December Edition â Happiness - UK Faculty of Public Health

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UP FRONTThe greatest happinessfor the greatestnumber is still our goalSPECIAL FEATURE: HAPPINESSFeeling sad –could there bean app for that?Coming of ageA new focus for the Whitehall Study is providing vital information about ourageing population, say Eric Brunner, Archana Singh-Manoux and Mika KivimakiWHITEHALL II is a cohort study of healthand ageing based at University CollegeLondon, now in its 27th year. The studyof 10,308 men and women was set upby Michael Marmot in 1985 to understandthe nature of social inequalities in health,and coronary heart disease (CHD) inparticular. The graded associationbetween socioeconomic position andmortality had already been demonstratedin the original Whitehall study of 17,500male civil servants begun by GeoffreyRose and Donald Reid in 1967, whenthe CHD epidemic was reaching itspeak.Whitehall II extended the findings towomen, who made up one third of thebaseline age cohort (35-55 years) of civilservants, and documented stepwise socialpatterning of incidence for many causes ofmorbidity, both physical and psychological.The study showed that widerdeterminants, such as low perceivedcontrol at work, and influences fromchildhood, as well as biological andbehavioural factors, contribute to healthinequalities. Evidence from Whitehall II andother studies helped to place the socialdeterminants of health firmly on the publichealth policy agenda.The participants are now aged 60 orover and the cohort is increasingly valuableas a platform for studying age-relatedaspects of health. Participants are highlyphenotyped by virtue of five-yearly clinicalexaminations and their loyalty to the study,with high response rates over more than aquarter of a century.Cognitive function was assessed in 1998,2003 and 2008; and during 2012/13 some6,000 participants are completing cognitivetests for the fourth time. We are able tocharacterise variation in the trajectories ofage-related decline in physical as well ascognitive function. Repeat objectivemeasures of physical function includewalking speed, handgrip strength andstanding balance. Mental health is thethird major domain of interest. These andother assessments permit us to constructcomposite measures of frailty, disability,and activity limitations at one end of theageing spectrum, and healthy or idealageing at the other.In the ageing population, decline inphysical, mental and cognitive function isof increasing concern. We have developeda detailed research programme fordiscovery science, centred on thelongitudinal effects of midlife biologicaland behavioural risk factors on old-agefunctional decline. An important driver inour thinking is that there is greatunexplained heterogeneity in rates ofdecline between individuals. Whitehall IIdata shows that individual healthybehaviours in midlife explain only a modestproportion of differences in old-agefunctioning and health, but their combinedimpact is more substantial. In 2008, weadded aortic pulse wave velocity, ameasure of aortic stiffness, to the clinicalprotocol. It predicts later functioning, and awider set of cardiovascular risk factors wasstrongly related to subsequent cognitivedecline, supporting the view that vascularhealth is a key determinant of bothphysical and cognitive ageing.Early Whitehall II results on socialinequalities have made a majorcontribution to public health policy. Withthe new focus on ageing, we plan totranslate the effects observed in theWhitehall II cohort into potential impactson the ageing British population. Theindirect linkage of Whitehall II withother population-scale data will producenovel estimates of the proportion offunctional loss and dependence that ispreventable.Eric Brunner, Archana Singh-Manoux and Mika KivimakiDepartment of Epidemiology andPublic HealthUniversity College LondonGOOGLE the word ‘sadness’ and you get11,600,000 results. That’s a whole lot ofsadness. But google ‘happiness’ and upcomes an amazing 312,000,000.Conclusion? Humanity is roughly 27 timeshappier than it is sad.Er... maybe not. Measuring happiness isnot quite that easy – as several articles inour special feature section point out.Distilling the essence of happiness, findingways to define and quantify it, anddeveloping validated scales and practicaltools for measuring it have spawned anarmy of academics and contributed to aswathe of disciplines from psychology toeconomics, and from neuroscience topublic health.It was the philosopher Jeremy Bentham,one of the greatest luminaries of theEnlightenment, who laid the foundationsof our thinking about the links betweenhappiness, wellbeing, wealth and health,and more specifically the part played bypublic policy in creating a harmonioussociety. He expounded the utilitarianprinciple of “the greatest happiness for thegreatest number,” which still forms acentral tenet of public health practicetoday.What makes us happy? Well you couldwrite a book about that (and we review acouple of them on p19). Successive surveyspoint to the importance of physical andmental health, the strength of family andcommunity ties, leisure time and a sense ofcontrol over one's life. Another factor isinner fortitude, often formed in one’s earlyyears. Economist Richard (Lord) Layard seesa person's happiness as more stronglyrelated to their emotional health as a childthan almost anything else.How important is money in all this? Arecent Office of National Statistics reportfound a surprising lack of correlationbetween levels of deprivation andhappiness, area by area, across the country– and yet we know from other studiesthat, as far as the individual is concerned,relative income is a key factor in wellbeing,raising the issues of fairness and socialjustice.So it’s all wonderfully complex. Moneycan’t buy you love – or happiness – but itcan buy comfort and choice. According toWoody Allen: “Money is better thanpoverty – if only for financial reasons.”And as Wilkinson and Pickett so ablydemonstrated in The Spirit Level, fairness inthe distribution of wealth, resources andservices makes for a happier, healthier andmore stable society. At no time can thissound utilitarian principle be moreimportant than as we enter yet anotheryear of cuts and austerity.Alan Maryon-DavisEditor in ChiefWOULDN’T it be great if there was a cheap,widely available happiness app that reallyworked? In the current economic climateany therapy that is commissioned needs tojustify the resources allocated to it. CognitiveBehavioural Therapy (CBT) has done well inthis area. There is ever-expanding evidencefor its effectiveness in most psychiatricdisorders in children and adults. We knowCBT does make mentally ill people happier.CBT is incredibly versatile. Many structuredmodels have been developed to addressspecific diagnoses, but one of its strengthsis its flexibility in providing a framework tounderstand human distress and worktowards the patient’s individual unique goals.But with access to accredited therapists stilllimited on the NHS, an important questionis: can an online therapy have a significantimpact on psychiatric symptomatology?There’s a growing number of online CBTresources for treating mental illness, somewith good evidence to support theirefficacy. Often they require a therapist’ssupport, although some are stand-alone.Yet it is not a panacea. For CBT to beeffective, a patient needs to:n be motivatedn collaborate with the therapistn be able to think about their inner worldn be able to act differentlyn reflect on the consequences of theseactions.The evidence for the impact of CBT inpeople without a mental illness is muchless well-established. As the old adagegoes: “Absence of evidence is not evidenceof absence.” Probably it’s just a matter oftime before more evidence to support thisemerges. A CBT model for an illness andtreatment can be manualised and hencecomputerised. But the problem is that thedifficulties of a dissatisfied person with awish for greater happiness are not yetspecific enough for an illness model and acomputerised approach. An experiencedtherapist, however, is able to work withthe individual to develop understandingand achieve their goals and so promotegreater happiness. It seems for the timebeing that a happiness app is still somewayoff. Unfortunately, there just don’t seem tobe any short cuts to human happiness.Stephen WestgarthConsultant child and adolescentpsychiatristCity Hospitals Sunderland6 PUBLIC HEALTH TODAYDECEMBER 2012 7
SPECIAL FEATURE: HAPPINESSSPECIAL FEATURE: HAPPINESSDEBATE: Should we measure happiness? Paul Dolan says it helps us focus on theultimate prize of better lives, while Steve Davies argues it is too unreliable to be usefulSubjectivehappiness is themain objectiveHOW are you doing? Well, I hope. Theonly way I can find out is to ask you. Sure,other things, such as your health, matter,but such information would only be usefulin allowing me to predict how you aredoing. And that prediction would be farfrom perfect; health and other things allmatter, but they matter to each of us todifferent degrees. But how we are all doingdoes depend on one important thing –how we feel.Life goes better when you feel better. Or,more accurately, life goes better when youfeel better for longer. So we need todirectly measure happiness. Yes, but it’s allsubjective, I hear some of you say. Tooright it is. Our feelings and experiences oflife are all subjective. Objectivecircumstances matter, but only becausethey affect how we feel, and, if not today,then tomorrow. And remember that pain isa subjective experience, and we trustpeople’s reports of how much it hurts.We have made enormous advances inthe last couple of decades in developingmeasures of happiness, and we now knowquite a lot about the causes andconsequences of happiness. We know thatmental health affects happiness muchmore than physical functioning and hasYESobvious implications for the relativepriorities afforded to different conditions.We also know that people adapt toobesity, and so there is little hedonicincentive to shed the pounds. If we wantto understand and change health-relatedbehaviours, we need a betterunderstanding of the feedback loopbetween what we do and how we feelabout it.Happiness measures are now beingtaken seriously by governments andpolicymakers around the world. The Officefor National Statistics in the UK ismonitoring national happiness and manyother countries are following our lead.Happiness measures are now part of theUK Treasury’s Green Book on economicappraisal and, as a consequence, they areincreasingly being used to evaluateinterventions in many areas of publicpolicy. This will allow us to compare theeffectiveness of healthcare relative to otheruses of public money.I have no doubt that policy shouldseek to help people feel as good as theycan for as long as they can. This overarchinggoal can easily get lost in a worldof national targets, performancebenchmarks and healthcare league tables.Happiness measures can now provideus with a robust metric that focuses oureyes firmly on the ultimate prize of betterlives.Paul DolanDepartment of Social PolicyLondon School of EconomicsThe real Shangri-La?Happiness is more important than GNP to the government of Bhutan. Peter Horbyassesses what the Himalayan kingdom can tell us about measuring the H-wordA fool’s gamethat leaves uswith truismsGOVERNMENTS around the world areincreasingly interested in measuringnational wellbeing, or happiness, as analternative to conventional measuressuch as gross domestic product (GDP).However, measuring subjectivewellbeing is so fraught with problemsthat it is probably not worth theeffort.Measurements of happiness aretypically on a scale of one-to-three orone-to-five and focus on two things:‘life satisfaction’ (evaluating life so far)and ‘immediate happiness’ (usually theprevious few days). This seems simple,but the results throw up problemswhen you try to draw conclusions fromthem.Every national survey comes up withan overall life satisfaction rating ofabout seven (where 10 is blissful andone is suicidal). This happens regardlessof factors such as economic conditionsand crime. In fact it is remarkablyconstant over time and has nocorrelation with any other significantfactor such as wealth, equality oreconomic performance.The reason seems to be twofold.Firstly, people are reluctant to say theyare very unsatisfied or totally content –so they cluster around ‘satisfied butwith room for improvement’. Secondly,trying to measure this on a scale withNOthree or five points is inherentlyproblematic. For the national level tochange, a huge number of peoplewould have to move by at least tworanks in a 1-5 scale, which is alwaysunlikely. So it’s not clear that this tellsus much.You can ask more personal questions,but then any patterns tend to disappearin individual variation. We are leftwith statements such as that peopleare less immediately happy whenthey are bereaved or ill. There aresome unexpected findings, such asthat women are on average happierbut more anxious than men, butit’s not clear what follows fromthis.Moreover you can affect happinesssurvey results in many ways. You getmuch higher reported happiness ifyou ask people questions on a Fridaythan on a Monday. People reportsignificantly lower happiness if askedfirst about politics and then afterwardshow they have felt over the previousfew days.Attempts to measure subjectivewellbeing tend to leave us with truisms,not real insights. People are likely to feelbetter when they are better off, have astable life and friends. You hardly needexpensive research to find this out, andit’s not clear how this gives any kind ofguidance to policy at the national(rather than a very local) level.Steve DaviesEducation DirectorInstitute of Economic AffairsTHE fourth Dragon King of Bhutan was 17years old when in 1972 he declared:“Gross National Happiness is moreimportant than Gross National Product.”Although slow to mature, the idea hasbeen tenacious, and the constitution ofBhutan now requires the state to “promotethose conditions that will enable thepursuit of Gross National Happiness.”Bhutan held its first survey of GrossNational Happiness (GNH) in 2007.While cynics might argue that a shiftfrom measuring wealth to measuringhappiness is a desperate attempt by thecaptain of a sinking ship to redefinefloating, it is hard to dismiss the philosophyof measuring GNH. Although health andwealth are desirable, happiness is notcontingent on them: the rich and healthyare not always happy, and the poor andunwell can be remarkably cheerful. Thepursuit of happiness rather than materialwealth as a national goal has thereforeproved appealing and 2011 saw a UNresolution inviting member states todevelop measures of happiness to guidedevelopment goals and public policies.The crux of many criticisms of GNH liesnot in the desirability of ‘happiness’ as anoutcome, but in measuring it. How canmetrics of happiness be defined that arecomparable across ages, genders, cultures,countries and time? Happiness is trulymercurial: it’s hard to predict, quick tochange, sensitive to environmentalconditions and difficult to capture.Happiness is also multi-dimensional. The2010 Bhutan survey of GNH defined ninedimensions of happiness, included over750 indicators and took an average ofthree hours to complete by a trainedinterviewer.Bhutann Population: 738,000n Size: 38,364 sq km (14,812 sq miles)n Life expectancy: 66 (men), 70 (women)n GNI per person: £1,300n Main exports: Electricity, timber,cement, agricultural products, handicraftsn Religion: Buddhism (official), Hinduismn National dress is compulsoryn Tourism is heavily restrictedn Limited television and internet servicesallowed in 1999 for the first timen Unrest amongst ethnic Nepali minorityIn 2010 David Cameron announced thatthe Office of National Statistics (ONS)would soon begin to measure nationalwellbeing. The concept of nationalwellbeing seeks to balance the ficklenature of happiness by combiningmeasures of subjective wellbeing (feelingsof happiness and self-worth) with objectivemeasures, such as healthy life expectancyat birth and crime rates. After a period ofconsultation on “what matters to you?” inJuly 2012, the ONS announced 10 domainsand 38 indicators that would be used toroutinely measure national wellbeing. Inrecent months ONS has released a numberof publications on wellbeing.Any attempt to measure the impact ofpublic policies in a holistic way and to setan alternative, non-cash, framework fordevelopment indicators has to beapplauded, but there is a long way to go.Like the fourth Dragon King when heannounced GNH, the methodology is stilljust a teenager. It is not clear thatindicators can be developed which arevalid over time and across socio-culturaland political systems, nor that we knowthe right policy levers to direct changes innational wellbeing.In short, the evidence that surveys ofwellbeing contribute to improvements inwellbeing is not yet there. The Bhutansurvey of GNH has a category of “not-yethappy”.I would put myself in this categoryif asked for my view on happiness andwellbeing surveys.Peter HorbyDirectorOxford University Clinical Research UnitHanoi, Vietnam8 PUBLIC HEALTH TODAYDECEMBER 2012 9
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December Edition â Happiness - UK Faculty of Public Health