Our own work in the National Health Service has focused on re-developing our services for people living with acquired brain injury. In addition to traditional impairment focused services, we are developing interventions to improve wellbeing, social relationships, community integration and social identity in addition to some interventions with a specific focus on environmental sustainability. We are doing so in collaboration with academic institutions as well as community, third sector and industry organisations. This service development, based on our GENIAL framework, has application across chronic conditions.
We discuss our work further in the following section.
Discussion
Here we have presented a modern understanding of wellbeing; one that involves 'connection'... connection to ourselves, to others and to the environment. We suggest that vagal function provides an important mediator of wellbeing that affects and is affected by activities to promote wellbeing across these multiple domains. The vagus nerve connects us to ourselves (i.e. 80% of vagal nerve fibres are afferent nerves
\cite{Agostoni_1957} providing a structural link between mental and physical health), to others (increases in vagal function facilitate a 'calm and connect' response promoting social connectedness,
\cite{Porges:2011wv,Kemp_2017,Kok_2013}), and to nature (vagal function is impacted on by a host of environmental factors, as discussed in section
\ref{170385}, that will subsequently promote individual health and wellbeing). Vagal function may be considered as an index of resilience, underpinned by psychological flexibility
\cite{Kashdan_2010} that can be enhanced through a variety of interventions within individual, community and environmental domains, providing a target for focused interventions. We suggest that benefits to vagal function could be maximised by drawing upon multiple interventions that span these multiple domains of wellbeing. While we have been greatly influenced by the maturing discipline of positive psychology, we argue that the field has been limited by a restricted focus on strategies that promote positive psychological moments and experience. As recent research has argued that the impacts of positive psychological interventions are smaller in size than previously reported
\cite{White_2019a}, we argue that their impact 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
\cite{Chekroud2018}. Integrating interventions within community and environmental domains will likely improve the impact of interventions further. I
t is also important to note that wellbeing can be influenced through sociostructural factors such as governmental policy, a consideration highlighted in our original GENIAL model \cite{Kemp_2017} (see section \ref{605389}). Our updated GENIAL model (section
\ref{170385}) further extends beyond the individual and community, to incorporate the broader impacts of the environment. Mindful of previously proposed social ecological theories such as Glenn Albrecht's work on 'Earth Emotions'
\cite{albrecht2019}, which emphasise the connectedness between human emotions and the state of our natural environment, we emphasise that the individual is intimately connected to the community and environment within which they live, in a 'symbioment'. In this regard it is interesting to observe calls
\cite{Bratman_2019} for the modification of the
natural environment in ways that will promote the mental health of communities, with research even demonstrating relationships between urban tree density and numbers of antidepressant medications prescribed \cite{Taylor_2015}. Researchers have also argued that sociostructural changes aimed at improving the natural environment will further contribute to improvements in wellbeing through the reduction of inequalities \cite{Bratman_2019}. As noted earlier, income and welath inequalities have substantial impacts on societal wellbeing, and this topic is now the subject of major international and interdisciplinary reviews on the subject (e.g. the 5-year Deaton Review: https://www.ifs.org.uk funded by the Nuffield Foundation). Over the last few years, we have developed a novel 8-week positive psychotherapy intervention (see table
\ref{544962} for a summary of individual components) built on our innovative GENIAL framework, incorporating interventions that focus on the individual, community and environmental domains. Presently, we are working with university undergraduate students and people living with acquired brain injury, although we are seeking to broaden our focus to patients with a variety of chronic conditions including for example, diabetes, obesity, cardiovascular disease, common mental disorders and their comorbidity. Interventions focusing on the individual include activities from positive psychology (section
\ref{407732}) as well as education relating to positive health behaviours (section
\ref{489909}). Interventions involving the community domain focus on building positive relationships with others in line with social identity theory
\cite{2018}, supported by partnership working with community organisations, such as "Surfability" (
https://surfabilityukcic.org/) and "Bikeability" (
https://bikeability.org.uk/), which serve to encourage community integration (section
\ref{417151}). Finally, interventions focusing on the environment include activities such as mindful photography, as well as partnership working with the community organisation, 'Down to Earth' (
https://www.downtoearthproject.org.uk/). This organisation promotes wellbeing in disadvantaged populations through engagement with the environment, especially in regards to environmental sustainability and social ecology. For instance, our patients with acquired brain injury were recently involved in the construction of a 'community building' using sustainable and locally sourced raw materials on the Gower Peninsula, the first place in Britain to be named an Area of Outstanding Natural Beauty. These are just some selected examples to illustrate the potential to promote wellbeing in each of the domains, and we are always seeking to engage with other academic groups, health boards and community organisations to improve health and wellbeing in the community, based on strong theoretical foundations.