns regarding wellbeing and satisfaction with life began 10 emerge. Martin Seligman (2002, 2003) proposed a paradigm shift to a positive model ofpsychology, which focused on positive subjective experiences, strengths, and promoting health and wel1being. Seligman and Csikszentmihalyi (2000) predicted that positive psychology would "allow psychologists to understand and build those factors that allow individuals, communities, and societies ta f1ourish" (p. 13). Positive psychology, as a theoretical framework, does not imply the dichotom ization of human experience inlo positive or negative; rather it views experience as a continuum that spans the whole spectrum of human experiences from health to illness and from distress to weUbeing (Keyes, 2002; WHO, 2005). For examplc, positive and negative psychological states can oceu r contiguously or even simultaneously, and evcn when faced with highly stressful circumstances, positive psychological states can occur (Folkman & Moskowitz, 2000). Gable and Haidt (2005) defined positive psychology as "the study of the conditions and processes that contribute to the flourishing or optimal functioning of people, g~oups, and institutions" (p. 104). Seligman (2003) forwarded three pillars of positive psychology: positive subjective experiences (e.g., optimism, hope, happiness); positive individual characteristics (e.g., personal strengths that promote mental health); and positive social institutions and communities (e.g., those that contribute to individual happiness and health). According to Seligman and Csikszentmihalyi (2000), "the aim of Positive Psychology is to begin to catalyse a change in the focus of psychoJogy from a preoccupation only with repairing the worst things in life to aIso building positive qualities" (p. 5). A key contribution made by proponents of positive psychology has been the classification system forwarded by Peterson and Seligman's (2004) character strengths and virtues (CSV) mode! dcsigned to provide a theoretical framework and common language to assist in developing interventions to enable human thriving. The CSV model provided six un iversai virlues endorsed by almost every culture and gcneration: wisdom and knowledge, courage, humanity, justice, tempcrance, and transcendence. The six virtues are comprised of 24 character strengths that can be reliably measured and used to sustain and even increase wellbeing (sec Dahlsgaard et al., 2005). Shared strength profiles can then be utilized to facilitate the devclopment of specifie interventions to enhance weUbeing and improve health outcomes.

Positive health Seligman (2008) extended positive psychology to indude the discipline of positive health. Seligman operationalized positive health as a combination ofbiological, subjective, and functional measures that promote emotional and physical wellbeing. Positive health interventions bave becn shown to enhance weUbeing and alleviate the effects of negative states, such as depression (see meta-analysis by Sin & Lyubomirsky, 2009), and provide a buffer against physical and mental iIIness, and futu re stress (Seligman, 2008). Positive health outcomes arc weil documented in the epidemiologicalliterature, which recognîzes that promoting positive psychological health benefits physical health by improving overaU health (see review Chida & Steptoe, 2008), lowering mortality, and increasing longevîty (Diener & Chan, 2011). For example, positive emotions are associated with teduced incidences of stroke

.

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and improved poststroke survÎval rates (Ostir et al., 2001), provide protection from coronary heart d isease (Sanjuan et al., 2010) , and m ay influence inflarnmatory and coagulation facto rs that are involved in cardiovascular diSt:ase (Chida & Steptoc, 2008) . Furthermore, positive emotions have been shown to decreasc depression (Fava et al., 2005), provide highcr immu ne functioni ng (Segerstro m & Sephto n, 2010). be protective against the rapid progression of H IV (Taylor et aL. 2000), are negative1ycorrelated withobesity (de Wit et al.. 2010), and lower mortality rates among older people (Cohen & Pressman. 2006) . Additionally. Chida and Steptoe's (2008) meta-analysis examining positive wellbeing and mortality in bath healthy and diseased populations indicated that positive psychological wellbeing was rclated to lower mortality and increased longevity in both populations. Consequently. the last 50 years of wellbeing rcsearch have been focused on understanding, defining, operationalizing, and dclineating the measurement of wellbcing in order to improve QOL.

Quality ofLife and Wellbeing Quality ofLife ernerged as a discipline in the 1970s and in 1975 McCali suggcsted that the besi way to approach QOL was to measure the extent to which the individual's "happiness requirement" was met. However, thcre is !ittle consensus of what constitutes happiness (see review by Schalock. 2000) and debate continues over the contributions of objective happiness (captured through measurement of b ram waves) and subjective happiness (asking people how happy they feel) (Frey & Stutzer, 2002). Therefore, as the determlnants of happiness are unresolved, it has been more productive at times to retreat and to measure QOL, which has received more rigorous empirical investigation (Eid & Larsen. 2008). The construct ofQO L is prominent in the health literature; however, there are over 100 defini· tions (Cummins 1997; Rapley 2003), which consist of a wide range of interprctations generating considerable conceptual confus io n (Rapley 2003 ). Early efforts 10 define QOL took an objective (or economic indicator) approach to assessing the state of a nation's health; however. objective measures account fo r only a smaU proportion of an individ llal's subjectivcly reported QOL (Diener & Suh, 1997). For éxample. physical health can be ascribed to longevitystatistics or the number of people with major il1nesses. An aggregare of fam ily welJbeing may be measured in divorce rate or incidents of domestic violence. Previous rcsearch has established that meaSllres of objective wellbeîng, often referred to as social indicators, are easily measured (e.g., gross national product. infant mortality rate) and facilitate making comparisons between groups and across nations (Diener & Suh, 1997) Objective îndicators aise reflect aspects beyond economic indices, such as social issues (e.g.• d imate change, deforestatîon ), which provide opportunitîcs to initiate global solutions to sodetal problems (Diener & Suh, 1997). However, objective weIlbeiog measures fail to accou nt fo r individu al preferences, intcrests, goals, att itudes. and life history/experiences (Haq, 2009) and are only weakly correlated with li re satisfaction (Cu mmins, 2oooa, 20oob; Diener, 2000). Austral ian and international research has confi rmed that the power of more money to increasc happi ness is only significant at low incomes, and that once basic needs are met happincss does not incrcase as income rises (Cummins, 2006) . Rojas (2006) fou nd no correlatio n between incorne and subjective wellbeing (SWB) . Recent stlldics have indicated that "relative income" in poor and middle·incorne countries, even in the context of extreme poverty, may be a better pred.ictor of QOL than absolllte incorne (Fafchamps & Shilpi, 2008; Guillen -Royo. 201 1). Thereforc. objective wellbeing indicators have becn shown to be mislcading indicatorsoflife satisfaction as thcyprovide an Îl1complete pictllre of ooe's QOL (Cummins. 1996, 2000a; Diener, 2003).

Conceptual Models of Psychosocial Wellbeing

115

Wellbeing

Objective wellbeing (OWB)

For example: Gross national product mortality rate

Subjective wellbeing (SWB)

Psychological wellbeing

Social wellbeing

For example: Cognition Negative and positive affect

For example: Relationships Social integration

Figure 9. 1 Conceptual d iagram of the basic structure of wellbeing. consisting of both objective and subject ive wellbeing. The WHO Quality of Life Group (1995) defined QOL as "individuals' perception of thcir position in life in the context of the culture and value systems in which they live and in relation 10 their goals. expectations. standards. and eonccrns" (p. 1404). While the ideals of the WHO Qual ity of Li fe Group are admirable goals, a more prec ise defini tion is required looperationalize QOL for research purposes. Despitc considerable debare abou t how to define QOL, the operational definit ion of wcllbci ng forwarded byCummins ( 1996) has becn widelyacccpted ( Rapley, 2003) and adopted by the AUSlralian Centre on Quality of Life (ACQOL), "Quality of life is both objective and subjective. Each of these two axes comprises several domains which, together, define the total construet. Objective domains are rneasured throllgh CLllturally relevant indices of objective well being. Subjective domains are rneasured through q uestions o f satisf.l.ction" (ACQOL, 201 1, n.p.). SWB directly reflects an individual's self-asscssment about indîvid llal preferences, satisfaction with life as a whole, sense of community, and happi ness (Cummins, 1996; Diener, 1984). To assist in distingllishing QOL, objective wellbeing, and SWB, and based on a gelleral synt hesis of the litcrature, Figure 9.1 provides the structure of wellbcing as conceptualizcd by the authors of this chaptcr.

Subjective Wellbeing The theoretical structure of SWB has been subjccted to extensive empi rieal investigation for more than fo ur decades (sec reviews by Diene r, 1984; Diener et al., 1999); however, the study of SWH is still considered to he in its for mative stages with considerable debate about theoretical structure, composition, conceptual characteristics, and how best to measure SW B. For the purpose

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of this discourse, a broad dcfinition of $WB forwarded by Diencr (2006) captures the essence ofSWB:

Subjective wcllbeing refers 10 ail of the various types of cvaluations, both positive and ncgati ve. Ihat people make oftheir lives. It includes reflective cognitive evaluatÎons, such as life satisfaction and work satisfaction, intcrcst and engagement, and affective reactiOlls 10 life evenls, such as jay and sadncss. Thus, subject ive wellbeing is an umb rella teTm for the d ifferent valuations people make rcgarding Iheir lives, the events happening to them, their bodies and minds, and the circumstanccs in which they live. (pp. 399-400)

Seminal Tcsearch conducted by Bradburn (1%9) provided evidenee that SWB was at lcast a hYo-dimensional construct whcre positive affect (PA) and negative affect (NA) were shown 10 be independent of each other and influcnced by diffcrcnt variables. Diener and colleagues (c.g., Diener et al., 1985; Kuppens et al., 2008) have conducted exhaustive studies on the two-factor (PA and NA) modcl ofSWB and proposed that SWB had three distinct components: PA, NA, and life satisfaction (LS). Lucas et al. (1996) reported that SWB was comprised of m ultiple, separable components [hat were not strictly indepcndent. High PA does not necessa rily result in low NA, and LS was separable into specific life domains, such as domain satisfaction (or DS) (Oishi & Diener, 2001) . Cognitive app raisals of LS and positive functioning have led to both global and domain-specifie levels ofSWB gaining prominence (e.g., Argyle, 2001; Diener et al., 1999). Further complicating the exploration in 10 the composition and structure ofSWB a re botlom-up (e.g., social demographic status, such as education) and top-down (e.g., derived (rom personality traits) theories (see review br Diener, 1984). Early proponenls of the bottom-up theory of SWB (c.g., Andrews & Withey, 1976) argued that the accumulation of satisfaction in many domains leads to satisfaction with life overall. Conversely, top-down theorists of SWB (e.g., Brief el aL, 1993) proposed that satisfaction with life as a whole can be attributed to satisfaction wilh lifc in specifie domains. Bottom-up perspectives have been criticizcd for explaining onlya smaU amount of the variance in wellbeing (Diener et al., 1999), and top-down approaches have been criticizcd for cxplaining too much ·variance due to the overlap of predietor and criterion variables (Schmitte & Ryff, 1997). Other researchers (e.g., Mallard et al., 1997) argued for a bidirectional model of SWB wnere bottom-up and top-down theories ofSWB occur simultaneously and bidirectionally. Finally, more recen t research conducted by Gonzâlez et al. (20 10) provided an a rgument, based on the bottom-up approach, for the value of adopting a nonlinear approach 10 the measurement of life satisfaction and SWB. Despite disagrccment about the structure of SWB, il is generally acccpted that tnere is no sole determinant ofSWB and Ihus most SWB models are multid imensional. Thesc include Ryff's ( 1989a, 1989b, 1995 ) six. dimensions ofpsychological wellbeing (PWB) and Keyes' (1998; Keyes & Shapiro, 2004) five dimensions of social wellbeing. Due to possible con fusion between acronyms, SWB will be used in Ihis cnapter to denote subjective wellbeing and Keyes' (1998) model will be referred to as the social wellbeing mode\. The International Wellbeing Group's (fWbGi 2006) mode! of personal wellbeing consisted of eight dimensions ofSWB and a separate global measure of SWB. Recently, spirituality has bcen added as a new dimension of the personal wellbeing index-adult (PWI-A) version (Casas et al., 2009; IWbG, 2006). Also rccendy, niener et al. (2009) forwarded a conceptual h ierarchical model of SWB, which consisted of four dimensions and 24 subdimensions. To assiSl in understanding sorne of the major models of SWB, Table 9.1 presents fou r models of SWB that arc frequently used both nationally and internationally. They were sclected based on their theorctital framework, thcir cross-national validation, and the extensive

Most widely used scale in SWB resc3rc h (Eid & Larsen, 2008)

Diener et al. (1985)

\wice a year sinet' 2003.

Projec! nas measured the SWB of th e Aus tralia n popula tio n

Aust ralian UnityWcll bcing Index Relationships Safety Community Future security Spirituality

4. 5. 6. 7. 8.

Test- retest coefficient of 0.82 wi lh il 2 monlh in terval (Diencr etn/., 1985;

Convergent rdjabi lilYwilh numerous SWB meilsures (Diener el al., 1985 ).

momentary moods.

on long-Ierm states rather than

Translated inlo 28 la nguages.

2009).

(conrinlled)

Te mporal stability of 0.54 for 4 years a nd d iscriminant validity from cmotional wcllbcing measurcs (Pavoi & Dieller,

Pavot & Diener, 2009). Simi lar

Positive affect Negative affect

Construct validit y, Cronbach's alpha = 0.87.

translalcd into 20 languages.

multicultural societies and has been

which is useful considering

coefficient of 0.84 (Lau et al., 2005). Emphasis on cross-cultu ral va lidity,

Test-retest reliability acroS$ 1-2 week interval with an intra-class correlation

Interdomain correlations 0.30-0.55 and item-total correlations are at least 0.50.

with the satisfaction wi th life scale (Diener et al., 1985).

findings by Yardlcy and Rice (1991) .

1. 2.

Two dimensions:

Health Achievemcnts

2. 3.

0.71-0.85. Convergent validity = correlalion of 0.78

Constru ct validity, Cronb3ch's alpha =

Psychomerrie propu/in

Ihat constitutes SWB; (3) SWB focuses

et al.. 2002). Satisfaction with life scale (SWLS)

satisfaction wüh life as a whole (Cummi ns

Stand ard of living

1.

Eight dimensions:

DÎmemÎ01l5

happy; (2) it is solely the individual's internai experien ce, o r perspect ive,

enlire range of wdlbcing from cxtrcmely unhappy to extremdy

three dimensions: (1) SWB CQvers the

Global satisfaction with life Oiener's (2000) SWB model comp ri~s

bya system ofhomeoslasis; howeve r, in limes of prolonged challenges it can fail (Cummins, 20 10).

reliably predicts 50% of the var iance of

satisfaction with life as a who!c question

changing extcmal circum stances. It is activeJy m anagcd to lie within a narrow, positive set point (mean is 75)

onto a 0-100 scale. And a one- item global

0-10 that transform

Eight fo rced respon~ q uestions rated on an Il-point Likert satie

a.rcas. SWB is not free to vaTras a function of

a.dopts a domain-Ievel approiU:h (0 measure satisfaction with eight life

Represellts a first-level deconstruclion of satisfaction with life as a wholc and

index- adult (PWI-A)

Personal wcllbeing

Thcory and mode! of subjective well bei ng homeostasis

MeQ5ure

Modd

Prominent modds ofSWB, mcas ures, dimensiollS, a nd psychomct ricstrengths

CumminslACQOL and the Internatio nal Wcllbcing Group (2003-2011)

Table 9.1

wellbeing d UTing life transitions (S howers & Ryff, 1996),

life (Ryff, 1995), succeS5 in growing aide r (Ryff, 1989;\), and autonomy ~nd

life's transitions ( Kling er al., 1997), variations of self in adu lt and elderly

to evaluate life change. For exalllple, the ch~ n ge of self-collcept through

Psychological wellbeing (PWB) The PWI3 seale has been used extensively

stron gly disagrcc)

(s trongly agrec 10

ques tions raled on an 6-poinl Li kerl scale

PWBseak Eighly-four fo rced- responsc

Social acttla!i~1t i on Social coherence

4.

Posit ive relat io ns with

••

S.

others Purpose in life Self-acceptante

'1.

3.

2.

Autonomy Environmental m astery Personal growth 1.

Six dimensions:

S.

Social contributio n

3.

Ryff0989a.1989b)

strongly disagree)

(srrongly agrce ta

6-point Likcrt scale

Social inlegration Social acceptance

1. 2.

Five dimensions:

Social wcllbcing

Keyes(I998)

Soci:llwellbeing .$Cale Fjfteen forced-l'esponse q uestions raled on an

Dimensiolls

Model

Prominent models of SWB, measures, dimensions, and psychometrie strengths (Continucd)

Aut/!or(s)

Table 9.1

2006).

dist inct dimensions (Spri nger

CI

al.,

langua ges (Ryff & Singer, 1996). Construct validjty (" jlcd to shmv six

wceks (Ryff, 1989b). Translated illtO ilt Icast 18 diffcrent

0.30-0.76. Test- retest rcliability 0.81-0.88 ,)( 6

scale = 0.97-0.98 (Ryff & Kcyes, 1995). Subsellic intercorrelations werc

0.83-0.91) for each dimension ,1I1d correlation with 20· ite m pilrenl

Internai consistency, Cronbach's alpha =

social wellbeing may he unequa lly distributed in Ihe population (Keyes, 1998; Keyes & Shapiro, 2004).

d imension overlap and suggests that

The author acknowle
the normalmess.es of life, ca n work produclively and fru Îtfully. and is able la make a contribution ta hisor her communilY. (WHO, 2001, n.p. )

COll cep tuai

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127

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