A public dialogue on understanding the barriers to raising population wellbeing.
Problems and Purpose
People with high levels of wellbeing are less likely to suffer from mental health difficulties, to have better physical health, better relationships, be more productive at work, and are more likely to be active in communities. In 2008, the Government Office for Science published the findings from the Foresight project on Mental Capital and Wellbeing, which had reviewed the scientific research on the subject. As part of the Foresight project, the new economics foundation (nef) developed a set of simple, evidence-based public health messages that could communicate key findings from the Foresight project about the kinds of activities that promote positive mental health and wellbeing. nef's “Five Ways to Wellbeing” were launched in 2008 and are, in summary, Connect, Be Active, Take Notice, Keep Learning, Give.
The Ways to Wellbeing public dialogue project was designed to build on nef's “Five Ways” and deepen understanding of the extent to which people understand and feel able to make the kinds of changes in their lives that scientific evidence suggests would lead to increased wellbeing.
The dialogue aimed to explore three main questions:
1. To what extent do people feel able to make the kinds of discretionary changes in their lives that (evidence suggests) would lead to increased subjective wellbeing?
2. What, if any, are the structural or systemic barriers that prevent people engaging in activities that would improve their wellbeing?
3. How might people react to messages that use concepts and words of wellbeing and positive mental health, and what should messages be like, who should they be from and should they use science? 
Background History and Context
Recent developments in UK mental health strategy have emphasised the need to move from a largely ‘deficit’ model to an approach giving equal weight to promotion and prevention. In this new approach, the focus widens to emphasise the importance of considering the mental health and wellbeing of the population as a whole, not instead of, but in addition to, a renewed focus on caring for those with particular mental health needs.
Improving the nation’s mental health is important for a number of reasons. Mental health difficulties are estimated to cost the UK some £110 billion per year, of which around £32 billion is attributable to lost productivity. Perhaps more importantly, not only are people with high levels of wellbeing less likely to suffer from mental health difficulties, but they are also likely to have better physical health, better relationships, be more productive at work and more likely to be actively involved in their communities.
In 2008, the report of the Foresight project on Mental Capital and Wellbeing was published. This extensive review synthesised research on the causes and consequences of mental capital and wellbeing, and explored the challenges for government in supporting the wellbeing of the population in future. As part of the Foresight project, nef published the Five Ways to Wellbeing, a set of simple, evidence-based public messages about the kinds of activities that promote positive mental health and wellbeing. Although the Five Ways were generally well-received, concerns emerged about the effectiveness of promoting wellbeing to the public mainly through public education and social marketing methods.
In February 2011, the Government launched a new Mental Health Strategy, which highlighted the importance of promoting positive mental health and wellbeing as well as improving access to mental health services. The Ways to Wellbeing project was designed to link to this strategy by exploring the barriers that people experience to increasing their engagement with activities thought to increase wellbeing, and what messages would be most effective. It aimed to bring the public’s views to bear on the development of government policy around wellbeing, public mental health and positive behaviour change, as well as providing benefits for the members of the public participating in the dialogue. 
Organizing, Supporting, and Funding Entities
Cost of project: £264 000 (Sciencewise contribution: £132 000)
The Department of Health and the new economics foundation (nef) commissioned the project. nef (the new economics foundation) is an independent think-and-do tank that inspires and demonstrates real economic well-being.
Following a competitive tender process, Corr Willbourn were contracted to deliver the project. Corr Willbourn Research and Development provides qualitative market research, brand development and deliberative facilitation.
Laura Grant Associates was the project evaluator, whose specialization include public engagement with science and engineering and programme evaluation. 
A Department for Business, Innovation and Skills funded programme, Sciencewise-ERC brings scientists, government and the public together to explore the impact of science and technology. Its core aim is to develop the capacity of Government to carry out good dialogue, to gather and disseminate good practice, and have successful two-way communications with the public and other stakeholders.
Participant Recruitment and Selection
Number of public participants: 96
Number of stakeholders: 6
Recruitment was conducted through a network of Market Research Society (MRS) trained recruiters, according to a specification developed jointly by nef, DH, and Corr Willbourn. Public participants were recruited to provide a reasonable cross-section of age, ethnicity and socio-economic group. 
Methods and Tools Used
The project involved a series of different activities. First, a rapid review was conducted by nef of existing knowledge on the topic covering the relevant science, known socio-economic risk factors, existing attitudes to mental health issues, and existing initiatives.
A series of dialogue events with the public were held in six places across the country (London, Guildford, Exeter, Hartlepool, Altrincham and Coventry) in February and March 2011. Public participants were recruited to the deliberative workshops to provide a reasonable cross- section of age, ethnicity and socio-economic group.
What Went On: Process, Interaction, and Participation
The dialogue events had three stages which were, in summary:
1) Twelve single-gender group discussions around 1.5 hours long in the six locations with eight people in each group. Each discussion was facilitated, audio recorded, and transcribed. Participants discussed life in general before being introduced to the notion of wellbeing and the Five Ways
2) A week-long, self-guided deliberation in participants’ own environments captured in workbooks distributed at the first workshop. The workbooks provided summaries of the scientific evidence about the impact of Five Ways-type activities on wellbeing and links to sources of further information. There were also open questions to provide a framework for participants to reflect on issues discussed in the first events and with family and friends.
3) Six mixed-gender workshops, around one week later, lasting about 3 hours in the same six locations, with the same 96 participants (16 in each workshop). These were more structured than the first workshops: participants worked through a series of discussion exercises developed to address the research questions in detail. These sessions were video recorded.
In addition, eight in-depth (1.5 hour) interviews were conducted with individuals with low levels of wellbeing in Manchester, Stoke on Trent, and London. Interviews also focused around the research questions and were recorded and transcribed.
The dialogue produced rich and nuanced qualitative data in the video footage, workshop discussion and interview transcripts, and workbooks. These data were analysed leading to the production of a final report, published by nef in September 2011.
Key Messages from the Public
Barriers to engaging in Five Ways activities:
For some people, there were no significant barriers. These people typically felt confident in their ability to change their behaviours as they wished, in control of their lives, or manifestly engaged in a high level of Five Ways-type activities already.
For others, there were clear barriers of three main types:
- External barriers, such as lack of time and money, lack of available facilities or opportunities, or major life events
- Internal psychological barriers, such as depression or a strong sense of incapacity, lack of control/autonomy
- Psycho-social barriers. Most of the barriers reported fell between the external and internal realms, and were about how individuals interact with their social environment and are constrained by social norms. These included that they couldn’t find an enjoyable or relevant form of activity, motivation was missing, or the activities were outside what they normally did or what they felt it was appropriate for them to do. For some, a sense of a lack of control in their lives led to an inability to change their behaviour.
Underpinning many of these barriers was the lack of a sense of agency, a sense that you can do what want to do. This emerged as a key issue preventing people from making lifestyle changes to improve their wellbeing.
The public’s responses to the term ‘wellbeing’ were extremely mixed. Some felt that it is impenetrable and too abstract; some equated it with ‘feel-good’ products and services (skincare, aromatherapy); others linked it to mental health problems. The Five Ways to Wellbeing themselves were interpreted and experienced negatively as well as positively.
Rather than being motivating, framing wellbeing as a scientific issue seemed to be unnecessary and even unwelcome for many people. Common sense or personal experience was more convincing than the science.
In summary, the public dialogue concluded that attempts to reach the public through social marketing around issues of improving wellbeing should:
- Ensure that messages do not appear to come from ‘the Government’ as there was a general wariness about government interest in this area
- Use concrete messaging that suggests particular activities or actions, such as ‘walk in the park’, ‘phone a friend’ or ‘lend a hand’
- Avoid framing messages as ‘scientific’ - contrary to expectations, invoking science was seen as redundant and, in some cases, seemed to arouse suspicion
In addition, the dialogue concluded that the objective of communication should go beyond merely providing information about wellbeing and the Five Ways and should instead:
- Work to create a new common language for positive mental health and wellbeing, in a way that makes it seem desirable and attainable. The term 'wellbeing' was seen to lack resonance. In addition, communications should, in future, be through trusted individuals (e.g. healthcare professionals)
- Raise awareness of opportunities for engaging in wellbeing activities
- Focus on increasing people’s sense of agency. Communications could focus on ‘giving permission’ for people to make different choices, by supporting and encouraging existing individual choices, and making activities seem commonplace among people ‘like them’
Influence, Outcomes, and Effects
There was one, key, immediate policy impact of the dialogue: it helped to avoid launching an expensive and ineffective messaging campaign, potentially saving significant costs.
The case study observes, at the time of its publication, that it is too soon after the public dialogue to identify many other specific policy impacts from the project, although the following policy influencing activities have taken place:
- A tailored dissemination plan was developed, with nef and the Department of Health working with various groups across government to co-develop recommendations for policy change as a result of the dialogue results.
- A short briefing paper was circulated among stakeholders at the Department of Health, followed by a meeting held in May 2011 with stakeholders from different policy teams including mental health, public health, health improvement, substance misuse, children and older people.
- Three further meetings were held to discuss the findings with senior officials within government: two with teams from the Department of Health and one with the Department of Work and Pensions.
- The most likely area for future policy influence as a result of the dialogue project findings is in the development of new public- health arrangements, as the findings relate to health promotion, behaviour change and social marketing in relation to population health and wellbeing. The project will be used as one of the key reference sources in on-going discussions within and between policy teams that are involved in the establishment of the new system for public health due to be in place from 1 April 2013. 
Analysis and Lessons Learned
Summary of good practice and innovation
This was a dialogue focused on an established area of science, although it drew extensively on scientific research on the topic. Scientific experts were not involved in the workshops, so the dialogue was able to be very participant led. Participants enjoyed the discussions, which were friendly and relaxed, frank, diverse, open and engaging. A range of techniques was used to maintain energy and maximise participation.
As well as providing a large amount of valuable data to feed into policy development, the dialogue was seen as worthwhile by most public participants (84%), and as robust, credible, and well-designed and implemented by stakeholders because of the variety of opinions expressed, the openness and the range of participants.
The mix of informal, single-gender, smaller workshops first, followed by more structured and purposeful, mixed gender and larger second workshops worked well to allow people to develop confidence and feel comfortable in discussions of some quite personal issues.
The tailored dissemination plan, including working with various groups across government to co-develop recommendations, was expected to have strong potential for influence. The role of nef in continuing the engagement with policy makers after the main dialogue project, when there can be a risk of losing momentum, is expected to maximise the dialogue’s impacts.
Lessons for the future
Lack of clarity among some public participants about why the dialogue was being done took up some time, and their frustration and confusion slightly affected the mood in the workshops, although it did not affect people's willingness to fully engage in discussions. Some deliberate vagueness was part of the design, to help ensure spontaneous discussions without 'leading' participants, although this needed to be balanced with sufficient clarity.
The budget for the dialogue was seen by policy makers as quite small in terms of overall spend on these issues and that influenced their expectations of time commitments (i.e. minimal). Clarity is needed about the time commitments likely to be needed, without suggesting these are overly demanding.
There was some lack of clarity about the roles and responsibilities of some key stakeholders. It is important that oversight, ownership, and governance are clarified early among all stakeholders. 
 Sciencewise (2011) “Case Study: Ways to wellbeing”
 Sciencewise (2017) “Ways to wellbeing” [ONLINE] Available at: https://webarchive.nationalarchives.gov.uk/20170110133028/http://www.sciencewise-erc.org.uk/cms/ways-to-wellbeing/
 Nef (2011) “Understanding the barriers to raising population well-being: Final Report”, https://neweconomics.org/2011/09/understanding-barriers-raising-population-wellbeing