Basic material conditions for health

As the selected theory is focused on psychological wellbeing (Fisher, Reference Fisher2019) it does not examine in detail the material conditions required for general child development and health such as good nutrition, decent housing, sanitation, healthcare and protection from toxic substances and contagious disease vectors. However, I acknowledge that physical health and mental health are intimately related, such as with nutrition and mental health (Rucklidge and Kaplan, Reference Rucklidge and Kaplan2016). Physical ill-health is a risk factor for psychological distress and chronic stress affects both physical and mental health (Chrousos, Reference Chrousos2009). Therefore, social policy for psychological wellbeing must pay attention to material conditions for general good health. My reasons for focusing on conditions required for psychological wellbeing in particular are not to downplay the importance of these other factors, but rather to recognise something about how SDMH work.

There are many ways that social conditions can affect health which don’t exploit a stress pathway. However, with SDMH, the role of acute stress in regulation of social cognition and the potential for chronic stress come to the fore as pathways for those effects (Chrousos, Reference Chrousos2009; Fisher, Reference Fisher2019; Fisher and Baum, Reference Fisher and Baum2010; Thoits, Reference Thoits2010). Thus, my focus here is on particular conditions that affect psychological wellbeing, because they are identified as determinants of health with a specific relation to social cognition, self-regulation and the role of stress.

Meaningful work

Human beings find it rewarding to do work that exercises skills and has a sense of meaning related to completing a task, achieving a goal, meeting family needs, or contributing to society. Meaningful work is not limited to paid employment. Work that is felt to make a positive difference to others is particularly valuable (Fisher, Reference Fisher2019). Conversely, there is a range of ways in which workplace matters such as management styles, employment security and working conditions can cause chronic stress (Wilkins and Beaudet, Reference Wilkins and Beaudet1998).

To advance the exercise of wellbeing ability #1, people should have access to work that exercises skills and is meaningful and socially rewarded. To advance ability #6, we should be working shorter hours in conventional employment, leaving more time for other self-directed pursuits as per ability #3. To cultivate abilities #4 and #5, more paid work should be available caring for children and other adults, and caring for nature. A sense of meaning in work is enhanced when it is publically valued and offers a realistic sense of making a positive difference to broader social or environmental problems.

The task of social policy is to address access to meaningful work, education for learning salient skills, and workplace and employment conditions as potential causes of stress. Although a market economy can supply access to skilled, meaningful work, it won’t deliver universal access of its own accord. Both governments and communities have an essential role, to broaden the scope and availability of meaningful work.

Child development and parenting

Early childhood is crucial for neuro-psychological and behavioural development (Mustard, Reference Mustard2008). Maternal stress in pregnancy and child exposure to stressors are both risk factors for children’s health (Morsy and Rothstein, Reference Morsy and Rothstein2019). Wellbeing abilities are developed in children by being exercised in nascent form and parents or other caregivers have an essential role to play. Ability #4 is developed through warm nurture and active, face-to-face child-parent interaction from birth, leading on to shared play and active conversation, among other things. Semi-structured activities such as drawing, painting, building with blocks or being read to enable development of ability #1 and form a foundation for positive expectancy states about more complex tasks as the child grows (Kristenson et al., Reference Kristenson, Eriksen, Sluiter, Starke and Ursin2004). Development of ability #2 is aided by non-violent discipline between ages of around 1 to 5 years, when a parent or carer decisively intervenes in anti-social behaviour, and requires specified changes in behaviour before activity and affectionate relations are resumed. Free play and contact with nature begins to develop ability #5. The task of social policy is to engage with parents and care givers on a universal basis, to build skills and gradually embed the required practices as social norms. In the process, parents should learn about wellbeing, contributing to ability #7.

Social relatedness

On average, people subject to social isolation have worse mental and physical health than those with positive social relationships, and increased stress arousal is strongly implicated in this effect (Cacioppo and Cacioppo, Reference Cacioppo and Cacioppo2014). Wellbeing ability #4 is the ability to maintain and enjoy social relationships based on mutual care, affection and respect. This is different from relationships in, say, a work situation where stress-arousing contingencies of expectation and conditional approval are at play (Fisher, Reference Fisher2019). The business of social policy is obviously not to curate social relationships directly but to cultivate social conditions and personal skills that favour social relatedness and reduce isolation. Other parts of this discussion speak to ways of doing this, such as those on child development and active communities. Indigenous philosophies put social relatedness and the thriving community at the centre on their conceptions of wellbeing (Dudgeon et al., Reference Dudgeon, Milroy and Walker2014) and hold crucial lessons for societies at large. Obviously, wider socio-cultural conditions can affect people’s capacities to conduct positive social relationships, and I will discuss those below.

Connection with and care for nature

Contact with ‘nature’ in various forms is beneficial for mental health, and stress reduction plays a significant part in this benefit (Bratman et al., Reference Bratman, Hamilton and Daily2012). Contact with and active caring for nature can contribute to the exercise of wellbeing abilities #1, #3 and #5. However, in modern societies contact with nature may be limited to short periods of ‘escape’ to places outside of one’s normal environs, for those who can afford it. Low income areas may have poor access to local ‘greenspace’ (McGreevy et al., Reference McGreevy, Harris, Delaney-Crowe, Fisher, Sainsbury, Riley and Baum2020). Even when in a pleasant natural environment, people may not know how to ‘relax into’ a contemplative, sensory state. Learning how to do so contributes to wellbeing abilities #5 and #7. Indigenous peoples’ philosophies commonly understand connectedness with the natural world as fundamental to human existence in practical, cultural and spiritual ways (Dudgeon et al., Reference Dudgeon, Milroy and Walker2014). Again, these philosophies represent a rich source of understanding to promote wellbeing.

The role of social policy is to shift social norms and living conditions toward a situation where contact with and care for nature is universally available and valued as part of everyday life. Active and aware human engagement with land and seas as responsible farmers, fishers, gardeners, protectors of natural heritage and contemplators of natural beauty constitutes a huge, untapped potential for wellbeing.

Neighbourhoods and active communities

Modern urban environments can affect human health and wellbeing in multiple ways and inequalities in access to healthy urban conditions contribute to health inequities (McGreevy et al., Reference McGreevy, Harris, Delaney-Crowe, Fisher, Sainsbury, Riley and Baum2020). Although macro-scale features such as telecommunications or transport infrastructure are relevant to our discourse, a focus on conditions for wellbeing demands special attention on the localised scale of urban living described as ‘neighbourhood’, ‘community’ or ‘town’. Localised communities that are safe, have high-quality housing and greenspace (street trees, parks, water courses), and provide walkable access to local businesses and services are good for wellbeing (McGreevy et al., Reference McGreevy, Harris, Delaney-Crowe, Fisher, Sainsbury, Riley and Baum2020). They support exercise of wellbeing abilities #1, #4, #5 and #6. They are an essential venue for social policy action in other key areas such as access to primary health and education services.

For social policy purposes, theoretic clarity on wellbeing as activity – as the exercise of wellbeing abilities – also demands strategies that engage individuals and communities as active participants in localised processes of cultivating conditions for wellbeing. This participatory element of wellbeing promotion raises challenges for social policy governance, discussed below.

Contemporary market economies require people to have specialised skills as paid producers while increasingly, as consumers, they can function without the ordinary skills of cooking, growing, making things, playing games or music and so on; relying instead on passive consumption of digital media, drugs or take-out food. However, these ‘ordinary skills’ are not out-of-date chores but constitute essential opportunities for exercising wellbeing abilities. Again the local domain is an essential venue in which opportunities for gaining and exercising these ordinary skills can be available to all. The commercialised imagery of success (and wellbeing) as the single-minded application of a specialised skill to gain popular acclaim or material wealth is deeply flawed.

Comprehensive primary health care

Engaging community members in localised actions for wellbeing does not remove from governments’ responsibilities to provide high quality social services. In order to promote wellbeing two basic forms of social service stand out; comprehensive primary health care and education services (discussed next). The proposition that these are basic to population health is hardly new. However, comprehensive primary health care (CPHC) is of particular importance because it has potential to contribute to several basic conditions required for wellbeing.

CPHC is first level health care that includes but extends beyond primary medical care to address health promotion, disease prevention and social determinants of health, through community-engaged services in localised settings (Fisher et al., Reference Fisher, Freeeman, Mackean, Friel and Baum2020). Thus, CPHC can address access to first-level medical care as a basic material need while also contributing to meaningful work, child development and parenting, social relatedness and active communities (Fisher et al., Reference Fisher, Mackean, George, Friel and Baum2021). Having theoretical clarity about wellbeing as such and conditions required to promote it can only strengthen CPHC.

Importantly, an appreciation of wellbeing abilities can offer new directions in mental health care. Structured opportunities to exercise wellbeing abilities, offered alongside or instead of conventional biomedical treatments, is likely to aid recovery from states of dysregulated social cognition and behaviour that we currently name as mood, anxiety or substance abuse disorders; because a lack of such exercise is a root cause of these states.

Education

Education is a known social determinant of health and there is no need to add anything on that general front here. However, there are three particular ways in which education can contribute to wellbeing. First, CPHC and early child education services – functioning in localised spaces – have an essential role in supporting healthy pregnancies, parenting and child development. Second, education during childhood and adolescence can cultivate a variety of physical, social and cognitive skills useful for exercise of wellbeing abilities #1, #2, #3 and #4. Third, while abilities #4, #5, #6 and #7 can be commenced in early life, they are likely to mature later, and thus are a suitable focus of adult education.

The ideational environment

There are two broad issues of concern in the way the ideational (or ‘informational’) environment interacts with social cognition and vulnerability to chronic stress (Fisher, Reference Fisher2019). First, functions of social cognition involved in ‘reading’ and evaluating the social environment do not necessarily discriminate between actual and virtual social stimuli. Second, because cognitive interpretation (based on prior learning) plays a role in these evaluation processes, the beliefs people hold about the world can enter into and shape their stress responses (Ochsner et al., Reference Ochsner, Ray, Cooper, Robertson, Chopra, Gabrieli and Gross2004). The first issue is of particular concern because the ideational environment we now occupy includes textual, spoken, visual and aural information conveyed via 24-hour digital media. The second issue matters because ideas taken on about the world have the potential to support or undermine exercise of wellbeing abilities.

On the negative side of this equation, ideas taken on as beliefs about threats can contribute to chronic stress and adversely affect social behaviour and mental health. This vulnerability can affect individuals’ lives in many ways, but also exposes populations to risks in the forum of public ideas where it is easy to circulate exaggerated or false beliefs which position an ‘us’ against some ‘other’ group represented as a threat. These messages work as social manipulation precisely because they exploit stress arousal, and they undermine wellbeing ability #4.

Information about real threats such as climate change will also act as a source of chronic stress for many, especially when people feel powerless to respond. Twenty-four hour media environments can contribute to stress arousal though continual presentation of decontextualized, often sensationalised information about violent, disturbing or otherwise threatening events.

However, there are also many ways in which the ideational environment can contribute to wellbeing, by offering ways for people to have a sense of safety, hope, meaningful contribution and connectedness to other people and the natural world. The question of shared social values must be considered, because these can act as normative ideas about the world able to condition social cognition and behaviour. Social values favourable to wellbeing are likely to be those that reinforce the natural leanings of social cognitive processes toward empathy (Fisher, Reference Fisher2019) and set norms for the treatment of others as persons first and foremost, across (perceived) differences of gender, race, ethnicity, sexuality, age or ability.

The role of social policy here – and public policy more broadly – is to be literate about the ideational environment as a determinant of wellbeing, to raise issues of concern from that position, and provide leadership. Regulation of digital media must be considered.

A primary focus on immediate conditions for wellbeing

When the basic conditions required for exercise of wellbeing abilities are specified it becomes readily apparent that many can be cultivated in the environs of daily living: home and family, neighbourhood or town, the workplace or local primary school. Therefore, it is right for social policy to conceptualise these immediate conditions of living as fundamental to the task of cultivating public wellbeing, by ensuring universal access to conditions for wellbeing. This is not to idealise the local or say that the broader dynamics of the economy or public policy are less important. It’s about positioning universal access to these immediate conditions as a primary objective. If the moral purpose of social policy is to promote human wellbeing (McClelland, Reference McClelland, McClelland and Smyth2015), then its primary operational purpose must be to ensure access to the relevant conditions. Wider issues and policy settings can then be approached as ancillary issues, to be tackled according to how they help or hinder this primary goal.

Putting the conditions required for wellbeing at the operational centre also demands some fundamental changes in conventional social policy structures and practices, which tend to consist in ‘top-down’ forms of governance where central agencies fund and regulate social services to meet ‘needs’ conceptualised in terms of social, biomedical or behavioural deficits (Fisher et al., Reference Fisher, Freeeman, Mackean, Friel and Baum2020). Recognition of community engagement and participation as valuable elements of wellbeing strategies demands governance mechanisms operating at a more local scale, with co-design and flexibility to adjust around local conditions (Bradford, Reference Bradford2005; Fisher et al., Reference Fisher, Freeeman, Mackean, Friel and Baum2020; de Leeuw, Reference de Leeuw2017). In Australia, Indigenous communities have led the way in calling for such changes (Fisher et al., Reference Fisher, Mackean, George, Friel and Baum2021).

A new social psychology

Appreciating the role of stress arousal as an ubiquitous feature of social cognition bridges space between individual and population perspectives on mental health and explains human vulnerability to chronic stress (Fisher, Reference Fisher2019). Chronic stress is likely when a person is exposed recurrently to social-environmental stressors and cannot find any way to resolve or avoid them (Kristenson et al., Reference Kristenson, Eriksen, Sluiter, Starke and Ursin2004; Fisher and Baum, Reference Fisher and Baum2010). Changes in population exposures to stressors can shift the distribution of mental health toward or away from wellbeing (Fisher, Reference Fisher2019). This basic understanding of human social cognition is needed as an explanatory social psychology and theoretical foundation for effective public policy to promote wellbeing. However, efforts to bring this explanatory framework forward as a basis for social policy will inevitably confront other constructs used to explain human psychology and behaviour, embedded in social, cultural or institutional norms and practices. The dominant biomedical view of mental ‘health’ is but one of these. Others take the form of ‘folk’ psychology; the everyday, ingrained ways in which people explain their social worlds and their own or others’ behaviour, which may differ between cultures (Newman, Reference Newman1993). Of particular concern for social policy are the folk psychologies embedded in particular political outlooks; for example, explanations of poverty as resulting from individual ‘laziness’. As a general rule, folk psychologies latch onto selected, descriptive aspects of human social psychology or behaviour and inflate them into ‘sufficient’ explanations. Thus, they may have intuitive appeal while simultaneously failing to offer explanations adequate to a more complex reality.

The challenge for social policy actors is to advance a critical social psychology of stress and wellbeing in the face of entrenched constructs, on the basis (I claim) that it offers more adequate explanations of the social facts with which social policy is concerned. (This is the test of good theory.) Sometimes, the argument can be made that it is not about replacing one theoretical construct with another, but applying different constructs for different purposes.

Acting on social determinants of health and health inequities

Models of social determinants of health (SDH) are consistent with my suggested approach insofar as they recognise that it is people’s conditions of daily living that directly affect their health (Commission on the Social Determinants of Health, 2008). However, advocacy for policy action on SDH has tended to focus on health inequities, drawing attention to the political conditions that distribute socioeconomic resources. Equally, in health policy, a focus on inequities can be operationalised as a need for targeted healthcare interventions (Fisher et al., Reference Fisher, Baum, MacDougall, Newman and McDermott2016). The first approach is too diffuse, the second is too narrow. Once again, for social policy purposes it is better to position universal access to daily living conditions for wellbeing as the primary operational goal, informed by salient theory. This step establishes definite areas for policy action that can be treated as the intermediary steps in a theory of change aiming to promote wellbeing, as in Figure 1. Commitments to universality can then be used to drive commensurate change in socioeconomic inequalities.

FIGURE 1. Social policy for wellbeing: A basic theory of change model.

Recognition of SDH has also fuelled arguments that policy action for population health cannot be confined to the Health sector, but must be the business of all policy sectors (Commission on the Social Determinants of Health, 2008); leading to various strategies that seek to motivate healthy public policy in practice. Some strategies, such as ‘Health in All Policies’, identify government agencies as the primary target for change, intending that they acknowledge and address the health impacts of their own policies (de Leeuw, Reference de Leeuw2017). With respect, this is a mistake. The above outline of domains of action for wellbeing makes clear that, for all those concerned with immediate conditions of living, actions in one area naturally intersect with actions in others. I would argue that these intersections are the substance of the more integrative approach to public health that policy advocates and actors have envisioned; but the integration occurs organically in the spaces where people actually live and work, rather than in agreements between government agencies. Thus, once again, the primary operational goal should be universal access to living conditions for wellbeing and then the ancillary issue is to ensure government agencies play their role, each according to their particular mandate, to achieve this outcome. A collaborative approach to healthy public policy can only be effective when the operational purpose is clear.

Knowing what will work to promote wellbeing

Under the mantra of ‘evidence-based policy’ social policy agencies appear to have widely taken up a particular operational perspective on what that means. This is to implement a quasi-biomedical approach where a tightly prescribed ‘intervention’ is implemented and quantitative information on intended outputs or outcomes is gathered and assessed. If the target output/outcomes are attained then the intervention ‘works’. If not, then we’ll move on to the next fashion. This approach may be appropriate for testing the efficacy of new biomedical treatments. However, in social policy and public health research where the broad aim is to promote public health and healthy social conditions, my observation is that – apart from consistent commitments to medical care – social policy tends to cycle through interventions and evaluations without arriving at any broader, more enduring understanding of what it is they’re trying to achieve. What is lacking is good theory that provides cogent evidence-based understanding of a broad social policy goal such as wellbeing and the conditions required to promote it. Along with empirical evidence, good theory is required to design effective policies and sustain them over time (Green, Reference Green2000).

A basic theory of change

When the proposed domains of social policy action and further perspectives on the task are combined, then a basic theory of change model can be derived, as shown in figure 1 below: