Making the links between Obesity & Well-being
A briefing paper developed for CSIP North West
By Lynn Snowden, Director, Inukshuk Consultancy
There is no health without mental health (WHO)
1.
Introduction
Mental well-being is a key factor of obesity and weight management. Good
mental health is a protective factor for good physical health and against
physical illness and is essential for making healthy lifestyle choices and
behaviour changes. Poor mental health can lead to unhealthy lifestyle choices
and unhealthy weight management. Obesity and physical illness can also
lead to poor mental health. People with mental health problems, especially
severe, are also at increased risk of obesity and related poor health.
Addressing mental well-being is therefore an essential component of all
healthy weight management strategies and programmes, for both the whole
population and those with or at risk of mental ill-health.
In order to ensure that strategies and programmes effectively address the
relevant mental well-being factors, a mental well-being impact assessment
(MWIA) could be undertaken. This process is based on health impact
assessment methodology and a set of evidence based mental well-being
determinants and factors, grouped under the four themes of enhancing
control, increasing resilience and community assets, facilitating
participation and promoting inclusion. The process also involves
identifying indicators to measure progress. Evaluation shows it is effective in
engaging stakeholders in service development and evaluation and it
increases understanding of mental well-being and its determinants.
2.
Definitions of Obesity and well-being
Overweight = Adults with a BMI of 25 kg/m2 or over
Obese = Adults with a BMI of 30 kg/m2 or over are obese
Morbidly obese = >40 kg/m2
** BMI is a measure of weight relative to height, defined as weight (kg) divided
by height (m2) (1).
Mental well-being –There is no single, standard definition of well being.
Broadly well being is generally seen as comprising the following domains:
subjective well-being/life satisfaction, personal and social relationships –
engagement/participation in community, and occupation (personal
development, employment and other activity) “how people think, feel and
function” (2).
The Foresight Review on Mental Capital and Wellbeing, released in 2008,
defined well-being as “a dynamic state, in which the individual is able to
develop their potential, work productively and creatively, build strong and
positive relationships with others, and contribute to their community”.(8)
The NW Well-being Hearing chose a definition of well-being as “The quality
of people’s experience of their lives” (3).
Mental health can be described as:
2
“a state of well-being in which the individual realises his or her own abilities,
can cope with the normal stresses of life, can work productively and fruitfully,
and is able to make a contribution to his or her community” (4 ).
3.
Epidemiology of Obesity
The prevalence of obesity and overweight is increasing worldwide. It is seen
in both genders and in virtually all age groups, pre-school and primary –
school-age children. In the UK the prevalence of obesity has more than
doubled in the last 25 years. In England, almost 25% of adults and
approximately 10% of children are now obese. The government’s Foresight
report suggested that “we can anticipate some 40% of Britons being obese by
2025” (5).
The trend of weight problems in children causes particular concern because
of evidence suggesting a ‘conveyor-belt’ effect in which excess weight
continues into adulthood.
4.
Epidemiology of Well-being
A National Programme for Improving Mental Health and Wellbeing was
launched by the Scottish Executive in October 2001. To provide a relevant
baseline the Scottish Executive commissioned the first national “Well? What
do you think?” survey in 2002 and a second in 2004. In 2006, Ipsos MORI
undertook the third survey, using a refined version of the questionnaire to
reflect key policy developments since 2004. A representative sample of 1,216
adults aged 16+ in Scotland completed the survey.
The 2006 survey also included the Warwick-Edinburgh Mental Well-being
Scale (WEMWBS), designed to measure positive mental wellbeing. On the
basis of their responses to WEMWBS, 14% of respondents were classified as
having 'good' mental wellbeing, 73% as having 'average' mental wellbeing
and 14% as having 'poor' mental wellbeing. This will now be included on a
regular basis to measure positive mental wellbeing.
Factors commonly identified by respondents as having a positive effect on
their emotions, mental health and mental wellbeing were spending time with
family and friends, leisure activities, hobbies and a good social life. Factors
considered to have a negative effect were weather, work, not having enough
money and physical illness.
Around two-thirds of respondents felt they had a good deal or complete
control over things that affect their mental health and wellbeing, compared
with 8% who felt they had little or no control. Among those most likely to feel
in control were people aged 16 to 24 years, those who found it easy to
manage on their income and those with good mental wellbeing.
The addition of WEMWBS to the survey reinforces the importance of strong
social networks in promoting positive mental health. Similarly, the observed
link between high WEMWBS scores and both low deprivation and satisfaction
3
with neighbourhoods points towards the significance of the physical
environment in promoting wellbeing (6).
The New Economics Foundation have been leaders in well-being in the UK.
They report that “although yet to devise systematic ways of capturing the wellbeing of citizens, the Uk government has been a leader in stimulating
discourse about well-being and its measurement into the policy mainstream.
This has now been reflected in international action (7).” For example, The
Department for Children, Schools and Families and Ofsted have recently
consulted on a list of proposed indicators to better assess the well-being
issues faced by pupils and to capture schools’ contribution to promoting pupil
well-being. The final indicator set is due for inclusion in Ofsted’s school
inspection framework from September 2009.
Recently, there have been calls for the development of an ‘over-arching
mental capital and wellbeing measure akin to the Communities and Local
Government’s (CLG) Index of Multiple Deprivation’ to be explored (8) and for
governments to introduce and systematically measure National Accounts of
Well-being (7).
Care Services Improvement Partnership North West (CSIP NW) is coordinating a research collaborative to survey population mental wellbeing at a
regional and local level (this will include the Short WEMWBS 7-item scale).
This will establish baselines for the first time for mental well-being that can be
used to measure change over time and between different populations and
intervention groups. It will help us understand the outcomes and determinants
of mental wellbeing within different populations (9).
5.
Impacts of obesity on physical health and mortality
The impacts of obesity on physical health and mortality are well described in
the literature. Those discussed include the following: Type 2 diabetes,
Hypertension, Respiratory effects, Cancers, Reproductive function,
Osteoarthritis, Non-alcoholic fatty liver disease and Social stigmatisation and
bullying are common and can, in some cases, lead to depression and other
mental health conditions (10). There is less identified about the mental health
and well being impacts in current literature.
6.
Populations affected
Some studies suggest the following are more at risk: women, more seriously
obese individuals and those who seek treatment for obesity. More specifically
the following are cited in several studies (11):
 People who suffer from physical ill-health and disability are more prone to
anxiety and depression and therefore obesity could be an indirect effect
because it affects physical ill-health, which in turn produces greater
anxiety and depression
 In the Swedish Obese Subjects (SOS) study, mental well being in severely
obese women was significantly poorer than in severely obese men, and
women perceived more psychosocial difficulties (12)
4
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



7.
In a study that utilized a structured interview to diagnose major depression
in a large sample of adults (23), obese women were likelier than nonobese women to have had a major depressive episode during the previous
year. Similarly obese women, when compared to non-obese women, were
likelier to report suicidal ideation and attempts. In contrast, obese men,
when compared to non-obese men had a reduced risk of depression,
suicidal ideation and suicide attempts. (13)
Other studies have suggested that obese women and men who sought
treatment had significantly poorer psychological quality of life than obese
individuals in the community not seeking treatment (14)
Depression may also be associated with decreases in physical activity,
which may increase obesity risk (11)
People with schizophrenia or bipolar disorder are 1.6 times more likely to
develop ischaemic heart disease, 1.9 times more likely to have a stroke,
and 1.3 times more likely to have hypertension .. The links with smoking
and obesity are well-known. In addition, major weight gain induced by
antipsychotics is well established and represents a serious concern
(discussed in (15).
Although prevalence rates vary widely, the literature reports wide
agreement on the increased prevalence of obesity and overweight among
people with learning disabilities. Two recent studies of people in contact
with primary care services in England and Wales reported rates of 28%
and 35%, with the rate for women being 40% in both studies. The high
rate for women corresponds with data from other studies, which also show
high rates for people living in more independent settings in the community
(15).
Links with health inequalities and the gap in life expectancy
The nature of the relationship between obesity and socioeconomic status is
unclear. Obesity may lead to lower socioeconomic status (e.g. through
discrimination in hiring-employment) or low economic status may lead to
obesity (e.g. through difficulties in sustaining a health promoting diet or
adequate levels of physical activity), or there may be other factors that
promote both obesity and lower socioeconomic status.
“Emerging social trends suggest there may be continued and growing
discrimination against obese people, which may reinforce wider social
inequalities, and perpetuate a situation where the least well off are also the
least well (16).
Obesity seems to be stratified by socio-economic group in society e.g. it
seems to be the rich in poorer countries and the poor in developed countries
that are worst afflicted. As a result, standard awareness interventions may
serve to enhance the socioeconomic divide in the UK (similar to what it is
thought to have done for smoking).
5
Poor mental health is both a cause and a consequence of social, economic
and environmental inequalities. Responses are needed, therefore, at a social
as well as individual level. (34)
8. The evidence – links between obesity and the factors that protect
and promote mental well-being in the MWIA toolkit.
At present there are a limited number of studies available on these links.
However, these links could inform the approach we take to obesity
interventions in the future. There is a need for further research in this area as
it is complex and multi-factorial.
The findings of some studies are summarised in Table 1.
Table 1. Summary of evidence of the links between obesity and mental wellbeing
6
Wellbeing Factors
Control
Skills & attributes –sense of control, belief
in own capabilities
Evidence/suggested evidence
Knowledge of healthy
Financial security
Employment
Unhealthy weight control practices. Also see exercise and food evidence next page.
Strong inverse relationship between obesity and socioeconomic status (18)
Some evidence of prejudice against hiring obese individuals as well as pay discrimination against
overweight women and discrimination against obese individuals in the workplace (19)
Resilience
Emotional wellbeing –self esteem
Cognitive functioning e.g. relationships with
others
Social networks
Learning and development
Access to green space
Binge eating and depression may contribute to weight gain and obesity, which, in turn, may
negatively affect mood (17)
Some research has shown that the co-occurrence of obesity and chronic illness is associated with
significant impairments in emotional well being Obesity has been linked to poor self esteem and
body image (20) A study on a family-based behavioural treatment (FBBT) for childhood obesity in a
clinical setting in the UK found a ↓ in BMI and self-esteem and depression improved significantly .
Qualitative research on WATCH IT: a community based programme for obese children and
adolescents (included clinics and sport sessions) indicated significant appreciation of the service,
with reported increase in self-confidence and friendships, and reduction in self-harm (23). Obesity
may have profound consequences for later social functioning e.g. one study found that women who
were obese in late adolescence were less likely seven years later to be married, and had less
education and lower incomes than did non-obese individuals (24).
Negative stereotypes associated with overweight are evident in children and may have significant
implications for social development during adolescence (13)
One study found that women who were obese in late adolescence were less likely seven years later
to be married, and had less education. Obesity is negatively correlated with education and
socioeconomic status (22, 24).
Maller, Townsend, Pryor, Brown and St Leger argue in their recent review that the individual and
community benefits arising from contact with nature include biological, mental, social, environmental
and economic outcomes. Therefore, “nature can be seen as an under-utilised public resource in
terms of human health and well-being, with the use of parks and natural areas offering a potential
goldmine for population health promotion” (25, 26).
Participation
7
Sense of belonging
Access to services e.g.
cost
Economic
Inclusion
Positive identities
Obese children are often the victims of social stigmatisation and obese children themselves endorse
negative stereotypes of obese individuals (27)
Studies have demonstrated bias by healthcare providers toward obese patients by dietitians,
psychologists, nurses, medical students and physicians. These attitudes may have critical
implications for whether obese individuals seek needed health care, as well as the quality of the care
they receive (24,,28,29),
Strong inverse relationship between obesity and socioeconomic status (18,24)
Strong inverse relationship between obesity and socioeconomic status (18,24)
Cultural norms and pressures –A study by Crocker and Cornwell noted that “the stigma attached
obesity is related to a response to appearance-related aspects of overweight, which are markedly
discrepant from western cultural preferences for a slim and fit body type, and to judgements about
character traits attributed to obese individuals (e.g. overweight people are lazy, gluttonous, or lack
willpower.” (30)
Obese adults face intense prejudice, although women are more likely to be stigmatised for being
obese (30)
Tolerance
Some research suggests teenagers are at risk of victimisation by peers and may be less likely to
develop romantic attachments (31)
Challenging stigma
Obese adults face intense prejudice, although women are more likely to be stigmatised for obesity
(32) This stigma has been related to a response to appearance-related aspects of overweight, which
are discrepant from western cultural preferences for a slim and fit body type, and to judgements
about character traits attributed to obese individuals (e.g. overweight people are lazy, gluttonous or
lack will power). Therefore, it is often assumed that obese individuals are responsible for their weight
problems, which may promote self-blame and exacerbate distress (30).
Discrimination
“Emerging social trends suggest there may be continued and growing discrimination against obese
people, which may reinforce wider social inequalities, and perpetuate a situation where the least well
off are also the least well.” (16)
Strong inverse relationship between obesity and socioeconomic status (18,24)
Health inequalities
8
9.
Evidence - What we know about exercise and food and well-being
9.1
Exercise
There is substantial evidence identifying a causal link between physical
activity and reduced clinically defined depression, and comparative studies
have demonstrated that exercise can be as effective as medication or
psychotherapy. Exercise has been associated with decreased anxiety,
decreased depression, enhanced mood, improved self-worth, and body
image, as well as improved cognitive functioning.
Biddle S., Fox K., Boutcher, S., Faulkner, G. (2000) The Way Forward For
Physical Activity And The Promotion of Psychological Well-Being, in Biddle S.,
Fox K., Boutcher, S., eds Physical Activity And The Promotion of
Psychological Well-Being London: Routledge.
Department of Health (2004) At Least Five A Week: Evidence On The Impact
Of Physical Activity And Its Relationship To Health, London: Department Of
Health.
Mental Health Foundation (2005) Exercise and depression Exercise referral
and the treatment of mild or moderate depression Information for GPs and
healthcare practitioners, London: Mental Health Foundation.
9.2
Food
A healthy diet is vital to decrease the risk of heart disease, diabetes, obesity
and other common physical problems. There is also growing evidence
suggesting that good nutrition may be just as important for our mental health
and that there is a role it can play in the treatment and care of people with
mental health problems. For example, a number of conditions, including
depression and Attention Deficit Disorder may be influenced by dietary
factors.
Mental Health Foundation (2007) Healthy eating and depression How diet
may help protect your mental health, London: Mental Health Foundation.
Mental Health Foundation (2006) Feeding Minds: the impact of food on
mental health, London: Mental Health Foundation.
9.3 nef’s model of well-being - physical activity, healthy eating and
mental health
The Big Lottery Fund Well-being programme has funded programmes across
England that improve well-being through addressing physical activity, healthy
eating and mental health. The New Economic Foundation is undertaking the
evaluation of the programme and developed a model to inform the approach,
as detailed in the Well-being Matters Issue 1 research and policy briefing.
Along with the three strands of the Well-Being Programme (physical activity,
healthy eating and mental health) personal and social well-being assets is
also seen as being central to the Programme. This is shown in figure 1.
9
Figure 1 – model of well-being
Mental health
Personal
Well-being
assets
Physical activity
Healthy Eating
Social
Well-being
assets
The important thing about this model is that each element within it interacts
with others. As a result a project working to improve one element can expect
to have positive impacts in other areas too, particularly with regards to
personal and social well-being assets. For example a project aiming to
improve eating habits, may lead to improvements in self-esteem and stronger
social ties. Perhaps more importantly, there is also evidence that these
changes at the assets level may be important in ensuring the sustainability of
changes at the strand level (33). -Being Matters research and policy briefing
as part of the national evaluation of the Well-being and Changing Spaces
programmes, Issue 1.
10.
The approach taken in healthy weight programmes is important in
terms of the potential well-being impact.
Our circle below highlights that individual interventions that adopt an inclusive
approach to healthy weight and obesity that empowers individuals and takes
into account the links between wellbeing and obesity are more likely to have a
positive outcome. Inclusion and empowerment will support self esteem, lead
to higher motivation and participation and adoption of healthier lifestyles.
10
Positive Approach to Obesity Programmes will improve wellbeing.
Interventions that are inclusive, empowering and increase confidence
Support behaviour
change
High self esteem,
worth and efficacy
High motivation
and
participation
Negative Approach to Obesity Programmes.
Interventions that exclude, label, individualise and disempower will
have a negative impact on wellbeing
Label stigma
Low self esteem,
worth and efficacy
Inability to change
behaviour
Low motivation
and not able to
participate
Conversely taking an approach that doesn’t take into account these factors
and leaves individuals feeling excluded, labelled, individualised and
disempowered is less likely to have a positive outcome. Stigma will lead to
poor self esteem, low motivation and low participation which do not support
11
11.
Mental Well-being Impact Assessment Training: North West
Obesity Programme Case Studies
A 3 day MWIA training course was commissioned by the North West Healthy Weight
Framework Group, DH and CSIP NW in order to build knowledge, expertise and best
practice in addressing mental well-being as a key determinant of obesity, in line with
NICE guidance. The training offered an opportunity for four self-selected teams (of 3
people each) to assess the potential impact of their Obesity Strategy or programme
in order to improve its effectiveness in addressing well-being. Below are the case
study proformas of the MWIAs that were carried out during the training.
Blackpool MWIA Case study
Area
Subject for
MWIA
Why did you
select this for
an MWIA
Blackpool
Family-based intervention – part of obesity-care pathway.
Intervention is delivered in a club format which is accessible to
families with parents and/or children that are overweight or obese.
The programme will last for 12 weeks, during which families will be
supported to make lifestyle changes.
It is a new initiative and definitive decisions have not yet been made
on the format of sessions, method of delivery and venue and the
MWIA formed part of the consultation process for deciding on how
best to proceed.
How did you do
your MWIA?
The then PCT lead for obesity and the lead for mental health
promotion carried out the screening and scoping exercises and the
community profiling. Information was also gathered through a
stakeholder workshop with representation from a number of relevant
services including, Dietetics, Health Visiting and Leisure Services.
What worked
well?
The workshop was very well-attended and there was a good mix of
services present, including Commissioning. The ice breaker
stimulated lots of debate and this interaction continued in the group
work sessions.
What worked
less well?
More time should have been allocated for the group work and initially,
it was difficult to explain the role of the protective factors. It would
also have been good to have representation from the client group that
this intervention would be offered to.
What has been
the outcome for
the MWIA?
The recommendations will be fed back to the person responsible for
commissioning this service. There were distinct issues relating to
access and the way the intervention would be delivered and
promoted and these can be addressed through the commissioning
process.
Any other
comments?
How does MWIA
link with the
obesity agenda
–how can it be
beneficial in
progressing
your work?
MWIA enables stakeholders to look at the issue of obesity in a wider
context. The act of undertaking this process helps establish the links
between mental wellbeing, obesity and potential interventions and
enables people to modify their services, strategies and policies so
that they do not look at obesity as a single, independent issue that
can be addressed separately from the other factors that impact on
people’s health and wellbeing.
12
Knowsley MWIA Case study proforma
Area
Subject for
MWIA
Why did you
select this for
an MWIA
How did you
do your
MWIA?
Knowsley.
Knowsley has recently published ‘early years healthy eating guidelines’
aimed at the early years settings (under 4yrs) within the borough. This
aimed to assess the impact of the guidelines on the children, their
parents and the staff from each setting.
As we were taking part in an MWIA training programme and had a short
time frame in which to implement a workshop it was a relatively simple
project for us to investigate and to learn from. We intend to use the
MWIA process on a major National Programme which has local impact
potential later in the year.
Workshop Agenda:
1. LUNCH
12.301.15
2. Welcome, introductions, ice breakers
1.151.25
3. Outline policy (ensure all have a copy)
1.251.40
4. Community Profile, what do we mean by 1.40mental health & wellbeing.
1.50
Exercise
1.502.05
5. What is the process of MHIA - how can 2.05this influence the implementation of the policy 2.15
6. BREAK
7. TASK 1
8. TASK 2
9. Feedback
10. Summarise and close
2.152.30
2.303.05
3.053.35
3.353.50
3.504.00
10 mins
15 mins
10 mins
15 mins
10 mins
15 mins
35 mins
30 mins
15 mins
10 mins
Followed the tool kit.
What worked
well?
We invited 18 people and ended up with only 8 on the day including
ourselves (so 5 additional attendees). Although we initially thought this
would be a bad thing it worked out much better as we were able to run
the session in a very relaxed and informal way and there was much
more opportunity for discussion. It also worked well just having
professionals attending (although parents and service users had been
invited) as we felt some of their knowledge and opinions may have
been intimidating for community members. We thought it may be
beneficial to have separate workshops for community and
professionals.
13
What worked
less well?
We had a very low response rate to the invitation – many staff saying
they did not feel it was relevant for them to attend. When we run an
MWIA again, we will need to put effort into recruiting staff and stressing
the importance of mental wellbeing in all our roles.
What has
been the
outcome for
the MWIA?
It is recommended that for the guidelines to have a positive impact that
the communication and implementation plan of the document is
carefully considered.
The workshop highlighted that unless the managers of the nurseries
fully accept the guidelines and ensured that staff would be able to
implement the new guidelines (for example providing healthy food at
lunch etc), it is likely to cause a negative effect on trust and control
factors. Therefore it is important that when the guidelines are promoted
that nursery managers fully understand and accept the implications of
these polices. To do this it is recommended that nurseries receive oneto-one visits to talk through the process and explain the contents of the
guidelines. This can be done via existing oral health and community
cooks team visits and by arranging appointments with centre managers.
It is important that the staff within the nurseries feel skilled and
understand the reasons that the guidelines are being adopted, and are
able to explain to parents the implications of the guidelines. It is
recommended that the staff have an opportunity to develop their
knowledge of the importance of healthy eating for children under 5
years. This can be accomplished via the target wellbeing pre school
nutrition project to develop nutrition training for early years staff.
In order to protect the control factor for parents it is important that they
have the opportunity to consult on how the guidelines are adopted
within their child’s nursery. It is recommended that nurseries provide an
opportunity to collect the views and /or concerns of parents before the
policy is implemented.
Any other
comments?
How does
MWIA link
with the
obesity
agenda –how
can it be
beneficial in
progressing
your work?
Mental wellbeing underpins all aspects of health and the choices people
make about their lifestyles. Understanding how to maximise positive
changes and minimise potential negative effects can only be a good
thing!
Wigan MWIA Case study proforma
Area
Subject for
MWIA –please
give a brief
Wigan
We were planning on conducting the MWIA on a pilot project –
routine feedback of National Weighing and Measuring Programme
results to parents.
14
description
including
community profile
Why did you
select this for
an MWIA
How did you do
your MWIA?
Unfortunately we came across some barriers locally in terms of time,
other priorities of members of the NCMP group and perhaps some
lack of understanding from partners about the potential benefits.
What worked
well?
What worked
less well?
What has been
the outcome for
the MWIA?
Any other
comments?
How does MWIA
link with the
obesity agenda
–how can it be
beneficial in
progressing
your work?
Despite the fact that we did not do the full MWIA with a wider group.
We found the sessions very beneficial, and found completing table 1,
p.29 risk and protective factors for mental well being, and tables 2a-d
very useful in exploring our proposed pilot in a wider sense with
considerations we would have overlooked had we not conducted the
exercise.
The programme report summaries the following benefits from the work:
Impact of the MWIA healthy weight capacity building programme:

Built MWIA capability for teams within four localities in the North West –
increasing knowledge and skills.

Increased awareness of the links between obesity and well-being for
participating practitioners and wider stakeholders.

Production of a well-being and healthy weight briefing paper will inform
wider learning and development.

The programme increased networking between localities.
15

Three teams screened local services for their impact on mental wellbeing.

Two teams facilitated a rapid impact assessment.

Increased stakeholders engagement in service development and
improvement.

Improvement recommendations are being taken forward on the
commissioning and delivery of a local family based intervention
services.

Improvements are now being made to a local child healthy eating
guidance.

Mental well-being impacts of a local pilot project on routine feedback of
the National Weighing and Measuring Programme results to parents
were identified through a screening assessment.

Plans were made to undertake further MWIA in order to improve
services.
The benefits of Mental Well-being Impact Assessment to the healthy
weight management and obesity agenda:

The process will refocus services on the core determinants and
priorities for mental well-being.

The MWIA toolkit is very applicable to the obesity agenda and can be
applied in a variety of ways by local practitioners to improve services.

The MWIA process can usefully inform the commissioning of healthy
weight programmes, including developing evidence based practice,
engaging stakeholders, service monitoring, developing indicators.

MWIA offers a broad and applicable set of well-being factors and
determinants (control, resilience, participation, inclusion) including
social determinants and the assessment of equalities issues.
16
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(2007). The Mental Well-being Impact Assessment Toolkit. Care Services
Improvement Partnership, North West.
3. New Economics Foundation.
4. WHO. (2001). The World Health Report 2001-Mental Health: New
Understanding, New Hope available at
www.who.int/whr/2001/en/index.html
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Universities and Skills.
6. Scottish Government Social Research, Edinburgh. (2006). “ Well? What
do you think?” The third national Scottish survey of public attitudes to
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8. Foresight Mental Capital and Wellbeing Project (2008) Final Project report.
The Government Office for Science, London.
9. National Institute for Mental Health in England NIHME (January 2009)
Mental Health Promotion update Gateway Reference Number 11153 p.15.
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Cross Government Strategy for England.
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