case study on health and wellbeing

Business of Well-being

The employee wellness case studies that will inspire you.

In today's fast-paced corporate world, employee wellness has become an essential focus for organizations looking to enhance productivity, improve employee satisfaction, and reduce healthcare costs. Companies across industries are implementing innovative wellness programs and initiatives to promote the well-being of their employees. In this article, we will delve into inspiring case studies that demonstrate the transformative power of employee wellness programs. These success stories highlight the positive impact such initiatives can have on individuals and organizations alike.

Case Study 1: TechCo's Holistic Wellness Approach ‍ TechCo, a leading technology company, recognized the importance of addressing the physical, mental, and emotional well-being of their employees. They implemented a holistic wellness program that encompassed various aspects of well-being. The program included regular exercise classes such as yoga, Pilates, and cardio workouts, along with workshops on mindfulness and stress reduction techniques. TechCo also provided access to mental health resources, including counseling services and meditation apps. Through this comprehensive approach, TechCo witnessed a notable reduction in employee absenteeism and improved overall engagement. The company also experienced an increase in employee retention, as staff members felt supported and valued by the organization.

Case Study 2: PharmaCorp's Health Challenge ‍ PharmaCorp, a pharmaceutical company, aimed to cultivate a culture of health and wellness among their employees. They introduced a company-wide health challenge that encouraged employees to engage in healthy activities and lifestyle choices. The challenge included friendly competitions, rewards, and recognition for participants. Employees were encouraged to track their progress using fitness trackers and wellness apps. Additionally, PharmaCorp organized health and wellness fairs where employees could access health screenings, nutritional counseling, and fitness assessments. As a result, PharmaCorp observed a significant improvement in employees' overall health metrics, including reduced body mass index, decreased cholesterol levels, and increased energy levels. Moreover, the challenge fostered a sense of camaraderie and team spirit among employees, promoting a positive work environment.

Case Study 3: FinServe's Financial Wellness Program ‍ FinServe, a financial services firm, recognized that financial stress can have a significant impact on employee well-being and productivity. To address this, they launched a comprehensive financial wellness program. The initiative included educational workshops on budgeting, retirement planning, and debt management. Additionally, FinServe partnered with financial advisors to offer one-on-one consultations for employees seeking personalized guidance. The program not only alleviated financial stress for employees but also enhanced their overall financial literacy. Employees gained a better understanding of managing their finances effectively, leading to reduced financial anxiety, improved job satisfaction, and increased productivity.

Case Study 4: RetailCo's Work-Life Balance Initiative ‍ RetailCo, a large retail chain, acknowledged the significance of work-life balance in employee well-being. They implemented flexible work arrangements to support their staff members' personal responsibilities and interests. This included remote work options, flexible hours, and compressed workweeks. RetailCo also encouraged employees to take regular breaks and provided opportunities for personal development and wellness activities during working hours. By prioritizing work-life balance, RetailCo saw a substantial decrease in employee burnout and an increase in job satisfaction. Employees reported improved mental health and enhanced productivity, resulting in a positive impact on the company's bottom line.

Case Study 5: ManufacturingCo's Healthy Cafeteria Initiative ‍ ManufacturingCo, a large manufacturing company, decided to promote healthy eating habits among their employees by revamping their cafeteria offerings. They partnered with nutritionists and chefs to create nutritious, delicious, and diverse meal options that catered to different dietary needs. The company introduced clear nutritional labeling for menu items, highlighting the nutritional content and allergen information. Additionally, ManufacturingCo provided nutrition education sessions and cooking workshops to empower employees to make healthier choices both in the cafeteria and at home. This initiative had a profound impact on ManufacturingCo's employees. By providing healthier food options, the company witnessed a positive shift in employees' eating habits and overall well-being. Employees reported feeling more energized and focused throughout the workday, resulting in increased productivity. Moreover, the company saw a decrease in absenteeism and a reduction in healthcare costs associated with diet-related illnesses. ManufacturingCo's commitment to promoting healthy eating not only improved the well-being of their employees but also fostered a culture of wellness within the organization.

Case Study 6: Consulting Firm's Mental Health Support Program ‍ A consulting firm recognized the importance of addressing mental health in the workplace and implemented a comprehensive mental health support program. The program included regular mental health awareness campaigns, training sessions for managers on recognizing and addressing mental health concerns, and confidential counseling services for employees. The consulting firm created a supportive environment where employees felt comfortable seeking help for mental health challenges without fear of judgment or repercussions. As a result, employees reported improved mental well-being, reduced stress levels, and increased job satisfaction. The firm also noticed a decline in mental health-related absenteeism and an improvement in overall team collaboration and productivity.

Case Study 7: Hospitality Company's Wellness Rewards Program ‍ A hospitality company sought to motivate and engage employees in their wellness journey by implementing a rewards program. The program encouraged employees to participate in various wellness activities, such as fitness challenges, health screenings, and stress management workshops. Employees earned points for their participation and were eligible for rewards and incentives based on their accumulated points. This approach not only incentivized employees to prioritize their well-being but also created a sense of friendly competition and camaraderie among the workforce. The company witnessed a significant increase in employee engagement, improved morale, and a decrease in lifestyle-related health issues.

Case Study 8: Education Institution's Employee Development and Wellness Integration ‍ An educational institution recognized the interconnectedness between employee development and wellness. They integrated wellness initiatives into their employee development programs to support the holistic growth of their staff members. The institution offered opportunities for professional development, skill-building workshops, and wellness activities such as yoga classes, meditation sessions, and mindfulness training. By fostering a culture that prioritized both professional growth and personal well-being, the institution experienced higher employee satisfaction, increased retention rates, and a positive impact on student outcomes.

These case studies exemplify the power of employee wellness programs in enhancing the well-being and productivity of individuals within organizations. From holistic wellness approaches and health challenges to financial wellness programs and work-life balance initiatives, these success stories demonstrate the transformative impact that investing in employee well-being can have.

By implementing wellness programs tailored to the unique needs of their workforce, organizations can create a positive work environment, boost employee engagement and satisfaction, and reduce healthcare costs. If you are seeking guidance on implementing or enhancing your organization's wellness program, Global Healthcare Resources offers comprehensive wellness consulting services. Their team of experts can assist you in developing customized strategies and initiatives that align with your company's goals and values.

Embrace the power of employee wellness and unlock the potential for a healthier, happier, and more productive workforce. To learn more about how Global Healthcare Resources can support your wellness journey, visit https://www.globalhealthcareresources.com/wellnessconsulting .

Remember, investing in your employees' well-being is an investment in the success and longevity of your organization. Start prioritizing employee wellness today and witness the positive impact it can have on your workforce and overall business performance.

To explore Global Healthcare Resources' wellness consulting services and discover how they can assist your organization in implementing an effective wellness program, visit https://www.globalhealthcareresources.com/wellnessconsulting .

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Center for Societal Benefit through Healthcare

COVID Response Center

• Open access
• Published: 10 August 2024

How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK

• Charlotte Parbery-Clark 1 ,
• Lorraine McSweeney 2 ,
• Joanne Lally 3 &
• Sarah Sowden 4  

BMC Public Health volume  24 , Article number:  2168 ( 2024 ) Cite this article

427 Accesses

Metrics details

Addressing socioeconomic inequalities in health and healthcare, and reducing avoidable hospital admissions requires integrated strategy and complex intervention across health systems. However, the understanding of how to create effective systems to reduce socio-economic inequalities in health and healthcare is limited. The aim was to explore and develop a system’s level understanding of how local areas address health inequalities with a focus on avoidable emergency admissions.

In-depth case study using qualitative investigation (documentary analysis and key informant interviews) in an urban UK local authority. Interviewees were identified using snowball sampling. Documents were retrieved via key informants and web searches of relevant organisations. Interviews and documents were analysed independently based on a thematic analysis approach.

Interviews ( n  = 14) with wide representation from local authority ( n  = 8), NHS ( n  = 5) and voluntary, community and social enterprise (VCSE) sector ( n  = 1) with 75 documents (including from NHS, local authority, VCSE) were included. Cross-referenced themes were understanding the local context, facilitators of how to tackle health inequalities: the assets, and emerging risks and concerns. Addressing health inequalities in avoidable admissions per se was not often explicitly linked by either the interviews or documents and is not yet embedded into practice. However, a strong coherent strategic integrated population health management plan with a system’s approach to reducing health inequalities was evident as was collective action and involving people, with links to a “strong third sector”. Challenges reported include structural barriers and threats, the analysis and accessibility of data as well as ongoing pressures on the health and care system.

We provide an in-depth exploration of how a local area is working to address health and care inequalities. Key elements of this system’s working include fostering strategic coherence, cross-agency working, and community-asset based approaches. Areas requiring action included data sharing challenges across organisations and analytical capacity to assist endeavours to reduce health and care inequalities. Other areas were around the resilience of the system including the recruitment and retention of the workforce. More action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Highlights:

• Reducing health inequalities in avoidable hospital admissions is yet to be explicitly linked in practice and is an important area to address.

• Understanding the local context helps to identify existing assets and threats including the leverage points for action.

• Requiring action includes building the resilience of our complex systems by addressing structural barriers and threats as well as supporting the workforce (training and wellbeing with improved retention and recruitment) in addition to the analysis and accessibility of data across the system.

Peer Review reports

Introduction

The health of our population is determined by the complex interaction of several factors which are either non-modifiable (such as age, genetics) or modifiable (such as the environment, social, economic conditions in which we live, our behaviours as well as our access to healthcare and its quality) [ 1 ]. Health inequalities are the avoidable and unfair systematic differences in health and healthcare across different population groups explained by the differences in distribution of power, wealth and resources which drive the conditions of daily life [ 2 , 3 ]. Essentially, health inequalities arise due to the systematic differences of the factors that influence our health. To effectively deal with most public health challenges, including reducing health inequalities and improving population health, broader integrated approaches [ 4 ] and an emphasis on systems is required [ 5 , 6 ] . A system is defined as ‘the set of actors, activities, and settings that are directly or indirectly perceived to have influence in or be affected by a given problem situation’ (p.198) [ 7 ]. In this case, the ‘given problem situation' is reducing health inequalities with a focus on avoidable admissions. Therefore, we must consider health systems, which are the organisations, resources and people aiming to improve or maintain health [ 8 , 9 ] of which health services provision is an aspect. In this study, the system considers NHS bodies, Integrated Care Systems, Local Authority departments, and the voluntary and community sector in a UK region.

A plethora of theories [ 10 ], recommended policies [ 3 , 11 , 12 , 13 ], frameworks [ 1 , 14 , 15 ], and tools [ 16 ] exist to help understand the existence of health inequalities as well as provide suggestions for improvement. However, it is reported that healthcare leaders feel under-skilled to reduce health inequalities [ 17 ]. A lack of clarity exists on how to achieve a system’s multi-agency coherence to reduce health inequalities systematically [ 17 , 18 ]. This is despite some countries having legal obligations to have a regard to the need to attend to health and healthcare inequalities. For example, the Health and Social Care Act 2012 [ 19 ], in England, mandated Clinical Commissioning Groups (CCGs), now transferred to Integrated Care Boards (ICBs) [ 20 ], to ‘have a regard to the need to reduce inequalities between patients with respect to their ability to access health services, and reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health services’. The wider determinants of health must also be considered. For example, local areas have a mandatory requirement to have a joint strategic needs assessment (JSNA) and joint health and wellbeing strategy (JHWS) whose purpose is to ‘improve the health and wellbeing of the local community and reduce inequalities for all ages' [ 21 ] This includes addressing the wider determinants of health [ 21 ]. Furthermore, the hospital care costs to the NHS associated with socioeconomic inequalities has been previously reported at £4.8 billion a year due to excess hospitalisations [ 22 ]. Avoidable emergency admissions are admissions into hospital that are considered to be preventable with high-quality ambulatory care [ 23 ]. Both ambulatory care sensitive conditions (where effective personalised care based in the community can aid the prevention of needing an admission) and urgent care sensitive conditions (where a system on the whole should be able to treat and manage without an admission) are considered within this definition [ 24 ] (encompassing more than 100 International Classification of Diseases (ICD) codes). The disease burden sits disproportionately with our most disadvantaged communities, therefore highlighting the importance of addressing inequalities in hospital pressures in a concerted manner [ 25 , 26 ].

Research examining one component of an intervention, or even one part of the system, [ 27 ] or which uses specific research techniques to control for the system’s context [ 28 ] are considered as having limited use for identifying the key ingredients to achieve better population health and wellbeing [ 5 , 28 ]. Instead, systems thinking considers how the system’s components and sub-components interconnect and interrelate within and between each other (and indeed other systems) to gain an understanding of the mechanisms by which things work [ 29 , 30 ]. Complex interventions or work programmes may perform differently in varying contexts and through different mechanisms, and therefore cannot simply be replicated from one context to another to automatically achieve the same outcomes. Ensuring that research into systems and systems thinking considers real-world context, such as where individuals live, where policies are created and interventions are delivered, is vital [ 5 ]. How the context and implementation of complex or even simple interventions interact is viewed as becoming increasingly important [ 31 , 32 ]. Case study research methodology is founded on the ‘in-depth exploration of complex phenomena in their natural, or ‘real-life’, settings’ (p.2) [ 33 ]. Case study approaches can deepen the understanding of complexity addressing the ‘how’, ‘what’ and ‘why’ questions in a real-life context [ 34 ]. Researchers have highlighted the importance of engaging more deeply with case-based study methodology [ 31 , 33 ]. Previous case study research has shown promise [ 35 ] which we build on by exploring a systems lens to consider the local area’s context [ 16 ] within which the work is implemented. By using case-study methodology, our study aimed to explore and develop an in-depth understanding of how a local area addresses health inequalities, with a focus on avoidable hospital admissions. As part of this, systems processes were included.

Study design

This in-depth case study is part of an ongoing larger multiple (collective [ 36 ]) case study approach. An instrumental approach [ 34 ] was taken allowing an in-depth investigation of an issue, event or phenomenon, in its natural real-life context; referred to as a ‘naturalistic’ design [ 34 ]. Ethics approval was obtained by Newcastle University’s Ethics Committee (ref 13633/2020).

Study selection

This case study, alongside the other three cases, was purposively [ 36 ] chosen considering overall deprivation level of the area (Indices of Multiple Deprivation (IMD) [ 37 ]), their urban/rural location, differing geographical spread across the UK (highlighted in patient and public feedback and important for considering the North/South health divide [ 38 ]), and a pragmatic judgement of likely ability to achieve the depth of insight required [ 39 ]. In this paper, we report the findings from one of the case studies, an urban local authority in the Northern region of the UK with high levels of socioeconomic disadvantage. This area was chosen for this in-depth case analysis due to high-level of need, and prior to the COVID-19 pandemic (2009-2018) had experienced a trend towards reducing socioeconomic inequalities in avoidable hospital admission rates between neighbourhoods within the local area [ 40 ]. Thereby this case study represents an ‘unusual’ case [ 41 ] to facilitate learning regarding what is reported and considered to be the key elements required to reduce health inequalities, including inequalities in avoidable admissions, in a local area.

Semi-structured interviews

The key informants were identified iteratively through the documentary analysis and in consultation with the research advisory group. Initially board level committee members (including lay, managerial, and clinical members) within relevant local organisations were purposively identified. These individuals were systems leaders charged with the remit of tackling health inequalities and therefore well placed to identify both key personnel and documents. Snowball sampling [ 42 ] was undertaken thereafter whereby interviewees helped to identify additional key informants within the local system who were working on health inequalities, including avoidable emergency admissions, at a systems level. Interview questions were based on an iteratively developed topic guide (supplementary data 1), informed from previous work’s findings [ 43 ] and the research advisory network’s input. A study information sheet was emailed to perspective interviewees, and participants were asked to complete an e-consent form using Microsoft Forms [ 42 ]. Each interviewee was interviewed by either L.M. or C.P.-C. using the online platforms Zoom or Teams, and lasted up to one hour. Participants were informed of interviewers’ role, workplace as well as purpose of the study. Interviewees were asked a range of questions including any work relating to reducing health inequalities, particularly avoidable emergency admissions, within the last 5 years. Brief notes were taken, and the interviews were recorded, transcribed verbatim and anonymised.

Documentary analysis

The documentary analysis followed the READ approach [ 44 ]. Any documents from the relevant local/regional area with sections addressing health inequalities and/or avoidable emergency admissions, either explicitly stated or implicitly inferred, were included. A list of core documents was chosen, including the local Health and Wellbeing Strategy (Table 1 ). Subsequently, other documents were identified by snowballing from these core documents and identification by the interviewees. All document types were within scope if produced/covered a period within 5 years (2017-2022), including documents in the public domain or not as well as documents pertaining to either a regional, local and neighbourhood level. This 5-year period was a pragmatic decision in line with the interviews and considered to be a balance of legacy and relevance. Attempts were made to include the final version of each document, where possible/applicable, otherwise the most up-to-date version or version available was used.

An Excel spreadsheet data extraction tool was adapted with a priori criteria [ 44 ] to extract the data. This tool included contextual information (such as authors, target area and document’s purpose). Also, information based on previous research on addressing socioeconomic inequalities in avoidable emergency admissions, such as who stands to benefit, was extracted [ 43 ]. Additionally, all documents were summarised according to a template designed according to the research’s aims. Data extraction and summaries were undertaken by L.M. and C.P.-C. A selection was doubled coded to enhance validity and any discrepancies were resolved by discussion.

Interviews and documents were coded and analysed independently based on a thematic analysis approach [ 45 ], managed by NVivo software. A combination of ‘interpretive’ and ‘positivist’ stance [ 34 , 46 ] was taken which involved understanding meanings/contexts and processes as perceived from different perspectives (interviewees and documents). This allowed for an understanding of individual and shared social meanings/reasonings [ 34 , 36 ]. For the documentary analysis, a combination of both content and thematic analysis as described by Bowen [ 47 ] informed by Braun and Clarke’s approach to thematic analysis [ 45 ] was used. This type of content analysis does not include the typical quantification but rather a review of the document for pertinent and meaningful passages of text/other data [ 47 ]. Both an inductive and deductive approach for the documentary analysis’ coding [ 46 , 47 ] was chosen. The inductive approach was developed a posteriori; the deductive codes being informed by the interviews and previous findings from research addressing socioeconomic inequalities in avoidable emergency admissions [ 43 ]. In line with qualitative epistemological approach to enquiry, the interview and documentary findings were viewed as ‘truths’ in themselves with the acceptance that multiple realities can co-exist [ 48 ]. The analysis of each set of themes (with subthemes) from the documentary analysis and interviews were cross-referenced and integrated with each other to provide a cohesive in-depth analysis [ 49 ] by generating thematic maps to explore the relationships between the themes. The codes, themes and thematic maps were peer-reviewed continually with regular meetings between L.M., C.P.-C., J.L. and S.S. Direct quotes are provided from the interviews and documentary analysis. Some quotes from the documents are paraphrased to protect anonymity of the case study after following a set process considering a range of options. This involved searching each quote from the documentary analysis in Google and if the quote was found in the first page of the result, we shortened extracts and repeated the process. Where the shortened extracts were still identifiable, we were required to paraphrase that quote. Each paraphrased quote and original was shared and agreed with all the authors reducing the likelihood of inadvertently misinterpreting or misquoting. Where multiple components over large bodies of text were present in the documents, models were used to evidence the broadness, for example, using Dahlgren’s and Whitehead’s model of health determinants [ 1 ]. Due to the nature of the study, transcripts and findings were not shared with participants for checking but will be shared in a dissemination workshop in 2024.

Patient and public involvement and engagement

Four public contributors from the National Institute for Health and Care Research (NIHR) Research Design Service (RDS) North East and North Cumbria (NENC) Public and Patient Involvement (PPI) panel have been actively engaged in this research from its inception. They have been part of the research advisory group along with professional stakeholders and were involved in the identification of the sampling frame’s key criteria. Furthermore, a diverse group of public contributors has been actively involved in other parts of the project including developing the moral argument around action by producing a public facing resource exploring what health inequalities mean to people and public views of possible solutions [ 50 ].

Semi-structured interviews: description

Sixteen participants working in health or social care, identified through the documentary analysis or snowballing, were contacted for interview; fourteen consented to participate. No further interviews were sought as data sufficiency was reached whereby no new information or themes were being identified. Participant roles were broken down by NHS ( n  = 5), local authority/council ( n  = 8), and voluntary, community and social enterprise (VSCE) ( n  = 1). To protect the participants’ anonymity, their employment titles/status are not disclosed. However, a broad spectrum of interviewees with varying roles from senior health system leadership (including strategic and commissioner roles) to roles within provider organisations and the VSCE sector were included.

Documentary analysis: description

75 documents were reviewed with documents considering regional ( n  = 20), local ( n  = 64) or neighbourhood ( n  = 2) area with some documents covering two or more areas. Table 2 summarises the respective number of each document type which included statutory documents to websites from across the system (NHS, local government and VSCE). 45 documents were named by interviewees and 42 documents were identified as either a core document or through snowballing from other documents. Of these, 12 documents were identified from both. The timescales of the documents varied and where possible to identify, was from 2014 to 2031.

Integrative analysis of the documentary analysis and interviews

The overarching themes encompass:

Understanding the local context

Facilitators to tacking health inequalities: the assets

Emerging risks and concerns

Figure 1 demonstrates the relationships between the main themes identified from the analysis for tackling health inequalities and improving health in this case study.

Diagram of the relationship between the key themes identified regarding tackling health inequalities and improving health in a local area informed by 2 previous work [ 14 , 51 ]. NCDs = non-communicable diseases; HI = health inequalities

Understanding the local context was discussed extensively in both the documents and the interviews. This was informed by local intelligence and data that was routinely collected, monitored, and analysed to help understand the local context and where inequalities lie. More bespoke, in-depth collection and analysis were also described to get a better understanding of the situation. This not only took the form of quantitative but also considered qualitative data with lived experience:

‛So, our data comes from going out to talk to people. I mean, yes, especially the voice of inequalities, those traditional mechanisms, like surveys, don't really work. And it's about going out to communities, linking in with third sector organisations, going out to communities, and just going out to listen…I think the more we can bring out those real stories. I mean, we find quotes really, really powerful in terms of helping people understand what it is that matters.’ (LP16).

However, there were limitations to the available data including the quality as well as having enough time to do the analysis justice. This resulted in difficulties in being able to fully understand the context to help identify and act on the required improvements.

‘A lack of available data means we cannot quantify the total number of vulnerable migrants in [region]’ (Document V).

‛So there’s lots of data. The issue is joining that data up and analysing it, and making sense of it. That’s where we don’t have the capacity.’ (LP15).

Despite the caveats, understanding the context and its data limitations were important to inform local priorities and approaches on tackling health inequalities. This understanding was underpinned by three subthemes which were understanding:

the population’s needs including identification of people at higher risk of worse health and health inequalities

the driving forces of those needs with acknowledgement of the impact of the wider determinants of health

the threats and barriers to physical and mental health, as well as wellbeing

Firstly, the population’s needs, including identification of people at higher risk of worse health and health inequalities, was important. This included considering risk factors, such as smoking, specific groups of people and who was presenting with which conditions. Between the interviews and documents, variation was seen between groups deemed at-risk or high-risk with the documents identifying a wider range. The groups identified across both included marginalised communities, such as ethnic minority groups, gypsy and travellers, refugees and asylum seekers as well as people/children living in disadvantaged area.

‘There are significant health inequalities in children with asthma between deprived and more affluent areas, and this is reflected in A&E admissions.' (Document J).

Secondly, the driving forces of those needs with acknowledgement of the impact of the wider determinants of health were described. These forces mapped onto Dahlgren’s and Whitehead’s model of health determinants [ 1 ] consisting of individual lifestyle factors, social and community networks, living and working conditions (which include access to health care services) as well as general socio-economic, cultural and environmental conditions across the life course.

…. at the centre of our approach considering the requirements to improve the health and wellbeing of our area are the wider determinants of health and wellbeing, acknowledging how factors, such as housing, education, the environment and economy, impact on health outcomes and wellbeing over people’s lifetime and are therefore pivotal to our ambition to ameliorate the health of the poorest the quickest. (Paraphrased Document P).

Thirdly, the threats and barriers to health included environmental risks, communicable diseases and associated challenges, non-communicable conditions and diseases, mental health as well as structural barriers. In terms of communicable diseases, COVID-19 predominated. The environmental risks included climate change and air pollution. Non-communicable diseases were considered as a substantial and increasing threat and encompassed a wide range of chronic conditions such as diabetes, and obesity.

‛Long term conditions are the leading causes of death and disability in [case study] and account for most of our health and care spending. Cases of cancer, diabetes, respiratory disease, dementia and cardiovascular disease will increase as the population of [case study] grows and ages.’ (Document A).

Structural barriers to accessing and using support and/or services for health and wellbeing were identified. These barriers included how the services are set up, such as some GP practices asking for proof of a fixed address or form of identification to register. For example:

Complicated systems (such as having to make multiple calls, the need to speak to many people/gatekeepers or to call at specific time) can be a massive barrier to accessing healthcare and appointments. This is the case particularly for people who have complex mental health needs or chaotic/destabilized circumstances. People who do not have stable housing face difficulties in registering for GP and other services that require an address or rely on post to communicate appointments. (Paraphrased Document R).

A structural threat regarding support and/or services for health and wellbeing was the sustainability of current funding with future uncertainty posing potential threats to the delivery of current services. This also affected the ability to adapt and develop the services, or indeed build new ones.

‛I would say the other thing is I have a beef [sic] [disagreement] with pilot studies or new innovations. Often soft funded, temporary funded, charity funded, partnership work run by enthusiasts. Me, I've done them, or supported people doing many of these. And they're great. They can make a huge impact on the individuals involved on that local area. You can see fantastic work. You get inspired and you want to stand up in a crowd and go, “Wahey, isn't this fantastic?” But actually the sad part of it is on these things, I've seen so many where we then see some good, positive work being done, but we can't make it permanent or we can't spread it because there's no funding behind it.’ (LP8).

Facilitators to tackling health inequalities: the assets

The facilitators for improving health and wellbeing and tackling health inequalities are considered as assets which were underpinned by values and principles.

Values driven supported by four key principles

Being values driven was an important concept and considered as the underpinning attitudes or beliefs that guide decision making [ 52 ]. Particularly, the system’s approach was underpinned by a culture and a system's commitment to tackle health inequalities across the documents and interviews. This was also demonstrated by how passionately and emotively some interviewees spoke about their work.

‛There's a really strong desire and ethos around understanding that we will only ever solve these problems as a system, not by individual organisations or even just part of the system working together. And that feels great.’ (LP3).

Other values driving the approach included accountability, justice, and equity. Reducing health inequalities and improving health were considered to be the right things to do. For example:

We feel strongly about social justice and being inclusive, wishing to reflect the diversity of [case study]. We campaign on subjects that are important to people who are older with respect and kindness. (Paraphrased Document O).

Four key principles were identified that crosscut the assets which were:

Shared vision

Strong partnership

Asset-based approaches

Willingness and ability to act on learning

The mandated strategy, identifying priorities for health and wellbeing for the local population with the required actions, provided the shared vision across each part of the system, and provided the foundations for the work. This shared vision was repeated consistently in the documents and interviews from across the system.

[Case study] will be a place where individuals who have the lowest socioeconomic status will ameliorate their health the quickest. [Case study] will be a place for good health and compassion for all people, regardless of their age. (Paraphrased Document A).

‛One thing that is obviously becoming stronger and stronger is the focus on health inequalities within all of that, and making sure that we are helping people and provide support to people with the poorest health as fast as possible, so that agenda hasn’t shifted.’ (LP7).

This drive to embed the reduction of health inequalities was supported by clear new national guidance encapsulated by the NHS Core20PLUS5 priorities. Core20PLUS5 is the UK's approach to support a system to improve their healthcare inequalities [ 53 ]. Additionally, the system's restructuring from Clinical Commissioning Groups (CCGs) to Integrated Care Boards (ICBs) and formalisation of the now statutory Integrated Care Systems (ICS) in England was also reported to facilitate the driving of further improvement in health inequalities. These changes at a regional and local level helped bring key partners across the system (NHS and local government among others) to build upon their collective responsibility for improving health and reducing health inequalities for their area [ 54 ].

‛I don’t remember the last time we’ve had that so clear, or the last time that health inequalities has had such a prominent place, both in the NHS planning guidance or in the NHS contract. ’ (LP15). ‛The Health and Care Act has now got a, kind of, pillar around health inequalities, the new establishment of ICPs and ICBs, and also the planning guidance this year had a very clear element on health inequalities.’ (LP12)

A strong partnership and collaborative team approach across the system underpinned the work from the documents and included the reoccurrence of the concept that this case study acted as one team: ‘Team [case study]'.

Supporting one another to ensure [case study] is the best it can be: Team [case study]. It involves learning, sharing ideas as well as organisations sharing assets and resources, authentic partnerships, and striving for collective impact (environmental and social) to work towards shared goals . (Paraphrased Document B).

This was corroborated in the interviews as working in partnership to tackle health inequalities was considered by the interviewees as moving in the right direction. There were reports that the relationship between local government, health care and the third sector had improved in recent years which was still an ongoing priority:

‘I think the only improvement I would cite, which is not an improvement in terms of health outcomes, but in terms of how we work across [case study] together has moved on quite a lot, in terms of teams leads and talking across us, and how we join up on things, rather than see ourselves all as separate bodies' (LP15).

‘I think the relationship between local authorities and health and the third sector, actually, has much more parity and esteem than it had before.' (LP11)

The approaches described above were supported by all health and care partners signing up to principles around partnership; it is likely this has helped foster the case study's approach. This also builds on the asset-based approaches that were another key principle building on co-production and co-creation which is described below.

We begin with people : instead of doing things to people or for them, we work with them, augmenting the skills, assets and strength of [case study]’s people, workforce and carers. We achieve : actions are focused on over words and by using intelligence, every action hones in on the actual difference that we will make to ameliorate outcomes, quality and spend [case study]’s money wisely; We are Team [case study ]: having kindness, working as one organisation, taking responsibility collectively and delivering on what we agreed. Problems are discussed with a high challenge and high support attitude. (Paraphrased Document D).

At times, the degree to which the asset-based approaches were embedded differed from the documents compared to the interviews, even when from the same part of the system. For example, the documents often referred to the asset-based approach as having occurred whilst interviewees viewed it more as a work in progress.

‘We have re-designed many of our services to focus on needs-led, asset-based early intervention and prevention, and have given citizens more control over decisions that directly affect them .’ (Document M).

‘But we’re trying to take an asset-based approach, which is looking at the good stuff in communities as well. So the buildings, the green space, the services, but then also the social capital stuff that happens under the radar.’ (LP11).

A willingness to learn and put in action plans to address the learning were present. This enables future proofing by building on what is already in place to build the capacity, capability and flexibility of the system. This was particularly important for developing the workforce as described below.

‘So we’ve got a task and finish group set up, […] So this group shows good practice and is a space for people to discuss some of the challenges or to share what interventions they are doing around the table, and also look at what other opportunities that they have within a region or that we could build upon and share and scale.’ (LP12).

These assets that are considered as facilitators are divided into four key levels which are the system, services and support, communities and individuals, and workforce which are discussed in turn below.

Firstly, the system within this case study was made up of many organisations and partnerships within the NHS, local government, VSCE sector and communities. The interviewees reported the presence of a strong VCSE sector which had been facilitated by the local council's commitment to funding this sector:

‘Within [case study], we have a brilliant third sector, the council has been longstanding funders of infrastructure in [case study], third sector infrastructure, to enable those links [of community engagement] to be made' (LP16).

In both the documents and interviews, a strong coherent strategic integrated population health management plan with a system’s approach to embed the reduction of health inequalities was evident. For example, on a system level regionally:

‘To contribute towards a reduction in health inequalities we will: take a system wide approach for improving outcomes for specific groups known to be affected by health inequalities, starting with those living in our most deprived communities….’ (Document H).

This case study’s approach within the system included using creative solutions and harnessing technology. This included making bold and inventive changes to improve how the city and the system linked up and worked together to improve health. For example, regeneration work within the city to ameliorate and transform healthcare facilities as well as certain neighbourhoods by having new green spaces, better transport links in order to improve city-wide innovation and collaboration (paraphrased Document F) were described. The changes were not only related to physical aspects of the city but also aimed at how the city digitally linked up. Being a leader in digital innovation to optimise the health benefits from technology and information was identified in several documents.

‘ Having the best connected city using digital technology to improve health and wellbeing in innovative ways.’ (Document G).

The digital approaches included ongoing development of a digitalised personalised care record facilitating access to the most up-to-date information to developing as well as having the ‘ latest, cutting edge technologies’ ( Document F) in hospital care. However, the importance of not leaving people behind by embedding digital alternatives was recognised in both the documents and interviews.

‘ We are trying to just embed the culture of doing an equity health impact assessment whenever you are bringing in a digital solution or a digital pathway, and that there is always an alternative there for people who don’t have the capability or capacity to use it. ’ (LP1).

The successful one hundred percent [redacted] programme is targeting some of our most digitally excluded citizens in [case study]. For our city to continue to thrive, we all need the appropriate skills, technology and support to get the most out of being online. (Paraphrased Document Q)

This all links in with the system that functions in a ‘place' which includes the importance of where people are born, grow, work and live. Working towards this place being welcoming and appealing was described both regionally and locally. This included aiming to make the case study the place of choice for people.

‘Making [case study] a centre for good growth becoming the place of choice in the UK to live, to study, for businesses to invest in, for people to come and work.’ (Document G).

Services and support

Secondly, a variety of available services and support were described from the local authority, NHS, and voluntary community sectors. Specific areas of work, such as local initiatives (including targeted work or campaigns for specific groups or specific health conditions) as well as parts of the system working together with communities collaboratively, were identified. This included a wide range of work being done such as avoiding delayed discharges or re-admissions, providing high quality affordable housing as well as services offering peer support.

‘We have a community health development programme called [redacted], that works with particular groups in deprived communities and ethnically diverse communities to work in a very trusted and culturally appropriate way on the things that they want to get involved with to support their health.’ (LP3 ).

It is worth noting that reducing health inequalities in avoidable admissions was not often explicitly specified in the documents or interviews. However, either specified or otherwise inferred, preventing ill health and improving access, experience, and outcomes were vital components to addressing inequalities. This was approached by working with communities to deliver services in communities that worked for all people. Having co-designed, accessible, equitable integrated services and support appeared to be key.

‘Reducing inequalities in unplanned admissions for conditions that could be cared for in the community and access to planned hospital care is key.’ (Document H)

Creating plans with people: understanding the needs of local population and designing joined-up services around these needs. (Paraphrased Document A).

‘ So I think a core element is engagement with your population, so that ownership and that co-production, if you're going to make an intervention, don't do it without because you might miss the mark. ’ (LP8).

Clear, consistent and appropriate communication that was trusted was considered important to improve health and wellbeing as well as to tackle health inequalities. For example, trusted community members being engaged to speak on the behalf of the service providers:

‘The messenger is more important than the message, sometimes.’ (LP11).

This included making sure the processes are in place so that the information is accessible for all, including people who have additional communication needs. This was considered as a work in progress in this case study.

‘I think for me, things do come down to those core things, of health, literacy, that digital exclusion and understanding the wider complexities of people.’ (LP12)

‘ But even more confusing if you've got an additional communication need. And we've done quite a lot of work around the accessible information standard which sounds quite dry, and doesn't sound very- but actually, it's fundamental in accessing health and care. And that is, that all health and care organisations should record your communication preferences. So, if I've got a learning disability, people should know. If I've got a hearing impairment, people should know. But the systems don’t record it, so blind people are getting sent letters for appointments, or if I've got hearing loss, the right provisions are not made for appointments. So, actually, we're putting up barriers before people even come in, or can even get access to services.’ (LP16).

Flexible, empowering, holistic care and support that was person-centric was more apparent in the documents than the interviews.

At the centre of our vision is having more people benefiting from the life chances currently enjoyed by the few to make [case study] a more equal place. Therefore, we accentuate the importance of good health, the requirement to boost resilience, and focus on prevention as a way of enabling higher quality service provision that is person-centred. [Paraphrased Document N).

Through this [work], we will give all children and young people in [case study], particularly if they are vulnerable and/or disadvantaged, a start in life that is empowering and enable them to flourish in a compassionate and lively city. [Paraphrased Document M].

Communities and individuals

Thirdly, having communities and individuals at the heart of the work appeared essential and viewed as crucial to nurture in this case study. The interconnectedness of the place, communities and individuals were considered a key part of the foundations for good health and wellbeing.

In [case study], our belief is that our people are our greatest strength and our most important asset. Wellbeing starts with people: our connections with our friends, family, and colleagues, our behaviour, understanding, and support for one another, as well as the environment we build to live in together . (Paraphrased Document A).

A recognition of the power of communities and individuals with the requirement to support that key principle of a strength-based approach was found. This involved close working with communities to help identify what was important, what was needed and what interventions would work. This could then lead to improved resilience and cohesion.

‛You can't make effective health and care decisions without having the voice of people at the centre of that. It just won't work. You won't make the right decisions.’ (LP16).

‘Build on the strengths in ourselves, our families, carers and our community; working with people, actively listening to what matters most to people, with a focus on what’s strong rather than what’s wrong’ (Document G).

Meaningful engagement with communities as well as strengths and asset-based approaches to ensure self-sufficiency and sustainability of communities can help communities flourish. This includes promoting friendships, building community resilience and capacity, and inspiring residents to find solutions to change the things they feel needs altering in their community . (Paraphrased Document B).

This close community engagement had been reported to foster trust and to lead to improvements in health.

‘But where a system or an area has done a lot of community engagement, worked really closely with the community, gained their trust and built a programme around them rather than just said, “Here it is. You need to come and use it now,” you can tell that has had the impact. ' (LP1).

Finally, workforce was another key asset; the documents raised the concept of one workforce across health and care. The key principles of having a shared vision, asset-based approaches and strong partnership were also present in this example:

By working together, the Health and Care sector makes [case study] the best area to not only work but also train for people of all ages. Opportunities for skills and jobs are provided with recruitment and engagement from our most disadvantaged communities, galvanizing the future’s health and care workforce. By doing this, we have a very skilled and diverse workforce we need to work with our people now as well as in the future. (Paraphrased Document E).

An action identified for the health and care system to address health inequalities in case study 1 was ‘ the importance of having an inclusive workforce trained in person-centred working practices ’ (Document R). Several ways were found to improve and support workforce skills development and embed awareness of health inequalities in practice and training. Various initiatives were available such as an interactive health inequalities toolkit, theme-related fellowships, platforms and networks to share learning and develop skills.

‛We've recently launched a [redacted] Fellowship across [case study’s region], and we've got a number of clinicians and managers on that………. We've got training modules that we've put on across [case study’s region], as well for health inequalities…we've got learning and web resources where we share good practice from across the system, so that is our [redacted] Academy.’ (LP2).

This case study also recognised the importance of considering the welfare of the workforce; being skilled was not enough. This had been recognised pre-pandemic but was seen as even more important post COVID-19 due to the impact that COVID-19 had on staff, particularly in health and social care.

‛The impacts of the pandemic cannot be underestimated; our colleagues and services are fatigued and still dealing with the pressures. This context makes it even more essential that we share the responsibility, learn from each other at least and collaborate with each other at best, and hold each other up to be the best we can.’ (Document U).

Concerns were raised such as the widening of health inequalities since the pandemic and cost of living crisis. Post-pandemic and Brexit, recruiting health, social care and third sector staff was compounding the capacity throughout this already heavily pressurised system.

In [case study], we have seen the stalling of life expectancy and worsening of the health inequality gap, which is expected to be compounded by the effects of the pandemic. (Paraphrased Document T)

‘I think key barriers, just the immense pressure on the system still really […] under a significant workload, catching up on activity, catching up on NHS Health Checks, catching up on long-term condition reviews. There is a significant strain on the system still in terms of catching up. It has been really difficult because of the impact of COVID.’ (LP7).

‘Workforce is a challenge, because the pipelines that we’ve got, we’ve got fewer people coming through many of them. And that’s not just particular to, I don't know, nursing, which is often talking talked [sic] about as a challenged area, isn't it? And of course, it is. But we’ve got similar challenges in social care, in third sector.’ (LP5).

The pandemic was reported to have increased pressures on the NHS and services not only in relation to staff capacity but also regarding increases in referrals to services, such as mental health. Access to healthcare changed during the pandemic increasing barriers for some:

‘I think people are just confused about where they're supposed to go, in terms of accessing health and care at the moment. It's really complex to understand where you're supposed to go, especially, at the moment, coming out of COVID, and the fact that GPs are not the accessible front door. You can't just walk into your GP anymore.’ (LP16).

‘Meeting this increased demand [for work related to reducing ethnic inequalities in mental health] is starting to prove a challenge and necessitates some discussion about future resourcing.’ (Document S)

Several ways were identified to aid effective adaptation and/or mitigation. This included building resilience such as developing the existing capacity, capability and flexibility of the system by learning from previous work, adapting structures and strengthening workforce development. Considerations, such as a commitment to Marmot Principles and how funding could/would contribute, were also discussed.

The funding’s [linked to Core20PLUS5] purpose is to help systems to ensure that health inequalities are not made worse when cost-savings or efficiencies are sought…The available data and insight are clear and [health inequalities are] likely to worsen in the short term, the delays generated by pandemic, the disproportionate effect of that on the most deprived and the worsening food and fuel poverty in all our places. (Paraphrased Document L).

Learning from the pandemic was thought to be useful as some working practices had altered during COVID-19 for the better, such as needing to continue to embed how the system had collaborated and resist old patterns of working:

‘So I think that emphasis between collaboration – extreme collaboration – which is what we did during COVID is great. I suppose the problem is, as we go back into trying to save money, we go back into our old ways of working, about working in silos. And I think we’ve got to be very mindful of that, and continue to work in a different way.’ (LP11).

Another area identified as requiring action, was the collection, analysis, sharing and use of data accessible by the whole system.

‘So I think there is a lot of data out there. It’s just how do we present that in such a way that it’s accessible to everyone as well, because I think sometimes, what happens is that we have one group looking at data in one format, but then how do we cascade that out?’ (LP12)

We aimed to explore a system’s level understanding of how a local area addresses health inequalities with a focus on avoidable emergency admissions using a case study approach. Therefore, the focus of our research was strategic and systematic approaches to inequalities reduction. Gaining an overview of what was occurring within a system is pertinent because local areas are required to have a regard to address health inequalities in their local areas [ 20 , 21 ]. Through this exploration, we also developed an understanding of the system's processes reported to be required. For example, an area requiring action was viewed as the accessibility and analysis of data. The case study described having health inequalities ‘at the heart of its health and wellbeing strategy ’ which was echoed across the documents from multiple sectors across the system. Evidence of a values driven partnership with whole systems working was centred on the importance of place and involving people, with links to a ‘strong third sector ’ . Working together to support and strengthen local assets (the system, services/support, communities/individuals, and the workforce) were vital components. This suggested a system’s committed and integrated approach to improve population health and reduce health inequalities as well as concerted effort to increase system resilience. However, there was juxtaposition at times with what the documents contained versus what interviewees spoke about, for example, the degree to which asset-based approaches were embedded.

Furthermore, despite having a priori codes for the documentary analysis and including specific questions around work being undertaken to reduce health inequalities in avoidable admissions in the interviews with key systems leaders, this explicit link was still very much under-developed for this case study. For example, how to reduce health inequalities in avoidable emergency admissions was not often specified in the documents but could be inferred from existing work. This included work around improving COVID-19 vaccine uptake in groups who were identified as being at high-risk (such as older people and socially excluded populations) by using local intelligence to inform where to offer local outreach targeted pop-up clinics. This limited explicit action linking reduction of health inequalities in avoidable emergency admissions was echoed in the interviews and it became clear as we progressed through the research that a focus on reduction of health inequalities in avoidable hospital admissions at a systems level was not a dominant aspect of people’s work. Health inequalities were viewed as a key part of the work but not necessarily examined together with avoidable admissions. A strengthened will to take action is reported, particularly around reducing health inequalities, but there were limited examples of action to explicitly reduce health inequalities in avoidable admissions. This gap in the systems thinking is important to highlight. When it was explicitly linked, upstream strategies and thinking were acknowledged as requirements to reduce health inequalities in avoidable emergency admissions.

Similar to our findings, other research have also found networks to be considered as the system’s backbone [ 30 ] as well as the recognition that communities need to be central to public health approaches [ 51 , 55 , 56 ]. Furthermore, this study highlighted the importance of understanding the local context by using local routine and bespoke intelligence. It demonstrated that population-based approaches to reduce health inequalities are complex, multi-dimensional and interconnected. It is not about one part of the system but how the whole system interlinks. The interconnectedness and interdependence of the system (and the relevant players/stakeholders) have been reported by other research [ 30 , 57 ], for example without effective exchange of knowledge and information, social networks and systems do not function optimally [ 30 ]. Previous research found that for systems to work effectively, management and transfer of knowledge needs to be collaborative [ 30 ], which was recognised in this case study as requiring action. By understanding the context, including the strengths and challenges, the support or action needed to overcome the barriers can be identified.

There are very limited number of case studies that explore health inequalities with a focus on hospital admissions. Of the existing research, only one part of the health system was considered with interviews looking at data trends [ 35 ]. To our knowledge, this research is the first to build on this evidence by encompassing the wider health system using wider-ranging interviews and documentary analysis. Ford et al. [ 35 ] found that geographical areas typically had plans to reduce total avoidable emergency admissions but not comprehensive plans to reduce health inequalities in avoidable emergency admissions. This approach may indeed widen health inequalities. Health inequalities have considerable health and costs impacts. Pertinently, the hospital care costs associated with socioeconomic inequalities being reported as £4.8 billion a year, mainly due to excess hospitalisations such as avoidable admissions [ 58 ] and the burden of disease lies disproportionately with our most disadvantaged communities, addressing inequalities in hospital pressures is required [ 25 , 26 ].

Implications for research and policy

Improvements to life expectancy have stalled in the UK with a widening of health inequalities [ 12 ]. Health inequalities are not inevitable; it is imperative that the health gap between the deprived and affluent areas is narrowed [ 12 ]. This research demonstrates the complexity and intertwining factors that are perceived to address health inequalities in an area. Despite the evidence of the cost (societal and individual) of avoidable admissions, explicit tackling of inequality in avoidable emergency admissions is not yet embedded into the system, therefore highlights an area for policy and action. This in-depth account and exploration of the characteristics of ‘whole systems’ working to address health inequalities, including where challenges remain, generated in this research will be instrumental for decision makers tasked with addressing health and care inequalities.

This research informs the next step of exploring each identified theme in more detail and moving beyond description to develop tools, using a suite of multidimensional and multidisciplinary methods, to investigate the effects of interventions on systems as previously highlighted by Rutter et al. [ 5 ].

Strengths and limitations

Documentary analysis is often used in health policy research but poorly described [ 44 ]. Furthermore, Yin reports that case study research is often criticised for not adhering to ‘systematic procedures’ p. 18 [ 41 ]. A clear strength of this study was the clearly defined boundary (in time and space) case as well as following a defined systematic approach, with critical thought and rationale provided at each stage [ 34 , 41 ]. A wide range and large number of documents were included as well as interviewees from across the system thereby resulting in a comprehensive case study. Integrating the analysis from two separate methodologies (interviews and documentary analysis), analysed separately before being combined, is also a strength to provide a coherent rich account [ 49 ]. We did not limit the reasons for hospital admission to enable a broad as possible perspective; this is likely to be a strength in this case study as this connection between health inequalities and avoidable hospital admissions was still infrequently made. However, for example, if a specific care pathway for a health condition had been highlighted by key informants this would have been explored.

Due to concerns about identifiability, we took several steps. These included providing a summary of the sectors that the interviewees and document were from but we were not able to specify which sectors each quote pertained. Additionally, some of the document quotes required paraphrasing. However, we followed a set process to ensure this was as rigorous as possible as described in the methods section. For example, where we were required to paraphrase, each paraphrased quote and original was shared and agreed with all the authors to reduce the likelihood to inadvertently misinterpreting or misquoting.

The themes are unlikely to represent an exhaustive list of the key elements requiring attention, but they represent the key themes that were identified using a robust methodological process. The results are from a single urban local authority with high levels of socioeconomic disadvantage in the North of England which may limit generalisability to different contexts. However, the findings are still generalisable to theoretical considerations [ 41 ]. Attempts to integrate a case study with a known framework can result in ‘force-fit’ [ 34 ] which we avoided by developing our own framework (Fig. 1 ) considering other existing models [ 14 , 59 ]. The results are unable to establish causation, strength of association, or direction of influence [ 60 ] and disentangling conclusively what works versus what is thought to work is difficult. The documents’ contents may not represent exactly what occurs in reality, the degree to which plans are implemented or why variation may occur or how variation may affect what is found [ 43 , 61 ]. Further research, such as participatory or non-participatory observation, could address this gap.

Conclusions

This case study provides an in-depth exploration of how local areas are working to address health and care inequalities, with a focus on avoidable hospital admissions. Key elements of this system’s reported approach included fostering strategic coherence, cross-agency working, and community-asset based working. An area requiring action was viewed as the accessibility and analysis of data. Therefore, local areas could consider the challenges of data sharing across organisations as well as the organisational capacity and capability required to generate useful analysis in order to create meaningful insights to assist work to reduce health and care inequalities. This would lead to improved understanding of the context including where the key barriers lie for a local area. Addressing structural barriers and threats as well as supporting the training and wellbeing of the workforce are viewed as key to building resilience within a system to reduce health inequalities. Furthermore, more action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Availability of data and materials

Individual participants’ data that underlie the results reported in this article and a data dictionary defining each field in the set are available to investigators whose proposed use of the data has been approved by an independent review committee for work. Proposals should be directed to [email protected] to gain access, data requestors will need to sign a data access agreement. Such requests are decided on a case by case basis.

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Acknowledgements

Thanks to our Understanding Factors that explain Avoidable hospital admission Inequalities - Research study (UNFAIR) PPI contributors, for their involvement in the project particularly in the identification of the key criteria for the sampling frame. Thanks to the research advisory team as well.

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This research was funded by the National Institute for Health and Care Research (NIHR), grant number (ref CA-CL-2018-04-ST2-010). The funding body was not involved in the study design, collection of data, inter-pretation, write-up, or submission for publication. The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care or Newcastle University.

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Charlotte Parbery-Clark

Post-Doctoral Research Associate, Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK

Lorraine McSweeney

Senior Research Methodologist & Public Involvement Lead, Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK

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Conceptualization - J.L. and S.S.; methodology - C.P.-C., J.L. & S.S.; formal analysis - C. P.-C. & L.M.; investigation- C. P.-C. & L.M., resources, writing of draft manuscript - C.P.-C.; review and editing manuscript L.M., J.L., & S.S.; visualization including figures and tables - C.P.-C.; supervision - J.L. & S.S.; project administration - L.M. & S.S.; funding acquisition - S.S. All authors have read and agreed to the published version of the manuscript.

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Parbery-Clark, C., McSweeney, L., Lally, J. et al. How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK. BMC Public Health 24 , 2168 (2024). https://doi.org/10.1186/s12889-024-19531-5

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Health and wellbeing: Southern Health and Social Care Trust

The Trust uses its Workplace Health and Wellbeing Framework to integrate health and wellbeing throughout the organisation, embedding it in culture, leadership and people management practices

The Southern Health and Social Care Trust (the Trust) is based in Northern Ireland. The Trust employs around 14,887 people across the four council areas of Armagh City, Banbridge and Craigavon; parts of Newry, Mourne and Downe; and the Mid-Ulster. Their Workplace Health and Wellbeing Framework 2022–2025 is part of their new People Framework and aims to embed health and wellbeing throughout the organisation. 

“What’s different about this framework is that it’s an intentional, systematic, coordinated, integrated approach across our policies and processes, through the three lenses of individual, team and organisation, which is being monitored and driven by our senior leadership team. Our ultimate aim is to create a great place to work: where our people feel valued, cared for and supported, where they feel psychologically safe to speak up when things don’t go as planned or share ideas to make things even better for our workforce and for the population we serve.” Anne Forsythe, Head of Workforce and Organisational Development  

“In Southern Trust the health and wellbeing of our people couldn’t be more important. It is more than just a moral obligation. Without deliberate attention to this agenda, we will not be able to respond to growing demand for health and social care services across our local community. Put simply, the capacity for, and quality of, patient care is underpinned by the health and wellbeing of our staff. Our Workplace Health and Wellbeing Framework (2022–2025) supporting our new People Framework (2022–2025) is about integrating health and wellbeing throughout the organisation, embedding it in our culture, our leadership and people management practices.” Maxine Williamson, Deputy HR Director – Workforce and OD  

• Creating a culture of wellbeing
• The three wellbeing pillars
• A strategic and systematic approach
• Impact so far

Creating a culture of wellbeing  

Looking after their people by creating a safe and healthy working environment and a culture of wellbeing is at the heart of the Trust’s ambition to be ‘ a great place to work ’ . The People Framework focuses on three people priorities of Wellbeing , Belonging and Growing , and by follow ing this systematic approach to create a better culture where people feel psychologically safe, valued, cared for , and supported, it will create a great place to wor k. I n other words , t ransforming the w orkplace and – ultimately – t ransforming c are (improving patient safety).  

To s upport people to seek help and develop their skills in compassionate self-care and other personal coping mechanisms , the Trust :  

s upport s and devel ops the capacity and capability of managers to ensure their approach has a positive impact on the experience and wellbeing of their team and themselves  

p romot es and nurtur es a culture of compassionate leadership and teamwork as a way of ensuring people feel cared for and supported  

t a kes all necessary measures and efforts required to keep people safe and well  

c ontinu es to promote, protect, and improve the health and wellbeing of their people  

e nsur es a relentless focus on the safety, quality , and experience of employees , patients, and service users.  

Developing the health and wellbeing framework  

The Trust’s Workplace H ealth and W ellbeing F ramework 202 2 – 2 025 was developed as the existing Health and Wellbeing Strategy (201 8 – 2 021) was coming to conclusion and as a building block to su pport the new ly launched People Framework (202 2 – 2 025) . In developing both frameworks, the T rust was keen to engage as widely as possible with the workforce in their development and there has been a considerable ‘engagement and listening journey ’ .    

A lot has been achieved since launching a health and wellbeing hub in 2018 , including setting up a multi-disciplinary Health and Wellbeing Steering Group to develop and roll out an action plan to support staff physical and psychological health , improve the work environment , and support good relationships in the workplace .    

There have been many initiatives, workshops and events along the way , includ ing :  

2018 – senior leadership commitment to Take 5 Health and Wellbeing pledge, working groups to roll out activity to support physical and psychological health , signing of a regional HSC Workplace Health and Wellbeing Charter , and launch of a Staff Menopause Toolkit and leaflet.  

2019 – establishment of a health champion role, launch of a men’s health toolkit , review of the occupational health and wellbeing service , and building the case for more holistic multi-disciplinary support , including the appointment of a c onsultant c linical p sychologist .  

2020 – a focused wellbeing plan in response to C OVID -19, launch of a menopause at work policy , and workforce-wide engagement events.  

2021 – a virtual menopause café, guidance for staff on cancer, relaunch of the wellbeing hub ‘ UMatter ’ .  

The three wellbeing pillars  

The Trust ’s health and wellbeing journey has culminated in the launch of its framework for 202 2 – 2 0 25 , based on three priority pillars of integrated wellbeing:  

Pillar 1: Healthy workplaces (supporting you)

R ecognising this is about in vesting in safe, healthy, inclusive and engaging workplace environments  

The T rust has developed a wide range of holistic support and health - promotion activities to support the ‘health y workplaces’ pillar, including:   

A clear pathway to promote health and wellbeing support and services available to employees, such as clear signposting to resources .  

Expansion of its occupational health and wellbeing service ( OHWS ) , with a shift towards ill health prevention and proactive provision by specialist occupational health and wellbeing practitioners.    

A new o ccupa tional h ealth psychology service that provides specialist trauma - informed psychological assessment and interventions to employees, managers and teams impacted by work - related stress/trauma.   

Enhanc ed external spaces to help employees enjoy the wellbeing benefits of nature and being outdoors . This includes provid ing positive outdoor spaces for people to work, rest and recuperate across its sites , with outdoor seating, retractable awning outside canteens to provide a more useable external eating space, and external landscaping to bring back colour - producing plants and shrubs to improve psychological wellbeing.  

Enhancing the Healthcare Library with books and resources (including online versions) dedicated to wellbeing . The library now has a standing desk, under - desk cycle, relaxation seating , shiatsu massage chairs , light boxes (reducing the impact of SAD) , and conference bags for delivering and returning books via i nternal mail.  

Menopause awareness s essions and training for wellbeing c hampions .  

New r e sources to promote and support financial w ellbeing .  

Pillar 2 : Healthy relationships (staying connected)

R ecognising relationships we form with others and the ways people work together with civility, respect and compassion are vital to mental and emotional wellbeing  

The wellbeing benefits of social cohesion, including peer and line manager support, is fully recognised in the Trust’s wellbeing framework. Its ‘healthy relationships’ pillar is brought to life through a wide range of training and coaching opportunities, leadership and management development programmes , and other initiatives , such as:  

Schwartz Rounds – these are forums that facilitate reflective practice and give people from all disciplines the opportunity to reflect on the emotional impact of their work  

d evelopment opportunities , including :  

a coaching service 

training interventions such as ‘looking after self/others’, ‘every conversation matters’ and ‘how we treat our people matters’  

toolkits covering the Trust’s values, civility and support to call out inappropriate behaviours 

leadership and management development programmes on topics, such as being an emotionally intelligent leader 

team development initiatives, such as ‘getting better together’ 

line manager training on people management issues, such as managing conflict, bullying and harassment, raising concerns, flexible working and attendance 

senior leadership team’s visibility plan with activities to promote engagement between senior leaders and the workforce, including the weekly opportunity to chat with the chief executive and leadership walks 

‘Your Appraisal’ – the new policy focuses on the quality of conversation and includes having a wellbeing conversation.   

Pillar 3 : Healthy body and mind (being you)

R ecognising the links between good mental and physical health  

The Trust has developed a wealth of initiatives to promote good physical and mental health that focuses on good wellbeing, ill health prevention , early intervention to help prevent issues from escalating , and rehabilitation support to support people with ongoing health conditions. This includes :

d eep relaxation workshops  

g uided mediation sessions  

m ental health awareness training for managers  

v arious physical activity sessions  

a comprehensive ‘recognising and responding to stress’ policy and promotion of the Trust’s Talking Toolkit resource to help managers and teams to prevent and manage stress  

f ast - track p hysio therapy and work conditioning classes  

l ong COVID-19 multi-disciplinary rehabilitation t eam made up of a s pecialist p hysiotherapist, o ccupational t herapist and c ognitive b ehavioural t herapist – t his team provide s support, advice and rehabilitation for those experiencing C OVID -19 - related symptoms beyond four weeks following a C OVID -19 infection which are impacting on their ability to return to work, or those who are in work but struggling. The aim is to support employees to improve their health, functional abilities and quality of life and facilitate a successful and sustainable return to work.   

The Health and W ellbeing F ramework operates in parallel with, and complements, the Trust’s People Framework (202 2 – 2 025). The three wellbeing pillars support the organisation’s three people priorities of ‘wellbeing, belonging and growing ’. Both frameworks were developed to be mutually reinforcing to drive a fully integrated wellbeing approach, with positive cultural change at its heart. The ambition is to create a great place to work, where people feel engaged, valued and work well together.   

A strategic and systematic approach  

The Trust views the many different support services, wellbeing activities and policy provision as mutually reinforcing to achieve its aim of being a great place to work. As Anne Forsythe explains: “ A defining feature of our approach is that it is systematic and can therefore lead to better and more sustainable outcomes for our people; we are changing the lens through which we view employee wellbeing. ”  

The T rust does not view health and wellbeing interventions as standalone but as part of a strategic whole and mutually reinforcing in terms of outcomes. This reflects the organisational approach it takes to improve health and wellbeing , for its people and also for its service users . “ Health and wellbeing interventions for individuals are not enough, ” comments Anne. “ We embed our framework at an organisation al , team and individual level by linking it to our corporate plan and through the foundations of compassionate and visible leadership combined with a culture of inclusion and belonging. ”  

Impact so far  

Eighty-seven per cent  of respondents agree that the Trust takes positive action on health and wellbeing. (Regional HSC Staff Survey, 2019) .  

Regional p ost - COVID-19 health and social care staff wellbeing survey 2021 r esults indicate :  

79.8% of respondents are aware of wellbeing support available within their Trust .  

88.5% of respondents agreed the organisation takes positive action on health and wellbeing .  

92.9% of respondents agreed the organisation provides advice on mental health and well being.  

In this series

As a health-focused charity, Macmillan recognises and understands the importance of colleague health and wellbeing

Tackling barriers to work today whilst creating inclusive workplaces of tomorrow.

More on this topic

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2 Jul, 2024

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A Northern Ireland summary of the CIPD Good Work Index 2024 survey report

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A case study of an HR function shifting from an Ulrich+ model towards an employee experience-driven model

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• Published: 07 August 2024

Well-being among university students in the post-COVID-19 era: a cross-country survey

• M. Bersia 1 ,
• L. Charrier 1 ,
• G. Zanaga 1 , 2 ,
• T. Gaspar 3 ,
• C. Moreno-Maldonado 4 ,
• P. Grimaldi 1 , 2 ,
• E. Koumantakis 1 , 2 ,
• P. Dalmasso 1 &
• R. I. Comoretto 1  

Scientific Reports volume  14 , Article number:  18296 ( 2024 ) Cite this article

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• Health care
• Human behaviour

University students have to handle crucial challenges for their future lives, such as succeeding in academic studies and finding attachment figures. These processes could potentially involve their well-being and mental health, with possible sociocultural differences based on the country of study. In order to explore such potential differences, a cross-sectional, multi-center survey was performed involving students from the University of Torino (Italy), Sevilla (Spain), and Lusòfona (Portugal). The survey, conducted from May to November 2023, investigated students’ demographic and educational details, socioeconomic status, social support, mental health, academic environment, perceived COVID-19 pandemic impact, and future plans. Demographic profiles showed a predominance of female participants and straight sexual orientation, followed by bisexuality. Italian students showed the lowest levels of mental well-being and the highest rates of mental problems (anxiety and depression) and suicidal risk across the three countries despite the relatively similar profiles of social support. The prevalence of the students’ confidence in their professional future is higher in Spain than in Italy and Portugal. This study provides a comprehensive examination of university students’ mental health and well-being in three Southern European countries, addressing the major mental health challenges among university students and offering valuable insights for public health purposes.

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Introduction.

The university years represent an intriguing life period with plenty of challenges, including academic issues, emotional delusions, and problems related to the transition between the end of adolescence and the beginning of adulthood 1 . The interplay of academic pressures, social dynamics, and developmental transitions provides a delicate balance in which mental vulnerabilities can easily thrive 2 , 3 , 4 . Furthermore, university experience can move the needle: indeed, college students are at higher risk of developing a mental condition compared to their non-college peers 5 , 6 . In particular, Beiter pinpointed three college-related individual concerns that may heighten mental risk: struggles with academic performance, intense pressure to succeed, and uncertainty about post-graduation life 7 . Furthermore, academic environments themselves, demanding high effort and commitment, could play a role in impairing the university experience 8 , 9 , 10 . All these elements could synergically stimulate the onset of both burnout and several mental conditions, such as anxiety, depression, and suicidality 8 , 9 , 10 , 11 . In this regard, a prevalence of about 30% % of depressive and anxiety symptoms among university students has been estimated 12 . In particular, the female gender, the pre-existing mental health conditions, and the lower socioeconomic status seem to be additional risk factors across multiple studies 13 , 14 , 15 . On the other hand, good social support can mitigate the above-mentioned risk factors for mental health, playing a crucial protective role as a source of motivation and promoting healthier lifestyles 16 . Further, the perceived social support could also represent a relevant individual background, capable of encouraging students’ resilience and having beneficial effects on academic performance 16 .

Beyond the well-known influential factors, the COVID-19 pandemic profoundly impacted students’ mental health worldwide in both the short- and long term. In the immediate phase after the COVID-19 pandemic eruption, the impairment was observed mainly in terms of difficulties concentrating, disruptions of sleep patterns, concerns about academic performance, and increased anxiety and depression 17 , 18 , 19 , 20 . Furthermore, several researchers assessed the impact of prolonged exposure to the pandemic on cognitive and affective processing among students, observing an increase in the prevalence and severity of conditions such as anxiety, depression, suicidality, chronic sleeping difficulties, appetite changes, and health-related anxiety 21 , 22 , 23 . More specifically, the pandemic could have contributed to impaired mental health also among college students through the implementation of distancing measures leading to distance learning modalities, social isolation, lack of access to traditional support services, and family financial difficulties 24 , 25 . Additionally, research suggests that female students and those residing in lower-quality housing during lockdowns displayed exacerbated declines in mental health 25 , 26 .

In May 2022, the WHO Director-General declared the global emergence related to the COVID-19 pandemic concluded 27 . However, the pandemic long-term consequences on youths’ mental health are still a relevant public concern, and they still deserve careful surveillance over time to address targeted mitigation policies. The still scarce literature on the topic mainly relies on data from national-level surveys, hampering the adoption of a transcultural approach 28 , 29 , 30 , 31 , 32 .

To our knowledge, literature still lacks studies assessing and comparing college students’ mental health and well-being across different environments in the delicate post-pandemic phase. In order to address these research gaps, the present study describes the main findings of an international project that explored university students' mental health and well-being in three universities in Italy, Spain, and Portugal. These Mediterranean countries share cultural and environmental similarities (e.g. dietary habits, natural environment, social bounds) 33 , 34 , 35 , despite the societal peculiarities (e.g. financial situation, physical activity habits) and the adoption of different pandemic-related measures potentially influencing mental health and well-being outcomes 36 , 37 , 38 , 39 . More specifically, the aim was to discern commonalities and differences in students’ characteristics and experiences across these countries through a comparative approach, trying to offer a more detailed understanding of well-being patterns among college students in the post-COVID-19 era.

Survey design

A cross-sectional and multi-center survey was conducted between May and November 2023 in three European universities, the University of Torino (Italy), Sevilla (Spain), and Lusòfona (Portugal).

Participants

Students were eligible for enrollment in the study if they were (1) between 18 and 35 years old and (2) attending a bachelor's or master’s degree program. Those who declined to provide informed consent were excluded from the study. All the eligible students (about 79,000 students in Italy, 60,000 in Spain, and 15,000 in Portugal) received an institutional email with a link to an anonymous online questionnaire. Students could agree to participate in the study by checking the box at the bottom of the personal data treatment information sheet on the first page of the online questionnaire. There was also a section explaining the study’s goals, clarifying that there was no obligation to complete the questionnaire and assuring confidentiality and anonymity of the collected data. Finally, the research team did not offer any incentives to increase recruitment nor played an active role in selecting and/or targeting specific subpopulations of students. Participation was entirely voluntary, with students having the option to opt-out at any stage. Informed consent was obtained from all subjects.

Ethical considerations

Data was collected anonymously, no personal identifiers were collected, and the IP address was not registered. Approval for this study has been obtained from the institutional ethics boards of the participating universities (Prot. no. 0059546 of 30 January 2023, for the University of Torino; approval no. 20/23 of 16 May 2023 obtained by the Comité de Ética en la Investigación de Sevilla; approval no. 9 of 8 March 2023 received by the Ethics and Deontology Commission For Scientific Research (CEDIC) for the Lusofona University). The study was conducted in accordance with the international guidelines and regulations and the Declaration of Helsinki.

Questionnaire

A multi-language online survey (i.e., in English, Italian, Spanish, and Portuguese) was implemented on the REDCap platform of the University of Torino 40 , 41 . Overall, we adopted standardized scales validated in English. When available, we used the validated versions of the scales in Italian, Spanish, and Portuguese; otherwise, the English scales underwent the forward–backward translation process. The specific process for each scale, with the relevant validation work, can be found in the Supplementary file, Table S1 . Respondents could choose the language in which they would fill out the questionnaire. The survey encompassed the following key components: demographic details (e.g., age, sex, sexual orientation), educational profile (course area, year of study, progress), socioeconomic status, social support, mental health and well-being, perceived COVID-19 impact, academic stress, and future perspectives information.

In particular, information related to sex at birth and sexual orientation was assessed following the GeniuSS Group guidelines 42 . Sexual orientation was asked as follows: ‘How do you identify yourself?’, adopting as possible answers: ‘straight’, ‘lesbian’, ‘gay’, ‘bisexual’, ‘queer’, ‘pansexual’, ‘asexual’, ‘unlabelled’, ‘questioning’, ‘other’.

Socioeconomic status (SES)

The students’ socioeconomic status was investigated using the MacArthur Scale of Subjective Social Status 43 . The scale visually represented a ladder in which steps were associated with numbers ranging from 1 (low perceived SES) to 10 (high perceived SES). Respondents were then asked to place themselves on the ladder compared to their peers. The personal financial situation was evaluated through one further question with four possible answers: ‘dependent on family’, ‘work’, ‘scholarship’, or ‘other’.

Social support

Social support was assessed using a well-known validated psychometric tool, the Multidimensional Scale of Perceived Social Support (MSPSS) 44 . The scale consists of 12 items exploring an individual's perceived social support distributed across three subscales: Family, Friends, and Significant Other Support. Individuals rated their agreement with each item on a 7-point Likert scale ranging from ’strongly disagree’ to ’strongly agree’. The scores for each subscale are added up and then divided by 4, while for the overall support, the sum score is divided by 12. Both the overall and subscales scores (ranging from 1 to 7) provide a measure of the individual’s perceived social support. Low, medium, and high social support are defined based on the overall score (i.e. 1–2.9, 3–5, and 5.1–7, respectively). An excellent internal consistency was found for the overall scale (α > 0.92), and the three subscales, consistently in the three countries.

Mental health

Mental health was evaluated using different validated tools based on the specific characteristics under investigation. Depression and anxiety were assessed through the Patient Health Questionnaire-2 (PHQ-2) 45 and the Generalized Anxiety Disorder-2 (GAD-2) 46 , respectively. These two brief self-report instruments derived from the longer Patient Health Questionnaire-9 (PHQ-9) 47 and the Generalized Anxiety Disorder-7 (GAD-7) 48 questionnaire, both commonly used tools in mental health assessments. Participants were asked to indicate the frequency of presentation of each symptom using a 4-point scale ranging from 0, ’not at all’, to 3, ‘nearly every day’. A total score ≥ 3 on the PHQ-2 assessment suggests the presence of anxiety symptoms, while a score ≥ 3 on the GAD-2 evaluation indicates the occurrence of depressive traits. The PHQ-2 and the GAD-2 scales showed good internal consistency (α = 0.80 and α = 0.85, respectively), consistently in the three countries.

Suicidal behaviors and ideation were evaluated with the Suicide Behaviors Questionnaire-Revised (SBQ-R) 49 . This self-report validated questionnaire includes four items inquiring about different aspects related to suicidal risk (suicidal ideation, past suicide attempts, and the likelihood of engaging in future suicidal behavior). SBQ-R can help identify individuals who may be at risk for suicidal behavior or who have a history of suicidal thoughts or attempts. Total scores (ranging from 3 to 18) have been categorized identifying groups with low (total score less than 7) and high risk (total score equal to or higher than 7) of suicidal behavior 49 . A good internal consistency was found in our sample (α = 0.82), independently by country. Before the SBQ-R questionnaire, participants were warned of questions about a particularly sensitive topic, and the section was optional.

Well-being was investigated through the Mental Health Continuum-Short Form (MHC-SF) 50 . The self-report validated scale consists of 14 items measuring the degree of several aspects of well-being: (a) Overall well-being (items 1–14); (b) Emotional well-being (items 1–3), defined in terms of positive affect and satisfaction with life; (c) Social well-being (items 4–8), as described in Keyes’ model of social well-being 51 ; and (d) Psychological well-being (items 9–14). The MHC–SF asks individuals how frequently they felt in a specific aptitude, from 0 (none of the time) to 5 (all of the time): the higher the overall score, the higher the level of well-being. In our sample, an excellent internal consistency (α > 0.90) was found referring to Overall and Emotional well-being, while a good internal consistency was shown for both Social, and Psychological well-being (α = 0.82, and α = 0.87, respectively), consistently in the three countries.

Perceived COVID-19 impact

A 10 items scale from the 2021/2022 Health Behavior in School-Aged Children was used to evaluate the subjective impact of COVID-19-related measures on various aspects of individuals’ lives: life in general, overall and mental health, relationships with family and friends, school performance, physical activity, eating behaviors, future expectations, financial situation 52 . Respondents were asked to assess the extent of the impact by selecting one of the following options on a five-point Likert scale: 1 = ‘’very negative’, 2 = ’somewhat negative’, 3 = ’neither positive nor negative’, 4 = somewhat positive’, or 5 = ’very positive’. Collapsing some response options, a three-level variable was obtained for each item, identifying negative (options 1 and 2), neutral (option 3), and positive (options 4 and 5) COVID-19 impact groups 53 .

• Academic stress

The Academic stress was evaluated using the Effort-Reward Imbalance—Student Questionnaire (ERI-SQ) 54 , a self-reported validated questionnaire based on the Effort-Reward Imbalance (ERI) theoretical framework 55 . The tool includes three subscales: the Effort (from items 1 to 3), the Reward (from items 4 to 9), and the Overcommitment dimensions (from items 10 to 14). The Effort score identifies the intensity and amount of effort an individual perceives in academic activities. It is calculated based on participants' responses to items regarding the study load, time pressure, and interruptions in doing the academic tasks. The Reward score reflects the perceived level of rewards gained in exchange for the efforts made. Rewards encompass social recognition, career advancement, job security, or other positive outcomes associated with academic accomplishments. In addition, the ERI-SQ incorporates a measure of Overcommitment, which denotes a personality trait characterized by an excessive dedication to work or academic tasks, regardless of the balance between effort and reward. From the previous measures, the Effort-Reward Imbalance (ERI) ratio is computed by dividing the Effort score by the Reward score multiplied by a correction factor 54 , 56 . The ERI ratio suggests a possible imbalance between the effort and the reward. For ERI ratio equal to 1, the student reports equal levels of effort and reward, an ERI ratio < 1 indicates less effort than rewards, while an ERI ratio > 1 indicates that the perceived effort is greater than the rewards, suggesting a greater likelihood of negative health outcomes due to stressors in the academic environment. Similarly, a high overcommitment score implies a propensity to invest excessive effort, even when the corresponding rewards are perceived as inadequate. The 14-item scale showed good internal consistency (overall α = 0.83), in contrast, independently by country, lower internal consistency levels were registered for Effort, Reward, and Overcommitment scales (α = 0.66, α = 0.69, and α = 0.80, respectively).

Future perspectives

Some further questions were asked about students’ future professional perspectives: (1) Plans for the future after completing higher education (the possible answers were pursuing further studies (post-graduate, master's, or Ph.D.), getting a job, working in another country, starting a business, or not having a specific plan); (2) Professional future: two questions with response options ranging from 1 (‘strongly disagree’) to 5 (‘strongly agree’) were provided to explore the readiness to manage and build the professional future after completing higher education and confidence in professional future. Dichotomized variables were then created based on high (options 4 or 5) or medium/low (equal or lower than 3) agreement. Furthermore, one further question exploring overall future expectations was provided. In this regard, subjects were asked to rate their expectations for the future on a scale from 0 to 10, where 0 represents poor expectations and 10 excellent ones. This assessment reflects general optimism or pessimism about prospects.

Data analysis

Demographic information and psychometric measures were described with absolute frequencies and percentages for categorical variables and medians and interquartile ranges (IQRs) for continuous ones. Data was stratified by country, and the rate of missing values for each aforementioned variable was reported. Afterward, further stratification by sex was performed within each country, and d fferences by sex were tested with a chi-square test for categorical variables and a Wilcoxon test for continuous ones. All statistical tests were two-sided, and the level of statistical significance was set at 0.05. Data were analyzed using the R software version 4.3.0 57 . Radar plots were generated to visually represent specific results by country, using Flourish 58 , a data visualization platform, and InkScape 59 , a vector graphics editor, to enhance their quality and clarity.

Demographic and Educational profile of participants

Our sample comprised 8773 students in Italy, 612 in Spain, and 396 in Portugal. The response rates in the three universities were 11.1% (Italy), 2.6% (Portugal), and 1.0% (Spain). We then excluded all participants who waived informed consent (n = 90), those older than 35 (n = 1308) or younger than 18 (n = 3), and those with missing information about sex (n = 72) obtaining a final overall sample of 8380 students (7559 students in Italy, 469 in Spain, and 352 in Portugal).

Table 1 shows the demographic and educational characteristics of the sample. The median age of respondents was homogeneous in the three countries. The majority of the sample was composed of females (more than 65% in the three countries) and declared a straight sexual orientation (> 70%). The main reported non-straight sexual orientation was bisexual, declared by 8–20% of the participants across countries (Most respondents attended a program concerning “Humanities and Philosophy” and “Social and Economic Sciences” areas, although over 12% of participants did not provide such information. Most students were in the first three years of college in the three countries (71% in Italy, 62% in Spain, and 88% in Portugal). Less than 50% of students in Italy and Spain declared themselves on track (44% and 46%, respectively), compared to 73% of Portuguese students.

Socioeconomic status and social support

The MacArthur Scale registered slightly higher levels of Subjective Social Status in Italy (median score: 7.0; IQR: 5.0–7.0) than in Spain and Portugal (median score: 6.0; IQR: 5.0–7.0 in both countries). Participants declared that they mainly depend on their families for financial support (> 75%), with variations in rates of work and scholarships across the countries. Notably, fewer respondents in Italy and Portugal (11% and 16%, respectively) relied on scholarships compared to the Spanish sample (29%), while an inverse trend was found regarding rates of work (i.e., lower in Spain than in Italy and Portugal) (Fig.  1 , Table 2 , and Table S2 , Supplementary file).

Financial situation among university students in Italy, Spain, and Portugal. Radar plots with percentages of financial situation are presented across the three countries.

The social support profiles emerging from the MSPSS showed similar perceived support levels on the three subscales among the three countries. Significant other subscales represented the primary source of support (median scores of at least 6.0 across the three countries). Overall, most respondents reported high social support (> 60%), mainly from Significant other and Friends, without relevant cross-country differences. Some sex differences were found within countries concerning social support (Table S3 , Supplementary file). More specifically, females declared higher Friends and Significant others support scores in Italy and Spain than their male peers (p < 0.001). In Portugal, males declared higher scores of Family support than females (p = 0.007). Patterns are globally confirmed adopting the categorized variables.

Mental health and well-being

In Italy and Spain, about two out of three respondents showed a high GAD-2 score (67% and 64%, respectively), while in Portugal, this anxious trait was presented by 50% of the sample (Table 3 , Fig.  2 ). However, the percentages of high depressive scores on the PHQ-2 were below 50% in all countries (44% in Italy, 44% in Spain, and 34% in Portugal). While students in Italy and Spain exhibited a higher frequency of both anxious and depressive symptoms compared to the Portuguese sample, a quite homogeneous picture emerged exploring SBQ-R scores. More specifically, 30%, 26%, and 29% of respondents were classified in the high suicidal risk group in Italy, Spain, and Portugal, respectively. Concerning the MHC-SF questionnaire, Italian respondents exhibited lower overall scores (median score: 30.0; IQR: 21.0–40.0) than Spanish and Portuguese ones (median scores: 41.0 (IQR: 29.0–51.0) and 39.0 (IQR: 29.0–48.0), respectively) indicating lower mental well-being among Italian participants compared to the others. This pattern is consistent across the three domains of the MHC-SF questionnaire.

Radar plots showing rates of mental problems and confidence levels in the professional future among university students in Italy, Spain, and Portugal. Radar plots with percentages of anxiety symptoms (GAD-2), depressive symptoms (PHQ-2), suicidal risk (SBQ-R), and confidence in professional future are presented across the three countries.

In terms of sex differences across the mental domains, Italian and Portuguese females presented higher scores in both the GAD-2 (p < 0.001 in both countries) and the PHQ-2 scales (p = 0.011 and p = 0.023, respectively), while no substantial patterns were found regarding SBQ-R. In the three countries, lower levels of well–being could be observed in girls than in boys in all domains of the MHC-SF questionnaire, with significant differences between the two sexes in Italy and Portugal for the overall score and social and psychological domains (Table S3 , Supplementary file).

Perceived impact of the COVID-19 pandemic

Results about the perceived impact of the COVID-19 pandemic are shown in Fig.  3 and Table S4 (Supplementary file). University students were more likely to report a negative than a positive pandemic impact on several life domains (i.e., life as a whole, overall and mental health, physical activity, eating behaviors, family financial situation, and future expectations), especially in Italy. In particular, half of Italian students (50.2%) reported a negative impact of the pandemic on their mental health compared to 40.3% and 37.8% of Spanish and Portuguese ones. Conversely, the COVID-19 pandemic’s influence on relationships with family and friends and school performance seemed to have been perceived more positively than negatively. A missing rate of 16% was observed consistently throughout the items.

Prevalence of positive (in blue) and negative (in red) perceived COVID-19 impact on several life domains among university students in Italy, Spain, and Portugal. Radar plots with percentages of perceived COVID-19 pandemic impact on students’ overall health, life in general, family relationships, friends’ relationships, mental health, school performance, physical activity, eating behaviors, future perspectives, and financial situation are presented across the three countries.

Academic stress and future perspectives

The ERI-SQ scoring revealed a homogeneous pattern in perceived overcommitment levels and the ERI ratio across countries (Table 4 ). In all countries, the median ERI ratio was slightly greater than 1, indicating that 6–13% of the effort was not met by the received rewards. In all countries, females seemed to have a significantly higher ERI ratio than males (Table S3 , Supplementary file).

The expectations for the future were similar in the analyzed universities (median score: 7.0; IQR: 5.0–8.0), while perspectives after graduation showed a higher variability across countries (Table 4 ). More specifically, in Italy, most students declared their intention to find a job after graduation (35%), while in Spain and Portugal, most planned to continue their studies (46% and 40%, respectively). Overall, a decreasing prevalence of participant students declaring confidence in their own professional future was found in Spain, Italy, and Portugal (47%. 34%, and 20%, respectively). Furthermore, Italian and Spanish students felt more prepared for work than Portuguese ones (35% and 29% vs. 19%, respectively).

The present cross-country project primarily aimed to identify common and specific mental health and well-being traits among university students in Italy, Spain, and Portugal.

Respondents were primarily females with a median age of 21, currently attending the first three academic years. About three out of four students declared a straight sexual orientation, while bisexuality represented the second most common sexual orientation, ranging from 8% in Italy to 20% in Spain. The high levels of bisexuality compared to the previous studies (up to 10%) could be the result of undergoing changes in sexual norms and behaviors, leading to even more youths identifying as bisexual 60 , 61 . Italian students presented higher median socioeconomic status than Portuguese and Spanish ones, reflecting the different economic wealth situations observed by the World Bank in such countries 38 , 39 . Conversely, quite similar patterns in social support were registered across universities, confirming the expected cultural similarities in social bonds in these three Mediterranean countries 35 , 62 , 63 . Overall, students declared a relatively higher support from Friends and Significant other than Family, underlying their developmental transition from adolescent to young adult supportive networks 64 , 65 , 66 .

The PHQ-2 and GAD-2 assessments showed high levels of anxiety (> 50%) and depressive symptoms (> 30%) among students in the three countries, being exacerbated among females than males. Furthermore, these first insights suggest higher levels of such mental problems among Italian and Spanish students than Portuguese ones. The disparities in emotional, social, and psychological well-being captured by MHC-SF are also noteworthy, with Italian students reporting lower scores than their counterparts in Spain and Portugal.

These results suggested different cross-country trends based on the indicators explored, enforcing the validity of conceptualizing mental health as a multidimensional construct in which the various dimensions can have different correlated patterns 51 , 67 , 68 , 69 , 70 . More specifically, the present study found that Italian students showed the lowest levels of well-being and the highest rates of mental problems across the three countries. These findings align with those reported by recent works on nationally representative samples of adolescents in the same countries, suggesting shared underlying causes at a macro-level, even among contiguous age groups (adolescents and young adults) 36 , 71 . Several factors could be involved in the observed pattern, including pandemic-related measures duration and strictness, as confirmed by the higher levels of negative perceived impact of COVID-19 on mental health in Italy, observed in the present and other studies 36 , 71 . Moreover, cross-country differences in physical activity could have had a contributing role 37 . In particular, the high negative impact of pandemic-related measures on students’ physical activity in Italy could have exacerbated the pre-pandemic cross-cultural exercise differences 37 .

Furthermore, the observed cross-country pattern of mental problems in the university environment may also be attributed to the significant social and academic pressures that Italian university students experience 10 , 72 . Our analysis revealed a lower percentage of scholarship recipients and higher rates of working students in Italy than in the other explored countries. These elements suggest differences in university study support policies across countries, reflecting the different financial frameworks, which also have consequences for the well-being of university students 73 .

Among the mental health issues explored in this survey, results about suicidality deserve to be discussed separately, in light of the latest evidence on this sensitive topic.

Approximately one-third of students within the three countries exhibited characteristics placing them in the “high risk” category in the SBQ-R assessment, with substantially geographically homogeneous patterns across countries. Such prevalence is higher than that emerged from other surveys conducted before the COVID-19 pandemic 74 , 75 , 76 , in line with data collected during 2020 77 , and slightly lower than levels registered in 2021 77 . In particular, literature exploring long-term temporal trends of suicidality suggested an increase in the phenomenon since 2021, which was attributed to the impact of COVID-19 on students’ lives 21 , 78 , 79 , 80 . Furthermore, in our sample, high rates of negative perceived impact of the COVID-19 pandemic on mental health were observed across the three countries, enforcing such possible association. From this perspective, the long-term consequences of COVID-19 pandemic-related measures on youths’ mental health could have left prolonged traces, still detectable in 2023, during the so-called post-COVID-19 era. In this regard, literature is still lacking, and further exploration of the topic is needed to increase the knowledge of the phenomenon and to guide the policy agenda promoting youths’ mental health 81 , 82 .

COVID-19 perceived impact assessment showed a relatively homogeneous picture among students across countries. Specifically, pandemic-related measures seemed to have negatively impacted several domains (i.e., mental health, physical activity, future perspectives, and financial situation). Still, a prevailing positive impact was perceived regarding relationships with family, friends, and school performance. Overall, our findings are consistent with other studies adopting the same measurement tool on nationally representative samples of adolescents in the three countries, enlightening shared environmental exposures across age groups 53 , 83 . More specifically, results referring to the pandemic impact on family relationships are consistent with the findings by other authors, who observed tighter family bonds after the lockdown establishment 17 , 25 , 84 , 85 , 86 , 87 , 88 .

The academic stress assessment pointed out similar trends among countries: the median ERI ratio was higher than one among students regardless of the country, indicating perceived rewards lower than expected, especially among girls. These findings align with results from previous works that showed unbalanced ERI ratios toward effort among university students 10 , 54 .

Finally, a quite heterogeneous geographical pattern was found regarding future professional perspectives: 20–30% of students in our sample felt prepared for work, and confidence in the professional future showed a decreasing pattern from Spain to Italy and Portugal. This presumably reflects the cross-country economic wealth differences and the widespread uncertainty about the future among youths 38 , 39 , 89 , 90 .

Limitations and strengths

The observed findings should be interpreted cautiously due to several limitations of the study. While our sample included over 8000 students, it only represented a small percentage of the target population (approximately 150,000 students in the academic year 2022–2023). This issue could potentially hinder the generalizability of our findings. Additionally, most students responded in Italy, resulting in an unbalanced sample and few participants in Spain and Portugal. These methodological issues could lead to analytical constraints regarding statistical comparisons between countries, making it possible to analyze differences only within each country. The unbalanced sample and the low sample size in 2 out of 3 countries also limited the exploration of the factors associated with well-being in a cross-country framework. Furthermore, the self-reported nature of the data and the cross-sectional design of the study also represented additional weaknesses.

Despite these limitations, the present work is one of the first cross-country surveys exploring academic stress, mental health, and well-being among university students in the post-COVID-19 era. This international research stands out for its rigorous methodology, using validated tools and a consistent protocol to assess the well-being of university students in Italy, Spain, and Portugal. The comparative approach adopted across countries allowed us to explore the complexities of three Southern European countries sharing cultural similarities and to study their influence on university students' well-being. In particular, we found cross-university patterns consistent with the existing studies on the topic despite a high level of heterogeneity recognized in the literature in psychometric instruments and target student populations. Finally, using validated tools like PHQ-2, GAD-2, SBQ-R, and MHC-SF allowed us to simultaneously capture different mental health and well-being dimensions among university students, providing a more comprehensive and holistic framework.

Conclusions

This cross-sectional survey explores the well-being levels and mental health patterns in three Southern European countries in the post-COVID-19 phase in light of their cultural similarities and peculiarities.

Overall, Italian students showed the lowest levels of mental well-being and the highest rates of mental problems (i.e., anxiety and depression) and suicidal risk across the three countries despite the relatively similar profiles of social support. The prevalence of the students’ confidence in their professional future is higher in Spain than in Italy and Portugal. The emerging picture offers valuable insights into this public health topic and paves the way for further exploration of the relationships between students' environmental factors (e.g., social support and academic stress) and various aspects of their well-being.

Data availability

Data is available from the corresponding author upon reasonable request.

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Acknowledgements

We would like to thank the students who participated in the study and the university staff who assisted us in sending the links for participation.

The present study was funded by the University of Torino (COMR_GFI_22_01_F, COMR_RILO_23_01_F, COMR_RILO_24_01).

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Bersia, M., Charrier, L., Zanaga, G. et al. Well-being among university students in the post-COVID-19 era: a cross-country survey. Sci Rep 14 , 18296 (2024). https://doi.org/10.1038/s41598-024-69141-9

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The true impact of workplace wellbeing: two case studies

Embedded Expertise, Published: January 29, 2020 - Updated: August 22, 2022

Mental health concerns are a leading cause of workplace absence , and as we see increasing incidents of mental health-related sick days, workplace wellbeing is paramount for both organisational and individual success.

Below I’ve written two real-life stories where bettering the wellbeing of a workplace can have dramatic effects on the individuals and business profitability itself. Hopefully this will inspire you to incorporate a wellness approach into your organisation or team, or take more notice of your own mental health.

Case study one: Michael thought he was fine

Michael* realised he was arguing a lot with his family at home and was becoming increasingly more reactive to situations that probably didn’t warrant it. He wasn’t terribly great at conducting conversations or maintaining relationships with coworkers and this spilled outside of work. Body aches and excessive headaches had also started to culminate: all obvious signs of deep stress that Michael was ignoring.

The thing is, he thought he was actually doing really well and managing his stress levels appropriately and that his behaviour and experiences were quite normal.

But in fact, he was suffering extreme levels of stress . Something he didn’t even comprehend until he connected with a workplace wellbeing expert and he had the opportunity to observe his behaviours.

After one week of dedicated and concentrated awareness on how he was reacting and experiencing situations and noticing stress levels, triggers and emotions as they arose, he started to really notice a difference.

‘After one week of dedicated and concentrated awareness… he started to really notice a difference.’

To mitigate his stress levels and improve his workplace wellbeing and relations, Michael also engaged in visualisations (similar to what athletes do ), particularly with conversations, which creates different pathways in the brain . From here he started acting differently, having better discussions and decisions and was significantly calmer everywhere throughout his life, not just in the workplace.

Case study two: bad behaviour, great worker

Company owner, Rajiv, was experiencing some staff problems that he’d tried to handle but wasn’t seeing any changes. One of his contract managers, Tom, was displaying bad behaviour whenever things would go wrong.

The thing was, it was abundantly clear that what Tom was saying and the problems that he identified were absolutely correct. And the company valued his hard work and how exceptional he was at his job, so there was no desire to terminate his contract early. Which can often be a case for difficult situations in the workplace— many people are too eager to throw the ‘baby out with the bathwater’ so to speak, rather than experiment with some alternative ways of reaching conflict resolution. Or even taking the time to discover what is really going on, stepping away from the ego and its primal behaviour of flight or fight mode.

After supportive discussions with Tom, the wellness team discovered that actually he felt isolated , alone and that he didn’t belong. And, because the mind seeks to confirm our beliefs (through confirmation bias), would create situations and replicate behaviour to further consolidate that belief. He was very caught up in his story that he was an outsider.

A sense of belonging

To further compound this position, Tom was contracted as part of a large project and he felt like he didn’t fit in with the permanent employees, who had established themselves in the internal culture.

Forbes states that, ‘Employees who do not naturally fit into established corporate norms will often times try to assimilate to those norms – or put themselves “on guard” – in order to avoid potential biases or discrimination.’ This can take considerable effort and energy, which could be better spent on a person’s core duties.

A sense of belonging in the workplace contributes greatly to retention and attraction of high-quality candidates, which leads to better productivity, outcomes, creative solutions and more profit. It can also result in 75 per cent fewer sick days and avoid millions of dollars’ worth of lost productivity.

‘A sense of belonging in the workplace contributes greatly to retention and attraction of high quality candidates…’

Fostering this sense of belonging ‘in the workplace makes employees engaged and produce work that is elevated above the ordinary…’.

Once identified, the workplace wellbeing team worked with Tom and Rajiv with proven techniques that involved awareness, cultural changes and compassion and saw rapid improvement within weeks, thanks in part to the commitment of the people involved.

The change was so significant that Rajiv was enthusiastic and hungry to find more ways in which he could change the dynamics to bring out better and better results within his company. The company also extended Tom’s contract when the opportunity became available.

Welcome contract workers too

It can be really easy to forget that contract staff are an integral part of your team, even if they are only on staff for a limited time. And it shouldn’t be a last minute or token effort.

‘… there needs to be a culture and allowance for people to connect as human beings. We shouldn’t need bonding or team leadership days to actually connect with our colleagues and make meaningful relationships ,’ says Dr Michelle Lim, a loneliness researcher and senior lecturer in clinical psychology at Swinburne University.

Incorporating contract workers as genuinely part of the team and treating them as well as you treat all employees will only promote excellent benefits for the business and wider society as a whole and help contribute to preventing distressing issues such as high suicide rates in the engineering industry.

Can you relate in full or in part to these stories? Improve your wellbeing in your workplace today. Discover more about our for our contracting professionals.

*We’ve changed these names to provide privacy and protect the identity of these people.

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An Exploratory Multi-Case Study of the Health and Wellbeing Needs, Relationships and Experiences of Health and Social Care Service Users and the People who Support them at Home

Dr louise henderson.

1 Bon Accord Care, Inspire Building, Beach Boulevard, Aberdeen, AB24 5HP, GB

2 Robert Gordon University, School of Nursing & Midwifery, Garthdee Road, Aberdeen, United Kingdom, AB10 7QE, GB

Dr Heather Bain

3 University of Highlands and Islands, Institute of Health Research and Innovation, Centre for Health Science, Old Perth Road, Inverness, United Kingdom, IV2 3JH, GB

Dr Elaine Allan

Catriona kennedy.

4 The Queens Nursing Institute Scotland, 31 Castle Terrance, Edinburgh, Scotland, United Kingdom, AH1 2EL, GB

5 The University of Limerick, Department of Nursing and Midwifery, Limerick, Ireland, V94 T9PX, GB

Introduction:

International policies and legislation set a precedence of person-centred sustainable integrated Health and Social Care (HSC) that meets the health and wellbeing needs of service users through improved experiences. However, current research focuses on service models, with fewer studies investigating experiences and needs.

This qualitative multi-case [n = 7] study was co-designed with key stakeholders and aimed to explore experiences and needs of people who access and provide HSC at home. Data were collected in a regional area of Scotland (UK) via single [n = 10] or dyad [n = 4] semi-structured interviews with service users [n = 6], informal carers [n = 5] and HSC staff [n = 7] and synthesised using Interpretive Thematic Analysis.

Interpersonal connections and supportive relationships were instrumental in helping all participant groups feel able to cope with their changing HSC needs and roles. They promoted reassurance, information sharing and reduced anxiety; when they were lacking, it negatively impacted upon experiences of HSC.

Discussion:

Promoting inter-personal connections that encourage supportive relationships between people who access and provide HSC and their communities, could promote person-centred Relationship-based care and improve HSC experiences.

Conclusions:

This study identifies indicators for improved HSC, advocating co-produced community-driven services to meet the self-defined needs of those who access and provide care.

Introduction

Many populations across the globe are ageing, with growing numbers of people living with multiple long-term conditions, leading to increased complexity of care provision and rising demand for services [ 1 ]. Integrated Health and Social Care (IHSC) services offer a potential solution to support individual citizens across these populations [ 2 ]. Defining integration can be challenging, it can be seen as a design feature of service provision, organisational structures, or as a medium for delivering person-centred care (PCC) in an efficient way [ 3 ]. To add clarity to its context in this paper, IHSC is considered to be care that is delivered jointly between service users (people who use health and/or social care services), informal carers (people who offer non-contractual support to a service user), and health care and social care (HSC) organisations (including third sector and community initiative groups). Integration aims to promote greater simplicity in public services and facilitate timely, stream-lined access to appropriate HSC [ 4 ]. The actuality for some people who access HSC reflects services that do not always work together to provide care in an integrated way [ 5 , 6 , 7 ]. Moreover, despite widespread acknowledgement in the literature that people who use HSC should be involved in making decisions about their own care, they do not always feel as though they are [ 5 ]. Regional and local access to HSC can be variable, unequal and ill-suited to their needs, being disproportionate to the need and demand for services and reducing access to support [ 8 , 9 ]. There is a plethora of literature containing evidence-based accounts of assessing need, planning, implementing and evaluating IHSC models of care. Whilst these can guide HSC services and sectors in providing care, the experiences of service users can help to decipher health and wellbeing outcomes that are important to them [ 10 , 11 ]. However, there appears to be a paucity of evidence on the experiences of those who access and provide such services.

Research design

Involving stakeholders in this study.

An integrative literature review was conducted as part of the lead authors PhD study. This review identified gaps in current knowledge about the experiences of people who accessed HSC. Findings were discussed with key stakeholders, including people who accessed and provided HSC services and members of the public. Those who accessed and provided HSC offered their verbal and written feedback in a series of three face-to-face roadshow events (April 2018 – Oct. 2019; attendance circa 80 people per event). Members of the public, who had expressed an interest in receiving information about research activity in their local area, also offered their verbal and written feedback in a community network group meeting (Dec. 2019; attendance circa 50 people). Their feedback and findings of the literature review informed the development of a short series of research questions ( Table 1 ), aim and objectives ( Table 2 ) for this PhD study. Their valued engagement, through early fieldwork and wider formal and informal engagement events, continued iteratively throughout this study, later converting to online engagement events under Covid-19 pandemic restrictions.

Research questions.

Key objectives.

Study design and methods

Relationships between stakeholders in HSC, were explored using Yin’s [ 12 ] embedded model of multi-case study design and qualitative methods ( Tables 1 , ​ ,2). 2 ). This design embraced each participant’s unique perspective whilst recognising a need for them to be ‘bound’ to others with whom they had a caregiver-receiver relationship.

Recruitment of contextual study sample

Scotland has an estimated population of 5,479,900, with 32 regional areas that have populations ranging from 626,410 to 22,190 [ 13 ]. Each regional area has one or more Health and Social Care Partnership (HSCP) areas within their geographical boundaries. These HSCPs facilitate operational delivery of an integration strategic plan to meet population health and wellbeing needs in their area [ 14 ].

An invitation to take part was distributed to potential participants in one regional area of Scotland with three HSCP areas, via professional social media accounts and a cascade email to HSCP staff. Service users [n = 6], informal carers [n = 5] and HSC staff members [n = 7] were recruited between September 2019 – February 2020. Participants [n = 18] were grouped in cases [n = 7]. A case was formed when a service user identified one or two people who supported them at home to take part with them.

Five cases had a service user, informal carer and staff member participant. One case contained one staff member participant, after the service user and informal carer withdrew from the study. One further case contained a staff member and a service user, when the informal carer participant withdrew. Cases were labelled A-F and participants were given pseudonyms to protect their identity ( Figure 1 ).

Contextual sample and cases.

Data collection

Data were collected via semi-structured interviews [n = 14] between Dec 2019 – March 2020. Service users chose an individual interview [n = 2] or a dyad interview [n = 4] with their informal carer. All Staff members [n = 7] and an informal carer [n = 1] were also interviewed individually. All interviews were conducted face-to-face, except for two individual telephone interviews [informal carer Esther; staff member Esme].

Data analysis

Simultaneous inter-case and cross-case analysis was conducted to explore the diversity of experiences and HSC needs across cases in the region [ 12 , 15 ]. Interpretive Thematic Analysis facilitated the development of a framework for developing insights, concepts and patterns of meaning across cases [ 12 , 15 , 16 ]. Researcher reflexive field notes, journaling, and ongoing review of the emerging findings promoted transparency and thick-description of methods, analysis and subsequent findings [ 15 , 17 , 18 ]. Analyses were reviewed by supervisors [n = 3] within the research team, and subject to ongoing external review via multiple research forums across both academic and HSC practice. Furthermore, members of the public in a community network group were invited to explore preliminary thematic findings during analysis, to iteratively develop interpretation of the data and subsequent findings [n = 12] (July 2021).

Promoting trustworthiness

Credibility, transferability, dependability and confirmability were promoted by incorporating multiple participant perspectives, pattern matching techniques, ongoing scientific review and involving stakeholders during data analysis, construction of themes and write-up [ 15 , 17 , 18 ]. Ethical approvals were gained in June 2019 at the hosting academic institution (SERP Reference Number: 19-12). Ethical approvals were granted in October 2019 by the UK-wide Integrated Research Application System (IRAS) (IRAS Project ID: 247771; REC reference: 19/NS/0148). They were granted with the IRAS Research Ethics Committee’s recommendation that people with learning disabilities and those with profound mental health issues were excluded (discussed further in the strengths and limitations section below).

Key findings

Context and overview of findings.

To offer context to the experiences participants shared within their case, relevant background information has been included in Table 3 .

Relevant background information for participants and their cases.

Following analysis, making interpersonal connections was identified as an overarching theme central to helping participants meet their health and wellbeing needs and/or those of others. Figure 2 presents five main themes representing the different contexts in which these connections were made, from understanding self, to linking with individuals, communities, services or wider systems. A summary of key factors that enhanced and hindered participants’ connections and experiences of HSC across these contexts is included in Figure 3 .

Overview of themes.

Factors that enhanced and hindered connections and experiences of HSC.

Understanding and coping with changing health and wellbeing needs

Participants across all groups discussed their experiences of understanding and coping with changing health and wellbeing needs or supporting others to do so.

Understanding changing health and wellbeing needs

Service user [n = 6] and informal carer [n = 7] participants’ understanding of their changing health and wellbeing needs, were shaped by their connections with others. They felt their experiences of accessing HSC could be challenging. Some HSC staff had focussed on service users’ medical conditions that were sometimes unrelated to their presenting complaint, suggesting some staff may not be adopting a person-centred approach to care:

[Caitlin, quoting her Gastric Surgeon’s referral letter, gestures air-quotes] ‘Met with Caitlin, slim lady with Multiple Sclerosis, and I recommend that you give her a stoma’ [Catlin pauses, furrows brow and rolls eyes] …that’s when I was an [gestures air-quotes again] ‘MS person’ and nothing else.” Caitlin, service user, HSCP 1 .

All informal carer participants [n = 5] highlighted the impact their caring role had on their health and wellbeing, and their own need for person-centred support in their caring role. However, informal carer Anisha described an encounter with a Social Worker who exhibited a judgemental attitude, questioning her commitment as a wife and her role as an informal carer, when she raised the prospect of becoming unwell herself and the potential that she might not be able to care for Arthur:

“The quote I got thrown back at me was, ‘a good wife would do that for her husband’, and I thought, yeah, if a good wife’s here type of thing but, I didn’t say it, I should’ve said it really or, maybe I should’ve just turned round and said, ‘well, I’m nae a good wife then!’, you know [crosses arms, frowns].” Anisha, informal carer, HSCP 1 .

Informal carers [n = 5] also highlighted the negative impact that increased stress, as a result of their caring responsibilities, had upon their wellbeing. They reported low mood, depression, emotional strain and physical exhaustion. Staff member participants [n = 7] acknowledged their role in supporting service users and informal carers whilst their health and wellbeing needs were changing.

Feeling able to cope with changing health and wellbeing needs

Service user and informal carer participants emphasised a need for support from HSC staff with their changing health and wellbeing needs. They wanted reassurance and support from staff to feel empowered to make decisions about their care, and to access information to help them cope:

“We get an appointment with them, just to go through things… they [HSC staff] don’t make up your mind for you but, they give the necessary information to allow you to come to a sensible decision… you canna make a decision on anything, if you don’t have the facts, you know.” Arthur, service user, HSCP 1 .

For service users and informal carers, coping with changing health and wellbeing needs was also linked to being able to attend to practical tasks, such as managing finances, personal care, eating and drinking, managing continence, housework and shopping tasks. For some, getting ‘out and about’ to meet others [n = 3 informal carers] and contact with HSC staff [n = 4 service users], promoted engagement with communities and social contacts. However, all service user participants [n = 6] reported feeling lonely and isolated, and this was a source of concern for their informal carers [n = 3] and staff members [n = 2].

Fostering connections and supportive relationships with others for health and wellbeing

Participants’ shared their experiences of fostering connections to build supportive relationships, which enhanced their health and wellbeing.

Building supportive relationships between service users, informal carers and HSC Staff

For all participant groups, connecting with others across HSC services, organisations and sectors to build a supportive relationship was facilitated through face-to-face interactions. Staff member [n = 4] and service user [n = 2] participants highlighted co-location of services as a means of promoting this. An interpersonal or ‘friendly’ connection was perceived by all participant groups as a necessary foundation for building supportive relationships. Commonalities between individuals was a key quality of these connections. Service user Donna, who had carers supporting her for a number of years, offers an example of this when she described her experiences of her need to connect with her HSC carer:

“She’s [Donna’s Carer] chatting to me when I’m showering and I, I find out about her family and things, chat about her family and, you know, that sort of thing… … I considered them as friends [her carers] and, I mean, I have a carer now, who’s been coming for over four years, in this company, and, I mean, she’s really efficient and, you know, I’m made to feel really comfortable and all that but, I mean, I said to her one day, do you think of me as a friend, or just another client [hesitates, looks down]… she [the carer] said, ‘well, just another client ’. Donna, service user, HSCP 2 .

During the interview, Donna’s non-verbal body language suggested she was disappointed with the disparity between the meaning her HSC carer had placed on the relationship and her own perceptions of it. For all participant groups, supportive relationships were fostered over a period of time, from a place of trust between two individuals, services or sectors. The opportunity to build up a trusting bond was afforded through continuity of contact between these groups, leading to a perception of more collaborative supportive relationships and HSC practices.

Key characteristics of supportive relationships

Key characteristics required for fostering a supportive relationship, as perceived by all participant groups, included personal attributes of empathy, trust, discernment and reliability:

“I think Beverley works well because I can, I can count on her… I know that she’ll be there and that, that she won’t, you know, she won’t turn up sometimes and not others, that’s really quite important to me.”   Barney, service user, HSCP 1 .

Furthermore, when service user and informal carer participants were looking to foster a supportive relationship with HSC staff, they also wanted those staff to be knowledgeable about their condition and circumstances. All participant groups looked to share information, offer support and reassurance when communicating within supportive relationships. However, communication was perceived as challenging across HSC organisations and sectors. All participants [n = 14] attributed this to inefficient methods of communicating across organisational boundaries, with some staff members [n = 5] reporting system-wide data protection issues when trying to share information about those whom they were supporting.

Connecting with communities for health and social wellbeing

Service user and informal carer participants’ experiences of connecting with communities helped them with practical tasks and to maintain social contacts, which were perceived to improve their health and wellbeing. Communities were defined by service user and informal carer participants as local geographical areas, meaning people who lived nearby. They also described communities, where people had a common interest or role such as a religious church group or a group of informal carers.

Maintaining and promoting practical tasks with support from the local community

Service users and informal carers reported that members of their communities provided valued reassurance and support. Some informal carers [n = 2] asked members of their communities to ‘check-in’ with their service user, and service users asked them to help with local grocery shopping and putting their rubbish bins out for collection [n = 2]. Connections that service users and informal carers had with people in their communities were often perceived as more cohesive than those they had with people from statutory HSC services. They attributed this to community members’ in-depth knowledge and understanding of their needs:

“People that support me, are often people who are integrated into the local community so, people know them, erm, and they kind of know me so, that’s quite important to me, like… they know what I need and they, they know that I can’t walk too far so if, for example… I’d went and got some very heavy shopping; they would pick it up and put it in the car for me.” Barney, service user, HSCP 1 .

However, for service user Grant, connecting with people in his community had become more challenging as local populations increased and neighbourly knowledge diluted:

“The village is expanded so much, everybody before knew who I was and knew who the kids were but, no… you don’t know all the people now, you see, and there isn’t that contact, village contact, if you like… I don’t think it’s that open, er, neighbourly kind of care that used to be. The people probably are more dependent on, er, trained professional people.” Grant, service user, HSCP 1.

People in his community no longer had knowledge of his circumstances, leading to reduced informal support and to Grant feeling disconnected from his community.

Improved health and wellbeing through social contact with people in the local community

Social contact with others had a positive influence on mental health and wellbeing. Previous knowledge of a service users’ circumstances helped community members to connect with them socially. All informal carers [n = 5] felt their service users’ social contact with others should be encouraged to promote mental wellbeing. Although service users wanted to maintain and make new social contacts [n = 4], when informal carer Esther encouraged service user Eddie to have social contact with others, he reminded her that he also needed time to himself:

“He’ll [Eddie] sort of remind us, ‘I’m in my 70s! I actually quite like just sitting on my own sometimes and, like just having, having a wee [small] rest and taking it easy’.” Esther, informal carer (talking about her father, service user Eddie), HSCP 2.

This highlighted disparity between the expectations of some informal carers and service users, with relation to service users’ desire and need for social contact with others.

Connecting with other service users and informal carers to feel supported

Communities played a vital role in supporting service users, promoting connections and supportive relationships with people who knew and understood their circumstances. Maintaining and making connections with other service user and informal carers offered an opportunity for participants to share their experiences and access information about their condition or caring role, whilst offering peer support and social contact. However, not all service users and informal carers wanted to connect with communities of people who had similar circumstances or conditions [n = 2]. They reported anxieties around their future, and a risk of mis-matched expectations between treatment and progression of their condition:

“My dad [Eddie] was sort of freshly diagnosed, he was sort of advised [by another person who also had Multiple Sclerosis] not to go along [to the support group], that he might find it a bit upsetting because there would be people there further along in the disease, in wheelchairs and really unwell. So, I think he sort of put off going” . Esther, informal carer, HSCP 2.

Service user participants who did attend these groups [n = 3], felt supported because they were able to exchange accounts of treatment options, discuss symptoms and disease progression, and connect with people who knew and understood their circumstances. However, it also presented challenges in other areas as highlighted through an anecdotal account from staff member Catherine:

“I suppose it’s a great charity that patients, erm, get a lot out of [the support group], I’m sure. Sometimes their [the third sector organisation] opinions can be quite forceful, and we have to look at treatment options from an evidence-based practice [point of view] as opposed to perhaps what’s purported by the – [third sector organisation].” Catherine, staff member, HSCP 1.

Connecting with HSC services for help to maintain and promote health and social wellbeing

Participants’ experiences of connecting with HSC services helped them maintain and promote their health and wellbeing, with availability, access, coordination and utility of HSC relevant to their needs.

Availability of and access to services, at a time when they were needed

Service user [n = 4], informal carer [n = 4] and staff member [n = 6] participants described their experiences of accessing HSC services, reporting fragmentation and reduced availability. It was important to all participants that service users and informal carers had timely access to services, such as physiotherapy and General Practitioners (GP). Service users [n = 6], informal carers [n = 5] and staff members [n = 7] reported reduced access to respite services, a need for greater flexibility in the way services were delivered, and reduced access to HSC services because of perceived obstructive ‘gatekeepers’:

“But there’s a woman in [location] who, you have to convince that you’re in need of the services.” Barney, service user, HSCP 1.

Some service users [n = 3] and informal carers [n = 3] attributed reduced access and availability of services to financial constraints, and inflexible ways of working across HSC systems. Service user Barney perceived HSC as a ‘post-code lottery’, where services were available in some areas but not others and where the nature of individual HSC staff members influenced care. However, when participants could gain access to services at a time when they thought they needed them, they felt supported and that their health and wellbeing needs were being met.

“She [GP] gives us [Barney and his wife] such good support. It seems to me to be a bit of a lottery [access to a supportive GP], it depends very much on the nature of the, of the particular GP.” Barney, service user, HSCP 1.

Coordinating and organising services within an HSC system

All participant groups were looking for further clarity on the way HSC was set up and organised across their services. Service users [n = 4] and informal carers [n = 5] perceived that having a named point-of-contact helped them achieve this:

“Having a Care Manager [as a named point-of-contact] that, you know, coordinated things, that would refer you if you needed physio or OT or anything like that, that worked very well.” Donna, service user, HSCP 2.

However, not all service users had a point-of-contact. For some, this led to a perception of reduced levels of access to care and coordination. Service users and informal carers were not always involved in planning their own care, leading to them feeling disempowered. When they were involved in planning their care, they felt it was more efficient and timelier. They sought the support of HSC staff to plan for the future in order to ensure their changing health and wellbeing needs would be met. However, service user Arthur and his informal carer Anisha felt their Social Worker had demonstrated a short-term view and lack of pre-emptive planning of their care. Anisha explained that this made her feel as though she had fraudulently requested potentially unreasonable support; her non-verbal communication during the interview portrayed a sense of anger and distaste:

[crosses arms, purses lips, raises eyebrows and clicks tongue on the roof of her mouth] “It made me feel, almost fraudulent, as though I was asking for something that I shouldn’t have been asking for at that stage, or at this stage.” Anisha, informal carer, HSCP 1.

Utilising HSC services to meet health and wellbeing needs

Participants’ use of HSC services to meet their health and wellbeing needs were varied. Some service users and informal carers were able to meet their needs through regular contact with a GP, specialist or wheelchair service. For some service users and informal carers, use of HSC was more challenging. They encountered lengthy waiting times and thought their care was not always appropriate, resulting in them using similar private sector services at their own expense.

“The waiting list is 15 weeks [for physiotherapy input], which isn’t handy if you can’t walk down the stairs! I couldn’t get away from it being sore… I think 15 weeks of that I would just be round the bend.” Caitlin, service user, HSCP 1 .

In addition, time constraints of support visits exerted negative pressure on service users and staff members relationships. For some staff members [n = 3], the relationships they formed with more experienced colleagues were instrumental in helping them to feel supported and boosting their confidence in their role.

Working together across HSC services to promote health and wellbeing

Participants’ experiences of working together across HSC services and systems to promote and maintain health and wellbeing needs highlighted their understanding of ‘integration’. They acknowledged the positive effect that integration could have on HSC services, with pooled information and resources to promote better outcomes for service users and informal carers. However, ‘integration’ appeared to be an abstract concept to many participants (across all groups). Abigail reported a lack of clarity about structural changes, and a lack of communication and preparation for progressing them:

“Integrated HSC started up here maybe a couple of years ago, we were never really given a lot of information about it, naebody [nobody] ever came to speak to us about it and, to be quite honest, we’re nae [not] really sure how it’s supposed to work ‘cause naebody’s ever discussed it with us… I think a lot of our Locality Managers now are HSCP, as opposed to being health board.” Abigail, staff member, HSCP 1.

Services were reported as disjointed, adopting unsafe communication and information sharing practices when bureaucratic processes did not meet the needs of HSC staff, the services or their HSC system. Some staff member participants [n = 6] suggested they needed further information about other HSC services working with people they were supporting. For staff member Debra, personal safety was compromised. She felt she had been placed at risk because of a communication breakdown that left her feeling vulnerable and uncomfortable:

“I had a patient who was very sexually inappropriate towards me, erm, I was just on my own in his house, so I called the Community Nursing staff to let them know [that the person had been inappropriate] but, they’d known about this for a long time and they had already made him double-visits [where two members of staff attend at the same time]. So, I’d been going in for months without knowing this, that was communication breakdown, it wasn’t nice what happened, and that could’ve been prevented had communication been that little bit better or, had we all been on the same system [electronic information system] and that would’ve flagged up for me. That would’ve saved a lot of uncomfortable feeling for myself [looks towards the floor, laughs uncomfortably, hesitates] … so.” Debra, staff member, HSCP 2.

She felt that, had communication in the HSC system been better (through a joined-up electronic information system) this situation could have been avoided, mitigating risk for staff. Promoting trust between people within HSC systems helped to strengthen their supportive relationships and communication, and collaboration was achieved when people were experienced, knowledgeable and flexible in their approach to working with others.

Discussion and theoretical contributions

Findings of this study support the need for significant investment in facilitating and protecting the allocation of HSC staff time to help them develop supportive relationships with service users, informal carers and other staff across HSC systems. This is based on the understanding those in the relationship maintain contact or interaction over a period of time through continuity [ 19 , 20 , 21 ]. Participants highlighted several key characteristics that they perceived as important in interpersonal connections and supportive relationships, which are represented in a typology below ( Figure 4 ).

Typology of interpersonal connection and supportive relationships in HSC.

In addition to the key characteristics of interpersonal connections and supportive relationships, participants across all groups outlined what they perceived as their health and wellbeing needs ( Table 4 ).

Health and wellbeing needs in HSC.

Findings of this study suggest models of HSC should promote the principles of interpersonal connection outlined above, and encourage supportive relationships between service users, informal carers and HSC staff members as a foundational principle of HSC. The concept of connection, through continuity of contact with someone who offers support, has long been acknowledged in relevant models and frameworks as a fundamental principle of PCC for people who access HSC services. Continuity has been advocated across a variety of contexts for many years, to help reduce admissions to hospital, lower HSC costs, and promote Service User and staff satisfaction [ 22 , 23 ]. Findings of this study support a significant investment in facilitating and protecting the allocation of HSC staff time; it can help them to develop supportive relationships with service users, informal carers and other staff across HSC systems.

Many existing frameworks, theories and concepts identify key principles for integrating, improving and delivering HSC and PCC [ 5 , 24 ]. Some key theories were considered when interpreting participants experiences in this study. It is suggested that the findings outlined add to these. When interpreting participants’ experiences of fostering connections and relationships in a care provider-receiver context, behaviours linked to applications of Bowlby’s Attachment theory across the lifespan, were instrumental [ 25 , 26 , 27 ]. To further acknowledge the influence of connection in an HSC environment, a ‘blended’ theoretical lens was adopted. Caring Theory [ 28 ], Person-centred Care [ 29 ], Relationship-Based Care theories [ 30 ] and evidence informed propositions about experiences of people who access HSC [ 5 ] were combined. Figure 5 , blends these key theoretical constructs and contextual influences that were important to study participants.

Theoretical and contextual influences: People-centred Relationship-based Care.

These theories and propositions intersect as People-centred Relationship-based Care, reflecting the key concepts of ‘integrating HSC’, as identified by the study participants: people, services and systems being ‘connected’ through supportive relationships; encouraging knowledge and understanding between people who access and provide HSC; being involved in making decisions about their own care or role, and working together to meet a shared desire for truly individualised care.

Key learning and application to HSC practice

In an online engagement event, members of the public, HSC service users, and informal carers, offered their insights on how this study’s findings might be applied to HSC practice in their local areas [n = 12] (July 2021). They were clear that they wanted their services to provide streamlined and holistic HSC, regardless of organisational or sectorial boundaries. The concepts of People-centred Relationship-based Care have been framed from the viewpoint of participants and entitled ‘My People-centred Relationship-based Health and Social Care’ (PRHSC) ( Figure 6 ).

My People-centred Relationship-based Health and Social Care (PRHSC).

The PRHSC model and its underpinning theories add an original perspective to key concepts of integrating HSC, as perceived explicitly by the people who are at the very centre of accessing and providing it (service users, informal carers and staff members). Furthermore, it could be argued that it could complement existing models of IHSC, for example, the International Foundation for Integrated Care’s nine key conceptual ‘Pillars of Integrated Care’ [ 31 , 32 ]. The PRHSC model’s underpinning blended theories ( Figure 5 ) align closely with fundamental human rights, contributing to social justice by promoting equality and inclusion [ 33 ]. They highlight key insight into participants’ perceptions of integrated care in HSC practice. The application of the PRHSC model should be tested across different groups of people who access HSC in a variety of settings, to establish reliability and the viability of its use. Further exploration of the potential transferability of findings beyond HSC would be warranted across wider communities. For example, industries or public service sectors where elements of caring are incorporated, such as policing or education. It could be argued that these communities may also benefit from a deeper understanding of interpersonal connections and supportive relationships to inform the caring elements of their work.

Strengths and limitations

The active part that members of the public and key stakeholders played in developing ideas, study design and refining interpretations, is key to the credibility of these findings. A further strength is its multi-case embedded design, which allowed multiple perspectives of participants’ reality to be represented in the data within each case. Reflexivity incorporating reflection, curiosity and consultation with key stakeholders and the research team, underpinned the entire research process thereby increasing the trustworthiness and transferability potential of these findings.

A potential limitation to the transferability of these findings is the contextual nature of HSC with the study population being from two HSCPs in one region in Scotland. In line with the ethics panel recommendations (Section 2.2.4), people who have learning disabilities or profound mental health issues were excluded from this study. This is recognised as a limitation and including these communities could have added depth of understanding and promoted relevance to wider practice areas [ 34 , 35 , 36 ].

The overarching purpose of this study was to explore and better understand the health and wellbeing needs, experiences and relationships of people who accessed HSC and the individuals who supported them at home. Interpersonal connections that developed into supportive relationships were perceived by participants in all groups as instrumental in helping them feel able to cope with their changing HSC needs and roles. Supportive relationships promoted reassurance, information sharing and reduced anxiety; when they were lacking, it negatively impacted upon their experiences of HSC. This study highlights that connections, relationships and cross-sectoral working are important and entirely necessary for integrating HSC services. It is important that policy makers and HSC providers recognise the contribution communities can make to HSC; those communities come in many forms, and one model of integrating HSC does not fit all. No one person or service can provide the whole care-package, and all those who access and provide HSC need to have an equal voice. If the integration of HSC is to be improved, we as a society, must be clear on what is expected of HSC services and systems, and how we prioritise the limited resource across all contexts of HSC to meet health and wellbeing needs.

Prof Anne Hendry, Senior Associate, International Foundation for Integrated Care (IFIC), Director, IFIC Scotland , Honorary Secretary, British Geriatrics Society, Honorary Professor, University of the West of Scotland, UK.

One anonymous reviewer.

Competing Interests

This paper has been produced to summarise and further disseminate findings of the lead authors PhD study; co-authors were part of the supervisory team. The full thesis is available here: https://doi.org/10.48526/rgu-wt-1677988 . PhD studentship was co-funded by Robert Gordon University and NHS Grampian. Funding for the publication of this paper was provided via the same studentship fund.

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Peer-reviewed

Research Article

Satisfaction of basic needs mediates relationships between incremental mindsets and well-being

Roles Conceptualization, Data curation, Funding acquisition, Investigation, Methodology, Project administration, Writing – original draft

Affiliation Center for Climate Action and Social Transformations (4CAST), Institute of Psychology, SWPS University, Warsaw, Poland

Roles Conceptualization, Formal analysis, Methodology, Writing – original draft

* E-mail: [email protected]

Affiliations Center for Climate Action and Social Transformations (4CAST), Institute of Psychology, SWPS University, Warsaw, Poland, Department of Psychological Sciences, College of William & Mary, Williamsburg, Virginia, United States of America

• Marzena Cypryańska, 
• John B. Nezlek

• Published: August 16, 2024
• https://doi.org/10.1371/journal.pone.0309079
• Reader Comments

Research on the extent to which people believe that people can change (incremental beliefs) suggests that incrementalist beliefs are positively related to well-being, whereas entity beliefs (people cannot change) are not. One explanation for this relationship is that incremental beliefs are associated with a mastery orientation, whereas entity beliefs are not. If this is the case, then autonomous and competence motives should mediate relationships between incrementalism and well-being because these motives reflect different aspects of mastery. The present study examined the possibility that autonomous and competence motives mediate relationships between self-theories and well-being. Participants were adult community members ( n = 428) who completed the Life Engagement Test (eudaimonic well-being), the Satisfaction with life Scale (hedonic well-being), the Mental Health Continuum Scale (eudaimonic, subjective, and psychological well-being), the Basic Needs Satisfaction scale (autonomy, competence, relatedness), and a measure of implicit theories of the self (incremental and entity beliefs). Regression analyses found that incremental beliefs were significantly related (positively) to all three measures of well-being, whereas entity beliefs were not significantly related to well-being. Regression analyses also found that incremental beliefs were positively related to satisfaction of autonomy and competence needs but were not related to satisfaction of relatedness needs. Entity beliefs were not related to the satisfaction of any of the three basic needs. A series of mediational analyses found that competence and autonomy motives mediated relationships between incremental beliefs and all three measures of well-being. In all but one case, satisfaction with life, the direct effects of incremental beliefs on well-being were rendered non-significant when satisfaction of autonomy and competence needs were included as mediators. The present results confirm and extend to the general domain the supposition that a mastery orientation is responsible for relationships between well-being and incremental theories of the self. They also conform the importance of the tenants of Self-Determination Theory in understanding self-theories.

Citation: Cypryańska M, Nezlek JB (2024) Satisfaction of basic needs mediates relationships between incremental mindsets and well-being. PLoS ONE 19(8): e0309079. https://doi.org/10.1371/journal.pone.0309079

Editor: Henri Tilga, University of Tartu, ESTONIA

Received: February 26, 2024; Accepted: August 6, 2024; Published: August 16, 2024

Copyright: © 2024 Cypryańska, Nezlek. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data are freely and immediately available via the Open Science framework. The site for this study includes a fully annotated SPSS file and an accompanying codebook, and a csv data file. The url is: https://osf.io/ajkh4/?view_only=13dbb2a2f98648499cbbe3cbbe8a439d .

Funding: The research described in this paper was supported by grant NSC 2013/11/B/HS6/01135) from the Polish National Science Centre (Narodowe Centrum Nauki) to MC. URL: https://www.ncn.gov.pl/ The funder had no role in the study design, in the collection, analysis and interpretation of data, in the writing of the report, and in the decision to submit the article for publication.

Competing interests: The authors have declared that no competing interests exist.

Introduction

As shown by a considerable body of research, individuals vary in the extent to which they believe that the self can change [ 1 ], and Dweck introduced the terms incremental and entity theories to refer respectively to people’s beliefs that the self can change and that it cannot. Research on mindsets, a term that is now commonly used to refer to the distinction between incremental and entity beliefs, has consistently found that incremental beliefs are more adaptive than entity beliefs. For example, performance in school has been found to be positively related to the strength with which students advocate incremental theories of the self, or alternatively, is negatively related to the strength with which students advocate entity theories of the self [e.g., 2]. Moreover, although much of the research on mindsets has concerned achievement (e.g., school performance) mindsets can play roles in various domains [ 1 ].

Although numerous underlying mechanisms and processes have been proposed for these relationships [ 2 ], few studies, particularly outside of the domain of academic achievement, have examined the essence of Dweck’s contention that “mastery” and “helpless” orientations are responsible (at least in part) for relationships between mindsets and positive outcomes. Regardless, there seems to be broad agreement that relationships between mindsets and various outcomes reflects the fact that incremental beliefs are associated with a mastery orientation, whereas entity beliefs are associated with a helpless orientation.

Conceptualizing mindsets: One factor or two?

An unresolved issue in the study of mindsets is the extent to which mindsets should be conceptualized as a uni-dimensional construct anchored at one end by incrementalist beliefs and anchored at the other end by entity beliefs, or as two separate constructs. Dweck and colleagues write as if mindsets consist of two components, referring frequently to incrementalist and entitative beliefs as they were distinct rather than opposite ends of a single continuum, but their research consistently represents mindsets with a single score reflecting the extent to which people advocate an incremental mindset.

Nevertheless, as long ago as 1995, Dweck and colleagues acknowledged the possibility that incremental and entity beliefs were distinct constructs [ 3 ]. Consistent with this possibility, a meta-analysis of young people’s mindsets regarding intelligence found clear support for two correlated factors [ 4 ]. Along the same lines, in a series of studies Karwoski has found that mindsets regarding creativity are best conceptualized as two factors corresponding to incremental and entity beliefs rather than a single factor [e.g., 5 ]. With this research and the content of the items of the scale in mind, we conceptualized mindsets in terms of two correlated constructs, and we examined how well our data fit this conceptualization before examining relationships among mindsets, well-being, basic need satisfaction, the primary focus of the present study.

Mindsets and well-being

The present study examined relationships between mindsets and well-being. Typically, the construct of mindsets has been applied to performance of some kind, to success at a task, or to the achievement of a goal. Nevertheless, examination of the items on some measures of mindsets suggests that mindsets can refer to more than achievement or performance [ 6 ]. For example, in the mindset questionnaire titled “Kind of person” entity beliefs are measured by items such as “People can do things differently, but the important parts of who they are can’t really be changed.” In contrast, incremental beliefs are measured by items such as “Everyone, no matter who they are, can significantly change their basic characteristics.” Such items refer to life in general, not to a specific domain such as academic achievement or work. As such, we expected that mindsets would be related to well-being defined in general terms.

Contemporary research on well-being suggests that well-being can be defined in terms of hedonic and eudemonic well-being. As noted by Ryan and Deci [ 7 ]: “Current research on well-being has been derived from two general perspectives: the hedonic approach, which focuses on happiness and defines well-being in terms of pleasure attainment and pain avoidance; and the eudaimonic approach, which focuses on meaning and self-realization and defines well-being in terms of the degree to which a person is fully functioning.” Although Deci and Ryan discuss how hedonic and eudemonic approaches differ and how they overlap, in terms of mindsets, we believe that possessing an incremental mindset should be associated with greater well-being whether well-being is conceptualized in hedonic or eudemonic terms. The sense of mastery inherent in an incremental mindset should facilitate both types of well-being, a supposition consistent with self-determination theory [SDT; 8 ] and with research about well-being that has been conducted within the context of SDT.

Self-determination theory and satisfaction of basic needs

Self-determination theory is a major theoretical framework that concerns human motivation broadly defined [ 9 , 10 ]. We choose SDT as our explanatory framework because of its breadth and its emphasis on constructs that we believed corresponded to the mastery orientation discussed by Dweck and colleagues. SDT. SDT discusses human motivation in terms of three needs: competence, autonomy, and relatedness. Within the context of SDT, we assumed that competence and autonomy corresponded to mastery as discussed by Dweck and colleagues.

Satisfaction of basic needs as mediators of relationships between mindsets and well-being

The extent to which the basic needs proposed by SDT are satisfied has been found to be positively related to well-being across various domains and cultures [ 11 ]. This suggested to us that need satisfaction might mediate relationships between mindsets and well-being. Dweck and colleagues have proposed that a sense of mastery is responsible for relationships between mindsets and well-being. We collected data that allowed us to determine if the extent to which the satisfaction of the basic needs of competence and autonomy mediated relationships between mindsets and well-being. We chose the satisfaction of the basic needs for competence and for autonomy because we thought that people’s beliefs about their competence in terms of life activities and their beliefs about the extent to which they were free to choose what they did (autonomy) were aspects of mastery.

Although the construct of “need satisfaction” may not immediately lead to an association with feeling autonomous or competent for some, inspection of the items on the Basic Needs Satisfaction Scale [BNS; 12 ] scale suggests that need satisfaction overlaps considerably with people’s beliefs about how competent or autonomous they are. For example, two items on the competence subscale of Gagne’s measure are: “Most days I feel a sense of accomplishment from what I do,” and “Often, I do not feel very competent” (reverse-coded). Two items on the autonomy scale are: “I generally feel free to express my ideas and opinions,” and “There is not much opportunity for me to decide for myself how to do things in my daily life” (reverse-coded). The scales measure how competent and autonomous a person feels, which is a measure of how well these needs are satisfied.

We understood mediation as described by Agler and De Boeck [ 13 ]: ‘…mediation processes are framed in terms of intermediate variables between an independent variable and a dependent variable, with a minimum of three variables required in total: X, M, and Y, where X is the independent variable (IV), Y is the dependent variable (DV), and M is the (hypothesized) mediator variable that is supposed to transmit the causal effect of X to Y. The total effect of X on Y is referred to as the total effect (TE), and that effect is then partitioned into a combination of a direct effect (DE) of X on Y, and an indirect effect (IE) of X on Y that is transmitted through M. In other words, the relationship between X and Y is decomposed into a direct link and an indirect link.”

In their classic description of mediation Baron and Kenny [ 14 ] described three criteria for mediation. (1) The predictor needs to be related to the outcome, or there is nothing to mediate, although there may be exceptions to this rule such as suppression [ 13 , 15 ]. (2) The predictor needs to be related to the mediator; otherwise, the mediator cannot mediate the relationship between the predictor and the outcome. (3) Including the mediator should lead to a reduction in the strength of the relationship between the predictor and the outcome. This is a simplified description of mediation. See Hayes [ 16 ] for a more thorough discussion of mediation.

Research questions and expectations

Within the present context and in terms of the mediational model to be tested, well-being is the outcome, mindsets are the predictors, and the satisfaction of basic needs are the mediators. We proposed this model assuming that mindsets lead to (or precede) the satisfaction of basic needs, and that in turn, the satisfaction of basic needs leads to (or precedes) well-being. One of the tenets of mindset theory is that incremental mindsets are associated with a sense of mastery over one’s environment (or some specific domain of life). In terms of SDT and BNS, mastery is represented by autonomy, a belief that one is acting on his/her own volition, and competence, a belief that one can achieve goals and accomplish tasks.

Therefore, we expected that the satisfaction of autonomy and competence needs (i.e., how autonomous and competent a person feels) would mediate relationships between incremental mindsets and well-being. Given that we distinguished incremental and entity mindsets, we assumed that this mediation would exist only for incremental mindsets, not for entity mindsets. Finally, mediation, particularly within the context of a cross-sectional design with only one measurement occasion, does not provide a strong basis for drawing causal inferences, and we discuss the issue of causal precedence in the discussion section.

Participants

Participants were 428 adults ( M age = 33.0 years, SD = 7.84, range 18–59 years; 211 women) who were recruited via calls on the internet to participate in a study on running and well-being. Data were collected from two samples, which were combined for the present analyses. The first sample was obtained between 21 March and 26 May 2015, and the second between 23 April and 22 August 2016. For both samples, participants were told that their names would be entered into a lottery for prizes ranging from running shoes and other running paraphernalia to an all-expense paid trip to a run held in Europe, and these prizes were awarded at the conclusion of each study.

Ethical statement

The study was conducted in accordance with the Declaration of Helsinki regarding the rights of research participants. Participants consented electronically by clicking on a link indicating their agreement to participate after being told that their names would not be associated with their answers and that they could terminate participation at any time without penalty. Consistent with these instructions, responses were de-identified prior to analysis. Ethics approval was obtained from the Ethics Committee for Scientific Research Involving Humans as subjects, School of Social Psychology, Campus in Poznań, protocol 5/2015/WZ, entitled "Personality traits, specific patterns of adaptation and well-being and related activity with preparation for long-distance runs (National study runners’ motivation),” approved on 18 March 2015.

Mindsets were measured with the eight-item “Kind of person” scale discussed by Dweck [ 6 ]. The scale has four items that measure incrementalist beliefs, e.g., “People can always substantially change the kind of person they are,” and four items that measure entity beliefs, e.g., “Everyone is a certain kind of person, and there is not much that can be done to really change that.” We used a Polish language version of the scale developed by Lachowicz-Tabaczek [ 17 ]. Responses were made using a six-point scale with endpoints labeled: 1 = definitely disagree and 6 = definitely agree.

Satisfaction of basic needs.

Satisfaction of basic needs was measured with the Basic Psychological Needs Satisfaction Scale [BNS; 8, 12 ]. The BNS consists of 21 items, seven items for each of the three subscales: Autonomy, Competence, and Relatedness. To create a Polish language version of the scale, the items on the scale were translated and back-translated by a team consisting of members fluent in both languages, some of whom had 25+ years of experience. Participants responded using seven-point scales with endpoints labeled: 1 = not at all true and 7 = completely true.

Well-being.

Well-being was measured with three scales: the Mental Health Continuum Short Form [MHC; 18 ], the Life Engagement Test [LET; 19 ], and the Satisfaction with Life Scale [SWLS; 20 ]. We used a Polish language version of the MHC created by Karaś et al. [ 21 ]. The MHC has three subscales: Eudaimonic, Social, and Psychological. Satisfaction with life was measured using a Polish language version of the SWLS created by Jankowski [ 22 ], and Life Engagement was measured using a Polish language version of the LET created by Bąk et al. [Unpublished]. Due to a programming error, item three of the MHC was not administered.

Responses to the MHC were made using six-point scales with endpoint labeled: 0 = ‘never’ and 5 = ‘every day.’ Responses to the LET were made using five-point scales with endpoint labeled: 1 = definitely disagree and 5 = definitely agree. Responses to the SWLS were made using seven-point scales with endpoints labeled: 1 = definitely disagree and 7 = definitely agree.

Factor structure of the measure of mindsets

Before conducting the primary analyses of the study, we examined the factor structure of the measure of mindsets. Based upon an inspection of the items and previous research [ 23 , e.g., 24 ], we used Mplus to conduct a confirmatory factor analysis that examined the fit between the data and a two factor model. We modeled items 1, 4, 7, and 8 as observed measures of a latent construct of incrementalist beliefs, and items 2, 3, 5, and 6 as observed measures of a latent construct of entity beliefs. The covariance between the factors was left to vary freely.

This analysis found that the proposed two-factor model fit the data well (CFI = .978; TFI = .978, SRMR = .029, RMSEA = .074, 95% CI = .055/.094), and the standardized coefficients are presented in Table 1 . The estimated standardized covariance between the two factors was -.776. The results of this analysis are summarized in Table 1 .

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https://doi.org/10.1371/journal.pone.0309079.t001

We also fit a single factor model, but this model did not appear to fit the data as well as the two-factor model. Although it was not possible to compare statistically the fits of these two models because they had the same df , for all fit indices, the fit of the two-factor model was better. For example, e.g., the sample-size adjusted BIC was 8575.4 for the two-factor model, and it was 8660.2 for the single factor model. The χ2 difference between the models was 84.8, and for the one factor model the TFI was .90 and the RMESA was .13.

Based on these analyses, we computed separate scores representing incremental and entity beliefs. These were defined as the mean of the four items that measured incremental beliefs (items 1, 4, 7, and 8) and the mean of the four items that measured entity beliefs (items 2, 3, 5, and 6).

Descriptive statistics

Before conducting the primary analyses of the study, we examined the means, standard deviations, reliabilities, and correlations between our measures. These summary statistics are presented in Table 2 . According to guidelines provided by Shrout [ 25 ], all measures had at least moderate reliability (.61 to .80), and most had substantial reliability (.81 and above).

https://doi.org/10.1371/journal.pone.0309079.t002

Relationships between mindsets and well-being.

The first requirement for mediation is that a predictor is related to an outcome; otherwise, there is nothing to mediate. To determine if our data met this requirement, we examined relationships between the measures of the two mindsets (predictors) and well-being (outcomes) with a set of regression analyses in which incrementalist beliefs and entity beliefs were regressed onto each measure of well-being. The results of these analyses were quite clear, and the results are summarized in Table 3 . When incremental and entity beliefs were considered simultaneously, incremental beliefs were significantly and positively related to all measures of well-being, whereas entity beliefs were not significantly related to any measure of well-being.

https://doi.org/10.1371/journal.pone.0309079.t003

Relationships between mindsets and satisfaction of basic needs. The second requirement for mediation is that predictors are related to potential mediators. To determine if our data met this requirement, we examined relationships between the measures of the two mindsets and satisfaction of basic needs in regression analyses in which incremental beliefs and entity beliefs were regressed onto each measure of satisfaction of basic needs. The results of these analyses were also quite clear, and the results are summarized in Table 4 . When incremental and entity beliefs were considered simultaneously, incremental beliefs were significantly and positively related to all three measures of satisfaction of basic needs, whereas entity beliefs were not significantly related to any measure of the satisfaction of basic needs.

https://doi.org/10.1371/journal.pone.0309079.t004

Relationships between satisfaction of basic needs and well-being.

Although relationships between mediators (satisfaction of basic needs) and outcomes (well-being) do not figure prominently in discussions of mediation, we examined these relationships nevertheless. This reflected in part our desire to have a complete understanding of the relationships among the variables we measured. This is consistent with what Agler and De Boeck [ 13 ] described as an “indirectness perspective” (p. 4). In addition, the results of these analyses contribute to our understanding of relationships between well-being and the satisfaction of basic needs.

Relationships between satisfaction of basic needs and well-being were examined in a series of regression analyses in which the three measures of satisfaction of basic needs were regressed onto each measure of well-being. The results of these analyses are summarized in Table 5 . As can be seen from these results, with only one exception, the satisfaction of all three basic needs was significantly and positively related to all measures of well-being. The exception was the relationship between the satisfaction of relatedness needs and MHC Eudemonia, which was significant at p = .07. Such relationships are consistent with the contention of SDT that the satisfaction of basic needs provides a foundation for well-being.

https://doi.org/10.1371/journal.pone.0309079.t005

Basic needs as mediators of relationships between incremental beliefs and well-being.

The preceding analyses were conducted in anticipation of the mediational analyses, which are the primary focus of this paper. After controlling for the relationship between incremental and entity mindsets, entity mindsets were not related to any measure of well-being, and entity mindsets were not related to any measure of satisfaction of basic needs. In other words, the measure of entity mindsets did not meet either criterion for mediation.

Given this, the mediational analyses were limited to how the satisfaction of basic needs mediated relationships between incremental mindsets and well-being. The present hypotheses concern how mastery mediates relationships between incremental mindsets and well-being, and only two of the three basic needs, autonomy and competence, concern mastery. Therefore, the mediational analyses focused on satisfaction of competence and autonomy needs as mediators.

The mediational analyses were done using the PROCESS macro [ 16 ], Model 4. In these analyses, a measure of well-being was the outcome, a score representing incremental beliefs was the predictor, and the satisfaction of autonomy and competence needs were the mediators. Both mediators were included simultaneously. To obtain 95% confidence intervals (CI), 5,000 bootstrap iterations were made. The results of these analyses are summarized in Table 6 . We present unstandardized coefficients to provide a basis to understand how total effects were partitioned into direct and indirect effects. To interpret the statistical significance of effects, we treated effects for which the CIs did not include 0 as different from 0.

https://doi.org/10.1371/journal.pone.0309079.t006

The results of these analyses were quite clear. The satisfaction of both autonomy and competence needs mediated the relationship between incremental beliefs and well-being for all five measures of well-being. Moreover, for the three MHC measures and the LET, the CI for the direct effect included 0, i.e., the direct effects were not different from 0. Also, tests of the differences of the indirect effects for autonomy and competence did not find any significant differences between them.

Although there is a robust debate about how to assess the strength of indirect effects in mediation, the indirect effects in the present analyses represented two-thirds or more (some close to 90%) of the total effects. This, combined with the lack of significant direct effects, provides strong support for the central hypothesis of the study that individual differences in mastery are responsible for relationships between incremental mindsets and well-being.

The results clearly supported our hypothesis that a sense of mastery mediates relationships between incremental mindsets and well-being. We found that the satisfaction of the basic needs of Autonomy and Competence mediated relationships between incremental beliefs and well-being for all measures of well-being. Moreover, this mediation was strong. For all but one measure of well-being, the direct effect between incremental beliefs and well-being was not significant after Autonomy and Competence were included as mediators. Some refer to this as “full mediation.” These results support our logic that the sense of mastery that has been discussed as one of the important reasons incrementalist beliefs are associated with success also applies to relationships between incrementalist beliefs and well-being.

The present results meaningfully extend the domain in which mindsets operate. Much of the work on mindsets has concerned performance in achievement domains such as school and work. The present results suggest that people’s beliefs about how they can changeare related to their well-being, generally defined. Such a possibility complements the extensive body of research demonstrating that perceived control over one’s environment is positively related to well-being

Entity beliefs as distinct from incremental beliefs

Although mindsets were initially conceptualized as an “either/or” single continuum that reflects a single construct, the present results suggest that it may be useful to conceptualize mindsets in terms of two, albeit related constructs: incremental mindsets and entity mindsets. Support for this contention comes from two sources: the results of confirmatory factor analyses and the results of analyses of relationships between mindsets and well-being. The CFA found solid support for the existence of two separate constructs, constructs that made conceptual sense.

The validity of conceptualizing mindsets as two constructs was demonstrated by the differences in the relationships between these two constructs and well-being. At the zero-order, incremental beliefs were positively correlated with well-being, whereas entity beliefs were negatively correlated with well-being. Moreover, when the two measures of mindsets were simultaneously regressed onto measures of well-being, entity beliefs were not significantly related to any measure of well-being, whereas incremental beliefs were positively related to all measures of well-being. This indicates that relationships between well-being and entity beliefs reflect the relationship between entity and incremental beliefs.

Moreover, the possibility that mindsets can be conceptualized in terms of two separate (albeit correlated) dimensions was discussed by Dweck et al. [ 3 ]. In responding to numerous commentators in an issue of Psychological Inquiry , Dweck et al. (pp. 323–324) noted:

“For simplicity’s sake, we have tended to portray the two implicit theories as mutually exclusive alternatives…Nonetheless, students of the human mind know that the fact that two beliefs are opposites does not prevent people from holding them both…This possibility-that many people actually hold both theories, albeit to differing degrees- raises many other intriguing possibilities and suggests that research into the circumstances that might elicit the different theories may well be in a fruitful direction.”

Despite this response about intriguing possibilities and fruitful directions, nearly 30 years later, the issue of the dimensionality of mindsets has not been explored very vigorously.

Regardless, conceptualizing mindsets as being comprised of two separate, but related dimensions is similar to distinctions that have been made in other domains. For example, in their seminal article, Cacioppo and Berntson [ 26 ] discussed how negative and positive evaluations are best conceptualized as a two-dimensional evaluative space, not single, bi-polar dimension. Along the same lines, Elliot and Thrash [ 27 ] demonstrated that approach and avoidance motives are best conceptualized as two separate motives, not opposite ends of a single continuum. Earlier, Diener and Emmons [ 28 ] found that reports of positive and negative affect were uncorrelated over longer periods of times (e.g., a year), and even though they were negatively correlated over shorter periods of time, these correlations were not strong enough to support a uni-dimensional or bi-polar model.

Are entity mindsets negatively related to well-being?

Although individual differences in entity mindsets were not related to well-being or to the satisfaction of basic needs when entity mindsets were analyzed with incremental mindsets, they were significantly (negatively) related to both well-being and to the satisfaction of basic needs at the zero-order (simple correlations). These correlations suggest that entity mindsets are not adaptive. Such correlations may represent the existence of what is sometimes referred to as a “pessimistic explanatory style” that has been found to interfere with people’s ability to cope with stress, and more generally, to thrive [ 29 ]. It is possible that entity mindsets are, at least in part, a manifestation of the same beliefs, cognitions, and emotions that characterize a pessimistic explanatory style and related constructs.

Nevertheless, the present results are somewhat ambiguous about such possibilities. That is, entity mindset did not play a role, even a minor role, in relationships among mindsets, the satisfaction of basic needs, and well-being when incremental mindsets were included in the analyses. The present results suggest that whatever relationships exist between entity mindsets and well-being or the satisfaction of basic needs are subsumed by relationships between incremental mindsets and these other constructs. Given the lack of attention to the possibility the mindsets may be best conceptualized as two factors rather than one, there is little research or theory that can be used to provide a context for the present results. This will require future research that focuses on this possibility.

Causal precedence

Within the context of a cross-sectional, single-occasion design such as that used in the present study, demonstrating that a variable (M) mediates a relationship between an outcome (Y) and a predictor (X) cannot serve as a basis for claims about causal relationships among the constructs being measured. Nevertheless, the fact that M mediates a relationship between X and Y can be interpreted as being consistent with, or supportive of, the existence of a causal sequence from X to M to Y. Such support can be meaningful when a mediational model is theory-driven, and when the components of the model represent relationships that have been supported by past research.

We think the present results provide credible support for the existence of a causal sequence from incremental beliefs through the satisfaction of autonomy and competence basic needs to well-being. The direct relationship between incremental beliefs and well-being is a straightforward extension of research on relationships between incremental beliefs and success in other domains. Dweck and colleagues have repeatedly discussed how incremental beliefs are associated with a mastery orientation, and it is this mastery orientation that is responsible for the relationship between incremental beliefs and success. The satisfaction of the basic needs of autonomy and competence are clearly components of a mastery orientation, and so the fact that they mediate relationships between incremental beliefs and well-being is fully consistent with Dweck’s model and the considerable body of research that has been conducted to examine it.

Nonetheless, as just described, the existence of mediation can be used to support, but not prove causality. Causality is best examined using experimental methods, although attempts to manipulate mindsets have produced mixed results [e.g., 30 ]. Other ways of examining causality include longitudinal models in which changes in mindsets and well-being are measured across time.

Conclusions

The present results suggest that: (1) mindsets can be conceptualized in terms of two independent sets of beliefs, incremental and entity, (2) incremental beliefs are positively related to well-being defined broadly, and (3) relationships between incremental beliefs and well-being reflect underlying relationship between incremental beliefs and mastery orientation and between a mastery orientation and well-being. Each of these findings is new, and collectively, they provide a basis for new directions in research on mindsets.

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• 17. Lachowicz-Tabaczek K. Potoczne koncepcje świata i natury ludzkiej. Gdańsk: Gdańskie Wydawnictwo Psychologiczne; 2004.
• 28. Diener E, Emmons RA. The independence of positive and negative affect. Vol. 47, Journal of Personality and Social Psychology. US: American Psychological Association; 1984. p. 1105–17.

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Advocacy Across Boundaries: Co-creating a framework to improve mental health in construction

Working across sectors to foster a community focused on connected policies and collaborative practices to improve mental health and wellbeing in the construction industry

1 March 2024

Grant: Grand Challenges Mental Health and Wellbeing Network Building Year awarded:  2023-24 Amount awarded:  £2,482.00

• Dr Jean Xu, Bartlett School of Sustainable Construction
• Dr Simon Addyman, Bartlett School of Sustainable Construction
• Dr Alexandra Pitman, Division of Psychiatry

The construction industry is a major employer in the UK, supporting 2.1 million workers and contributing 6% to the GDP. Yet, it faces a significant mental health crisis, with suicide rates 3.7x the national average. Addressing this issue is crucial for sustainable development, as workers endure pressures like tight schedules and financial instability, often leading to a reluctance to discuss mental health.

In a collaboration between the Bartlett School of Sustainable Construction (BSSC) and UCL Division of Psychiatry, a half-day roundtable event was held on 2 July 2024. The event brought together 25 professionals from different sectors of construction and 11 researchers from numerous disciplines and different universities. There was a mix of research presentations, panel discussions and roundtable workshops on various topics of mental health and wellbeing in construction. The panel consisted of 6 experts: 

• Ruth Pott, Head of Workplace Wellbeing, BAM UK and Ireland
• Jim Senior, CMIOSH, Health, Safety and Environmental Consultant
• Dr Susanna Bennett, Research Follow, Suicidal Behaviour Research Lab, University of Glasgow
• Professor Billy Hare, Professor of Construction Management, Glasgow Caledonian University
• Maisie Jenkins, PhD researcher at the University of Edinburgh and Research Manager at the Wellcome Trust
• Emeritus Professor Hedley Smyth, University College London

The conversation explored several questions, and further detail can be found in the event summary report:

• What are the specific challenges of managing mental health and wellbeing in the construction industry?
• What are the opportunities for addressing the mental health and wellbeing issues in construction?
• How to transcend the boundaries between professional disciplines and organisations for a more integrated approach to mental health and wellbeing in construction?

The project aimed to foster a community focused on connected policies and collaborative practices by engaging UCL researchers and industry leaders, culminating in a cross-disciplinary symposium to identify challenges and co-create solutions for systemic change. 

Outputs and Impact

• Received follow-on funding of £6,357 from UCL's Innovation & Enterprise's Innovation Network funding. 
• Established a network between researchers and industry experts in the topic of mental health and wellbeing in construction.
• Exchanged knowledge across organisations and disciplines about organisational support for mental health and wellbeing in construction, opportunities and challenges in the construction industry and how to transcend the boundaries between sectors, organisations and professions.

event report

• Industry attention and organisational actions to address mental health and wellbeing based on the co-created framework.
• Cross-disciplinary research collaboration based on identified future research directions in the event.
• UCL-Industry collaborations in the form of KTP, consultancy projects and other scholarships based on the established network

Related links

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• More Small Grants projects
• Grand Challenges Small Grants
• Grand Challenges funding opportunities

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An evaluation of the health and wellbeing needs of employees: An organizational case study

Affiliation.

• 1 Senior Physiotherapist, Royal Free London NHS Foundation Trust, Occupational Health and Wellbeing Centre, United Kingdom.
• PMID: 27853056
• PMCID: PMC5388618
• DOI: 10.1539/joh.16-0197-BR

Introduction: Workplace health and wellbeing is a major public health issue for employers. Wellbeing health initiatives are known to be cost-effective, especially when the programs are targeted and matched to the health problems of the specific population. The aim of this paper is to gather information about the health and wellbeing needs and resources of employees at one British organization.

Subjects and methods: A cross-sectional survey was carried out to explore the health and wellbeing needs and resources of employees at one British organization. All employees were invited to participate in the survey, and, therefore, sampling was not necessary.

Results: 838 questionnaires were viable and included in the analysis. Employees reported "feeling happier at work" was the most important factor promoting their health and wellbeing. Physical tasks, such as "moving and handling" were reported to affect employee health and wellbeing the most. The "provision of physiotherapy" was the most useful resource at work. In all, 75% felt that maintaining a healthy lifestyle in the workplace is achievable.

Conclusions: More needs to be done by organizations and occupational health to improve the working conditions and organizational culture so that employees feel that they can function at their optimal and not perceive the workplace as a contributor to ill-health.

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Case study: Tailoring a health and wellbeing strategy

The workforce at Arconic’s Kitts Green site weren’t engaged with health interventions, so HR created a strategy around their specific wellbeing needs

The organisation

Arconic is a global business that develops and manufactures products for the aerospace, commercial transportation and oil and gas markets. It has approximately 150 sites, around 40,000 employees, and in 2017 generated a turnover of $13 billion (£10.1 billion). Its history goes back a long way; the firm has been manufacturing in the UK since the 1830s, and supplied turbine blades for the first aircraft to be powered by a jet engine. Its 16 British manufacturing sites contributed around 6% to Arconic’s global 2017 revenue.

The problem

Arconic’s Kitts Green site in Birmingham manufactures and processes aluminium in a factory that runs 24/7. The shop floor employees work in a shift pattern of two 12-hour day shifts and two 12-hour night shifts followed by four days off. The workforce is largely male and ageing; 68% are over 40 and 20% are 55 or older. As such they’re vulnerable to health conditions associated with shift work (such as poor sleep), and older people (such as cardiovascular problems).

Prevailing attitudes among staff around seeking help at work to make changes were also a barrier. There was something of a stigma around using the wellness centre, for example, and engagement with healthy lifestyle messages was weak.

Although the site was running health campaigns there was no data on their uptake or success rate, and – chosen from an NHS list – they weren’t personalised to the workforce.

To identify the health and wellbeing status of the workforce and create a tailored two-year strategy, HR and health and safety joined forces. In 2016 the on-site wellness team (comprised of an occupational health nurse, an occupational health adviser and a healthy lifestyle adviser) planned a health-check roadshow in conjunction with HR.

These 10-minute checkups screened for 15 different health markers. Individual results were available to employees immediately along with personalised recommendations. There was also the opportunity to make a further appointment to see the nurse or healthy lifestyle adviser to discuss any concerns.

Although Arconic was already offering these checks in the wellness centre, key was getting out onto the shop floor to conduct them in canteens so that employees missed less time away from work.

“It was really important to get on the floor and start talking to the guys face to face. We feel that broke down a lot of barriers and made the wellness centre that much more accessible. They became comfortable, they put faces to the names, and I think that really opened the door,” explains Ines Balasa-Balint, Kitts Green’s HR business partner.

The easier-to-attend sessions proved much more popular than health checks previously had been; 175 employees took part in the roadshow checks.

The data gathered demonstrated that areas of particular concern were high body fat percentage, hydration and cholesterol. From this the team was able to establish a holistic health and wellbeing strategy focused around four key areas: environmental, occupational, social and health. Various interventions were launched under each area – for example more classes at the on-site gym, various health promotion campaigns on site, and health vending machines (environmental), free counselling, physio and chiropody services, and financial support through HR (occupational), and health screenings and subsided stop smoking programmes (health) to name a few. Particularly key was creating and developing a wellness committee (social).

“Ten different employees from different areas of the plant make up the wellness committee and they help with getting communication out to the shop floor. They’ll help us organise sporting events, external work for charity and family fun days,” says Claire Green, health and safety manager for Kitts Green.

Getting staff across the site engaged at the frontline was again vital to the interventions being a success. Posters were put up in each area displaying different shift patterns’ aggregate results from the health checks, which not only kept employees informed but also sparked conversations.

“It was like a bit of a competition actually between the areas. It became a good talking point between the work crews as well,” explains Green.

Generalised results were also published in the staff newsletter, which every employee gets a copy of.

To particularly target the three problem areas highlighted by the health checks (body fat, hydration and cholesterol), the business ran weight loss programmes, physical activity initiatives such as cycling clubs, a hydration campaign that included distributing informative water bottles, and took part in national awareness initiatives like National Heart Month and Know Your Numbers (which focuses on blood pressure awareness and testing).

Although not highlighted as an issue in the health-check roadshow, which tested mainly physical health markers, mental health has also been a focus. “We’ve sat down and said ‘look we’ve done really well with the physical side of things but now it’s time to step it up and include mental health’, because it is so important,” says Balasa-Balint.

It was decided some form of benchmark was needed, and that a mental health roadshow wouldn’t really work as it’s harder to ‘test’ for mental wellbeing issues. So a Mind Your Health survey was created and distributed earlier this year.

“We had an online survey sent out to all those who had computer access, but for the shop floor we decided that once again going out in person was key. So myself, Claire and Nadia [Fedotova, former environmental health and safety manager] spent a few weeks going to every single team briefing, and gave a 10-minute talk at the end about why it was important and what we wanted to do,” explains Balasa-Balint. “We actually gave people the option to fill in the survey then and there and had a whopping 320 people respond, which we were really excited about.”

Not only has Arconic enjoyed incredible internal success, it has also received external industry recognition in the form of HR magazine’s 2018 HR Excellence Awards Health and Wellbeing award.

Since the health checks and subsequent tailored health and wellbeing strategy there have been various broad improvements. Sickness absence dropped by 0.57% between 2016 and 2017, the lowest result seen since 2014. The latest employee engagement survey in late-2017 demonstrated that environment, health and safety areas are up by 3% and employee engagement is up 5% compared with other UK sites.

Kitts Green has collectively lost 138 kilograms, 30% of people identified with critical hypertension stage 2 blood pressure have been reduced to a less critical rating, and 61.5% of people screened in 2017 have hit the cholesterol target of a reading of 5mmol/L or below.

The stigma around seeking help also appears to have lessened; appointments to see the occupational health nurse increased by 139.9% from 2016 to 2017, and the on-site gym now has 288 members (42.4% of all employees). The team plans to repeat the health-check roadshow in 2019 so that it can compare data and establish whether there are additional areas requiring intervention.

“We expect a better uptake. We were chuffed with 175 at the time considering before then not much had been recorded or followed up really. But we hope to get numbers like we did for our mental health survey because that was just fantastic,” says Balasa-Balint.

She adds: “To have the success we’ve had so far is encouraging because I think we are making an impact on our employees. At the end of the day that’s what we want; we want happy, healthy people working for us who are happy to work for us”.

Further reading

Case study: Three UK's award-winning wellbeing strategy

Health and wellbeing investments made in manufacturing industry

Employee engagement closely tied to health and wellbeing

Pulse check: How SSE is powering up health and wellbeing

The A - Z of health and wellbeing

Tailoring health and wellbeing initiatives very valuable

Wunderman's inclusive approach to health and wellbeing

HR health and wellbeing special 5/6: managing the wellbeing of home workers and remote staff

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A group-wide project was launched last year to help everyone feel more able to talk openly about mental health in the workplace and ensure that our people understand how to access help if they need it.

Some of our mental health campaigns and initiatives

The health and safety of our people and communities is at the heart of everything we do, with mental wellbeing regarded as being as important as physical safety. A group-wide project was launched last year to help everyone feel more able to talk openly about mental health in the workplace and ensure that our people understand how to access help if they need it.

In 2019, the importance of mental health and wellbeing was firmly placed at the top of the NDA group employee agenda and given special project status and group-wide focus. With the ambition of embedding a strong mental health culture, a delivery group was formed to set strategic direction and share good practice and resources. The project group has since committed to standardising our Employee Assistance Programme, collaborated on national awareness campaigns and developed a consistent way to measure success in this area. Each business has also committed to meet the standards set out in the Thriving at Work report (ref 51) and progress is reported at quarterly performance reviews.

Strong leadership is a key factor in ensuring that mental health is embedded in our culture and executive leadership is represented in each of our businesses. Mental health first aiders have been put in place by most businesses in the group, with 14 trained individuals in the NDA. Their role is to signpost people to support and encourage them to speak up about mental health and seek help if they need it. We have also enlisted the guidance and support of charities like Mind and Samaritans, with people across the group fundraising to support their important work.

Early signs are showing that the focus on mental health is starting to pay off. A recent survey carried out across the NDA group showed a 30% increase in people who responded and agreed that mental health is openly discussed in the workplace, compared to 2 years ago. The survey also showed that 91% of respondents know how to access support if they need it. Marking the success of the project so far was a major highlight of our first ever NDA group Safety and Wellbeing Awards in 2019.

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JSmol Viewer

Ascending to well-being through mediated spaces: an alternative to informal learning and physical activity environments in vertical schools.

1. Introduction

2. learning and pedagogy, 2.1. what is learning, 2.2. children’s developmental aspects, 2.3. from traditional to innovative pedagogy.

• Type A: Traditional closed classrooms entered by a corridor or access space without direct access to other teaching spaces and openability between classrooms.
• Type B: Traditional classrooms with breakout space. Streetspace has been introduced into the teaching/learning cluster, while the classrooms have remained intact without any commons.
• Type C: Traditional classrooms with flexible walls and breakout space. “Convertible classrooms” are introduced here as learning clusters where flexible walls allow two or more traditional classrooms (and possibly adjacent meeting rooms and wet areas) to be combined into a single common. By using such an approach, a wide range of pedagogies can be employed while maintaining the reversibility of the traditional classroom.
• Type D: Open plan with the ability for separate classrooms. This type of “convertible streetspace” is used as it includes plans that open classroom clusters to the street and each other, creating a more extensive common.
• Type E: Open plan with some adjoining spaces. This type is characterised by “dedicated commons”, where a protected “commons” serves as the spatial core of a learning cluster because it cannot be transformed into closed classrooms without extensive renovations [ 22 ] (pp. 52–54).

3. Learning Environment and Nature

3.1. children’s problems in today’s learning environment, 3.2. background of integrating education, nature, and community, 3.3. vertical school as a learning environment type, 3.4. biophilic design, 4. definition of mediated spaces.

• Less human regulation than indoors: This would make the room less of a property of the person or community, and, consequently, their rights to change it are reduced.
• Varying climatic conditions: The seasonal weather conditions are higher outside than in, although this may be due to clothing or wind speed.
• Diversity of space: This is a function that will help people stay relaxed, offering relief from the sun and wind.
• Variety of use: For certain people, open areas are their workplace; for some, they are connected to recreation; and for others, they are a way of going from one indoor space to another. The multiple criteria and preferences will plan out the ideal environment differently.
• Wider comfort tolerance: The amount of discomfort currently calculated in outdoor environments is much lower than that projected for indoor spaces. This difference indicates that people could be more accepting of environments outdoors.
• Previous experience of space: While most people indoors have a clear sense of what to expect thermally, prior experience of the environment is less helpful in an outdoor space because the weather is continually changing, and that experience might be unusual [ 38 ] (pp. 1–2).

5. Analysis of Mediated Spaces in Schools

• Antonio Sant’ Elia Kindergarten—Como, Italy—Giuseppe Terragni: 1937;
• Emerson Junior High School—Los Angeles, USA—Richard Neutra: 1938;
• UCLA Lab School—Los Angeles, USA—Neutra and Alexander: 1959;
• Montessori Primary School—Delft, Netherlands—Herman Hertzberger: 1960;
• Boarding School—Morella, Spain—Carme Pinós and Enric Miralles: 1994;
• Hellerup School—Copenhagen, Denmark—Arkitema: 2002.
• Vertical gardens and green walls: Horizontal pedestrian-orientated gardens can be adapted into vertical gardens and green walls with low-maintenance plants, creating opportunities for natural exposure and informal learning in vertical schools.
• Sky terraces and rooftops: Outdoor courtyards and play areas can be transformed into sky terraces and rooftops, providing space for outdoor activities and sports.
• Bridges and ramps: Traditional courtyards can become habitable link bridges and ramps, maintaining connectivity and providing additional space for movement and social interaction.
• Climbing spaces: Adventure spaces in horizontal schools can be converted into climbing spaces in vertical schools, promoting physical activity.
• Internally enclosed courtyards: Non-enclosed outdoor courtyards or street spaces in horizontal schools can be adapted into internally enclosed courtyards connecting multiple levels, utilising staircases or slides for movement.

6. Results: Well-Being Benchmarks/Criteria of Mediated Space Design

• Criterion 1—Flexible Seating: Provide flexible seating arrangements for students’ social interaction, including studying together, eating, and mingling with other students from higher levels.
• Criterion 2—Vibrant Space: Provide gallery spaces and wall hangings to create a more vibrant space for socialising.
• Criterion 3—Visual Interaction: Provide transparency, visual, and natural interaction by creating views over voids, skylight/roof windows, and glass facades/walls/doors into the semi-outdoor or outdoor spaces.
• Criterion 4—Greening Strategies: Use of indoor plants, small gardening boxes, grass in semi-outdoor spaces and trees, vegetable gardens, and green walls in outdoor mediated or semi-outdoor conservatory spaces.
• Criterion 5—Extendable Spaces: Extend spaces outside by incorporating pivoting doors/windows and sliding glass walls/windows, i.e., provide capacity for spaces to adapt to variations in climatic conditions.
• Criterion 6—Personal Spaces: Create personal spaces for students while still remaining under the supervision of school staff.
• Criterion 7—Shading Solutions: Increase the extent of shading using cool surface materials, planting trees with dense canopies, turf wicking, and establishing green roofs and walls.
• Criterion 8—Natural Interaction: Provide interaction with nature both visually and by using natural materials like wood and elements like rocks, sand, and fire inside and outside the building.

7. Conclusions

Author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Ebrahimi Salari, E.; Westbrook, N. Ascending to Well-Being through Mediated Spaces: An Alternative to Informal Learning and Physical Activity Environments in Vertical Schools. Architecture 2024 , 4 , 613-638. https://doi.org/10.3390/architecture4030032

Ebrahimi Salari E, Westbrook N. Ascending to Well-Being through Mediated Spaces: An Alternative to Informal Learning and Physical Activity Environments in Vertical Schools. Architecture . 2024; 4(3):613-638. https://doi.org/10.3390/architecture4030032

Ebrahimi Salari, Elia, and Nigel Westbrook. 2024. "Ascending to Well-Being through Mediated Spaces: An Alternative to Informal Learning and Physical Activity Environments in Vertical Schools" Architecture 4, no. 3: 613-638. https://doi.org/10.3390/architecture4030032

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13th August 2024 Global Welfare and equalities

The wellbeing economy: Case studies and resources for local government

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Curated case studies of ways governments can adopt and promote local wellbeing economies. Examples this week come from Spain, Canada, New Zealand and the U.S.

Have your own example to share, get in touch !

Policy innovation and inspiration examples from the local government sector

SPAIN: Using technology for wellbeing economy policy design Developed in the aftermath of the 2008 financial crisis, the City of Barcelona’s  digital participation and democratic platform Decidim provides residents with a voice to decide on the future of their surroundings. The platform allows Barcelona’s citizens a chance to consult in an open participatory process, submit and track policy proposals, and take part in debates. When reviewing changes made on the platform, the city council considers not only the popularity of a proposal, but the number of neighbourhoods involved in the consultation process. By 2016, the platform had seen over 220,000 interactions, and the city had implemented wide ranging policy reforms aiming at re-municipalisation and localisation of resources and assets. The tool itself is open-source, ensuring it can be reused and improved upon by other governments should they wish.  Decidim / Wellbeing Economy Alliance

CANADA: City incorporates social wellbeing into design guidelines With multi-unit housing developments increasingly common across British Columbia, Canada, the City of Port Moody sought to ensure any of this new housing supports residents’ health, happiness, and inclusion. The city partnered with Happy Cities to develop Social Wellbeing Design Guidelines for new multi-unit housing developments. These guidelines incentivise housing developers to include social features and shared spaces, to boost amenity and connection. The guidelines are free to download online, and were adopted by the council in June 2024. Happy Cities

USA: Californian city uses ‘science of wellbeing’ to better understand residents’ quality of life Santa Monica, California is renowned for its seemingly aspirational lifestyle, an affluent and cultural area with beaches, sun, mountains and top-rated schools. Yet the  City of Santa Monica  sought to understand whether its citizens really have a high quality of life, both objectively and subjectively. The city launched the Wellbeing Project, which saw the council develop personalised ways to measure local wellbeing factors before going out in person to collect data from 2,200 local residents. The project created a Wellbeing Index, measuring residents’ quality of life across place, health, opportunity, community, learning and life outlook. It found that while general wellbeing was high, Santa Monicans did not feel enough day-to-day connection in their neighbourhoods. To build on the project, the citylaunched the Office of Civic Wellbeing to embed wellbeing measurement and action in its agencies and departments, leading efforts on community partnerships and racial equality. Wellbeing Economy Alliance

NEW ZEALAND: Award winning employment scheme designed to improve socio-economic wellbeing outcomes Many of New Zealand’s poorest people live in South Auckland, a region with a large proportion of Māori and Pasifika. As part of its 30-year city plan and place-based regeneration programme, Auckland Council has committed to improve Māori wellbeing, strengthen employment outcomes and help communities in greatest need. One example of this is the council’s Kia Puāwai programme, which sees unemployed local graduates in the city’s south work towards employment in the council’s contact centre workforce. The council consolidated six of its contact centres for the scheme to help its underprivileged graduates find a career and permanent employment. The idea behind the scheme is that widespread youth employment would have a ripple effect on families and communities, improving their finances and long-term outlook overall. The scheme has been successful, with 90% of graduate entrants finding permanent employment and reporting “a new sense of purpose” and has won industry awards for its local leadership. Taituarā  /  Our Auckland

Resources on the wellbeing economy

Report: Wellbeing economy ideas for cities: Lessons for implementation In this report, the concept of the wellbeing economy is broken down for those working at the city level. It outlines why this concept is increasingly necessary, and outlines six ways of working (vision, measurement, collaboration, citizen participation, prevention, and creative experimentation) related to successfully applying it at city level. 

Report: Creating an impactful and sustainable: Wellbeing Economy for better public health The key concepts and associated approaches supporting a wellbeing economy are set out in this report, alongside how we can measure its benefits and impact. In addition, this report highlights how a wellbeing economy ties into health policy and how health actors can lead the concept. 

Report: The wellbeing economy in brief: understanding the growing agenda and its implications This publication contains a collection of mini briefing papers that look at the idea of a wellbeing economy, how it relates to other ideas for economic change, and what some of the core elements of a wellbeing economy are.

Report: How to measure progress towards a wellbeing economy: distinguishing genuine advances from ‘window dressing’ Wellbeing economies seek to achieve social justice within the boundaries of our planet, acting as an alternative approach to economic design. This paper sets out a series of criteria to judge how successfully a local area is making progress towards a wellbeing economy.

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Twelve Case study: organisational change and employee health and wellbeing in the NHS

• Published: December 2011
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This chapter examines an often-neglected outcome of organisational-change programmes: the effects they have on employee health and wellbeing. It presents a case study of the organisational restructuring of Reproductive Medicine in a UK National Health Service Trust. Based on in-depth interviews with four maternity-services teams incorporating midwives, clinical support workers and administrators, the chapter examines the various inter-relations between organisational change and health. Interviews were conducted at three points over two years, allowing a detailed investigation of the trajectory of health outcomes during the change process. The ways in which staff reacted to change and also acted to influence change were seen to have powerful impacts on their health.

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