How nurses can promote well-being in personalised care
Intended for healthcare professionals
CPD    

How nurses can promote well-being in personalised care

Heather Henry Queen’s Nurse, owner/founder, Brightness Management Limited, Sale, England

Why you should read this article
  • To understand the role of well-being and happiness in health

  • To learn how to promote well-being in your practice

  • To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers)

  • To contribute towards your professional development and local registration renewal requirements (non-UK readers)

Between 2020 and 2024, personalised care will be made universal, improving the lives of approximately 2.5 million people in England. This article explores the role of well-being and happiness in health and care and what it can add to the concept of ‘what matters to me’.

It describes the evidence detailing how stress affects health and well-being and the factors that enable people to survive and even thrive during challenging moments of their lives.

The author examines how nurses can switch between assessing and meeting needs and enabling people to use their strengths to improve their well-being. Several examples of exceptional nursing care are provided and discussed, enabling readers to consider how they can develop their own initiatives to promote well-being in their practice.

Primary Health Care. doi: 10.7748/phc.2020.e1680

Peer review

This article has been subject to external double-blind peer review and has been checked for plagiarism using automated software

Correspondence

heather.henry@brightnessmanagement.org.uk

Conflict of interest

None declared

Henry H (2020) How nurses can promote well-being in personalised care. Primary Health Care. doi: 10.7748/phc.2020.e1680

Published online: 14 October 2020

Aim and intended learning outcomes

The aim of this article is to introduce nurses to several well-being theories and frameworks to enable them to further develop their range of nursing interventions. It will enable them to differentiate between when to use a biomedical model to improve health and when to introduce social approaches to improve well-being. This will support nurses to continue to develop optimal personalised care, continuing healthcare and social prescribing. This article will also assist nurses to apply what they have learned to the The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council (NMC) 2018) in respect of practising ‘in accordance with the best available evidence and listening to people and responding to their preferences and concerns’.

After reading this article and completing the time out activities, you should be able to:

  • Define well-being and happiness.

  • Describe the link between well-being and health.

  • Summarise how well-being is measured and its importance as a measure of a nation’s success.

  • Outline the factors that contribute to improving well-being such as response to stress, control, contact, confidence, meaning, purpose and achievement.

  • Start to recognise when it would be appropriate to switch between a medical and a social model of health and well-being.

Key points

  • The philosophy of person-centred care focuses on ‘what matters to people’

  • Well-being has been defined as ‘the state of being comfortable, healthy or happy’

  • Healthcare professionals can harness the strengths, knowledge, skills and resources of people and communities to improve well-being

  • Asset-based approaches to improving well-being require the nurse to encourage people-powered change

Introduction

In 2017, Health Education England (HEE) commissioned a person-centred approaches framework, a skills and training framework that aimed to teach healthcare professionals how to implement a person-centred approach to care (HEE, Skills for Health and Skills for Care 2017). The philosophy of person-centred care focuses on ‘what matters to people’ and emphasises the importance of understanding patients’ narratives of illness, coping, recovering and living well (HEE, Skills for Health and Skills for Care 2017).

In January 2019, NHS England published Universalised Personalised Care: Implementing the Comprehensive Model (NHS England 2019a). This document sets out how the commitments for personalised care outlined in chapter one of the NHS Long Term Plan (NHS England 2019b) will be delivered. Personalised care means people having a choice over how their care is planned and delivered, based on what matters to them, with evidence suggesting that personalised care provides improved outcomes for patients as well as addressing health inequalities (NHS England 2019a). However, the concept of improving well-being and its effect on improving health, as well as the evidence for how well-being can be improved, is still largely absent from either document.

This article describes how well-being can affect a person’s health, and how nurses can improve an individual’s well-being. Examples of working in partnership to enable people to develop their own solutions to their health and well-being issues are also described, along with an exploration of ‘asset-based nursing’, where nurses appreciate and engage people’s strengths and skills rather than just meeting their needs.

Time Out 1

Concept

From your own experience of care, consider how you would explain the concept of well-being to a colleague. Think about the components of well-being listed below.

Well-being and its relationship to happiness

Well-being has been defined as ‘the state of being comfortable, healthy, or happy’ (Mental Health Foundation 2015). The New Economics Foundation (2012), which researched the components of well-being and how to measure them, concluded that well-being is concerned with:

  • How people feel, such as anxious or happy.

  • How people function, such as how competent they feel they are.

  • How people see their life as a whole: their satisfaction and how they rate their life in comparison with their ‘best possible life’.

To support the increasing focus on well-being, the What Works Centre for Wellbeing (whatworkswellbeing.org) was developed as a primary source for evidence concerning well-being. It is part of a network of nine ‘What Works’ centres for evidence funded by the government, the National Lottery and others. These centres support more effective and efficient services across the public sector at national and local levels.

In contrast with well-being, happiness is more often described as a state of complete fulfilment and is generally recognised to be a transitory component of well-being (Theobald and Cooper 2012). Several influential thinkers, such as Layard (2005) and Csikszentmihalyi (1992), have researched happiness as a contributing factor in well-being. There is considerable overlap between both states. By cross-referencing Layard’s (2005) research with the What Works Centre findings (What Works Wellbeing 2020), the factors that are central to both happiness and well-being can be listed in order of importance:

  • Relationships, particularly with family, and how lonely people are.

  • Personal finance.

  • What people do with their time, particularly work.

  • A sense of belonging to community.

  • Health.

To these, the What Works Centre for Wellbeing website adds the following factors as contributors to well-being (What Works Wellbeing 2020):

  • Education and skills development.

  • Trust in government and democracy.

  • Air and water quality.

  • Personal well-being, which is measured using methods described later in the article.

  • Satisfaction with where a person lives.

Measuring well-being

The Office for National Statistics (ONS) has pioneered the measurement of personal well-being in the UK, making it one of the few countries to do so. There are four questions in which people are asked to evaluate aspects of their life on a scale of 0 to 10, where 0 is ‘not at all’ and 10 ‘completely’ (ONS 2018):

  • Overall, how satisfied are you with your life?

  • Overall, to what extent do you feel the things you do in your life are worthwhile?

  • Overall, how happy did you feel yesterday?

  • Overall, how anxious did you feel yesterday?

These questions measure subjective well-being and are included as part of the ONS’s Measuring National Wellbeing Programme, which began in 2010. They are included in an annual population survey that is administered to a representative sample of people in the UK. The four questions represent subjective measures of well-being and are designed to encourage individuals to reflect on their life. These questions are often used alongside the perhaps better-known Warwick-Edinburgh Mental Wellbeing Scale.

Well-being and its relationship to health

The then Department of Health (2014) produced a compendium of research on the link between physical and mental health and well-being, and found that the two elements influence each other. The research says ‘the effect of well-being on health is substantial (but variable) and comparable to other risk factors more traditionally targeted by public health such as a healthy diet’. For example, a chronically felt shortfall in well-being incrementally increases the risk of depression, while depression in turn may demotivate the person to secure the benefits of social interaction.

However, using a combination of Layard (2005) and the What Works Wellbeing (2020) findings, health ranks as only the fifth most important contributor to well-being. Layard (2005) explained this using research that showed that people can adapt to physical ailments. In contrast, Layard (2005) said pain and mental health issues cannot be as easily adapted to because they are linked to emotion.

Combining the findings of Layard (2005) and What Works Wellbeing (2020) suggests that aspects relating to community and personal relationships are greater determinants of a person’s well-being rather than being simply being concerned with health.

Using a community-centred approach to improve well-being and health

In 2018, Public Health England (PHE) (2018) published Health Matters, a resource detailing community-centred approaches to improving health and well-being. Community-centred approaches are based on the concept that positive health outcomes can only be achieved by addressing those factors that protect and develop health and well-being, and many of these are seen at a community level (PHE 2018). These include friendships, local groups or community associations, and issues related to the physical environment (PHE 2018). By addressing these factors, and empowering people to take control of them, healthcare professionals can improve the health and well-being of the community.

Figure 1 demonstrates PHE’s (2018) ‘family of community-centred approaches’ that can be used to improve community health and well-being.

Figure 1.

Public Health England’s family of community-centred approaches

phc.2020.e1680_0001.jpg

Case study 1 describes how a GP in Fleetwood, England, adapted social prescribing to address the well-being of the people attending his surgery. Social prescribing is about identifying the social, economic and environmental factors affecting someone’s health and well-being and, via a link worker, connecting them to sources of support in their own community. For example, supporting someone with social anxiety to attend a gardening group where they can gently learn to interact with others.

Time Out 2

Social prescribing

Consider Case study 1 to determine how healthcare professionals were able to modify the concept of social prescribing. Next, write down the types of community activities that might increase a sense of purpose and empowerment in people who have witnessed a decline within their community. As you meet with your patients in the community, begin to explore whether they relate communal activities to enhancing their personal health.

Stress, purpose and meaning in well-being

Hungarian endocrinologist Hans Selye (1936) was the first to develop a scientific explanation for how the body manages stress. He developed the general adaptation syndrome, which set out three stages in the management of stress or stressful situations:

  • Alarm – where the fight or flight response is triggered, and where hormones such as adrenaline (epinephrine) and cortisol are secreted.

  • Resistance – where the body learns to deal with the stressor. Sometimes the situation is resolved and hormone production, heart rate, and blood pressure begin to return to normal levels. However, sometimes the situation does not resolve and the body remains in high alert, which can begin to damage the individual’s health as the body adapts to manage the stress.

  • Exhaustion – where the body fails to manage the stress and burnout occurs.

In Case study 1, unemployment and financial challenges were likely the main causes of stress, and supporting others with community activities mediated this stress and improved health and well-being. However, these activities also provided a sense of purpose and meaning to the lives of those who participated.

In 2017 the New NHS Alliance published a Manifesto for Health Creation (New NHS Alliance 2017), based on the ‘salutogenic’ theories of sociologist Aaron Antonovsky (1987). The term is derived from the Latin ‘Salus’ meaning health, and the Greek word ‘genesis’ meaning origin.

Like Selye (1936), Antonovsky’s (1987) focus was on how people manage stress and ‘stay well’. He explained that people manage by using their personal resources to resist stress and strive for a life that is comprehensible, manageable and meaningful.

This focus on a life with meaning is also reflected in the experience of Viktor Frankl (1959), an Austrian psychiatrist who was interred in Auschwitz concentration camp in Poland during the second world war. As a prisoner, Frankl observed both his own well-being and that of his fellow prisoners. He saw that those who had meaning and purpose in their lives were more likely to survive than those who did not (Frankl 1959). Frankl survived the holocaust by using several mental tactics, which he then developed into a concept he later called logotherapy. He discovered a reason to live, attributed meaning to his experiences and described the ability to decide how to respond in any situation as the final freedom that humans have. Thus, his reason for living was to see his wife again, the meaning of his suffering was to be able to take lessons from his situation and teach them to his students, and he chose to consider these elements rather than give in to hopelessness (Frankl 1959).

The New NHS Alliance (2017) manifesto also included evidence from the Young Foundation’s research on neighbourliness (Hothi et al 2008), where the well-being of neighbours was improved when they were in control of the factors that contributed to their well-being, had meaningful social contact and were confident enough to live the life they wanted. The New NHS Alliance (2017) described the factors of control, contact and confidence to be the ‘3Cs’ that develop health and improve well-being.

Time Out 3

Making sense of crisis

Make time to talk to someone who has lived through a time of crisis, such as a war, pandemic, a tragic death or a major disaster such as the 2017 Grenfell Tower fire in London. How did they make sense of what happened? Did they attribute meaning to their experience? What personal resources did they draw on? Consider the ‘3Cs’ of control, contact and confidence. For example, what enabled them take control, did they have support from others, did their confidence levels change in any way?

Asset-based approaches to improving well-being

As well as addressing the needs of people and communities and providing services to improve people’s health, nurses can also harness the strengths, knowledge, skills and resources of people and communities to improve well-being. This is known as an asset-based approach to improving well-being (Foot and Hopkins 2010) and represents a community-centred method of addressing the issue of well-being. It differs from a deficit-based approach, which focuses on the needs and deficiencies of a community. By using an asset-based approach, people within a community can feel empowered to control their well-being, as opposed to the deficit-based approach, whereby communities can become dependent and passive recipients of services (Foot and Hopkins 2010).

Asset-based approaches can be viewed as complementary to needs-based ‘medical’ approaches. Asset-based approaches also change the role of the nurse. Instead of prescribing a cure or solution, the nurse becomes a facilitator of communal responses and supports the development of the community. The nurse’s expertise begins to relate more closely to human psychology, understanding stress and explanations of why shared activity can assist personal health. Examples of asset-based approaches can be found in both primary and community care nursing. Nurses often develop strong interpersonal relationships with patients based on years of experience and developing connections with the communities they serve, which can enable patients to mobilise. Case study 2 provides some examples of asset-based approaches that have empowered communities.

In 2015, the Health Foundation commissioned a review of the evidence for asset-based approaches to community development (Rippon and Hopkins 2015). Although the evidence is still emerging, the review concluded that asset-based approaches can assist with addressing the structural, material, social and relational barriers to people and communities achieving their full potential and make a significant contribution to tackling health and care inequalities (Rippon and Hopkins 2015).

Time out 4

Leadership

Consider Case study 2, then read more about the work of Ellie Lindsay and Sarah Everett using the links below.

Leg Club (legclub.org)

Dumbarton Democrat (tinyurl.com/DD-motivation)

Think about how these two nurses showed leadership and how their nursing care developed over time.

People-powered change and motivational interviewing

Asset-based approaches to improving well-being and developing communities requires the nurse to resist the temptation to ‘fix’ patients’ lifestyles and suggest solutions, and instead encourage people-powered change. Encouraging people to change their lifestyles, such as supporting them to stop smoking, is a recurring feature of the work of primary and community nurses. However, the power in many consultations focusing on changing behaviours often lies with the nurse rather than the patient. The temptation may be to deny the patient opportunities to talk about what might have happened before, such as successful attempts to quit, and what might be on their mind, such as concern for an unwell spouse. Rather, the focus is often on giving advice and suggesting actions. This can result in resistance from the patient, who may say, for example, that they have smoked for years and that it is ‘too hard’ to stop.

One technique now widely used in primary care is motivational interviewing (Droppa and Lee 2014). This involves identifying the person’s motivation to change their behaviour, shifting power towards the individual and avoiding the development of resistance. A patient may, for example, want to stop smoking not for their health but because it upsets their partner. Using motivational interviewing, the nurse attempts to identify and reflect the individual’s past strengths and successes.

Strengths-based questions

The concept of supporting people to understand their strengths is often a feature in social work where ‘strengths-based’ questions are used. The pioneer of this approach was Dennis Saleebey (Saleebey 2006), emeritus professor at the University of Kansas. Saleebey (2006) suggested that encouraging people to understand their strengths has three important components:

  • Possibility and positive expectations.

  • Capacity, courage and competence.

  • Reserves, resilience and resources.

Saleebey (2006) developed a set of seven strengths-based questions (Box 1).

Time Out 5

Motivational interviewing

Motivational interviewing centres on a belief in individuals and developing their capabilities. If you are familiar with the structure of a GP consultation you may recognise that many GPs include strength-based questions such as these.

You may use some of them yourself. Next time you are delivering person-centred care, try asking one or more of these questions. Avoid offering advice and focus on the patient’s issue. Give patients space to work out what they could do to ameliorate the issue and try not to interrupt with your own solutions. After this patient contact, reflect on what you have learned.

Box 1.

Seven strengths-based questions

  • 1. Survival questions – how have you managed to overcome/survive the challenges that you have experienced? What have you learned about yourself and your world during those struggles?

  • 2. Support questions – who are the people that you can rely on? Who has made you feel understood, supported or encouraged?

  • 3. Exception questions – when things were going well in life, what was different?

  • 4. Possibility questions – what do you want to accomplish in your life? What are your hopes for your future or the future of your family?

  • 5. Esteem questions – what makes you proud about yourself? What positive things do people say about you?

  • 6. Perspective questions – what are your ideas about your current situation?

  • 7. Change questions – what do you think is necessary for things to change? What could you do to make that happen?

(Saleebey 2006)

Moving from providing care to supporting patients to identify their own solutions is a major cultural change for many nurses. The Health Foundation (2011) sets out the principles of motivational interviewing and how best to train people in these techniques. It is important that nurses do not feel they have failed if they lapse back into familiar clinical situations – the use of strengths-based approaches takes time and practice.

Shifting from personal to community-centred approaches

Case study 3 describes how a nurse in Wigan, England, changed from a personal to a community-centred approach to improving the well-being of his patients. In it, Keith Cunliffe recognised that nurses cannot fix every issue or ‘prescribe’ health. However, they can support improvements in health and well-being. The Wigan Deal demonstrates some wider benefits that community activism can have on happiness and well-being. The people of Wigan had to innovate to overcome challenges, for example by taking over day centres and using them in new ways, including developing a former dementia day care centre into a community hub of health and well-being. As they did this, they developed a confidence and self-belief that spread across the borough. The initiative of the people had the full backing of council staff, who believed in and praised their work (Naylor and Wellings 2019).

Time Out 6

Volunteering

Take a moment to consider why people may volunteer for community activities. Write a list of all the reasons you can think of, based on what you have learned so far in this article.

Volunteering as a community-centred approach

Volunteering, as described in Case study 3, has been found to have several health benefits. Casiday et al (2008) found that volunteering decreased mortality and improved elements that contribute to well-being, such as life satisfaction and social interaction. Yeung et al (2018) concluded that volunteering should be promoted as an aspect of healthy lifestyles, after finding that volunteering was linked with improved health outcomes such as social well-being and life satisfaction.

Social prescribing and collaborative practice

The development of social prescribing represents a major step towards regarding well-being as an important component in health. Social connectedness and focusing on what matters to people are regarded as central tenets of social prescribing (NHS England 2019b).

In some cases, social prescribing has been further developed to offer people the opportunity to become involved in supporting each other, rather than simply providing a service. A voluntary organisation called Altogether Better upports healthcare services to introduce collaborative practice. This is a model of supporting healthcare services and the local community to find new ways of working together (Altogether Better 2018a).

Altogether Better works with general practices to invite local people to volunteer to set up community activities, ranging from knitting to baton twirling. To date, local people known as ‘champions’ and working alongside participant GP surgeries have set up over 200 types of activities. This represents a culture change in general practice, because these people are becoming part of the workforce. An internal evaluation from Altogether Better showed that 86% of champions and 94% of participants in the programme reported increased levels of confidence and well-being (Altogether Better 2018b).

An independent evaluation of the Altogether Better programme in the Oxford Terrace and Rawling Road GP practice in Gateshead, England showed a 30% fall in frequent GP attenders – defined as those who attend at least once a month – from over 1,000 people in 2015 to 700 in 2017 (Datasyrup 2019). Following the introduction of the programme, GPs in the practice were able to go home on time and the practice had spare appointments to offer to other local practices.

Moving from illness to wellness in nursing

The predominant paradigm of the biomedical model, which requires nurses to support people to stay healthy and recover from illness, is still required. However, personalised care means nurses need to go further and empower people to take control of their own care. Having control, meaning and purpose can mediate some of life’s stressors, provide a sense of satisfaction with life, and improve overall well-being (New NHS Alliance 2017).

This will present some challenges for nurses, for example:

  • Whether they will be able to move from managing the effects of socio-economic challenges to addressing the causes, such as unemployment leading to poverty. For example, a nurse could encourage somebody to volunteer, which provides them with the skills and confidence to apply and obtain a job.

  • Whether patients will recognise and accept the need to partner with nurses and take action rather than be cared for.

  • Whether nurses can support patients to understand their strengths and mobilise themselves as assets.

  • Whether nurses will be able to develop the ability to relinquish the ‘power’ gained from supporting people, and instead invite those people to support nurses.

Through techniques such as motivational interviewing and using strengths-based questions, nurses can support people to explore their narratives – their stresses and issues – and enable them to recognise what they can do for themselves. Nurses can move from ‘being the change’ to ‘facilitating the change’. Case studies such as the ones detailed in this article can inspire nurses and the people they support, offering useful ‘how to’ guides. Figure 2 sets out the continuum of nurses moving between needs-based and asset-based approaches.

Figure 2.

Continuum of nurses moving between needs-based and asset-based approaches

phc.2020.e1680_0002.jpg

Figure 2 takes the example of the nurse’s role in asthma care. On the left is the familiar needs-based biomedical approach, where it is important to provide nursing care to the patient. As nurses move from left to right, power and control becomes increasingly shared, solutions are coproduced, and social factors and ‘what matters to me’ come into view, as does a focus on finding and harnessing people’s strengths. This represents a continuum that enables nurses to transition between illness and wellness.

Conclusion

Universal personalised care is becoming increasingly important. However, the discourse concerning personalised care remains primarily focused on deficit-based, needs-based and service-driven models of care, with little focus on improving well-being. While health is a contributor to well-being it is not the most important factor, with personal relationships and a sense of belonging to a community having a greater effect on well-being.

Well-being has a substantial effect on a person’s health, and improving well-being can lead to improved health outcomes for communities. Nurses can facilitate improved well-being by moving between a needs-based biomedical approach to care and an asset-based approach.

Time Out 7

Consider how personalised care relates to The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council 2018), or for non-UK readers the requirements of your regulatory body

Time Out 8

Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account

Further Resources

Altogether Better

www.altogetherbetter.org.uk

Leg Club

legclub.org

Dumbarton Democrat motivation award

tinyurl.com/DD-motivation

Warwick-Edinburgh Mental Wellbeing Scale

tinyurl.com/WMBWMS

Case study 1. Adapting social prescribing to address well-being

Following the final ‘Cod War’ in 1976 (a fishing rights dispute with Iceland) the English town of Fleetwood experienced a decline in its fishing industry. Alongside the loss of fishing jobs, the retail industry and other businesses that relied on fishing also suffered.

By 2016 a local GP in the area, Mark Spencer, realised that hopelessness was motivating people to visit his surgery. He realised that his medical approach was not improving the issues for these people.

He decided to contact a charity based in Exeter called Connecting Communities (www.c2connectingcommunities.co.uk) – which was set up by retired health visitor Hazel Stuteley and specialises in working alongside communities – to understand how he could implement similar methods in Fleetwood. After a period of planning, Dr Spencer started to organise get-togethers for local people to regain the sense of community they felt had been lost, and asked them ‘what matters to you’? For example, some of the first events that were organised were litter picks on the beach. Here, the community were the ones organising these events based on what mattered to them, rather than them being prescribed by Dr Spencer. The activities provided a sense of purpose and meaning to those who participated.

This initiative encouraged others in the area to set up community activities such as singing, football and cooking groups. Over time, Dr Spencer noticed that people’s health and well-being improved. They were losing weight through taking part in the activities and they felt in control of their own well-being. All-cause non-elective hospital admissions fell by 20% as a result, and the approach has been extended across the local area.

Case study 2. AExamples of asset-based approaches that have empowered communities

In 1995, Ellie Lindsay, a district nurse from Suffolk, pioneered the Lindsay Leg Club for lower limb management. The clubs are a partnership between nurses and people with leg ulcers, who are empowered to own and manage the club.

Individuals are encouraged to meet in a non-medical setting and are transported to the club, often by volunteers. They are treated together rather than in their homes, which can avoid social isolation, particularly if they are housebound. The emphasis is on social interaction, participation, empathy and peer support. There are clubs across the UK, as well as one in Germany and two in Australia.

Sarah Everett is a practice sister at Govan Health Centre in Glasgow. She ‘cajoled’ socially isolated men to start a Men’s Shed, a well-being hub including activities such as cooking and gardening. She won RCNi’s Patient’s Choice award in 2019 for her work, which has been described by the club members as ‘life-changing’ (Healey 2019).

Case study 3. Moving from personal to community-centred approaches

Keith Cunliffe began his nursing career when volunteering at a local mental health hospital in Wigan, England, for three months. He subsequently spent 40 years working as a mental health nurse in the area and is now an elected borough councillor. When faced with huge budget cuts in 2011, he and others recognised that the 320,000-strong community of Wigan was an asset.

This led to a reshaping of the relationship between the council and the local people called The Wigan Deal (Naylor and Wellings 2019). The council began working with Nesta, a foundation that supports innovative ideas, to harness the activism and energy of a disadvantaged community in the Scholes area of Wigan. They invested money in factors that the residents considered important, such as a food poverty scheme where food that was near its expiry date was recycled and sold in a community café on a pay as you feel basis, and put the community in charge of delivering these factors.

Since 2013, the council has invested £10 million in community groups and projects. Staff have been retrained to use ethnological approaches to study the characteristics of people and their relationships, and encouraged to conduct what was called ‘a different conversation’ with the community, that identified what was most important to community members. Nine years on from the inception of the deal, healthy life expectancy has increased significantly in the area (Naylor and Wellings 2019)

References

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