2.2 Defining wellbeing
Wellbeing has become popular among policy makers as a generic term that embraces physical, mental and emotional health. Is this simply a matter of changing fashions in terminology or does it reflect particular assumptions about what it means to be healthy? Moreover, does the term have particular meanings when used in relation to young people? In this section we will analyse current ideas about what constitutes wellbeing for young people, and work towards producing a critical framework for understanding young people's health.
An early use of the term wellbeing as a synonym for health can be found in the definition adopted by the World Health Organization (WHO) in the years following the Second World War:
Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.
(World Health Organization, 1948)
What work is the word wellbeing doing in this definition? First, it signals an attempt to bring together different aspects of health – principally the physical and the mental – and to demonstrate the connections between them. This is an implicit criticism of earlier, medical models of health which had viewed these areas as discrete and unconnected. Second, the use of the word wellbeing reinforces the sense of health as a positive concept – a state of ‘wellness’ – rather than the mere absence of illness. Once again, there is an implicit criticism of a negative, medical focus on health ‘problems’. Third, the use of the word wellbeing represents an attempt to broaden the scope of what is meant by health, so that it includes not only physical and mental health but also what is here called ‘social’ wellbeing. Presumably, this means a sense of ‘wellness’ not only within the person but also in their social environment. This reflects an assumption that the causes of health, and of ill health, are not only located within the individual (as in the medical model) but also depend crucially on social factors, such as material resources and social relationships. There is an implicit recognition here of the part played by social disadvantages such as poverty in many people's experience of poor mental and physical health.
Writing in support of using the notion of wellbeing in public policy, Hetan Shah has argued that ‘an incredible amount is spent on our “health” service, but most of it focuses on dealing with physical symptoms of sickness’ and that ‘we need to reconfigure the purpose of the system in order to promote wellbeing’ (Shah, 2005, p. 39). Other writers have argued that the holistic concept of wellbeing is more in keeping with the way in which health is seen in the majority of societies and cultures in the world, than is the Westernised medical model (Frankel, 1986).
However, some commentators have been more cautious about adopting the positive model of health implied by the term wellbeing. Drawing attention to the emphasis on ‘complete … wellbeing’ in the WHO definition, at least one writer has criticised this model for presenting an idealistic counsel of perfection that ‘puts health beyond everyone's reach’ (Lewis, 2001, p. 59). How many people can claim to have experienced a ‘state of complete physical, mental and social wellbeing’, and is such a state desirable? Arguably, promoting this ideal as a standard puts pressure on individuals to constantly strive for its vision of perfection, and to be forever dissatisfied with their current state of health. Thus a holistic model of wellbeing, while appearing to present a more social vision, may paradoxically promote an individualised approach in which good health is not only every person's right, but also their personal responsibility.
Certainly, it can be argued that much recent health related policy, with its promotion of healthy lifestyles and ‘taking control’ of your own health, seeks to shift responsibility for health on to individuals and away from society as a whole. Some critics have seen this as part of more general attempts to ‘responsibilise’ individual citizens in a number of areas (O'Malley, 1996), a notion we will return to later in the course.
How does this movement away from a medical model of health and towards a positive and holistic model of wellbeing relate to the experience of young people, and to the ways in which their health has been discussed and promoted? Significantly, the UK government has adopted the term wellbeing as a key concept in its strategy Every Child Matters: Change for Children (DfES, 2003), which it describes as ‘a new approach to the wellbeing of children and young people from birth to age 19’. The five outcomes for children and young people which are at the heart of Every Child Matters are described as ‘a positive vision of the outcomes we want to achieve’. The outcomes are:
being healthy: enjoying good physical and mental health and living a healthy lifestyle
staying safe: being protected from harm and neglect
enjoying and achieving: getting the most out of life and developing the skills for adulthood
making a positive contribution: being involved with the community and society and not engaging in anti-social or offending behaviour
economic wellbeing: not being prevented by economic disadvantage from achieving their full potential in life.
(DfES, 2003, pp. 6–7)
This vision of wellbeing clearly goes beyond even the World Health Organization's definition and at the same time gives a particular meaning to ‘social’ wellbeing. As with the WHO definition, many people's first response to the government's five outcomes will probably be to see them as a progressive movement away from defining young people's health in negative terms, and as an advance on an individualised model which overlooked the impact on young people's health of other aspects of their lives, such as education and work. By contrast, this definition construes wellbeing as resulting from a combination of personal and social influences.
However, the model of the healthy young person that lies behind the five outcomes is also open to criticism. For example, some youth organisations have criticised the outcomes for being insufficiently youth focused and as having an inherent bias towards younger children, with their emphasis on protection and the absence of any reference to encouraging autonomy and participation. The National Youth Agency, for example, has argued that ‘the Green Paper generally reflects children and young people as passive recipients of adult care, rather than as partners and active citizens with a full range of human rights and a need for encouragement and support to take increasing responsibility for their own lives’ (National Youth Agency, 2003, p. 1).
Paradoxically, the vision presented in the five outcomes can also be criticised for over-emphasising young people's responsibility for their health. At least three of the outcomes focus on the individual's active contribution to their own wellbeing. The healthy young person presented in this vision is one who is ‘achieving’ in education and making a ‘contribution’ to their community, both positively through volunteering and negatively by staying out of trouble. Even the first and most directly health related outcome emphasises the individual's responsibility for ‘living a healthy lifestyle’.
So this vision represents a move away from a traditional welfarist model of health in which responsibility rests with society to provide the conditions that promote young people's wellbeing. As Shah acknowledges, a shift to a focus on wellbeing often entails an emphasis on ‘promoting self-efficacy’ rather than viewing people as ‘passive recipients of welfare’ (Shah, 2005, pp. 35–6). There is very little role for the active state in this vision, but a major role for the active, achieving, enterprising individual. Although economic disadvantage is mentioned, economic wellbeing is less about the right to basic resources, as in traditional social democratic welfare policy, and more about supporting individuals to achieve economic wellbeing for themselves.
Nikolas Rose has charted the ways in which the ‘private self’ has increasingly become a focus of government intervention in late modern societies. Under neo-liberalism, a political philosophy associated with free markets and reduced government intervention, policy is directed towards the promotion of the enterprising individual:
The theme of enterprise that is at the heart of neo-liberalism certainly has an economic reference … But enterprise also provides a rationale for the structuring of the lives of individual citizens. Individuals are to become, as it were, entrepreneurs of themselves, shaping their own lives through the choices they make among the forms of life available to them … The political subject is now less a social citizen with powers and obligations deriving from membership of a collective body, than an individual whose citizenship is to be manifested through the free exercise of personal choice among a variety of marketed options.
(Rose, 1999, p. 230)
It can be argued that recent policies aimed at promoting young people's wellbeing have sought to encourage the notion of young people as ‘entrepreneurs of themselves’, largely responsible for their own health and happiness. Another criticism might be that government strategies such as the five outcomes seek to impose a particular model of wellbeing on all young people and to deny the viability of alternative ways of being young. Critics might argue that there is little room simply to ‘be’ in the Green Paper's vision of youth as a time of achieving and contributing, and that outcomes such as ‘making a positive contribution’ transform something that should be voluntary and spontaneous into a government directed duty.
Activity 3 Healthy outcomes?
What is your view of the UK government's five outcomes and their vision of young people's wellbeing? Can you think of any outcomes that might contribute to young people's wellbeing that are not included?
You might have noted that the five outcomes make only passing reference to the importance of basic material resources. They also have little to say about the impact on young people's wellbeing of personal and social relationships, despite the fact that most research into young people's mental health emphasises these as a ‘protective’ factor (see Section 4). The five outcomes also omit young people's rights, such as the right to participate in decisions affecting their health, and do not mention the impact of inequality and discrimination on wellbeing.