Introductory Chapter: The Global Framework for Wellness – Concepts, Theories, Measurements, Interventions and New Directions

*Jasneth Mullings, Tomlin Paul, Leith Dunn, Audra Williams, Julie Meeks-Gardner, Sage Arbor and Tafline Arbor*

### **1. Introduction**

This body of research-based papers from across the globe, brings new perspectives on concepts from diverse disciplines and geographical regions. Policy makers, development practitioners and ordinary citizens can reflect on well-being from many linked perspectives and find common ground that can lead to new sustainable solutions. The book presents research across a spectrum of issues on health, wellness and well-being, including perspectives on well-being and happiness; new paradigms in measuring well-being; well-being across the lifespan and wellness in the workplace. Additionally, the section on 'wellness in practice' offers readers practical tips to improve or sustain their own health and well-being.

The authors commence the introductory chapter, *The Global Framework for Wellness: Concepts, Theories, Measurements, Interventions & New Directions* by articulating the global agenda for wellness and explaining key concepts related to health and well-being. All of this links people and the planet, to health and well-being, while embodying the guiding principles of equity, inclusivity, resilience, peace and partnerships, as well as climate action, which are integral to the United Nation's Sustainable Development Goals (SDGs), the World Health Organization's (WHO) Geneva Charter for Well-being and the WHO's One Health Initiative. This chapter further explores the subjects of measuring well-being; regional health disparities; well-being policies and programmes across the lifespan, inclusive of support mechanisms such as digital health. The chapter concludes by acknowledging the relevance of re-defining the dominant narratives around wellness to incorporate issues of culture and lived experiences within the global village.

#### **2. Planetary well-being and the global frameworks for health**

Planet Earth and its inhabitants face an existential crisis that threatens the wellbeing and survival of both humans and the environment [1]. Despite global, regional and national commitments to human rights and sustainable development, there is abundant evidence of worsening social, economic, political and environmental hazards that threaten well-being for all. Planetary well-being as defined by Kortetmäk et al. [2] is a concept that explains the *moral* need to give equal value and consideration to both human well-being and non-human well-being. This concept promotes transdisciplinary, cross-cultural discourse to not only address current social and ecological crises but to also promote social and cultural transformation of underlying systems that impact well-being. Kortetmäk et al. [2] state that:

'Planetary well-being is a state where the integrity of Earth's system and ecosystem processes remains unimpaired to a degree that species and populations can persist to the future and organisms have the opportunity to achieve well-being' ([1], p. 1). Planetary well-being and the sustainable development goals (SDGs) address similar planetary challenges and; promote sustainable policies, programmes and partnerships. Both reflect a symbiotic relationship between humans and the environment, and the sustainable use of resources to meet present and future needs.

The WHO's [3] One Health Initiative also promotes 'an integrated, unifying approach to balance and optimize the health of people, animals and the environment' ([3], p. 1). It seeks to 'prevent, predict, detect, and respond to global health threats such as the COVID-19 pandemic' ([3], p. 1). It also promotes cooperation, coordination and collaboration between various sectors, communities and disciplines. The goal of the initiative is to identify and address the root causes of health-related problems and create long-term solutions. Programme priorities to promote wellbeing address issues such as: food, nutrition and water safety; the control of diseases that can spread between animals and humans; pollution management, and action to combat the emergence of microbes that are resistant to antibiotic therapy, as well as chronic non-communicable diseases (CNCDs) [3].

The WHO's (2021) Geneva Charter for Well-Being [4], also promotes global health and well-being. It charts a new approach to respond to the global social environment and health challenges. It uses multidisciplinary approaches that address inequities in both human behavior and the environment. The Charter's Principles promote holistic approaches to health that integrate physical, mental, spiritual and social well-being, as well as peace with nature and the environment. Like the SDGs [5], it is human rights-based and promotes social and environmental justice, peace, solidarity, as well as gender and inter-generational equity. Indicators of success in health and wellbeing, go beyond gross domestic product (GDP). They consider human and planetary well-being which contributes new perspectives and priorities for public spending and focus on empowerment, inclusivity, equity and meaningful participation.

Global well-being is also closely linked to climate change which the United Nation's (UN's) Intergovernmental Panel on Climate Change 2008 (IPCC) [6] defines as 'a change in the state of the climate that can be identified … by changes in the mean and / or the variability of its properties, and that persists for an extended period, typically decades or longer' [6]. Boehm and Schumer [7] highlight 10 major findings of the IPCC 2023 report that highlight major risks to global well-being from climate change. Amidst the closing window to address climate change crises, the IPCC highlights possible actions to avert these risks, offering some hope for sustainable planetary well-being.

#### **3. Well-being: Theoretical concepts, models and measurements**

#### **3.1 Theoretical concepts and models**

The concept of well-being is multi-dimensional in nature and has been studied for many years by various health professionals. The concept is closely linked to

#### *Introductory Chapter: The Global Framework for Wellness – Concepts, Theories, Measurements… DOI: http://dx.doi.org/10.5772/intechopen.112547*

other concepts such as happiness, life satisfaction, and quality of life among others. Generally, well-being can be described as 'what is inherently, ultimately, or noninstrumentally good for a person for that person's sake' Lee et al. ([8], p. 378). There have been several other definitions ranging from what may be considered simple to more complex. As a result of the differing definitions, there is a multiplicity of correlates that can include but are not limited to subjective components of well-being. Some examples would be positive thinking, fitness level, spirituality, financial security and personal relationships [9]. Alternatively, objective components that are considered on the societal level would include income, literacy and life expectancy [10].

Bronfenbrenner's [11] socio-ecological model is one of the many models that has been used to describe the different systems that affect an individual's development. It was adjusted and combined with the works of Belsky's [12] and Steuart's [13] to yield the social-ecological model of health proposed by McLeroy et al. [14]. The model has been used to describe the different factors that impact an individual's health and well-being. The focus of the model is to target these factors with the intention of achieving positive health changes in different populations. The model consists of five factors that impact how the individual interprets, achieves and sustains their health and well-being.

According to McLeroy et al. [14] they include:


Like most models, the social-ecological model of health integrates its dimensions to assess the holistic well-being of the individual [14]. Another concept that falls in the ambit of well-being is social connectivity. Social connectivity is an integral aspect of well-being that falls in the interpersonal bracket of the social-ecological model of health. As human beings, we are innately social and oftentimes many of our principles, values and meanings are derived from an eclectic combination of the persons we associate with. According to the National Center for Chronic Disease Prevention and Health Promotion 2023 [15], the concept of social connectivity takes into consideration the need for social interactivity as well as how influential relationships and friendships are particularly to well-being. It can undoubtedly be linked to how well-being is perceived by the individual.

Self-perceived health is considered a subjective component of well-being where the focus is placed on the individual to define their health by answering a variant of the question: How is your health in general? Generally, the response to this question ranges from 'very poor' to 'excellent'. This component of well-being is powerful and is used by health professionals to better serve the health and wellness needs of people.

The wellness wheel created by Bill Hettler in 1976 initially had only six dimensions [16]. In Stowen's [17] dimensions of wellness, the wheel currently has eight interrelated dimensions which include: physical, intellectual, emotional, social, spiritual, vocational, financial and environmental. Much like the social-ecological model of health, the wellness wheel represents the different aspects of life that impact the health and well-being of the individual. Additionally, the model is used as a means for persons to assess their current overall well-being [17].

The benefits of research on well-being are undeniable. The multidimensionality of the concept provides a framework to acknowledge and represent the diversity of people and how they perceive themselves, their health and their well-being. The socio-ecological model, self-perceived health, social connectedness and the wellness wheel are but a few examples of how the individual's well-being can be assessed using a conceptual framework.

#### **3.2 Measurements**

Quality of Life (QoL) measurements are at the cornerstone of assessing and measuring health status. Such measures can be at the individual, city, national or global level. These measures take into consideration the important issue of morbidity which represents a deficit in health status. Quality adjusted life years (QALY) measurements typically range from 0 to 1 where 0 represents death, 1 represents a year of perfect health and 0.5 represents a significant health deficit such as a patient that is bedridden [18, 19]. Although rare, QALY values can be less than zero or greater than one which signify a state worse than death or exceeding perfect health (e.g., euphoria). In addition, an inverse scale can be used such as disability adjusted life years (DALY) which represents the years of life lost due to a disease. While a high QALY represents good health, a high DALY represents the opposite [20]. The standardization of these QoL measurements makes them powerful and useful but can also present problems.

The cost to achieve QALY gains can be calculated and translated into monetary terms, while the set range (e.g., 0–1) permits the comparison of interventions. For example, the financial expense of increasing a QALY from 0.5 to 0.9 (an increase of 0.4) for a disease in one person can be compared to the same financial expense applied to increasing two people with a different disease from 0.5 to 0.7. If only the summation of QALYs is calculated and the costs are similar (e.g., \$10,000 per 0.4 QALY gained), these would seem equivalent. However, the greater increase for one person is often chosen as societies appear to avoid the rationing of care. In this example, half as many people could be treated (e.g., only the insured, or those with a more dire clinical write-up) and the nuance of the untreated is lost because it is not as exposed to the voting populace as the threat of not having the option for the best treatment. Another problem in translating the quality of the human condition to a normalized cost metric, in order to make decisions about interventions, is that applying strict logic to ethical decisions strikes many as unfair. One example of ethical complexity is in the possibility of weighting QALYs by age. The fair innings theory suggests a QALY gain of 1 year is of greater value for a younger person than an older one, since the younger person should have the chance to live the year the older person already enjoyed [21, 22]. In contrast, a purely economic perspective might weigh age as a measure of how much individuals contribute to their country's GDP. This perspective values people more heavily during their economically productive years (i.e., middle age), wherein a QALY gain for young and old are weighted less than those middle-aged.

*Introductory Chapter: The Global Framework for Wellness – Concepts, Theories, Measurements… DOI: http://dx.doi.org/10.5772/intechopen.112547*

At an individual level, measuring well-being can be customized by metrics designed for the situation. These might include select metrics for use during cancer treatment, for those who are clinically depressed or for those with symptomatic dementia. Such disease—and situation—specific metrics can change more readily in a given field, which adds nuance but may complicate comparisons unless translated into economic costs. Economic costs are a type of gross universal language on the difficulty to move from a given human condition.

#### **4. Global health estimates and health disparities**

The Global Health Estimates (GHE) produced by the WHO [23] provides critical insight into the leading causes of mortality and morbidity globally. These insights provide further guidance for the crafting of health policy as well as guiding resource allocation. Disaggregated data by sex, age and geographic location are also critical to provide decision-makers with the relevant information to mount effective responses to epidemiological changes in real-time [24].

Globally, CNCDs have featured as the leading contributors to deaths and disability globally, moving apace since 2000. In particular, ischaemic heart disease, stroke and chronic obstructive pulmonary disease are the top three contributors [25]. Over the 20-year period, 2000–2019, there was a marked decline in communicable diseases such as lower respiratory infections, neonatal conditions and diarrhoeal diseases (**Figure 1**) [25].

**Figure 1.** *Leading causes of death globally.*

In examining the morbidity statistics, as measured by DALYs 2000–2019, DALYs due to CNCDs are the standout contributors, including an 80% increase in DALYs from diabetes mellitus and doubling of DALYs from Alzheimer's disease and other dementias. Notably DALYs from communicable diseases registered a 50% decline over the same period [26].

#### **4.1 Regional disparities**

There are significant differentials in mortality across regional and income classification boundaries. Across the African region in 2019 communicable diseases accounted for six of the top ten leading causes of death, being the only region where HIV/AIDS and malaria are still counted in the top ten. Furthermore, neonatal conditions, lower respiratory illnesses and diarrhoeal diseases accounted for leading contributors to DALYs for the same period [24]. The picture in the Americas places diabetes mellitus as the number two contributor to DALYs in the region. In 2019, diabetes became the second greatest contributor to the regional DALYs. Notably, the Region of the Americas was the only region where high rates of mortality from interpersonal violence ranked among the top ten leading causes of death [25].

CNCDs are a significant feature in the mortality and DALYs profile of the regions of the Western Pacific, Europe and the Eastern Mediterranean. Notably in the South-East Asia region between 2000 and 2019, there was a marked reduction in communicable diseases and deaths from neonatal conditions, with a concomitant rise in CNCDs and road traffic injuries which entered the top ten in 2019 [25].

#### **4.2 Income disparities**

By way of income classification, communicable diseases predominate in lowincome countries (i.e., lower respiratory infections, neonatal conditions), whereas CNCDs are the prevailing causes of death in lower-middle income (i.e. ischaemic heart disease, stroke); upper middle income (i.e. ischaemic heart disease, stroke and chronic obstructive pulmonary disease) and upper income countries (i.e. ischaemic heart disease, Alzheimer's and other dementias and stroke) [25].

#### **4.3 Mortality and morbidity: disparities by sex**

When death and disability data are examined by sex, women registered a 15% reduced rate of annual mortality and DALYs compared to men. On contrast, in measuring years lived with disability (YLDs), overall women spent some 20% more years of YLDs than men. Alzheimer's disease and other dementias claim the lives of 80% more women than men and contribute to 70% more DALYs among women [26].

#### **4.4 The COVID-19 pandemic and global disruptions in mortality and morbidity**

The COVID-19 pandemic brought with it a dramatic shift in the global mortality pattern and was a stand-out moment in the public health landscape where timely and reliable data were critical to the global public health response [25].

Reporting on excess mortality as a result of the COVID-19 pandemic (January 2020–December 2021), the Lancet estimated 18.2 million deaths, as compared to

*Introductory Chapter: The Global Framework for Wellness – Concepts, Theories, Measurements… DOI: http://dx.doi.org/10.5772/intechopen.112547*

official statistics of 5.94 million deaths [27]. The excess mortality contributed by COVID-19 was 120 deaths per 100,000 populations. These estimates suggest a far more critical scenario than that painted by official mortality statistics, which do not provide a comprehensive enough account of the burden of mortality from the pandemic. The global ratio of excess to reported mortality (2020–2021) was 3.07. The highest levels of excess mortality were reported in South Asia, North Africa, the Middle East and Eastern Europe [27].

The COVID-19 pandemic is expected to result in a significant erosion of the gains made since the year 2000, including life expectancy and healthy life expectancy [28]. The majority of excess deaths globally occurred among persons aged 45 years and older. Notably, global excess deaths were concentrated in the 45 and 64 years (31%) and 65–84 years (46%) age groups. Across the six regions of the WHO the pattern of mortality reflected marked heterogeneity. Across the globe, age-specific mortality rates (i.e., excess mortality) demonstrated consistently higher rates among males [29].

Disaggregated data are keys to informing decisions on resource allocation and services. Concerns exist about the accuracy of these data in some settings, in particular low-income countries where the public health systems are less developed and data may be less available.

#### **5. Well-being policies, programmes and interventions across the lifespan**

Universal health coverage (UHC) is a foundational investment in human capital, with significant implications for economic development. As such, health is a critical component of national, regional and global development frameworks and having access to affordable, high-quality primary health care is at the heart of UHC [30] and the attainment of the SDGs 2030.

#### **5.1 Child and adolescent health**

In 2023, an estimated 25% of the world's populations are children of aged 0–14 years; and adolescents aged 10–19 years account for 16% of the global population [31]. Health and wellness policies and intervention programmes for children and adolescents play an important role in promoting their overall well-being and preventing various health problems.

The overarching policy of universal health care seeks to ensure that all children and adolescents have access to essential health care services, regardless of their ability to pay, their race, sex, ethnicity or any other factors [30]. This includes preventive care, vaccinations, regular check-ups and treatment for illnesses and injuries, specialized care for chronic conditions, and appropriate screening interventions and support for developmental disorders.

Other policies and programmes targeting children and adolescents focus on:

*Vaccination policies*, such as mandating immunizations and interventions such as immunization screenings and delivery at schools. Cuba has a well-established and robust vaccination programme that has gained worldwide recognition for its success in controlling and preventing the spread of infectious diseases [32]. However, the COVID-19 pandemic has highlighted concerns about the ethics of mandatory vaccinations of children [33].

*Nutrition programmes*, with policies that may regulate the availability of nutritious foods in schools and restrict unhealthy food and drink options, and interventions that may include nutrition education and school lunch programmes [34, 35].

*Violence and injury prevention*, particularly in school-based settings [36], where policies may advocate for safety measures in schools, and intervention programmes may involve education about traveling in groups rather than alone, avoiding fights and resolving conflicts [37].

*Substance abuse prevention policies* can enforce strict regulations on the sale and distribution of tobacco, alcohol and drugs to youth [38], while intervention programmes might involve educational campaigns, peer-led initiatives and counseling services focused on substance abuse prevention [39].

*Mental health policies* may require schools to offer counseling services, and intervention programmes may include mental health screenings, awareness campaigns, peer support groups, and access to qualified mental health professionals [40, 41].

*Health education policies* might mandate comprehensive health education in schools, covering topics like nutrition, sexual health and personal hygiene, while intervention programmes can include guest speakers, workshops and interactive educational resources to engage children and adolescents [42].

These are just a few policies that governments might select for implementation, balancing many problems and usually limited resources.

Notably, there is a significant variance in the ability of countries to adequately provide the package of care and services as outlined in the UHC goals, with marked variations in SDG indicators on service coverage across the regions of the WHO. Service Coverage Index data (SCI) (2000–2019) ranked the Americas, Europe and the Western Pacific as having performed better than the regions of Africa, South-East Asia and the Eastern Mediterranean [43].

Prior to the COVID-19 pandemic, countries were struggling to attain UHC. This position has only worsened with the pandemic, with widespread disruption to the delivery of essential health services. On average, in 2021, 35% of countries reported disruption in service delivery, with primary health care being the hardest hit at 48%. Disruptions were most often felt in countries outside of the high-income bracket [43].

UHC is based on the need to provide ethical care and service. The ten principles which underlie the Ethical Principles in Health Care (EPiHC) establish a foundational platform of shared principles across the health care ecosystem. These are aimed at shaping system values and building trust between health care providers and service users [44].

Among the UHC successes to be considered is the Canadian health care system, known as Medicare, which provides all essential medical care for all residents [45]. Another example is Brazil, which has made significant strides in establishing a universal health care system known as the Sistema Único de Saúde or SUS [46].

#### **5.2 Workplace health**

The Centers for Disease Control define workplace health programmes as '…coordinated and comprehensive set of health promotion and protection strategies implemented at the worksite that includes programs, policies, benefits, environmental supports, and links to the surrounding community designed to encourage the health and safety of all employees' [47].

Workplace wellness programmes are intended to benefit both employers and employees through increased productivity, less absenteeism, improved morale and *Introductory Chapter: The Global Framework for Wellness – Concepts, Theories, Measurements… DOI: http://dx.doi.org/10.5772/intechopen.112547*

reduced health care costs, including reduced insurance premiums and compensation claims. Comprehensive and systematic workplace health promotion programmes involve assessments, planning, implementation and evaluation [48, 49].

There being no standard blueprint for workplace wellness, organizations have engaged various models and strategies for physical and mental wellness, including educational and activity-based interventions with policy or regulatory supports [48, 50–52]. These have ranged from educational sessions on health and wellness, and in particular chronic diseases and weight management, physical activity/fitness programmes, support hotlines, smoking cessation, among other initiatives [53, 54]. While outcomes and successes have varied across programmes and organizations, those programmes which utilized multidisciplinary strategies were usually the most successful [55–59].

#### **5.3 Digital health**

Digital health technologies are increasingly forming part of the landscape to improve global health and well-being. In Ref. to digital health the WHO defines it as 'the field of knowledge and practice associated with the development and use of digital technologies to improve health' ([60], p. 11). The definition encompasses a range of technological systems and solutions, including eHealth, big data analytics and artificial intelligence.

The WHO's Global Strategy on Digital Health 2020–2025 [60] aims to strengthen health care systems globally, with applications across the board, inclusive of low and middle-income countries. This strategy identified digital health as a cornerstone of health priorities, which is expected to safely, ethically and equitably benefit the world at large and should be rooted in principles such as accessibility, privacy, and confidentiality [60]. The WHO further acknowledges the likelihood of increased difficulty in the adoption and implementation of digital health technologies in low- and middleincome countries but proposes the concept of global solutions and shared services between member states.

Digital technologies including social media, mobile health and digital/wearable devices are increasingly being utilized as an integral part of health promotion programming across diverse settings and especially among youth audiences [61, 62]. As new technologies emerge, digital health is even more relevant in its application to life-span-based health care programming (i.e., from children to the elderly), and in targeting the diverse settings (i.e., homes, schools, communities and workplaces) in which health-related activities or interventions are implemented [63, 64].
