The multidimensionality of well-being: Theory, measurement and empirical investigations

Background: Well-being within this thesis is defined as the multidimensional quality of a person’s life, which can be broken down into ‘subjective’ and ‘objective’ forms. Despite persistent study, researchers fail to agree on the meaning of well-being or how it should be studied. Aim: The first half of the thesis aims to examine the meaning, measurement and theory of well-being. The second half of the thesis aims to investigate the factors associated with subjective well-being (SWB), and the influence of attributes of well-being on preferences for the future. Methods: A systematic review was conducted to identify measures of well-being for use in adults (general population). The dimensions within these measures were organised into a framework using thematic analysis. Further, the theories underpinning these measures were identified and described. Fixed-effect regression models were used to study the factors important for SWB using data from a longitudinal (1996 – 2013) cohort of middle aged-older adults in the United States (n = 2049). Finally, preferences for life in the future were estimated in a sample of young ‘emergent adults’ (n =140) in the United Kingdom, using discrete choice experiments (DCEs). Results: The systematic review identified 99 measures of well-being, which included 196 distinct dimensions. These measures were influenced by a diverse range of theories (n = 98). Mental health, social integration and satisfaction with work had a significant impact on each of the SWB outcome variables (life satisfaction, positive affect and negative affect) in the fixed-effects analysis. The DCE indicated that stated preferences for life in the future among emergent adults were particularly driven by the prospect of social support from family and an aversion to experiencing mental health difficulties. Conclusion: This thesis has investigated inconsistencies in how well-being is understood, measured and studied. In response to this, a framework has been developed which organises the many measures available around key themes. Following on from the fixed-effects analysis and the DCE, future empirical research should be undertaken to investigate the interdependence of well-being and mental health.University of Exeter Medical Schoo

Review of 99 self-report measures for assessing well-being in adults:exploring dimensions of well-being and developments over time

OBJECTIVE: Investigators within many disciplines are using measures of well-being, but it is not always clear what they are measuring, or which instruments may best meet their objectives. The aims of this review were to: systematically identify well-being instruments, explore the variety of well-being dimensions within instruments and describe how the production of instruments has developed over time. DESIGN: Systematic searches, thematic analysis and narrative synthesis were undertaken. DATA SOURCES: MEDLINE, EMBASE, EconLit, PsycINFO, Cochrane Library and CINAHL from 1993 to 2014 complemented by web searches and expert consultations through 2015. ELIGIBILITY CRITERIA: Instruments were selected for review if they were designed for adults (≥18 years old), generic (ie, non-disease or context specific) and available in an English version. RESULTS: A total of 99 measures of well-being were included, and 196 dimensions of well-being were identified within them. Dimensions clustered around 6 key thematic domains: mental well-being, social well-being, physical well-being, spiritual well-being, activities and functioning, and personal circumstances. Authors were rarely explicit about how existing theories had influenced the design of their tools; however, the 2 most referenced theories were Diener's model of subjective well-being and the WHO definition of health. The period between 1990 and 1999 produced the greatest number of newly developed well-being instruments (n=27). An illustration of the dimensions identified and the instruments that measure them is provided within a thematic framework of well-being. CONCLUSIONS: This review provides researchers with an organised toolkit of instruments, dimensions and an accompanying glossary. The striking variability between instruments supports the need to pay close attention to what is being assessed under the umbrella of ‘well-being’ measurement

Drug Use in Street Sex worKers (DUSSK) study – results of a mixed methods feasibility study of a complex intervention to reduce illicit drug use in drug dependent female sex workers

OBJECTIVES: The majority of female street-based sex workers (SSWs) are dependent on illicit drugs and sell sex to fund their drug use. They typically face multiple traumatic experiences, starting at a young age, which continue through sex work involvement. Their trauma-related symptoms tend to increase when drug use is reduced, hindering sustained reduction. Providing specialist trauma care to address post-traumatic stress disorder (PTSD) alongside drug treatment may therefore improve treatment outcomes. Aims to (1) evaluate recruitment and retention of participants; (2) examine intervention experiences and acceptability; and (3) explore intervention costs using a mixed methods feasibility study. SETTING: Female SSW charity premises in a large UK inner city. PARTICIPANTS: Females aged 18 years or older, who have sold sex on the street and used heroin and/or crack cocaine at least once a week in the last calendar month. INTERVENTION: Female SSW-only drug treatment groups in a female SSW-only setting delivered by female staff. Targeted PTSD screening then treatment of positive diagnoses with eye movement desensitisation and reprocessing (EMDR) therapy by female staff from a specialist National Health Service trauma service. RESULTS: (1) Of 125 contacts, 11 met inclusion criteria and provided informed consent, 4 reached the intervention final stage, (2) service providers said working in collaboration with other services was valuable, the intervention was worthwhile and had a positive influence on participants. Participants viewed recruitment as acceptable and experienced the intervention positively. The unsettled nature of participant's lives was a key attendance barrier. (3) The total cost of the intervention was £11 710, with staff costs dominating. CONCLUSIONS: Recruitment and retention rates reflected study inclusion criteria targeting women with the most complex needs. Two participants received EMDR demonstrating that the three agencies working together was feasible. Staff heavy costs highlight the importance of supporting participant attendance to minimise per participant costs in a future trial

Longitudinal study of use and cost of subacromial decompression surgery:the need for effective evaluation of surgical procedures to prevent overtreatment and wasted resources

OBJECTIVES:To illustrate the need for better evaluation of surgical procedures, we investigated the use and cost of subacromial decompression in England over the last decade compared with other countries and explored how this related to the conduct and outcomes of randomised, placebo-controlled clinical trials. DESIGN:Longitudinal observational study using Hospital Episode Statistics linked to Payment by Results tariffs in England, 2007/2008 to 2016/2017. SETTING:Hospital care in England; Finland; New York State, USA; Florida State, USA and Western Australia. PARTICIPANTS:Patients with subacromial shoulder pain. INTERVENTIONS:Subacromial decompression. MAIN OUTCOME MEASURES:National procedure rates, costs and variation between clinical commissioning groups in England. RESULTS:Without robust clinical evidence, the use of subacromial decompression in England increased by 91% from 15 112 procedures (30 per 100 000 population) in 2007/2008, to 28 802 procedures (52 per 100 000 population) in 2016/2017, costing over £125 million per year. Rates of use of subacromial decompression are even higher internationally: Finland (131 per 100 000 in 2011), Florida State (130 per 100 000 in 2007), Western Australia (115 per 100 000 in 2013) and New York State (102 per 100 000 in 2006). Two randomised placebo-controlled trials have recently (2018) shown the procedure to be no more effective than placebo or conservative approaches. Health systems appear unable to avoid the rapid widespread use of procedures of unknown effectiveness, and methods for ceasing ineffective treatments are under-developed. CONCLUSIONS:Without good evidence, nearly 30 000 subacromial decompression procedures have been commissioned each year in England, costing over £1 billion since 2007/2008. Even higher rates of procedures are carried out in countries with less regulated health systems. High quality randomised trials need to be initiated before widespread adoption of promising operative procedures to avoid overtreatment and wasted resources, and methods to prevent or desist the use of ineffective procedures need to be expedited

Digital Technology Use and Mental Health Consultations:Survey of the Views and Experiences of Clinicians and Young People

BackgroundDigital technologies play an increasingly important role in the lives of young people and have important effects on their mental health. ObjectiveWe aimed to explore 3 key areas of the intersection between digital technology and mental health: the views and experiences of young people and clinicians about digital technology and mental health; implementation and barriers to the UK national guidance recommendation—that the discussion of digital technology use should form a core part of mental health assessment; and how digital technology might be used to support existing consultations. MethodsTwo cross-sectional web-based surveys were conducted in 2020 between June and December, with mental health clinicians (n=99) and young people (n=320). Descriptive statistics were used to summarize the proportions. Multilinear regression was used to explore how the answers varied by gender, sexuality, and age. Thematic analysis was used to explore the contents of the extended free-text answers. Anxiety was measured using the Generalized Anxiety Disorder Questionnaire-7 (GAD-7). ResultsDigital technology use was ubiquitous among young people, with positive and negative aspects acknowledged by both clinicians and young people. Negative experiences were common (131/284, 46.1%) and were associated with increased anxiety levels among young people (GAD-7 3.29; 95% CI 1.97-4.61; P<.001). Although the discussion of digital technology use was regarded as important by clinicians and acceptable by young people, less than half of clinicians (42/85, 49.4%) routinely asked about the use of digital technology and over a third of young people (48/121, 39.6%) who had received mental health care had never been asked about their digital technology use. The conversations were often experienced as unhelpful. Helpful conversations were characterized by greater depth and exploration of how an individual’s digital technology use related to mental health. Despite most clinicians (59/83, 71.1%) wanting training, very few (21/86, 24.4%) reported receiving training. Clinicians were open to viewing mental health data from apps or social media to help with consultations. Although young people were generally, in theory, comfortable sharing such data with health professionals, when presented with a binary choice, most reported not wanting to share social media (84/117, 71.8%) or app data (67/118, 56.8%) during consultations. ConclusionsDigital technology use was common, and negative experiences were frequent and associated with anxiety. Over a third of young people were not asked about their digital technology use during mental health consultations, and potentially valuable information about relevant negative experiences on the web was not being captured during consultations. Clinicians would benefit from having access to training to support these discussions with young people. Although young people recognized that app data could be helpful to clinicians, they appeared hesitant to share their own data. This finding suggests that data sharing has barriers that need to be further explored