research paper on health and wellbeing

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• Published: 19 June 2020

Well-being is more than happiness and life satisfaction: a multidimensional analysis of 21 countries

• Kai Ruggeri 1 , 2 ,
• Eduardo Garcia-Garzon 3 ,
• Áine Maguire 4 ,
• Sandra Matz 5 &
• Felicia A. Huppert 6 , 7  

Health and Quality of Life Outcomes volume  18 , Article number:  192 ( 2020 ) Cite this article

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Recent trends on measurement of well-being have elevated the scientific standards and rigor associated with approaches for national and international comparisons of well-being. One major theme in this has been the shift toward multidimensional approaches over reliance on traditional metrics such as single measures (e.g. happiness, life satisfaction) or economic proxies (e.g. GDP).

To produce a cohesive, multidimensional measure of well-being useful for providing meaningful insights for policy, we use data from 2006 and 2012 from the European Social Survey (ESS) to analyze well-being for 21 countries, involving approximately 40,000 individuals for each year. We refer collectively to the items used in the survey as multidimensional psychological well-being (MPWB).

The ten dimensions assessed are used to compute a single value standardized to the population, which supports broad assessment and comparison. It also increases the possibility of exploring individual dimensions of well-being useful for targeting interventions. Insights demonstrate what may be masked when limiting to single dimensions, which can create a failure to identify levers for policy interventions.

Conclusions

We conclude that both the composite score and individual dimensions from this approach constitute valuable levels of analyses for exploring appropriate policies to protect and improve well-being.

What is well-being?

Well-being has been defined as the combination of feeling good and functioning well; the experience of positive emotions such as happiness and contentment as well as the development of one’s potential, having some control over one’s life, having a sense of purpose, and experiencing positive relationships [ 23 ]. It is a sustainable condition that allows the individual or population to develop and thrive. The term subjective well-being is synonymous with positive mental health. The World Health Organization [ 45 ] defines positive mental health as “a state of well-being in which the individual realizes 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”. This conceptualization of well-being goes beyond the absence of mental ill health, encompassing the perception that life is going well.

Well-being has been linked to success at professional, personal, and interpersonal levels, with those individuals high in well-being exhibiting greater productivity in the workplace, more effective learning, increased creativity, more prosocial behaviors, and positive relationships [ 10 , 27 , 37 ]. Further, longitudinal data indicates that well-being in childhood goes on to predict future well-being in adulthood [ 39 ]. Higher well-being is linked to a number of better outcomes regarding physical health and longevity [ 13 ] as well as better individual performance at work [ 30 ], and higher life satisfaction has been linked to better national economic performance [ 9 ].

Measurement of well-being

Governments and researchers have attempted to assess the well-being of populations for centuries [ 2 ]. Often in economic or political research, this has ended up being assessed using a single item about life satisfaction or happiness, or a limited set of items regarding quality of life [ 3 ]. Yet, well-being is a multidimensional construct, and cannot be adequately assessed in this manner [ 14 , 24 , 29 ]. Well-being goes beyond hedonism and the pursuit of happiness or pleasurable experience, and beyond a global evaluation (life satisfaction): it encompasses how well people are functioning, known as eudaimonic, or psychological well-being. Assessing well-being using a single subjective item approach fails to offer any insight into how people experience the aspects of their life that are fundamental to critical outcomes. An informative measure of well-being must encompass all the major components of well-being, both hedonic and eudaimonic aspects [ 2 ], and cannot be simplified to a unitary item of income, life satisfaction, or happiness.

Following acknowledgement that well-being measurement is inconsistent across studies, with myriad conceptual approaches applied [ 12 ], Huppert and So [ 27 ] attempted to take a systematic approach to comprehensively measure well-being. They proposed that positive mental health or well-being can be viewed as the complete opposite to mental ill health, and therefore attempted to define mental well-being in terms of the opposite of the symptoms of common mental disorders. Using the DSM-IV and ICD-10 symptom criteria for both anxiety and depression, ten features of psychological well-being were identified from defining the opposite of common symptoms. The features encompassed both hedonic and eudaimonic aspects of well-being: competence, emotional stability, engagement, meaning, optimism, positive emotion, positive relationships, resilience, self-esteem, and vitality. From these ten features an operational definition of flourishing, or high well-being, was developed using data from Round 3 of the European Social Survey (ESS), carried out in 2006. The items used in the Huppert and So [ 27 ] study were unique to that survey, which reflects a well-being framework based on 10 dimensions of good mental health. An extensive discussion on the development and validation of these measures for the framework is provided in this initial paper [ 27 ].

As this was part of a major, multinational social survey, each dimension was measured using a single item. As such, ‘multidimensional’ in this case refers to using available measures identified for well-being, but does not imply a fully robust measure of these individual dimensions, which would require substantially more items that may not be feasible for population-based work related to policy development. More detailed and nuanced approaches might help to better capture well-being as a multidimensional construct, and also may consider other dimensions. However, brief core measures such as the one implemented in the ESS are valuable as they provide a pragmatic way of generating pioneering empirical evidence on well-being across different populations, and help direct policies as well as the development of more nuanced instruments. While this naturally would benefit from complementary studies of robust measurement focused on a single topic, appropriate methods for using sprawling social surveys remain critical, particularly through better standardization [ 6 ]. While this paper will overview those findings, we strongly encourage more work to that end, particularly in more expansive measures to support policy considerations.

General approach and key questions

The aim of the present study was to develop a more robust measurement of well-being that allows researchers and policymakers to measure well-being both as a composite construct and at the level of its fundamental dimensions. Such a measure makes it possible to study overall well-being in a manner that goes beyond traditional single-item measures, which capture only a fraction of the dimensions of well-being, and because it allows analysts to unpack the measure into its core components to identify strengths and weaknesses. This would produce a similar approach as the most common reference for policy impacts: Gross Domestic Product (GDP), which is a composite measure of a large number of underlying dimensions.

The paper is structured as follows: in the first step, data from the ESS are used to develop a composite measure of well-being from the items suggested by Huppert & So [ 27 ] using factor analysis. In the second step, the value of the revised measure is demonstrated by generating insights into the well-being of 21 European countries, both at the level of overall well-being and at the level of individual dimensions.

The European social survey

The ESS is a biannual survey of European countries. Through comprehensive measurement and random sampling techniques, the ESS provides a representative sample of the European population for persons aged 15 and over [ 38 ]. Both Round 3 (2006–2007) and Round 6 (2012–2013) contained a supplementary well-being module. This module included over 50 items related to all aspects of well-being including psychological, social, and community well-being, as well as incorporating a brief measure of symptoms of psychological distress. As summarized by Huppert et al. [ 25 ], of the 50, only 30 items relate to personal well-being, of which only 22 are positive measures. Of those remaining, not all relate to the 10 constructs identified by Huppert and So [ 27 ], so only a single item could be used, or else the item that had the strongest face validity and distributional items were chosen.

Twenty-two countries participated in the well-being modules in both Round 3 and Round 6. As this it within a wider body of analyses, it was important to focus on those initially. Hungary did not have data for the vitality item in Round 3 and was excluded from the analysis, as appropriate models would not have been able to reliably resolve a missing item for an entire country. To be included in the analysis and remain consistent, participants therefore had to complete all 10 items used and have the age, gender, employment, and education variables completed. Employment was classified into four groups: students, employed, unemployed, retired; other groups were excluded. Education was classified into three groups: low (less than secondary school), middle (completed secondary school), and high (postsecondary study including any university and above). Using these criteria, the total sample for Round 6 was 41,825 people from 21 countries for analysis. The full sample was 52.6% female and ranged in age from 15 to 103 (M = 47.9; SD = 18.9). Other details about participation, response rates, and exclusion have been published elsewhere [ 38 ].

Huppert & So [ 27 ] defined well-being using 10 items extracted from the Round 3 items, which represent 10 dimensions of well-being. However, the items used in Round 3 to represent positive relationships and engagement exhibited ceiling effects and were removed from the questionnaire in Round 6. Four alternatives were available to replace each question. Based on their psychometric properties (i.e., absence of floor effects and wider response distributions), two new items were chosen for positive relationships and engagement (one item for each dimension). The new items and those they replaced can be seen in Table  1 (also see Supplement ).

Development of a composite measure of psychological well-being (MPWB)

A composite measure of well-being that yields an overall score for each individual was developed. From the ten indicators of well-being shown in Table 1 , a single factor score was calculated to represent MPWB. This overall MPWB score hence constitutes a summary of how an individual performs across the ten dimensions, which is akin to a summary score such as GDP, and will be of general value to policymakers. Statistical analysis was performed in R software, using lavaan [ 40 ] and lavaan.survey [ 35 ] packages. The former is a widely-used package for the R software designed for computing structural equation models and confirmatory factor analyses (CFA). The latter allows introducing complex survey design weights (combination of design and population size weights) when estimating confirmatory factor analysis models with lavaan, which ensures that MPWB scoring followed ESS guidelines regarding both country-level and survey specific weights [ 17 ]. Both packages have been previously tested and validated in various analyses using ESS data (as explained in detail in lavaan.survey documentation).

It should be noted that Round 6 was treated as the focal point of these efforts before repeating for Round 3, primarily due to the revised items that were problematic in Round 3, and considering that analyses of the 2006 data are already widely available.

Prior to analysis, all items were coded such that higher scores were more positive and lower scores more negative. Several confirmatory factor analysis models were performed in order to test several theoretical conceptualizations regarding MPWB. Finally, factor scores (expected a posteriori [ 15 ];) were calculated for the full European sample and used for descriptive purposes. The approach and final model are presented in supplemental material .

Factor scores are individual scores computed as weighted combinations of each person’s response on a given item and the factor scoring coefficients. This approach is to be preferred to using raw or sum scores: sum or raw scores fail to consider how well a given item serves as an indicator of the latent variable (i.e., all items are unrealistically assumed to be perfect and equivalent measures of MPWB). They also do not take into account that different items could present different variability, which is expected to occur if items present different scales (as in our case). Therefore, the use of such simple methods results in inaccurate individual rankings for MPWB. To resolve this, factor scores are both more informative and more accurate, as they avoid the propagation of measurement error in subsequent analyses [ 19 ].

Not without controversy (see Supplement ), factor scores are likely to be preferable to sum scores when ranking individuals on unobservable traits that are expected to be measured with noticeable measurement error (such as MPWB [ 32 ];). Similar approaches based on factor scoring have been successfully applied in large international assessment research [ 21 , 34 ]. With the aim of developing a composite well-being score, it was necessary to provide a meaningful representation of how the different well-being indicators are reflected in the single measure. A hierarchical model with one higher-order factor best approximated MPWB along with two first-order factors (see supplement Figure S 1 ). This model replicates the factor structure reported for Round 3 by Huppert & So [ 27 ]. The higher-order factor explained the relationship between two first-order factors (positive functioning and positive characteristics showed a correlation of ρ = .85). In addition, modelling standardized residuals showed that the items representing vitality and emotional stability and items representing optimism and self-esteem were highly correlated. The similarities in wording in both pairs of items (see Table 1 ) are suspected to be responsible for such high residual correlations. Thus, those correlations were included in the model. As presented in Table  2 , the hierarchical model was found to fit the data better than any other model but a bi-factor model including these correlated errors. The latter model resulted in collapsed factor structure with a weak, bi-polar positive functioning factor. However, this bi-factor model showed a problematic bi-polar group factor with weak loadings. Whether this group factor was removed (resulting in a S-1 bi-factor model, as in [ 16 ]), model fit deteriorated. Thus, neither bi-factor alternative was considered to be acceptable.

To calculate the single composite score representing MPWB, a factor scoring approach was used rather than a simplistic summing of raw scores on these items. Factor scores were computed and standardized for the sample population as a whole, which make them suitable for broad comparison [ 8 ]. This technique was selected for two reasons. First, it has the ability to take into account the different response scales used for measuring the items included in the multidimensional well-being model. The CFA model, from which MPWB scores were computed, was defined such that the metric of the MPWB was fixed, which results in a standardized scale. Alternative approaches, such as sum or raw scores, would result in ignoring the differential variability across items, and biased individual group scores. Our approach, using factor scoring, resolves this issue by means of standardization of the MPWB scores. The second reason for this technique is that it could take account of how strongly each item loaded onto the MPWB factor. It should be noted that by using only two sub-factors, the weight applied to the general factor is identical within the model for each round. This model was also checked to ensure it also was a good fit for different groups based on gender, age, education and employment.

Separate CFA analyses per each country indicate that the final model fit the data adequately in all countries (.971 < CFI < .995; .960 < TFI < .994; .020 < RMSEA < .05; 0,023 < SRMR < 0,042). All items presented substantive loadings on their respective factors, and structures consistently replicated across all tested countries. Largest variations were found when assessing the residual items’ correlations (e.g., for emotional stability and vitality correlation, values ranged from 0,076 to .394). However, for most cases, residuals correlations were of similar size and direction (for both cases, the standard deviation of estimated correlations was close of .10). Thus, strong evidence supporting our final model was systematically found across all analyzed countries. Full results are provided in the supplement (Tables S 2 -S 3 ).

Model invariance

In order to establish meaningful comparisons across groups within and between each country, a two-stage approach was followed, resulting in a structure that was successfully found to be similar across demographics. First, a descriptive comparison of the parameter estimates unveiled no major differences across groups. Second, factor scores were derived for the sample, employing univariate statistics to compare specific groups within country and round. In these analyses, neither traditional nor modern approaches to factor measurement invariance were appropriate given the large sample and number of comparisons at stake ([ 8 ]; further details in Supplement ).

From a descriptive standpoint, the hierarchical structure satisfactorily fit both Round 3 and Round 6 data. All indicators in both rounds had substantial factor loadings (i.e., λ > .35). A descriptive comparison of parameter estimates produced no major differences across the two rounds. The lack of meaningful differences in the parameter estimates confirms that this method for computing MPWB can be used in both rounds.

As MPWB scores from both rounds are obtained from different items that have different scales for responses, it is necessary to transform individual scores obtained from both rounds in order to be aligned. To do this between Round 3 and Round 6 items, a scaling approach was used. To produce common metrics, scores from Round 3 were rescaled using a mean and sigma transformation (Kolen & Brennan 2010) to align with Round 6 scales. This was used as Round 6 measures were deemed to have corrected some deficiencies found in Round 3 items. This does not change outcomes in either round but simply makes the scores match in terms of distributions relative to their scales, making them more suitable for comparison.

As extensive descriptive insights on the sample and general findings are already available (see [ 41 ]), we focus this section on the evidence derived directly from the proposed approach to MPWB scores. For the combined single score for MPWB, the overall mean (for all participants combined) is fixed to zero, and the scores represent deviation from the overall mean. In 2012 (Round 6), country scores on well-being ranged from − 0.41 in Bulgaria to 0.46 in Denmark (Fig.  1 ). There was a significant, positive relationship between national MPWB mean scores and national life satisfaction means ( r =  .56 (.55–.57), p  < .001). In addition, MPWB was negatively related with depression scores and positively associated with other well-being measurements (see Supplement ).

Distribution of national MPWB means and confidence intervals across Europe

Denmark having the highest well-being is consistent with many studies [ 4 , 18 ] and with previous work using ESS data [ 27 ]. While the pattern is typically that Nordic countries are doing the best and that eastern countries have the lowest well-being, exceptions exist. The most notable exception is Portugal, which has the third-lowest score and is not significantly higher than Ukraine, which is second lowest. Switzerland and Germany are second and third highest respectively, and show generally similar patterns to the Scandinavian countries (see Fig. 1 ). It should be noted that, for Figs.  1 , 2 , 3 , 4 , 5 , countries with the lowest well-being are at the top. This is done to highlight the greatest areas for potential impact, which are also the most of concern to policy.

Well-being by country and gender

Well-being by country and age

Well-being by country and employment

Well-being by country and education

General patterns across the key demographic variables – gender, age, education, employment – are visible across countries as seen in Figs.  1 , 2 , 3 , 4 , 5 (see also Supplement 2 ). These figures highlight patterns based on overall well-being as well as potential for inequalities. The visualizations presented here, though univariate, are for the purpose of understanding broad patterns while highlighting the need to disentangle groups and specific dimensions to generate effective policies.

For gender, women exhibited lower MPWB scores than men across Europe (β = −.09, t (36508) = − 10.37; p  < .001). However, these results must be interpreted with caution due to considerable overlap in confidence intervals for many of the countries, and greater exploration of related variables is required. This also applies for the five countries (Estonia, Finland, Ireland, Slovakia, Ukraine) where women have higher means than men. Only four countries have significant differences between genders, all of which involve men having higher scores than women: the Netherlands (β = −.12, t (1759) = − 3.24; p  < .001), Belgium (β = −.14, t (1783) = − 3.94; p  < .001), Cyprus (β = −.18, t (930) = − 2.87; p  < .001) and Portugal (β = −.19, t (1847) = − 2.50; p  < .001).

While older individuals typically exhibited lower MPWB scores compared to younger age groups across Europe (β 25–44  = −.05, t (36506) = − 3.686, p  < .001; β 45–65  = −.12, t (36506) = − 8.356, p  < .001; β 65–74  = −.16, t (36506) = − 8.807, p  < .001; β 75+  = −.28, t (36506) = − 13.568, p  < .001), the more compelling pattern shows more extreme differences within and between age groups for the six countries with the lowest well-being. This pattern is most pronounced in Bulgaria, which has the lowest overall well-being. For the three countries with the highest well-being (Denmark, Switzerland, Germany), even the mean of the oldest age group was well above the European average, while for the countries with the lowest well-being, it was only young people, particularly those under 25, who scored above the European average. With the exception of France and Denmark, countries with higher well-being typically had fewer age group differences and less variance within or between groups. Only countries with the lowest well-being showed age differences that were significant with those 75 and over showing the lowest well-being.

MPWB is consistently higher for employed individuals and students than for retired (β = −.31, t (36506) = − 21.785; p  < .00) or unemployed individuals (β = −.52, t (36556) = − 28.972; p  < .001). Unemployed groups were lowest in nearly all of the 21 countries, though the size of the distance from other groups did not consistently correlate with national MPWB mean. Unemployed individuals in the six countries with the lowest well-being were significantly below the mean, though there is little consistency across groups and countries by employment beyond that. In countries with high well-being, unemployed, and, in some cases, retired individuals, had means below the European average. In countries with the lowest well-being, it was almost exclusively students who scored above the European average. Means for retired groups appear to correlate most strongly with overall well-being. There is minimal variability for employed groups in MPWB means within and between countries.

There is a clear pattern of MPWB scores increasing with education level, though the differences were most pronounced between low and middle education groups (β = .12, t (36508) = 9.538; p  < .001). Individuals with high education were significantly higher on MPWB than those in the middle education group (β = .10, t (36508) =11.06; p  < .001). Differences between groups were noticeably larger for countries with lower overall well-being, and the difference was particularly striking in Bulgaria. In Portugal, medium and high education well-being means were above the European average (though 95% confidence intervals crossed 0), but educational attainment is significantly lower in the country, meaning the low education group represents a greater proportion of the population than the other 21 countries. In the six countries with the highest well-being, mean scores for all levels of education were above the European mean.

Utilizing ten dimensions for superior understanding of well-being

It is common to find rankings of national happiness and well-being in popular literature. Similarly, life satisfaction is routinely the only measure reported in many policy documents related to population well-being. To demonstrate why such limited descriptive approaches can be problematic, and better understood using multiple dimensions, all 21 countries were ranked individually on each of the 10 indicators of well-being and MPWB in Round 6 based on their means. Figure  6 demonstrates the variations in ranking across the 10 dimensions of well-being for each country.

Country rankings in 2012 on multidimensional psychological well-being and each of its 10 dimensions

The general pattern shows typically higher rankings for well-being dimensions in countries with higher overall well-being (and vice-versa). Yet countries can have very similar scores on the composite measure but very different underlying profiles in terms of individual dimensions. Figure  7 a presents this for two countries with similar life satisfaction and composite well-being, Belgium and the United Kingdom. Figure 7 b then demonstrates this even more vividly for two countries, Finland and Norway, which have similar composite well-being scores and identical mean life satisfaction scores (8.1), as well as have the highest two values for happiness of all 21 countries. In both pairings, the broad outcomes are similar, yet countries consistently have very different underlying profiles in individual dimensions. The results indicate that while overall scores can be useful for general assessment, specific dimensions may vary substantially, which is a relevant first step for developing interventions. Whereas the ten items are individual measures of 10 areas of well-being, had these been limited to a single domain only, the richness of the underlying patterns would have been lost, and the limitation of single item approaches amplified.

a Comparison of ranks for dimensions of well-being between two different countries with similar life satisfaction in 2012: Belgium and United Kingdom. b Comparison of ranks for dimensions of well-being between two similar countries with identical life satisfaction and composite well-being scores in 2012: Finland and Norway

The ten-item multidimensional measure provided clear patterns for well-being across 21 countries and various groups within. Whether used individually or combined into a composite score, this approach produces more insight into well-being and its components than a single item measure such as happiness or life satisfaction. Fundamentally, single items are impossible to unpack in reverse to gain insights, whereas the composite score can be used as a macro-indicator for more efficient overviews as well as deconstructed to look for strengths and weaknesses within a population, as depicted in Figs.  6 and 7 . Such deconstruction makes it possible to more appropriately target interventions. This brings measurement of well-being in policy contexts in line with approaches like GDP or national ageing indexes [ 7 ], which are composite indicators of many critical dimensions. The comparison with GDP is discussed at length in the following sections.

Patterns within and between populations

Overall, the patterns and profiles presented indicate a number of general and more nuanced insights. The most consistent among these is that the general trend in national well-being is usually matched within each of the primary indicators assessed, such as lower well-being within unemployed groups in countries with lower overall scores than in those with higher overall scores. While there are certainly exceptions, this general pattern is visible across most indicators.

The other general trend is that groups with lower MPWB scores consistently demonstrate greater variability and wider confidence intervals than groups with higher scores. This is a particularly relevant message for policymakers given that it is an indication of the complexity of inequalities: improvements for those doing well may be more similar in nature than for those doing poorly. This is particularly true for employment versus unemployment, yet reversed for educational attainment. Within each dimension, the most critical pattern is the lack of consistency for how each country ranks, as discussed further in other sections.

Examining individual dimensions of well-being makes it possible to develop a more nuanced understanding of how well-being is impacted by societal indicators, such as inequality or education. For example, it is possible that spending more money on education improves well-being on some dimensions but not others. Such an understanding is crucial for the implementation of targeted policy interventions that aim at weaker dimensions of well-being and may help avoid the development of ineffective policy programs. It is also important to note that the patterns across sociodemographic variables may differ when all groups are combined, compared to results within countries. Some effects may be larger when all are combined, whereas others may have cancelling effects.

Using these insights, one group that may be particularly important to consider is unemployed adults, who consistently have lower well-being than employed individuals. Previous research on unemployment and well-being has often focused on mental health problems among the unemployed [ 46 ] but there are also numerous studies of differences in positive aspects of well-being, mainly life satisfaction and happiness [ 22 ]. A large population-based study has demonstrated that unemployment is more strongly associated with the absence of positive well-being than with the presence of symptoms of psychological distress [ 28 ], suggesting that programs that aim to increase well-being among unemployed people may be more effective than programs that seek to reduce psychological distress.

Certainly, it is well known that higher income is related to higher subjective well-being and better health and life expectancy [ 1 , 42 ], so reduced income following unemployment is likely to lead to increased inequalities. Further work would be particularly insightful if it included links to specific dimensions of well-being, not only the comprehensive scores or overall life satisfaction for unemployed populations. As such, effective responses would involve implementation of interventions known to increase well-being in these groups in times of (or in spite of) low access to work, targeting dimensions most responsible for low overall well-being. Further work on this subject will be presented in forthcoming papers with extended use of these data.

This thinking also applies to older and retired populations in highly deprived regions where access to social services and pensions are limited. A key example of this is the absence in our data of a U-shaped curve for age, which is commonly found in studies using life satisfaction or happiness [ 5 ]. In our results, older individuals are typically lower than what would be expected in a U distribution, and in some cases, the oldest populations have the lowest MPWB scores. While previous studies have shown some decline in well-being beyond the age of 75 [ 20 ], our analysis demonstrates quite a severe fall in MPWB in most countries. What makes this insight useful – as opposed to merely unexpected – is the inclusion of the individual dimensions such as vitality and positive relationships. These dimensions are clearly much more likely to elicit lower scores than for younger age groups. For example, ageing beyond 75 is often associated with increased loneliness and isolation [ 33 , 43 ], and reduction in safe, independent mobility [ 31 ], which may therefore correspond with lower scores on positive relationships, engagement, and vitality, and ultimately lower scores on MPWB than younger populations. Unpacking the dimensions associated with the age-related decline in well-being should be the subject of future research. The moderate positive relationship of MPWB scores with life satisfaction is clear but also not absolute, indicating greater insights through multidimensional approaches without any obvious loss of information. Based on the findings presented here, it is clearly important to consider ensuring the well-being of such groups, the most vulnerable in society, during periods of major social spending limitations.

Policy implications

Critically, Fig.  6 represents the diversity of how countries reach an overall MPWB score. While countries with overall high well-being have typically higher ranks on individual items, there are clearly weak dimensions for individual countries. Conversely, even countries with overall low well-being have positive scores on some dimensions. As such, the lower items can be seen as potential policy levers in terms of targeting areas of concern through evidence-based interventions that should improve them. Similarly, stronger areas can be seen as learning opportunities to understand what may be driving results, and thus used to both sustain those levels as well as potentially to translate for individuals or groups not performing as well in that dimension. Collectively, we can view this insight as a message about specific areas to target for improvement, even in countries doing well, and that even countries doing poorly may offer strengths that can be enhanced or maintained, and could be further studied for potential applications to address deficits. We sound a note of caution however, in that these patterns are based on ranks rather than actual values, and that those ranks are based on single measures.

Figure 7 complements those insights more specifically by showing how Finland and Norway, with a number of social, demographic, and economic similarities, plus identical life satisfaction scores (8.1) arrive at similar single MPWB scores with very different profiles for individual dimensions. By understanding the levers that are specific to each country (i.e. dimensions with the lowest well-being scores), policymakers can respond with appropriate interventions, thereby maximizing the potential for impact on entire populations. Had we restricted well-being measurement to a single question about happiness, as is commonly done, we would have seen both countries had similar and extremely high means for happiness. This might have led to the conclusion that there was minimal need for interventions for improving well-being. Thus, in isolation, using happiness as the single indicator would have masked the considerable variability on several other dimensions, especially those dimensions where one or both had means among the lowest of the 21 countries. This would have resulted in similar policy recommendations, when in fact, Norway may have been best served by, for example, targeting lower dimensions such as Engagement and Self-Esteem, and Finland best served by targeting Vitality and Emotional Stability.

Targeting specific groups and relevant dimensions as opposed to comparing overall national outcomes between countries is perhaps best exemplified by Portugal, which has one of the lowest educational attainment rates in OECD countries, exceeded only by Mexico and Turkey [ 36 ]. This group thus skews the national MPWB score, which is above average for middle and high education groups, but much lower for those with low education. Though this pattern is not atypical for the 21 countries presented here, the size of the low education group proportional to Portugal’s population clearly reduces the national MPWB score. This implies that the greatest potential for improvement is likely to be through addressing the well-being of those with low education as a near-term strategy, and improving access to education as a longer-term strategy. It will be important to analyze this in the near future, given recent reports that educational attainment in Portugal has increased considerably in recent years (though remains one of the lowest in OECD countries) [ 36 ].

One topic that could not be addressed directly is whether these measures offer value as indicators of well-being beyond the 21 countries included here, or even beyond the countries included in ESS generally. In other words, are these measures relevant only to a European population or is our approach to well-being measurement translatable to other regions and purposes? Broadly speaking, the development of these measures being based on DSM and ICD criteria should make them relevant beyond just the 21 countries, as those systems are generally intended to be global. However, it can certainly be argued that these methods for designing measures are heavily influenced by North American and European medical frameworks, which may limit their appropriateness if applied in other regions. Further research on these measures should consider this by adding potential further measures deemed culturally appropriate and seeing if comparable models appear as a result.

A single well-being score

One potential weakness remains the inconsistency of scaling between ESS well-being items used for calculating MPWB. However, this also presents an opportunity to consider the relative weighting of each item within the current scales, and allow for the development of a more consistent and reliable measure. These scales could be modified to align in separate studies with new weights generated – either generically for all populations or stratified to account for various cultural or other influences. Using these insights, scales could alternatively be produced to allow for simple scoring for a more universally accessible structure (e.g. 1–100) but with appropriate values for each item that represents the dimensions, if this results in more effective communication with a general public than a standardized score with weights. Additionally, common scales would improve on attempts to use rankings for presenting national variability within and between dimensions. Researchers should be aware that factor scores are sample-dependent (as based on specific factor model parameters such as factor loadings). Nevertheless, future research focused on investigating specific item differential functioning (by means of multidimensional item response functioning or akin techniques) of these items across situations (i.e., rounds) and samples (i.e., rounds and countries) should be conducted in order to have a more nuanced understanding of this scale functioning.

What makes this discussion highly relevant is the value of a more informed measure to replace traditional indicators of well-being, predominantly life satisfaction. While life satisfaction may have an extensive history and present a useful metric for comparisons between major populations of interest, it is at best a corollary, or natural consequence, of other indicators. It is not in itself useful for informing interventions, in the same way limiting to a single item for any specific dimension of well-being should not alone inform interventions.

By contrast, a validated and standardized multidimensional measure is exceptionally useful in its suitability to identify those at risk, as well as its potential for identifying areas of strengths and weaknesses within the at-risk population. This can considerably improve the efficiency and appropriateness of interventions. It identifies well-understood dimensions (e.g. vitality, positive emotion) for direct application of evidence-based approaches that would improve areas of concern and thus overall well-being. Given these points, we strongly argue for the use of multidimensional approaches to measurement of well-being for setting local and national policy agenda.

There are other existing single-score approaches for well-being addressing its multidimensional nature. These include the Warwick-Edinburgh Mental Well-Being Scale [ 44 ] and the Flourishing Scale [ 11 ]. In these measures, although the single score is derived from items that clearly tap a number of dimensions, the dimensions have not been systematically derived and no attempt is made to measure the underlying dimensions individually. In contrast, the development approach used here – taking established dimensions from DSM and ICD – is based on years of international expertise in the field of mental illness. In other words, there have long been adequate measures for identifying and understanding illness, but there is room for improvement to better identify and understand health. With increasing support for the idea of these being a more central focus of primary outcomes within economic policies, such approaches are exceptionally useful [ 13 ].

Better measures, better insights

Naturally, it is not a compelling argument to simply state that more measures present greater information than fewer or single measures, and this is not the primary argument of this manuscript. In many instances, national measures of well-being are mandated to be restricted to a limited set of items. What is instead being argued is that well-being itself is a multidimensional construct, and if it is deemed a critical insight for establishing policy agenda or evaluating outcomes, measurements must follow suit and not treat happiness and life satisfaction values as universally indicative. The items included in ESS present a very useful step to that end, even in a context where the number of items is limited.

As has been argued by many, greater consistency in measurement of well-being is also needed [ 26 ]. This may come in the form of more consistency regarding dimensions included, the way items are scored, the number of items representing each dimension, and changes in items over time. While inconsistency may be prevalent in the literature to date for definitions and measurement, the significant number of converging findings indicates increasingly robust insights for well-being relevant to scientists and policymakers. Improvements to this end would support more systematic study of (and interventions for) population well-being, even in cases where data collection may be limited to a small number of items.

The added value of MPWB as a composite measure

While there are many published arguments (which we echo) that measures of well-being must go beyond objective features, particularly related to economic indicators such as GDP, this is not to say one replaces the other. More practically, subjective and objective approaches will covary to some degree but remain largely distinct. For example, GDP presents a useful composite of a substantial number of dimensions, such as consumption, imports, exports, specific market outcomes, and incomes. If measurement is restricted to a macro-level indicator such as GDP, we cannot be confident in selecting appropriate policies to implement. Policies are most effective when they target a specific component (of GDP, in this instance), and then are directly evaluated in terms of changes in that component. The composite can then be useful for comprehensive understanding of change over time and variation in circumstances. Specific dimensions are necessary for identifying strengths and weaknesses to guide policy, and examining direct impacts on those dimensions. In this way, a composite measure in the form of MPWB for aggregate well-being is also useful, so long as the individual dimensions are used in the development and evaluation of policies. Similar arguments for other multidimensional constructs have been made recently, such as national indexes of ageing [ 7 ].

In the specific instance of MPWB in relation to existing measures of well-being, there are several critical reasons to ensure a robust approach to measurement through systematic validation of psychometric properties. The first is that these measures are already part of the ESS, meaning they are being used to study a very large sample across a number of social challenges and not specifically a new measure for well-being. The ESS has a significant influence on policy discussions, which means the best approaches to utilizing the data are critical to present systematically, as we have attempted to do here. This approach goes beyond existing measures such as Gallup or the World Happiness Index to broadly cover psychological well-being, not individual features such as happiness or life satisfaction (though we reiterate: as we demonstrate in Fig.  7 a and b, these individual measures can and should still covary broadly with any multidimensional measure of well-being, even if not useful for predicting all dimensions). While often referred to as ‘comprehensive’ measurement, this merely describes a broad range of dimensions, though more items for each dimension – and potentially more dimensions – would certainly be preferable in an ideal scenario.

These dimensions were identified following extensive study for flourishing measures by Huppert & So [ 27 ], meaning they are not simply a mix of dimensions, but established systematically as the key features of well-being (the opposite of ill-being). Furthermore, the development of the items is in line with widely validated and practiced measures for the identification of illness. The primary adjustment has simply been the emphasis on health, but otherwise maintains the same principles of assessment. Therefore, the overall approach offers greater value than assessing only negative features and inferring absence equates to opposite (positives), or that individual measures such as happiness can sufficiently represent a multidimensional construct like well-being. Collectively, we feel the approach presented in this work is therefore a preferable method for assessing well-being, particularly on a population level, and similar approaches should replace single items used in isolation.

While the focus of this paper is on the utilization of a widely tested measure (in terms of geographic spread) that provides for assessing population well-being, it is important to provide a specific application for why this is relevant in a policy context. Additionally, because the ESS itself is a widely-recognized source of meaningful information for policymakers, providing a robust and comprehensive exploration of the data is necessary. As the well-being module was not collected in recent rounds, these insights provide clear reasoning and applications for bringing them back in the near future.

More specifically, it is critical that this approach be seen as advantageous both in using the composite measure for identifying major patterns within and between populations, and for systematically unpacking individual dimensions. Using those dimensions produces nuanced insights as well as the possibility of illuminating policy priorities for intervention.

In line with this, we argue that no composite measure can be useful for developing, implementing, or evaluating policy if individual dimensions are not disaggregated. We are not arguing that MPWB as a single composite score, nor the additional measures used in ESS, is better than other existing single composite scoring measures of well-being. Our primary argument is instead that MPWB is constructed and analyzed specifically for the purpose of having a robust measure suitable for disaggregating critical dimensions of well-being. Without such disaggregation, single composite measures are of limited use. In other words, construct a composite and target the components.

Well-being is perhaps the most critical outcome measure of policies. Each individual dimension of well-being as measured in this study represents a component linked to important areas of life, such as physical health, financial choice, and academic performance [ 26 ]. For such significant datasets as the European Social Survey, the use of the single score based on the ten dimensions included in multidimensional psychological well-being gives the ability to present national patterns and major demographic categories as well as to explore specific dimensions within specific groups. This offers a robust approach for policy purposes, on both macro and micro levels. This facilitates the implementation and evaluation of interventions aimed at directly improving outcomes in terms of population well-being.

Availability of data and materials

The datasets analysed during the current study are available in the European Social Survey repository, http://www.europeansocialsurvey.org/data/country_index.html

Abbreviations

Diagnostic and Statistical Manual of Mental Disorders

European Social Survey

Gross Domestic Product

International Classification of Disease

Multidimensional psychological well-being

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Acknowledgements

The authors would like to thank Ms. Sara Plakolm, Ms. Amel Benzerga, and Ms. Jill Hurson for assistance in proofing the final draft. We would also like to acknowledge the general involvement of the Centre for Comparative Social Surveys at City University, London, and the Centre for Wellbeing at the New Economics Foundation.

This work was supported by a grant from the UK Economic and Social Research Council (ES/LO14629/1). Additional support was also provided by the Isaac Newton Trust, Trinity College, University of Cambridge, and the UK Economic and Social Research Council (ES/P010962/1).

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KR is the lead author and researcher on the study, responsible for all materials start to finish. FH was responsible for the original grant award and the general theory involved in the measurement approaches. ÁM was responsible for broad analysis and writing. EGG was responsible for psychometric models and the original factor scoring approach, plus writing the supplementary explanations. SM provided input on later drafts of the manuscript as well as the auxiliary analyses. The authors read and approved the final manuscript.

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Additional file 1: figure s1.

. Hierarchical approach to modelling comprehensive psychological well-being. Table S1 . Confirmatory Factor Structure for Round 6 and 3. Figure S2 . Well-being by country and gender. Figure S3 . Well-being by country and age. Figure S4 . Well-being by country and employment. Figure S5 . Well-being by country and education. Table S2 . Item loadings for Belgium to Great Britain. Table S3 . Item loadings for Ireland to Ukraine.

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Ruggeri, K., Garcia-Garzon, E., Maguire, Á. et al. Well-being is more than happiness and life satisfaction: a multidimensional analysis of 21 countries. Health Qual Life Outcomes 18 , 192 (2020). https://doi.org/10.1186/s12955-020-01423-y

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Determinants of wellbeing in university students: The role of residential status, stress, loneliness, resilience, and sense of coherence

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Maintaining wellbeing in university students is a government priority, but robust evidence has been lacking. Higher wellbeing is associated with better mental and physical health, higher self-esteem, self-efficacy, and effective coping strategies. This study aimed to identify, through an online survey in 2018, key determinants of wellbeing amongst a sample of 574 (65.5% female) students across all levels of study at a university in the UK. Most respondents (526 (91.8%)) reported feeling unusually stressed or overwhelmed at university. Residential students reported higher loneliness and number of stressors than commuter students, and postgraduate students reported higher wellbeing, resilience, and sense of coherence, and lower perceived stress and loneliness. Hierarchical regression analyses showed that 71.8% of the variance in wellbeing was predicted by a model containing demographics (age/gender, level of study, number of stressors), psychosocial variables, and perceived stress, with perceived stress, sense of coherence, loneliness, and resilience the strongest predictors. The findings suggest that interventions designed to improve resilience and sense of coherence, and reduce loneliness and perceived stress are likely to be effective in enhancing wellbeing in a student population.

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Introduction

Mental health and wellbeing in university students is of increasing concern throughout the world (Royal College of Psychiatrists,  2011 ; Brown, 2018 ; Hughes & Spanner, 2019 ). Increasing numbers of students are reporting and seeking support for mental health difficulties (Auerbach et al., 2018 ), possibly due to a number of factors including increasing financial pressures, uncertain future career prospects, widening participation, and an increased awareness of the signs and symptoms of mental health difficulties (Pollard et al., 2019 ; Royal College of Psychiatrists, 2011 ). Although this trend is reflected in the general population – mental health difficulties have increased in young people aged 16–24 across a similar timescale (Johnson & Crenna-Jennings, 2018 ) – students have in recent years scored lower than their non-student counterparts on a number of measures of wellbeing (Neves & Hillman, 2019 ). Students attending university for the first time at this age are vulnerable to mental health difficulties, with evidence suggesting that the majority of mental illnesses develop by the time an individual reaches their mid-20 s (Kessler et al., 2007 ).

The transition to university is often a time of great upheaval requiring rapid adjustment and considerable personal resources (Lipson & Eisenberg, 2018 ). During this period, students may not only need to move home, often to a new place away from friends and family, but also need to make new social connections, manage finances, manage a household and manage their own time, which can be frightening new experiences for them. Many students also have to juggle academic study with paid work and other commitments, alongside an increasingly busy social life. Combined with the transition towards academic autonomy, the requirement for considerable independent study, and constant assessment deadlines with reduced support from tutors compared to their previous school experience, the university experience itself can be a source of stress and has been associated with increased mental health difficulties (Cleary et al., 2011 ). However, little published research exists on how the university experience affects student wellbeing (Barkham et al., 2019 ), and how individual psychological characteristics, such as personality, outlook, and coping resources, might influence students’ ability to maintain their wellbeing in the face of personal and academic stressors. Thus, understanding the determinants of student wellbeing across all levels of study and personal circumstances is vital to enable universities to help support students and prevent the development of mental health difficulties that may continue throughout their lives.

University-Related Factors

The university experience is changing. Financial pressures and widening participation initiatives have resulted in greater numbers of students remaining in the family home while undertaking their university studies (Pollard et al., 2019 ). This is particularly the case in city-based universities, where strong transport links facilitate commuting to the university campus, enabling more students to study from home in their local area. These ‘commuter’ or ‘stay-at-home’ students, who constitute as much as 90% of the student population at some universities (Jones, 2020 ), experience university in a qualitatively different way to ‘residential’ students who live in halls or shared accommodation, and are more likely to come from underrepresented groups and experience lower progression rates than their peers (Office for Students, 2020a ). Lower achievement can lead to negative impacts on mental health and wellbeing, which for commuter students is compounded by the challenge of developing social connections with fellow students, particularly when social events are held on campus during the evenings or weekends. In addition, commuter students are often overlooked by student societies or support services. Evidence suggests that commuter students fare less well than their residential counterparts in terms of academic achievement (Office for Students, 2020a ) and satisfaction with life (Blackman, 2020 ; Office for Students, 2020b ).

Although there is a paucity of longitudinal research on student wellbeing, one such study demonstrated that psychological wellbeing and anxiety levels fluctuated across the three-year undergraduate degree, and across the academic year (Bewick et al., 2010 ). Macaskill ( 2013 ) reported increased psychiatric symptoms amongst second year undergraduates, although the reasons for this warrant further investigation. High levels of mental distress and low wellbeing have also been reported amongst postgraduate research students (Byrom et al., 2020 ). Understanding the predictors of wellbeing at different stages of the university experience is vital for ensuring student support services are tailored appropriately.

University students experience many stressors including assessments, financial difficulties, relationship and family difficulties, and job insecurity. Lazarus and Folkman’s ( 1984 ) transactional model of stress conceptualises perceived stress as an individual’s appraisal of their circumstances as stressful in relation to their ability to cope. High perceived stress has been associated with higher levels of mental health difficulties, including anxiety and depression (Stowell et al., 2021 ). Perceived stress, particularly relating to assessment, has been shown to be a strong predictor of student mental health and wellbeing (Denovan & Macaskill, 2017 ; McIntyre et al., 2018 ; Neves & Hillman, 2019 ).

Psychosocial Resources

Research into the determinants of wellbeing has emphasised the importance of psychosocial factors and resources in underpinning an individual’s approach and response to life circumstances, which in turn influences their outlook and mental wellbeing (Diener et al., 1999 ). Three such factors are loneliness, resilience and sense of coherence.

Loneliness has also been shown to be an important determinant of student wellbeing and mental distress (McIntyre et al., 2018 ). Although – and possibly because – university is often championed as a time of increased social connectedness, where students will meet life-long friends or romantic partners, increasing numbers of students report feeling lonely (Diehl et al., 2018 ). This issue is especially acute for commuter students who remain more connected to their family and childhood friendships than their academic peers (Office for Students, 2020a ). This can also create a disconnect for these students both socially and intellectually when ‘transitioning’ back into their home lives and mixing with family and peers who may not have attended university themselves (Office for Students, 2020b ).

Resilience is here conceptualised as a process by which an individual ‘bounces back’ from adversity (Fletcher and Sarkar, 2013 ; Windle, 2011 ), enabling them to respond to stressful situations in a positive way and both maintain their wellbeing and/or use the experience to flourish by developing their personal skills and resources. Resilience has been strongly associated with subjective and psychological wellbeing, including mental health difficulties, in a variety of populations (Smith et al., 2008 ; Windle, 2011 ), including young adults (Campbell-Sills et al., 2006 ). Understanding and supporting the development of resilience has been highlighted as a key priority within higher education policy and practice (McIntosh & Shaw, 2017 ).

Sense of coherence (SOC) stems from Antonovsky’s ( 1987 ) salutogenic approach to stress and health – focussing on the factors and resources that help people maintain their health and wellbeing in the face of life’s challenges. SOC is thought to develop in early adulthood and remain stable across the life course (Antonovsky, 1987 ; Hakanen et al., 2007 ). It incorporates three dimensions: meaningfulness (whether one’s life conveys purpose and meaning), comprehensibility (whether the circumstances of one’s life make sense and are understandable), and manageability (whether a person feels they can cope with the circumstances of their life). There are similarities between these dimensions and other psychological constructs, most notably purpose and meaning (Ryff & Keyes, 1995 ), self-determination theory (Ryan & Deci, 2000 ), and self-efficacy (Bandura, 1977 ). SOC is theorised to play a mediating role, enabling individuals to mobilise psychosocial resources such as personality and social support to ensure successful coping and adaptation in response to adversity. This theory has been confirmed empirically in adults (Gana, 2001 ), and older adults (Wiesmann & Hannich, 2013 ). Sense of coherence has been strongly associated with both physical and mental health (Eriksson, 2022 ). However, very little research has hitherto investigated its role in facilitating student wellbeing.

Drawing together the theory and evidence presented, we propose the model of wellbeing in students outlined in Fig.  1 . In essence, how a student feels (particularly how stressed they feel) will influence how they rate their wellbeing. A student’s perceived stress will be influenced by what is happening to them (including background demographics and current circumstances) and their ability to cope with challenges (represented by psychosocial resources such as resilience, sense of coherence, and social support). Overall, a student’s wellbeing will be influenced by a combination of these three—circumstances, psychosocial resources, and perceived stress.

Proposed model of wellbeing in students

The current study aimed to test this model of wellbeing in a student population at a large, city-based university in the UK. We adopted a salutogenic approach, focussing on the factors that enhance positive mental wellbeing in students, in contrast to the pathogenic approach adopted by most previous research on the wellbeing of students, which focusses on mental health and illness (Hernández-Torrance et al., 2020). The study was innovative in both the salutogenic approach and in comparing wellbeing and its determinants across all levels and subjects of university study, whereas much previous research has focussed on individual year groups or subjects.

Based on previous literature, and the proposed model of wellbeing, the study aimed to address the following hypotheses:

1. Commuter and residential students will differ on measures of wellbeing, perceived stress, and psychosocial resources.

2. Scores on measures of wellbeing, perceived stress, and psychosocial resources will differ across different levels of study.

3. A significant amount of variance in wellbeing will be explained by a model containing background demographics / circumstances, psychosocial resources (resilience, sense of coherence, and loneliness) and perceived stress.

4. Each component or step of the model will explain a significant amount of variance in wellbeing.

A cross-sectional correlational design was conducted with mental wellbeing as the dependent variable and demographics (age, gender, residential status, level of study, number of stressors), psychosocial resources (resilience, sense of coherence, loneliness) and perceived stress as predictor variables.

Participants

All students currently registered at a large post-92 university in the north west of England, UK (N =  ~ 20,000), were invited via email to participate in the study, which was conducted online in February-April 2018. Due to the success of widening participation initiatives, the student population at this university is diverse and includes a good balance of commuter and residential students. It is, therefore, well placed to provide a representative sample of university students in the UK. 574 students (mean age = 24.51, s.d. = 8.39, range 17–67) completed at least part of the online questionnaire. 376 (65.5%) were female, 112 (19.5%) male, 4 (0.7%) other, 2 (0.3%) prefer not to say, and 80 (13.9%) did not answer the gender question.

Demographics

Participants were asked to give their gender and age in years, the main subject area of their degree (based on the university’s administrative structure), and their level of study from 3 (foundation year) through 4–6 (undergraduate 1 st to 3 rd year) up to 7 (postgraduate masters level) and 8 (doctorate). Due to small numbers of students from level 3, levels 3 and 4 were collapsed into one category for statistical analysis.

Residential status

Participants were asked to indicate whether their living status was “at home, commuting into university” or “living with other students in halls or shared accommodation”. If neither of these, they were asked to provide more details. The responses were grouped into four categories: commuter, residential, postgrad/mature (incorporating students who owned their own home or lived alone AND were at level 7 or 8), and other. Only one student fell into the ‘Other’ category – they reported living in halls during the week and returning home at weekends for paid work purposes.

Experiences and Causes of Stress

Participants were asked to indicate whether, during their time at university, they had ever felt unusually stressed or overwhelmed. They were then asked to indicate their primary sources of stress using the following question: “If you have felt or think you ever would feel increased stress or pressure, what would be the main trigger?”. Response options were pre-determined based on previous literature and student consultation and included managing university workload, personal problems outside of university work, social worries, money worries, concerns about finding a job after university, difficulty settling into Liverpool, loneliness, and other. Further information given in the ‘other’ category was used to further categorise common stressors. The total number of stressors (or potential stressors) reported was calculated for each participant.

Mental Wellbeing

The Warwick Edinburgh Mental Wellbeing Scale (Tennant et al., 2007 ) was used to measure mental wellbeing. Participants were asked to indicate, on a Likert-type scale of 1–5, the extent to which they had experienced 14 positively-worded statements during the last 2 weeks. Possible scores range from 14–70, with high scores indicating greater mental wellbeing.

Sense of Coherence

The 13-item Orientation to Life Scale (Antonovsky, 1987 ) was used to measure SOC. Participants were asked to respond to a series of statements covering the three dimensions of meaningfulness (SOC Me), comprehensibility (SOC Co), and manageability (SOC Ma), on a Likert-type scale of 1–7. After reversal of appropriate items, scores are calculated for each of the dimensions and the total (range 13–91), with higher scores indicating a higher sense of coherence.

The Brief Resilience Scale (BRS; Smith et al., 2008 ) was used to measure resilience. This consists of 6 items, on a scale of 1–5. After reversal of three items, the mean score of all 6 items was calculated, with higher scores indicating higher resilience.

Perceived Stress

The Perceived Stress Scale (PSS; Cohen et al., 1983 ) was used. Participants were asked to read a series of 10 statements and indicate, on a four-point scale from 0–4 from Never to Very often, the extent to which this was true of them over the last month. After appropriate reversals, scores are summed to give a total perceived stress with a range of 0–40, higher scores indicating greater stress.

This was measured using a single item: “Loneliness can be a serious problem for some people and not for others. At the present moment do you feel lonely?” This item has been used in a number of longitudinal cohort studies and has been shown to be strongly associated with measures of subjective wellbeing (Gow et al., 2007 ). Participants provided their response on a five point scale from Most of the time (1) to None of the time (5), with higher scores indicating lower loneliness.

Participants were presented with the participant information sheet online. Consent was implied by completion of the study questionnaire. Participants were then invited to complete the questionnaires, which took an average of 23 minutes. All participants were fully debriefed on completion of the study.

Ethical Considerations

Ethical approval for the study was granted by the appropriate university Research Ethics Committee (REF: 18/NSP/0008). Participants were informed of the purpose and nature of the study in the participant information sheet. Consent was implied by completion of the study questionnaire. All data was fully anonymous at the point of collection and participants were debriefed at the end of the study.

Statistical Analysis

Independent sample t-tests were used to compare commuter and residential students and one-way ANOVA to investigate the effect of level of study on resilience, SOC, loneliness, perceived stress, number of stressors, and wellbeing.

Pearson bivariate correlations were calculated to investigate associations between all the predictor variables and mental wellbeing.

Hierarchical linear regression analysis was then conducted to test the effect of the predictor variables on mental wellbeing. Level of study was recoded as dummy variables, with level 3–4 as the reference, in order to ascertain differences in wellbeing across levels. Variables were entered into the model based on the proposed model of wellbeing. Age, gender, level of study dummy variables and number of stressors were entered at the first step, resilience, SOC and loneliness at the second, and perceived stress at the third step.

Summary demographics, including experiences of stress and number of stressors, for all participants are presented in Table 1 .

Due to small numbers in level 3 (foundation year), levels 3 and 4 were collapsed into one category for all inferential analyses. Overall, 526 (91.6%) participants reported having felt unusually stressed or overwhelmed since starting university, citing a mean number of 3.17 (S.D. = 1.51) stressors. Chi squared tests indicated significant differences between levels of study (X 2 (4, N = 494) = 15.274, p < 0.01), with students at levels 5, 6, and 8 more likely to report having experienced stress while at university – this was echoed in the number of stressors reported (F(4,489) = 11.341, p < 0.001).

Descriptive statistics for all psychological variables for all participants, and divided by gender, residential status, and level of study, are shown in Table 2 . Independent samples t-tests indicated that females reported significantly higher perceived stress (t(476) = -3.145, p < 0.01), lower resilience (t(486) = 2.912, p < 0.01), and lower SOC manageability (t(481) = 2.746, p < 0.01) than males.

Residential Status

Independent samples t-tests indicated that residential students reported significantly higher loneliness (t(452) = 3.580, p < 0.001) and a greater number of stressors (t(451.353) = -5.820, p < 0.001) than commuter students. No other differences were significant at the p < 0.01 level.

Level of Study

One-way ANOVAs indicated significant differences in scores between students at different levels of study, with post-hoc tests suggesting greater wellbeing (F(4,475) = 8.109, p < 0.001), resilience (F(4,489) = 5.521, p < 0.001), lower perceived stress (F(4,479) = 6.511, p < 0.001), and lower loneliness (F(4,489) = 6.103, p < 0.001) amongst the two postgraduate groups (levels 7 and 8, masters and PhD) compared to the three undergraduate groups.

Postgraduate students at level 7 and 8 also reported greater scores on the measure of sense of coherence (F(4,466) = 8.781, p < 0.001) and its subscales: meaningfulness (F(4,484) = 9.240, p < 0.001), comprehensibility (F(4,475) = 6.981, p < 0.001), and manageability (F(4,484) = 6.508, p < 0.001).

Determinants of Wellbeing

Bivariate correlations (Table 3 ) showed significant associations between mental wellbeing and all the predictor variables. All were in the expected direction: higher resilience, higher SOC, lower perceived stress, and lower loneliness were all associated with higher wellbeing. Older age and higher year of study were also associated with higher wellbeing. The strongest associations were between wellbeing and perceived stress and SOC.

The hierarchical linear regression analysis results are shown in Table 4 . All three models significantly predicted wellbeing. Demographics explained 17.5% of the variance (model F(7, 425) = 14.13, p < 0.001), psychosocial resources explained an additional 44.1% (model F(10, 422) = 71.94, p < 0.001) and perceived stress explained an additional 9.4% (model F(11, 421) = 100.78, p < 0.001). The final model explained 71.8% of the variance in wellbeing. The strongest predictors were perceived stress, SOC, loneliness, and resilience. Age, gender, level of study, and number of stressors all did not reach significance in the final model. All assumptions of linear regression were met.

The findings show that commuter and residential students did not differ significantly on measures of wellbeing or psychosocial resources, although residential students did report greater loneliness and a higher number of stressors. Postgraduate students reported greater wellbeing, resilience, and SOC, and lower perceived stress and loneliness than undergraduate students. In terms of determinants of wellbeing, over 70% of the variance in wellbeing was explained by the final model, with SOC, perceived stress, loneliness, and resilience all making significant independent contributions and each model component predicting significant variance in wellbeing.

The observed differences between commuter and residential students were, perhaps, encouraging. While the findings contrast with previous research (Neves & Hillman, 2019 ) and our first hypothesis, they are not altogether surprising. Commuter students are often living within the family home, providing them with greater access to companionship and support and removing the personal stressors associated with transition to university such as the need to make new social connections and manage one’s own household and finances. Postgraduate and mature students – who are often more settled in their residential status – reported better outcomes on all measures, although this again is unsurprising given the considerable differences in life circumstances between this group and other students.

Level of study appears to have had a significant impact on experiences of stress, mental wellbeing, and all psychosocial variables. Postgraduate students in general reported higher levels of wellbeing, resilience, and SOC, and lower loneliness and perceived stress, which contrasts with previous research (Byrom et al., 2020 ) – although doctoral students were more likely to report having experienced stress. Undergraduates in their 2 nd and 3 rd year reported a greater number of stressors, lower wellbeing, and higher perceived stress than the other groups, which is in keeping with previous research (Bewick et al., 2010 ; Macaskill, 2013 ).

The data support our proposed model of wellbeing, with each component of the model explaining significant variance in wellbeing. Psychosocial resources contributed the greatest amount of variance, which is in keeping with previous research (Brett et al., 2012 ; Diener et al., 1999 ; McIntyre et al., 2018 ).

Perceived stress was the strongest predictor of wellbeing in this study. The number of stressors reported, while significantly associated with wellbeing in univariate analyses and in step 1 of the hierarchical regression, did not reach significance in the final model, suggesting that how stressors are perceived by students is more important than the number of stressors experienced. This is in keeping with previous studies and the conceptualisation of perceived stress (Denovan & Macaskill, 2017 ; Lazarus & Folkman, 1984 ).

The finding that SOC and resilience were both significant predictors of wellbeing – even after controlling for the more proximal measures of perceived stress and loneliness – suggests these more stable psychological variables have a role to play in enabling students to maintain their wellbeing in the face of stress and adversity, and supports the adoption of a salutogenic approach to wellbeing in students, focussing on the factors that help students manage their stress and maintain their wellbeing, rather than mental health and illness (Antonovsky, 1987 ; Chu et al., 2016 ; Hernández-Torrano et al., 2020 ). Indeed, there is increasing awareness of the importance of resilience and interventions to enhance resilience amongst young people, including students, has become a key priority in higher education (McIntosh & Shaw, 2017 ) and public health (Association for Young People’s Health, 2016 ). Multi-faceted, skills-based interventions have been shown to be effective in a variety of populations, with interventions combining Cognitive Behavioural Therapy techniques and mindfulness training proving effective in universities (Joyce et al., 2018 ). In contrast, despite its importance in promoting optimal functioning and wellbeing, there is a paucity of literature on the development of SOC (Joseph & Sagy, 2017 ). This is particularly the case in young people, with much research on SOC focussing on its role in promoting wellbeing in older adults.

Limitations

The current study has a number of limitations which affect the generalisability of its findings. The study took place within a single, city-based, higher education institution in a city in northwest England. Although the city is culturally and socioeconomically diverse, the findings may not be generalisable to other student populations. In particular, the experience of residential students on campus-based universities may be qualitatively different, with greater opportunities to meet other students and make friends. However, the study findings suggest – contrary to previous research – that residential status did not have an impact on wellbeing, although loneliness and perceived stress – two significant predictors of wellbeing – were higher amongst residential students.

A further limitation is the possibility of sample bias. The sample size of 574 represents only a small proportion (2.87%) of the 20,000 active students at the institution. Practical factors likely influenced this low response rate: the study invitation originated from an academic unknown to the majority of students, and via a generic student mailing list. However, it is also possible that participation was influenced by psychological factors that might have had a confounding effect on the study findings. First, although the male:female ratio at the institution is roughly 50:50, females were overrepresented in the study sample. Second, participating in a study on wellbeing might appeal more to students who are interested in this topic, either on a personal or academic level. Third, the survey invitation was sent out towards the end of semester two of the academic year, which can be a time of high stress due to the large number of assessment deadlines, resulting in low engagement with activities unrelated to assessment. Indeed, in Bewick et al.’s ( 2010 ) study, wellbeing was lowest and anxiety highest during semester two. However, as this was a cross-sectional study with all participants completing the survey during the same time period, the impact of this on the study findings will have been attenuated.

The final, key, limitation is that this study did not measure any potential mediating or moderating factors that might explain the relationship between the predictor variables and wellbeing. For example, personality traits are likely to contribute to students’ susceptibility to experience stress, while understanding students’ social connectedness – including social networks and social support – might further explain the observed differences in loneliness between residential and commuter students.

Implications and Conclusion

It is well documented that university can be a time of great stress for students (Neves & Hillman, 2019 ), which can lead to high levels of mental health difficulties among the student population (Royal College of Psychiatrists, 2011 ; Brown, 2018 ; Hughes & Spanner, 2019 ). This study found support for a new model of wellbeing which emphasises the importance of perceived stress and psychosocial resources including resilience, sense of coherence, and loneliness in determining wellbeing in students – over and above demographic variables, current circumstances, and the number of stressors experienced. It may be well-nigh impossible for universities to reduce the stressors experienced by students due to the difficulties of balancing assessment demands and student wellbeing (Jones et al., 2021 ), and the financial pressures resulting from government policy (Johnson & Crenna-Jennings, 2018 ). However, adopting a salutogenic approach by prioritising interventions to enhance students’ ability to cope with stressors might, therefore, help them maintain or improve their wellbeing and prevent the development of mental health difficulties. The results also suggest that reducing loneliness – for example by facilitating social connectedness amongst students – might also help improve wellbeing, particularly amongst residential students.

Further research is needed to fully understand the development of resilience and sense of coherence within the student population, and the mechanisms underlying their relationship with wellbeing. The model of wellbeing proposed here could be further developed to incorporate additional psychosocial factors such as personality, social support, optimism, and current mood. Finally, longitudinal research is needed to identify and understand the changes in wellbeing and its determinants that occur throughout the university journey.

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Brett, C.E., Mathieson, M.L. & Rowley, A.M. Determinants of wellbeing in university students: The role of residential status, stress, loneliness, resilience, and sense of coherence. Curr Psychol 42 , 19699–19708 (2023). https://doi.org/10.1007/s12144-022-03125-8

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• Published: 15 September 2020

The SDGs and human well-being: a global analysis of synergies, trade-offs, and regional differences

• Jan-Emmanuel De Neve 1 , 2 &
• Jeffrey D. Sachs 3 , 4  

Scientific Reports volume  10 , Article number:  15113 ( 2020 ) Cite this article

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• Psychology and behaviour
• Sustainability

This paper explores the empirical links between achieving the Sustainable Development Goals (SDGs) and subjective well-being. Globally, we find that in terms of well-being, there are increasing marginal returns to sustainable development. Unpacking the SDGs by looking at how each SDG relates to well-being shows, in most cases, a strong positive correlation. However, SDG12 (responsible production and consumption) and SDG13 (climate action) are negatively correlated with well-being. This suggests that in the short run there may be certain trade-offs to sustainable development, and further heterogeneity is revealed through an analysis of how these relationships play out by region. Variance decomposition methods also suggest large differences in how each SDG contributes to explaining the variance in well-being between countries. These and other empirical insights highlight that more complex and contextualized policy efforts are needed in order to achieve sustainable development while optimising for well-being.

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Introduction.

This paper explores the empirical links between sustainable development and human well-being. Sustainable development is a broad and easily misunderstood concept 1 , but the term first entered mainstream policy circles with the publishing of the Brundtland report in 1987, in which it was defined as ‘development that meets the needs of the current generation without compromising the ability of future generations to meet their own needs’ 2 . Debate continues as to whether sustainable development in practice can live up to its normative promises of economic development, environmental stewardship and social equity 3 . Nonetheless, in 2015 the international community rallied around the idea, and sustainable development gained further exposition with the adoption of the Sustainable Development Goals (SDGs), as part of the broader 2030 Agenda. As the successors to the Millennium Development Goals, the 17 SDGs are a comprehensive set of policy goals that aim to end world poverty and hunger, address climate change and environmental protection, and ensure universal access to healthcare, education and equality 4 .

Parallel discussions have centred around the need to move away from GDP as an assessment of countries’ performance towards measures that better capture levels of happiness and well-being 5 . Subjective well-being measures differ from objective well-being indicators, such as observable health and material outcomes, in that they are based on respondents’ self-evaluations of their own life 6 . Varied research suggests that subjective well-being (SWB) measures, especially life evaluations, reflect underlying well-being 7 . As such, there is now a growing consensus among governments and international institutions that SWB—whilst imperfect 8 —has an important role to play in defining success and, as such, an increasing significance in policy-making 9 .

This research aims to explore the relationship between sustainable development and subjective well-being, with the potential to support future policy-making. To do so, we combine two major data-gathering efforts. We leverage the SDG Index which measures countries’ progress towards achieving the SDGs 10 . We also draw on an item from the Gallup World Poll which is representative of over 98% of the world’s population and asks survey participants to evaluate their lives on a scale of 0–10. The paper begins by discussing the headline positive correlation between the SDG Index and SWB. We analyse the quadratic relationship between the two, demonstrating that a higher SDG Index score correlates more strongly with higher SWB at higher levels of the SDG Index. Globally, we find that there are increasing marginal returns to sustainable development in terms of human well-being. In the next section, the SDG Index is split into its 17 component goals. We analyse the varying relationships with well-being, as well as how these relationships play out by region, finding that two of the environmental goals, Goal 12 (responsible consumption and production) and Goal 13 (climate action), are significantly negatively correlated with SWB. We finish by conducting a variance decomposition analysis to show which goals are most strongly contributing to the variation in well-being between countries and the world’s regions 11 .

Our analysis finds that more complex and contextualised policy efforts are needed in order to simultaneously achieve sustainable development and advance well-being. Human well-being is at the core of the 2030 Agenda 12 : the SDGs aim to ensure that ‘all human beings can fulfil their potential in dignity, equality and in a healthy environment 4 .’ Thus, one might expect to find a positive correlation between the SDGs and SWB. Detailed empirical work, however, shows the relationship to be more nuanced than might first appear. Whilst all SDGs are important, our analysis shows that some are more relevant to well-being than others, and reveals some inherent tensions that involve trade-offs between current and future well-being. Since governments are dependent on the current cohort of electors to decide their fate 13 , more cautious policy is needed to resolve trade-offs, allowing for sustainable development that also optimises for human well-being 14 . Unpacking the SDGs in terms of well-being also shows how their relative importance varies across different regions, highlighting the need for differentiated policy priorities when advancing the 2030 Agenda.

Data and methods

The SDG Index (SDGI) was developed in 2015 as a composite system to benchmark the performance of countries across the SDGs. Several indicators are selected to monitor the progress towards each goal, positioning them between the worst (0) and the target outcome (100). The overall SDGI score represents the mean of a country’s total SDG scores, where all goals are weighted equally. The same basket of indicators is used for all countries to generate comparable scores and rankings. For our analysis we use the 2019 SDG index, which includes 114 indicators covering 162 countries 10 . Note that in our analysis, the SDG Index is modified to remove the SWB score, which is one of the indicators for SDG 3 (Health and Well-being). Given the large number of variables that make up the SDG Index, we find that leaving in or taking out the SWB variable does not meaningfully impact any results. Limitations in collecting data for SDG indicators hinder full assessment of progress towards SDGs. There are also issues with the aggregation of goals into a single number 15 , nonetheless there is consensus that the SDGI provides ‘the most comprehensive picture of national progress on the SDGs’ 16 .

For our analysis we use life evaluations, the standard measure of well-being used in the World Happiness Report rankings and most other research on the topic 17 , 18 . We draw on data from the Gallup World Poll, which continually surveys 160 countries representing about 98% of the world’s adult population. The survey item asks respondents to value their current lives on a 0–10 scale, with the worst possible life as 0 and the best possible life as 10. The data is from nationally representative samples, for the years 2016–2018. Some methodological issues remain with subjective well-being measures 6 , but life evaluations are widely recognised as the standard measure of subjective well-being 7 , 19 . Data on other dimensions of subjective well-being, such as the experience of positive and negative emotions, are analysed separately and can be found in the Supplementary Information section online.

The analyses done in this paper rely on standard univariate linear correlations and OLS regressions. In line with the SDGI methodology, where scores are missing for specific goals, we impute using the regional average to avoid losing observations. This is most relevant for goal 14 (Life below water).

The variance decomposition method (dominance analysis) employed in Figs.  4 , 5 and 6 is run in Stata using the domin command. Dominance analysis calculates the relative contribution to the variance explained in well-being (R-squared) for the 17 SDGs. This is an ensemble method that works by calculating a regression of well-being on every possible combination of the 17 SDGS. The dominance of a goal is calculated as the weighted average marginal contribution to the explained variance that the goal makes across all models in which the goal is included. One important assumption being made in such an analysis is that it forces the SDGs to explain all of the variance in well-being between countries. There are also a number of other important limitations in that the method hinges on there being variance in the first place, and yet the measurements for some SDGs do not vary much.

Are the SDGs conducive to human well-being?

Figure  1 shows the scatterplot for the SDG Index and SWB for all countries in the dataset. Countries are coded to represent the six regions they belong to: Europe, Middle East and Northern Africa, Americas, Sub-Saharan Africa and Former Soviet Union. The G7 and BRICS countries are labelled as well as some of the outlier countries. The SDG Index and SWB have a highly significant correlation coefficient of 0.79. The countries with a higher SDG Index score tend to do better in terms of subjective well-being (SWB)—with the Nordic countries topping both rankings. Interestingly, the line of best fit is not linear but quadratic indicating that a higher SDG Index score correlates more strongly with higher SWB at higher levels of the SDG Index. Thus, sustainable development results in increasing marginal returns to human well-being.

Sustainable development and subjective well-being, a scatterplot for the overall SDGI score (mean of total SDG score, where all goals are weighted equally) and SWB score for all countries in the data set. This scatterplot was produced using matplotlib package (version 3.2.1) in python: https://matplotlib.org .

In the online Supplementary Information section, we show that the quadratic fit is statistically superior compared to a pure linear fit (see Table S1 ). This is also the case for higher-powered models as borne out when applying the Bayesian information criterion and Akaike information criterion to test the relative quality of model fits (see Table  S2 ). As countries become more developed, a higher SDG Index score is associated with an ever higher SWB score. This suggests that economic activity is more important for well-being at lowers levels of economic development. As countries become richer the well-being of their citizens stagnates unless further economic growth is more sustainable by, for example, addressing inequality and improving environmental quality. The notion of increasing marginal returns to sustainable development contrasts starkly with the decreasing marginal returns that are typically observed when mapping well-being onto GDP per capita 20 .

Our measure of SWB is an evaluative measure of well-being and the survey responses may differ from emotional measures of well-being, especially when looked at in relation to economic measures such as income and development. As such, in the Supplementary Information section we also report on the relationship between the SDG Index and measures of emotional well-being (see Figure S1 and Figure  S2 ). The Gallup World Poll includes measures of positive emotions such as “enjoyment” and “smile or laugh” as well as negative emotions such as “worry”, “sadness”, “stress”, and “anger”. Correlating an index of positive emotional experiences with the SDG Index scores leads to a correlation coefficient of 0.27—while statistically significant, this indicates a much weaker empirical link between achieving the SDGs and the experience of positive emotions as compared to life evaluations already examined. This is less the case for an index of negative emotional experiences, for which we obtain a correlation coefficient that is − 0.57 suggesting that countries that are not doing well in terms of the SDGs also tend to have populations that are experiencing more negative emotions. In general, these results are in line with the notion that evaluative measures correlate more strongly with economic measures such as income, development, and inequality than emotional measures of well-being 21 , 22 .

In the Supplementary Information section we list the countries that deviate most from the trend line (see Table  S3 ). The countries significantly above the line of best fit clearly punch above their weight in terms of happiness relative to where the model would expect these countries to be given their scores on the SDG Index, with the reverse being true for those below the line of best fit. These empirical observations indicate that there are a number of aspects that drive human well-being that are not fully captured by the SDGs.

How does each SDG relate to well-being?

In Table  1 we report on how each SDG correlates with well-being both globally and regionally. As expected from the aforementioned general results, we find that at the global level most SDGs correlate strongly and positively with higher well-being. At the same time, we discover much heterogeneity in how some of the SDGs relate to well-being. In fact, we find SDGs 14 (Life below water), 15 (Life on land), and 17 (Partnerships for the goals) to be generally insignificant. Importantly, we find that SDGs 12 (Responsible consumption and production) and 13 (Climate action) are significantly negatively correlated with human well-being.

When looking at the relationship between SDGs and well-being by region we detect further levels of heterogeneity in how individual SDGs relate to well-being in different contexts. It is, however, important to note that considering these data by region reduces the number of observations and therefore both the precision of the coefficient and the statistical power to report significant differences. As Fig.  1 revealed visually, there is a stronger link between the SDG Index and well-being at higher levels of economic development. In Table  1 we indeed find that the general correlation between the SDGs and well-being is considerably lower in regions with mostly developing nations. In fact, only for Europe, Asia, and the Americas do we pick up a strong statistically significant correlation between the SDG Index and well-being. When looking at the SDGs individually, we pick up even more variation in how some SDGs are more strongly correlated than others with well-being. Some noteworthy regional results include (1) the important role of SDG 8 (decent work and economic growth) for countries in the former Soviet Union; (2) the relative importance of SDG 9 (industry, innovation and infrastructure) for nations in Europe and the MENA region; and (3) SDG 10 (reducing inequality) is strongly correlated with well-being for the European nations. These regional correlations need to be taken with due caution given the relatively low number of observations available but, taken together, Table  1 paints a vivid picture of the varied and complex ways in which the SDGs relate to human well-being and how these pathways are highly context specific.

Are there trade-offs between the SDGs and human well-being?

Table  1 reveals that SDG 12 (responsible consumption and production) and SDG 13 (climate action) have, in fact, strong negative correlations with self-reported measures of human well-being. Moreover, these negative correlations appear to hold for each one of the world’s regions and therefore merit more academic and policy attention.

SDG12 aims to ensure responsible consumption and production patterns, in order to prevent the over-extraction and degradation of environmental resources. The indicators underlying SDG12 measure the per capita material footprint of each country, accounting for municipal solid waste (kg/year/capita), E-waste generated (kg/capita), production-based SO 2 emissions (kg/capita), imported SO 2 emissions (kg/capita), nitrogen production footprint (kg/capita), net imported emissions of reactive nitrogen (kg/capita), non-recycled municipal solid waste (MSW in kg/person/year times recycling rate) 10 . Fig.  2 shows the negative correlation between achieving SDG 12 and subjective well-being. It suggests that countries which have a smaller per capita material footprint—and are therefore performing well on SDG12—are associated with lower levels of SWB. Countries like Canada, meanwhile, have a high material footprint and score badly on SDG12 but perform well in terms of SWB. The relationship between countries’ well-being and material footprint may well be explained by economic development, as countries with higher GDPs tend to produce and consume more, which is usually associated with higher living standards. However, as reported in Table  2 , when we control for the general level of economic development, SDG12 continues to correlate negatively with SWB, suggesting that material consumption itself is an important factor explaining this negative correlation. This analysis therefore suggests that advancing on responsible consumption and production may result in a trade-off in terms of average self-reported well-being, at least in the short run. However, it is important to note the handful of countries in the top right-hand corner of Fig.  2 (listed in Supplementary Table S4 online) which run counter to this trend. For example, Costa Rica scores highly in terms of SWB whilst also scoring well on SDG12, suggesting that it is in fact possible to advance human well-being at moderate consumption levels.

Responsible consumption and production (SDG12) and subjective well-being, a scatterplot for SDG12 score and SWB score for all countries in the data set. This scatterplot was produced using matplotlib package (version 3.2.1) in python: https://matplotlib.org .

SDG 13 asks that countries take urgent action to combat climate change and its impacts by curbing emissions. It measures countries’ energy-related CO 2 emissions per capita (tCO 2 /capita), imported CO 2 emissions, technology adjusted (tCO 2 /capita), people affected by climate-related disasters (per 100,000 population), CO 2 emissions embodied in fossil fuel exports (kg/capita), effective carbon rate from all non-road energy, excluding emissions from biomass (€/tCO 2 ) 10 . In general, countries that have lower emissions—and are therefore performing well on SDG13—tend to have lower levels of subjective well-being. As was the case with SDG 12, countries that are more economically developed tend to pollute more while also having higher well-being. In contrast with SDG12, however, we find that accounting for the general level of economic development turns a negative correlation into an insignificant one as reported in Table  2 . This suggests that the underlying measures for climate action are strongly correlated with the level of economic development in the first place which, in turn, drives the relationship with well-being. Again, there are a handful of countries in the top right of Fig.  3 (listed in Supplementary Table S5 online), which appear to be resolving the trade-off, performing well on SDG13 whilst maintaining high levels of SWB.

Climate action (SDG13) and subjective well-being, a scatterplot for SDG13 score and SWB score for all countries in the data set. This scatterplot was produced using matplotlib package (version 3.2.1) in python: https://matplotlib.org .

Variance decomposition analysis of the SDGs in relation to well-being

In this section, we apply variance decomposition to explore the relative importance of each SDG in explaining the variance in well-being between countries. This method, called “dominance analysis”, investigates the relative contribution to the variance explained in well-being (R 2 ) for a given set of predictors—in this case the 17 SDGs 11 .

Figure  4 presents the results of the variance decomposition and suggests large differences in how each SDG contributes to explaining the variance in well-being between countries. This figure paints a picture that aligns closely with the correlation coefficients reported in Table  1 . SDGs 10, 14, 15 and 17 would appear to contribute negligibly to explaining variation in well-being across the globe. On the other hand, the greatest explanatory power seems to lie with SDGs 3, 8, 9, and 12. SDG 8 (decent work and economic growth), SDG 9 (industry, innovation and infrastructure), and SDG 12 (responsible consumption and production) each explain 10% or more of the variance. It is important to note, of course, that SDG 12 (as well as SDG 13) are negatively correlated with well-being, as was shown earlier on in Table  1 .

Relative importance of SDGs in explaining the variance in subjective well-being between countries.

Variance decomposition analysis of regional SDG groups in relation to well-being

In these analyses, we group the SDGs into Economic (4, 8, 9), Social (1, 5, 10), Health (3), Law (16), and Environmental goals (2, 6, 7, 11, 12, 13, 14, 15). Figure  5 first shows the results for how well these SDG groups explain the variance between all countries. In Fig.  6 we show the results by region. The general takeaway from the regional variance decomposition analyses is that there is much regional heterogeneity hidden behind a global analysis, with the regional context driving which SDGs are most important in explaining the variance in well-being between countries in the region. In Europe (N = 33), and especially in the countries of the former Soviet Union (N = 15), we find the great importance of the Economic SDGs in explaining regional variation in well-being. In Asia (N = 23) we find a fairly balanced role for the Economic, Law, Social, and Health SDG groups in explaining regional differences in well-being. In the Americas (N = 23) we find that Health plays the most important role in driving regional variation in well-being. The results for Sub-Saharan Africa (N = 38) point towards the Social SDGs playing the key role in explaining regional differences. For the countries in the MENA region (N = 17) we find a more balanced picture with the Health and Economic SDGs driving most of the variation, but an important role as well for the Social, Law, and Environmental SDGs.

Relative importance of SDG groups in explaining the variance in subjective well-being between countries.

Relative importance of SDG groups in explaining regional subjective well-being variance.

This paper has studied the empirical relationship between the Sustainable Development Goals and subjective well-being using data from the SDG Index and the Gallup World Poll. We find a strong correlation between achieving sustainable development and self-reported measures of well-being. Moreover, our analyses indicate that there are increasing marginal returns to sustainable development in terms of well-being.

While most SDGs are positively correlated with well-being, our analysis reveals that SDG12 (responsible consumption and production) and SDG13 (climate action) are negatively correlated with SWB 23 . These findings are perhaps unsurprising: the world economy has long relied on economic growth and the consumption of natural resources to generate human welfare at the expense of environmental sustainability 3 , 24 . Today, however, it is increasingly clear that if we are to avoid ecological collapse, we must bring our consumption of natural and material resources within ecological limits 25 , 26 . This transformation is captured by SDG12 and SDG13; it will involve real reductions in emissions, and quantitative as well as qualitative changes to consumption and production patterns 27 . In particular, high income countries must reduce their ecological footprint to allow for increased consumption in economically developing countries, where it is necessary for meeting basic needs 23 , 28 . This is not an easy task given that our growth-driven economic system is reliant on ever-increasing consumption and production to provide employment and support livelihoods 29 . Thus, under current structures, advancing on SDG12 and SDG13 could have serious socio-economic consequences and, as such, negatively impact well-being levels, particularly those of the most vulnerable 27 . Given that lowering well-being erodes support for incumbent governments, this makes such policies even more difficult to implement 13 . More cautious policies are therefore needed to ensure that progress towards SDG12 and SDG13 also safeguards livelihoods and well-being 30 , 31 .

Nevertheless, environmental stewardship does not necessarily entail reductions in well-being. Varied research has shown the importance of environmental integrity for human well-being: for instance, subjective well-being is negatively influenced by poor air quality 32 ; people are willing to pay for observably cleaner air 33 ; and there is evidence to suggest that being exposed to nature improves mental health 34 . Furthermore, as we have shown elsewhere there is a strong positive correlation between SWB and the Environmental Protection Indicator (a measure which is much wider in scope than the environmentally-oriented SDGs, covering a broad range of issues such as biodiversity and eco-systems, climate and energy, air pollution, water resources, agriculture, heavy metals, water and sanitation, and air quality) 35 . These research insights indicate that well-being is correlated with the long-term outcomes of environmental policies, even if it is not necessarily positively correlated with the short-run efforts required of such policies.

The challenge for policy-makers is thus to resolve the short-term trade-off by de-coupling human well-being improvements from the consumption of natural resources and GHG emissions 36 . A recent report by the OECD attempts to address this challenge by proposing climate change mitigation through a well-being lens, putting people at the centre of climate action 37 . The outlier countries highlighted in our analysis (see Supplementary Table S4 and S5 online) that are performing well on SDG12 and SDG13, whilst also achieving high levels of well-being, indicate that there might be pathways to improving well-being that do not hinder environmental sustainability 38 , 39 . These countries represent a proportional mix of relatively large and small countries across the world. For example, Germany has invested heavily in renewable energy infrastructure 40 , providing ‘green jobs’ while simultaneously reducing emissions. The combination of carbon taxes and incentives for renewable energy, combined with ambitious social policy, has allowed the Nordic countries to transition away from fossil fuels, without punishing low-income families with higher energy bills 41 , 42 . Equally, Costa Rica is among the top countries for investment in new renewable power and fuels relative to GDP, and has committed to achieving carbon neutrality starting from 2021 43 . It thus offers an alternative model for developing countries to avoid the Western carbon-intensive development path 44 . Interestingly, many Latin American countries with warmer climates and a lower propensity to engage in international trade 36 perform strongly in terms of self-reported well-being whilst also scoring highly in terms of SDG12 (sustainable consumption and production), supporting the notion that human well-being decouples from environmental impact beyond minimum levels of consumption 39 . More research is needed to better understand the development trajectories of these countries and the policy mechanisms which allow for synergies between well-being and ecological sustainability 36 . Policies such as investment in public services to moderate private consumption 27 and harnessing productivity gains to reduce working hours 45 have been proposed. There is also increasing evidence from sustainable cities that supports the notion that it is possible to mitigate environmental issues and simultaneously improve quality of life 46 .

Trade-offs between the SDGs and SWB can also arise as a result of interactions between different SDGs. In particular, SDGs 11, 13, 14, 16, and 17 continue to have negative trade-offs and non-associations with other SDGs 47 . The highly positive links we identified between goals 11 and 16 and human well-being may possibly compensate for these intra-SDG trade-offs, but policy-makers may find pursuing SDGs 13, 14, and 17 more difficult due to the negative or insignificant correlation with the well-being of current generations. Needless to say, however, that the urgency of climate change does require action to ensure the well-being of future generations 48 , 49 .

Regional analyses have revealed that what accounts for human well-being varies greatly according to regional and socio-economic context; policy efforts must therefore be differentiated. For example, we find that while in Europe reducing inequalities significantly contributes to well-being, poverty reduction is more important in sub-Saharan Africa. These findings complement a recent study of SDG interactions, which finds poverty alleviation in low-income countries and reducing inequalities in high-income countries to have compounded positive effects on all SDGs 50 , thus helping to support the prioritization of these SDGs according to region. Our findings confirm that general analyses often hide important heterogeneity; moreover, we recognise that the picture becomes even more nuanced at the local level, which is increasingly the site where sustainable development policy is implemented 51 . Importing policy models or ‘best practices’ from elsewhere without a deep understanding of the local context can often obscure effective policy-making on sustainable development issues 52 . As explored in the policy mobilities literature, there is often a mismatch between local governance structures and top-down frameworks like the SDGs which can hinder the overall success of such agendas 53 . Where policies are too insensitive to specific local variations, the goals of sustainable development can be squandered. Therefore, a more comprehensive understanding of how the SDGs can be implemented at the local level is critical 54 in order to advance the 2030 agenda such that both people and planet can thrive.

Our analysis is of course limited by data gaps for several SDG indicators, we therefore emphasize the need for increased transparency and co-operation from governments. Regional analyses are limited by the relatively low number of observations available. It is also important to reiterate that variance decomposition analyses are constrained by their methods and the number of observations. As such, these results are meant to be seen as cautious exploration of large-scale trends that are correlational in nature and thus open to potential reverse causality and omitted variable bias. Our aim here is to stimulate thinking and further research on how the SDGs relate to human well-being—and to show that general analyses may hide important heterogeneity when looking at individual SDGs and in the context of different regions. We recognize that in addition to the macro-level statistical analysis conducted here, more research and careful qualitative analysis is needed to understand local complexities and how they interact with the SDG framework.

We have studied the link between the SDGs and SWB of current generations. Future research should investigate the extent to which self-reported SWB metrics account for the well-being of future generations. This is especially relevant when considering SDG 12 (responsible consumption and production) and SDG 13 (climate policy). Implementing these policies requires intergenerational reciprocity, the idea that we must act on the behalf of future generations, which has in turn been shown to depend on the behavior of previous generations 55 . This work also does not address international dynamics. The sustainable development of a country may come at a cost to other countries, or the actions of countries may influence the well-being in others 56 . Furthermore, the model of linking SDGs with well-being assumes only direct relationships, whereas recent work shows that addressing SDGs have knock-on effects for other SDGs 57 .

A potential dynamic that is worthwhile highlighting is the extent to which the well-being of populations may itself exert influence on their country’s approach to development. Changes in well-being have been documented to have wide-ranging effects on economic, social, and health outcomes 58 . Given these objective benefits of subjective well-being there is an urgent need to combine the SDG and SWB research and policy agendas to generate solutions that advance human well-being, without compromising the environmental integrity of our planet.

Data availability

Data from the SDG index is freely available and can be downloaded from www.sdgindex.org . The Gallup World Poll data is not freely available however the data used in this analysis is made available in the online appendix for the World Happiness Report from https://worldhappiness.report .

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Acknowledgements

This article builds on work done for a chapter published in the World Happiness Report 2020 and reproduces some material from that chapter. We are grateful to Sidharth Bhushan, Hedda Roberts, and Pekka Vuorenlehto for outstanding research assistance. We thank Guillaume Lafortune and Grayson Fuller at the Sustainable Development Solutions Network for guidance on the SDG Index data. The Gallup World Poll data is generously made available by The Gallup Organization. We also acknowledge very helpful comments from John Helliwell, Richard Layard, Andrew Oswald, Steve Bond, Tyler VanderWeele, and participants at seminar meetings of the Wellbeing Research Centre at Oxford.

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De Neve, JE., Sachs, J.D. The SDGs and human well-being: a global analysis of synergies, trade-offs, and regional differences. Sci Rep 10 , 15113 (2020). https://doi.org/10.1038/s41598-020-71916-9

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• Published: 21 May 2024

The bright side of sports: a systematic review on well-being, positive emotions and performance

• David Peris-Delcampo 1 ,
• Antonio Núñez 2 ,
• Paula Ortiz-Marholz 3 ,
• Aurelio Olmedilla 4 ,
• Enrique Cantón 1 ,
• Javier Ponseti 2 &
• Alejandro Garcia-Mas 2  

BMC Psychology volume  12 , Article number:  284 ( 2024 ) Cite this article

Metrics details

The objective of this study is to conduct a systematic review regarding the relationship between positive psychological factors, such as psychological well-being and pleasant emotions, and sports performance.

This study, carried out through a systematic review using PRISMA guidelines considering the Web of Science, PsycINFO, PubMed and SPORT Discus databases, seeks to highlight the relationship between other more ‘positive’ factors, such as well-being, positive emotions and sports performance.

The keywords will be decided by a Delphi Method in two rounds with sport psychology experts.

Participants

There are no participants in the present research.

The main exclusion criteria were: Non-sport thema, sample younger or older than 20–65 years old, qualitative or other methodology studies, COVID-related, journals not exclusively about Psychology.

Main outcomes measures

We obtained a first sample of 238 papers, and finally, this sample was reduced to the final sample of 11 papers.

The results obtained are intended to be a representation of the ‘bright side’ of sports practice, and as a complement or mediator of the negative variables that have an impact on athletes’ and coaches’ performance.

Conclusions

Clear recognition that acting on intrinsic motivation continues to be the best and most effective way to motivate oneself to obtain the highest levels of performance, a good perception of competence and a source of personal satisfaction.

Peer Review reports

Introduction

In recent decades, research in the psychology of sport and physical exercise has focused on the analysis of psychological variables that could have a disturbing, unfavourable or detrimental role, including emotions that are considered ‘negative’, such as anxiety/stress, sadness or anger, concentrating on their unfavourable relationship with sports performance [ 1 , 2 , 3 , 4 ], sports injuries [ 5 , 6 , 7 ] or, more generally, damage to the athlete’s health [ 8 , 9 , 10 ]. The study of ‘positive’ emotions such as happiness or, more broadly, psychological well-being, has been postponed at this time, although in recent years this has seen an increase that reveals a field of study of great interest to researchers and professionals [ 11 , 12 , 13 ] including physiological, psychological, moral and social beneficial effects of the physical activity in comic book heroes such as Tintin, a team leader, which can serve as a model for promoting healthy lifestyles, or seeking ‘eternal youth’ [ 14 ].

Emotions in relation to their effects on sports practice and performance rarely go in one direction, being either negative or positive—generally positive and negative emotions do not act alone [ 15 ]. Athletes experience different emotions simultaneously, even if they are in opposition and especially if they are of mild or moderate intensity [ 16 ]. The athlete can feel satisfied and happy and at the same time perceive a high level of stress or anxiety before a specific test or competition. Some studies [ 17 ] have shown how sports participation and the perceived value of elite sports positively affect the subjective well-being of the athlete. This also seems to be the case in non-elite sports practice. The review by Mansfield et al. [ 18 ] showed that the published literature suggests that practising sports and dance, in a group or supported by peers, can improve the subjective well-being of the participants, and also identifies negative feelings towards competence and ability, although the quantity and quality of the evidence published is low, requiring better designed studies. All these investigations are also supported by the development of the concept of eudaimonic well-being [ 19 ], which is linked to the development of intrinsic motivation, not only in its aspect of enjoyment but also in its relationship with the perception of competition and overcoming and achieving goals, even if this is accompanied by other unpleasant hedonic emotions or even physical discomfort. Shortly after a person has practised sports, he will remember those feelings of exhaustion and possibly stiffness, linked to feelings of satisfaction and even enjoyment.

Furthermore, the mediating role of parents, coaches and other psychosocial agents can be significant. In this sense, Lemelin et al. [ 20 ], with the aim of investigating the role of autonomy support from parents and coaches in the prediction of well-being and performance of athletes, found that autonomy support from parents and coaches has positive relationships with the well-being of the athlete, but that only coach autonomy support is associated with sports performance. This research suggests that parents and coaches play important but distinct roles in athlete well-being and that coach autonomy support could help athletes achieve high levels of performance.

On the other hand, an analysis of emotions in the sociocultural environment in which they arise and gain meaning is always interesting, both from an individual perspective and from a sports team perspective. Adler et al. [ 21 ] in a study with military teams showed that teams with a strong emotional culture of optimism were better positioned to recover from poor performance, suggesting that organisations that promote an optimistic culture develop more resilient teams. Pekrun et al. [ 22 ] observed with mathematics students that individual success boosts emotional well-being, while placing people in high-performance groups can undermine it, which is of great interest in investigating the effectiveness and adjustment of the individual in sports teams.

There is still little scientific literature in the field of positive emotions and their relationship with sports practice and athlete performance, although their approach has long had its clear supporters [ 23 , 24 ]. It is comforting to observe the significant increase in studies in this field, since some authors (e.g [ 25 , 26 ]). . , point out the need to overcome certain methodological and conceptual problems, paying special attention to the development of specific instruments for the evaluation of well-being in the sports field and evaluation methodologies.

As McCarthy [ 15 ] indicates, positive emotions (hedonically pleasant) can be the catalysts for excellence in sport and deserve a space in our research and in professional intervention to raise the level of athletes’ performance. From a holistic perspective, positive emotions are permanently linked to psychological well-being and research in this field is necessary: firstly because of the leading role they play in human behaviour, cognition and affection, and secondly, because after a few years of international uncertainty due to the COVID-19 pandemic and wars, it seems ‘healthy and intelligent’ to encourage positive emotions for our athletes. An additional reason is that they are known to improve motivational processes, reducing abandonment and negative emotional costs [ 11 ]. In this vein, concepts such as emotional intelligence make sense and can help to identify and properly manage emotions in the sports field and determine their relationship with performance [ 27 ] that facilitates the inclusion of emotional training programmes based on the ‘bright side’ of sports practice [ 28 ].

Based on all of the above, one might wonder how these positive emotions are related to a given event and what role each one of them plays in the athlete’s performance. Do they directly affect performance, or do they affect other psychological variables such as concentration, motivation and self-efficacy? Do they favour the availability and competent performance of the athlete in a competition? How can they be regulated, controlled for their own benefit? How can other psychosocial agents, such as parents or coaches, help to increase the well-being of their athletes?

This work aims to enhance the leading role, not the secondary, of the ‘good and pleasant side’ of sports practice, either with its own entity, or as a complement or mediator of the negative variables that have an impact on the performance of athletes and coaches. Therefore, the objective of this study is to conduct a systematic review regarding the relationship between positive psychological factors, such as psychological well-being and pleasant emotions, and sports performance. For this, the methodological criteria that constitute the systematic review procedure will be followed.

Materials and methods

This study was carried out through a systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews) guidelines considering the Web of Science (WoS) and Psycinfo databases. These two databases were selected using the Delphi method [ 29 ]. It does not include a meta-analysis because there is great data dispersion due to the different methodologies used [ 30 ].

The keywords will be decided by the Delphi Method in two rounds with sport psychology experts. The results obtained are intended to be a representation of the ‘bright side’ of sports practice, and as a complement or mediator of the negative variables that have an impact on athletes’ and coaches’ performance.

It was determined that the main construct was to be psychological well-being, and that it was to be paired with optimism, healthy practice, realisation, positive mood, and performance and sport. The search period was limited to papers published between 2000 and 2023, and the final list of papers was obtained on February 13 , 2023. This research was conducted in two languages—English and Spanish—and was limited to psychological journals and specifically those articles where the sample was formed by athletes.

Each word was searched for in each database, followed by searches involving combinations of the same in pairs and then in trios. In relation to the results obtained, it was decided that the best approach was to group the words connected to positive psychology on the one hand, and on the other, those related to self-realisation/performance/health. In this way, it used parentheses to group words (psychological well-being; or optimism; or positive mood) with the Boolean ‘or’ between them (all three refer to positive psychology); and on the other hand, it grouped those related to performance/health/realisation (realisation; or healthy practice or performance), separating both sets of parentheses by the Boolean ‘and’’. To further filter the search, a keyword included in the title and in the inclusion criteria was added, which was ‘sport’ with the Boolean ‘and’’. In this way, the search achieved results that combined at least one of the three positive psychology terms and one of the other three.

Results (first phase)

The mentioned keywords were cross-matched, obtaining the combination with a sufficient number of papers. From the first research phase, the total number of papers obtained was 238. Then screening was carried out by 4 well-differentiated phases that are summarised in Fig.  1 . These phases helped to reduce the original sample to a more accurate one.

Phases of the selection process for the final sample. Four phases were carried out to select the final sample of articles. The first phase allowed the elimination of duplicates. In the second stage, those that, by title or abstract, did not fit the objectives of the article were eliminated. Previously selected exclusion criteria were applied to the remaining sample. Thus, in phase 4, the final sample of 11 selected articles was obtained

Results (second phase)

The first screening examined the title, and the abstract if needed, excluding the papers that were duplicated, contained errors or someone with formal problems, low N or case studies. This screening allowed the initial sample to be reduced to a more accurate one with 109 papers selected.

Results (third phase)

This was followed by the second screening to examine the abstract and full texts, excluding if necessary papers related to non-sports themes, samples that were too old or too young for our interests, papers using qualitative methodologies, articles related to the COVID period, or others published in non-psychological journals. Furthermore, papers related to ‘negative psychological variables’’ were also excluded.

Results (fourth phase)

At the end of this second screening the remaining number of papers was 11. In this final phase we tried to organise the main characteristics and their main conclusions/results in a comprehensible list (Table  1 ). Moreover, in order to enrich our sample of papers, we decided to include some articles from other sources, mainly those presented in the introduction to sustain the conceptual framework of the concept ‘bright side’ of sports.

The usual position of the researcher of psychological variables that affect sports performance is to look for relationships between ‘negative’ variables, first in the form of basic psychological processes, or distorting cognitive behavioural, unpleasant or evaluable as deficiencies or problems, in a psychology for the ‘risk’ society, which emphasises the rehabilitation that stems from overcoming personal and social pathologies [ 31 ], and, lately, regarding the affectation of the athlete’s mental health [ 32 ]. This fact seems to be true in many cases and situations and to openly contradict the proclaimed psychological benefits of practising sports (among others: Cantón [ 33 ], ; Froment and González [ 34 ]; Jürgens [ 35 ]).

However, it is possible to adopt another approach focused on the ‘positive’ variables, also in relation to the athlete’s performance. This has been the main objective of this systematic review of the existing literature and far from being a novel approach, although a minority one, it fits perfectly with the definition of our area of knowledge in the broad field of health, as has been pointed out for some time [ 36 , 37 ].

After carrying out the aforementioned systematic review, a relatively low number of articles were identified by experts that met the established conditions—according to the PRISMA method [ 37 , 38 , 39 , 40 ]—regarding databases, keywords, and exclusion and inclusion criteria. These precautions were taken to obtain the most accurate results possible, and thus guarantee the quality of the conclusions.

The first clear result that stands out is the great difficulty in finding articles in which sports ‘performance’ is treated as a well-defined study variable adapted to the situation and the athletes studied. In fact, among the results (11 papers), only 3 associate one or several positive psychological variables with performance (which is evaluated in very different ways, combining objective measures with other subjective ones). This result is not surprising, since in several previous studies (e.g. Nuñez et al. [ 41 ]) using a systematic review, this relationship is found to be very weak and nuanced by the role of different mediating factors, such as previous sports experience or the competitive level (e.g. Rascado, et al. [ 42 ]; Reche, Cepero & Rojas [ 43 ]), despite the belief—even among professional and academic circles—that there is a strong relationship between negative variables and poor performance, and vice versa, with respect to the positive variables.

Regarding what has been evidenced in relation to the latter, even with these restrictions in the inclusion and exclusion criteria, and the filters applied to the first findings, a true ‘galaxy’ of variables is obtained, which also belong to different categories and levels of psychological complexity.

A preliminary consideration regarding the current paradigm of sport psychology: although it is true that some recent works have already announced the swing of the pendulum on the objects of study of PD, by returning to the study of traits and dispositions, and even to the personality of athletes [ 43 , 44 , 45 , 46 ], our results fully corroborate this trend. Faced with five variables present in the studies selected at the end of the systematic review, a total of three traits/dispositions were found, which were also the most repeated—optimism being present in four articles, mental toughness present in three, and finally, perfectionism—as the representative concepts of this field of psychology, which lately, as has already been indicated, is significantly represented in the field of research in this area [ 46 , 47 , 48 , 49 , 50 , 51 , 52 ]. In short, the psychological variables that finally appear in the selected articles are: psychological well-being (PWB) [ 53 ]; self-compassion, which has recently been gaining much relevance with respect to the positive attributional resolution of personal behaviours [ 54 ], satisfaction with life (balance between sports practice, its results, and life and personal fulfilment [ 55 ], the existence of approach-achievement goals [ 56 ], and perceived social support [ 57 ]). This last concept is maintained transversally in several theoretical frameworks, such as Sports Commitment [ 58 ].

The most relevant concept, both quantitatively and qualitatively, supported by the fact that it is found in combination with different variables and situations, is not a basic psychological process, but a high-level cognitive construct: psychological well-being, in its eudaimonic aspect, first defined in the general population by Carol Ryff [ 59 , 60 ] and introduced at the beginning of this century in sport (e.g., Romero, Brustad & García-Mas [ 13 ], ; Romero, García-Mas & Brustad [ 61 ]). It is important to note that this concept understands psychological well-being as multifactorial, including autonomy, control of the environment in which the activity takes place, social relationships, etc.), meaning personal fulfilment through a determined activity and the achievement or progress towards goals and one’s own objectives, without having any direct relationship with simpler concepts, such as vitality or fun. In the selected studies, PWB appears in five of them, and is related to several of the other variables/traits.

The most relevant result regarding this variable is its link with motivational aspects, as a central axis that relates to different concepts, hence its connection to sports performance, as a goal of constant improvement that requires resistance, perseverance, management of errors and great confidence in the possibility that achievements can be attained, that is, associated with ideas of optimism, which is reflected in expectations of effectiveness.

If we detail the relationships more specifically, we can first review this relationship with the ‘way of being’, understood as personality traits or behavioural tendencies, depending on whether more or less emphasis is placed on their possibilities for change and learning. In these cases, well-being derives from satisfaction with progress towards the desired goal, for which resistance (mental toughness) and confidence (optimism) are needed. When, in addition, the search for improvement is constant and aiming for excellence, its relationship with perfectionism is clear, although it is a factor that should be explored further due to its potential negative effect, at least in the long term.

The relationship between well-being and satisfaction with life is almost tautological, in the precise sense that what produces well-being is the perception of a relationship or positive balance between effort (or the perception of control, if we use stricter terminology) and the results thereof (or the effectiveness of such control). This direct link is especially important when assessing achievement in personally relevant activities, which, in the case of the subjects evaluated in the papers, specifically concern athletes of a certain level of performance, which makes it a more valuable objective than would surely be found in the general population. And precisely because of this effect of the value of performance for athletes of a certain level, it also allows us to understand how well-being is linked to self-compassion, since as a psychological concept it is very close to that of self-esteem, but with a lower ‘demand’ or a greater ‘generosity’, when we encounter failures, mistakes or even defeats along the way, which offers us greater protection from the risk of abandonment and therefore reinforces persistence, a key element for any successful sports career [ 62 ].

It also has a very direct relationship with approach-achievement goals, since precisely one of the central aspects characterising this eudaimonic well-being and differentiating it from hedonic well-being is specifically its relationship with self-determined and persistent progress towards goals or achievements with incentive value for the person, as is sports performance evidently [ 63 ].

Finally, it is interesting to see how we can also find a facet or link relating to the aspects that are more closely-related to the need for human affiliation, with feeling part of a group or human collective, where we can recognise others and recognise ourselves in the achievements obtained and the social reinforcement of those themselves, as indicated by their relationship with perceived social support. This construct is very labile, in fact it is common to find results in which the pressure of social support is hardly differentiated, for example, from the parents of athletes and/or their coaches [ 64 ]. However, its relevance within this set of psychological variables and traits is proof of its possible conceptual validity.

Analysing the results obtained, the first conclusion is that in no case is an integrated model based solely on ‘positive’ variables or traits obtained, since some ‘negative’ ones appear (anxiety, stress, irrational thoughts), affecting the former.

The second conclusion is that among the positive elements the variable coping strategies (their use, or the perception of their effectiveness) and the traits of optimism, perfectionism and self-compassion prevail, since mental strength or psychological well-being (which also appear as important, but with a more complex nature) are seen to be participated in by the aforementioned traits.

Finally, it must be taken into account that the generation of positive elements, such as resilience, or the learning of coping strategies, are directly affected by the educational style received, or by the culture in which the athlete is immersed. Thus, the applied potential of these findings is great, but it must be calibrated according to the educational and/or cultural features of the specific setting.

Limitations

The limitations of this study are those evident and common in SR methodology using the PRISMA system, since the selection of keywords (and their logical connections used in the search), the databases, and the inclusion/exclusion criteria bias the work in its entirety and, therefore, constrain the generalisation of the results obtained.

Likewise, the conclusions must—based on the above and the results obtained—be made with the greatest concreteness and simplicity possible. Although we have tried to reduce these limitations as much as possible through the use of experts in the first steps of the method, they remain and must be considered in terms of the use of the results.

Future developments

Undoubtedly, progress is needed in research to more precisely elucidate the role of well-being, as it has been proposed here, from a bidirectional perspective: as a motivational element to push towards improvement and the achievement of goals, and as a product or effect of the self-determined and competent behaviour of the person, in relation to different factors, such as that indicated here of ‘perfectionism’ or the potential interference of material and social rewards, which are linked to sports performance—in our case—and that could act as a risk factor so that our achievements, far from being a source of well-being and satisfaction, become an insatiable demand in the search to obtain more and more frequent rewards.

From a practical point of view, an empirical investigation should be conducted to see if these relationships hold from a statistical point of view, either in the classical (correlational) or in the probabilistic (Bayesian Networks) plane.

The results obtained in this study, exclusively researched from the desk, force the authors to develop subsequent empirical and/or experimental studies in two senses: (1) what interrelationships exist between the so called ‘positive’ and ‘negative’ psychological variables and traits in sport, and in what sense are each of them produced; and, (2) from a global, motivational point of view, can currently accepted theoretical frameworks, such as SDT, easily accommodate this duality, which is becoming increasingly evident in applied work?

Finally, these studies should lead to proposals applied to the two fields that have appeared to be relevant: educational and cultural.

Application/transfer of results

A clear application of these results is aimed at guiding the training of sports and physical exercise practitioners, directing it towards strategies for assessing achievements, improvements and failure management, which keep them in line with well-being enhancement, eudaimonic, intrinsic and self-determined, which enhances the quality of their learning and their results and also favours personal health and social relationships.

Data availability

There are no further external data.

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Peris-Delcampo, D., Núñez, A., Ortiz-Marholz, P. et al. The bright side of sports: a systematic review on well-being, positive emotions and performance. BMC Psychol 12 , 284 (2024). https://doi.org/10.1186/s40359-024-01769-8

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Maintaining health and well-being as we age

Although many older adults demonstrate high levels of resilience, they are also more prone to social isolation and loneliness than any other age group. Having strong social connections is especially important for mental health and well-being as we age, and is associated with lower instances of depression and anxiety.

Simon Fraser University (SFU) professor of mental health and aging Theodore D. Cosco researches a range of factors that promote healthy aging and resilience in older adults, from digital interventions to physical activity. He leads the Precision Mental Health Lab , a transdisciplinary research group dedicated to community-engaged and innovative technological approaches to improve well-being across all age groups.

One of his major research projects is studying data from the Canadian Longitudinal Study on Aging (CLSA). Cosco is a co-investigator on the CLSA, a national, long-term study of more than 50,000 Canadians who were 45 to 85 years old when the program began in 2009. Over 160 researchers from 26 universities across Canada are involved in the CLSA.

Cosco and colleagues, including three PhD students he supervises:  Lucy Kervin , Shawna Hopper , and Indira Riadi have found that during the coronavirus pandemic, the decreased ability to participate in social and physical activity was associated with increased risk of depression and anxiety in older adults.

These findings are outlined in Worsened ability to engage in social and physical activity during the COVID-19 pandemic and older adults’ mental health ,   published in Innovation in Aging .

We spoke to professor Cosco about his research.

What did your research reveal about older adults’ diminished ability to engage in physical and social activities during the coronavirus pandemic?

Our team used data from 24,108 participants surveyed during the first nine months of the COVID-19 pandemic and found roughly 22% screened positively for depression and 5% for anxiety.

Generally, older adults who reported worsened ability to participate in social and physical activities during the pandemic had poorer mental health outcomes than those whose ability remained the same or improved. We also found that participating in these activities had a buffering effect on depression and anxiety.

How does this research apply now that the pandemic is behind us? Do you have recommendations?

Our findings highlight the importance of fostering social and physical activity resources to mitigate the negative mental health impacts of future pandemics or other major life stressors that may affect the mental health of older adults. Beyond the pandemic these results highlight the importance of staying socially and physically active. You do not need to be socializing seven nights a week, nor do you need to be running marathons. Doing anything is better than nothing, so finding ways to integrate socializing and exercising into one’s life is an excellent strategy. Pick up the phone, walk to the shops, or find a way that you can integrate activity into one’s own life.

How do you approach the study of vast amounts of data from the CLSA? Do you have specific research questions to investigate, or does the study reveal topics that you want to pursue?

When working with large datasets, it is crucial to understand the types of data included, their collection dates and their sources. Once familiar with the available data, you can delve into current research and literature to formulate hypotheses. With extensive datasets, specificity in your initial hypotheses and deliberate in your analysis approaches are vital. Because of the dataset's size and the significant statistical power it provides, running numerous models to explore every possible outcome can often lead to “statistically significant” findings that occur by chance. This practice, known as “fishing” or “data dredging,” is discouraged because it may result in misleading associations. Therefore, it's important for us to be very purposeful in testing our hypotheses to avoid these issues.

In a previous Scholarly Impact of the Week, you discussed how during the pandemic older adults and their families quickly adopted the use of technology to increase connectedness. Is this trend still going strong, and do you have new insights on technology and older people?  

During the pandemic, older adults and their families rapidly embraced technology to stay connected, a trend that remains strong today. This period really spotlighted both the advantages and limitations of our current technology. It became clear that tech companies need to move away from a one-size-fits-all approach. Products specifically designed with older adults in mind—taking into account their unique needs and preferences tend to be more successful. These intentionally crafted tools are not only more widely accepted but also have a more significant impact. The pandemic has shown us the importance of such tailored technology solutions in enhancing social connectedness for older populations.

For more: See professor Cosco’s previous Scholarly Impact of the Week article, Understanding the impacts of COVID-19 on older adults , and visit the Precision Mental Health Lab web page.  

SFU's Scholarly Impact of the Week series does not reflect the opinions or viewpoints of the university, but those of the scholars. The timing of articles in the series is chosen weeks or months in advance, based on a published set of criteria. Any correspondence with university or world events at the time of publication is purely coincidental.

For more information, please see  SFU's Code of Faculty Ethics and Responsibilities  and the  statement on academic freedom .

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• Health Topics A-Z

About Emotional Well-Being

• Positive emotional well-being is when people manage emotions well and have a sense of meaning, purpose, and supportive relationships.
• Positive emotional well-being can lower your risk of disease, sickness, and injury.
• There are ways you can improve your overall emotional well-being.

Why it's important

• Positive emotional well-being helps people manage their thoughts and feelings.
• People with positive emotional well-being have a sense of meaning and purpose.
• Without positive emotional well-being people may have difficulty connecting socially.

Adapting to challenges

People who experience positive emotional well-being have the skills to adapt to and deal with life challenges.

Skills that can create positive emotional well-being include:

• Identifying, processing, and expressing emotions in healthy ways.
• Knowing how to deal with uncertainty, stress, and change.
• Being able to work through disagreements.
• Looking for solutions to problems in useful ways.
• Asking others for help and support.

Health benefits

Improving emotional well-being can benefit your mental and physical health. It can also enhance your social connections to other people and your community.

Benefits of positive emotional well-being

• Lower risk of disease, sickness, and injury.
• Faster recovery after being sick or getting injured.
• Improved mental health.
• Being able to bounce back from negative experiences (resilience).
• Stronger relationships and higher self-esteem.
• Having a sense of contentment, meaning, and purpose in life.
• Better productivity and performance at work.

A buffer against stress

People with positive emotional well-being can still feel sad or stressed during tough times. But they can manage these challenges better.

Improving emotional well-being

How to boost your emotional well-being.

You can improve your emotional well-being by learning how to:

• Identify your emotions.
• Manage negative feelings.
• Deal with stress.
• Communicate better.
• Work through problems.
• Reach out to others for social support.
• Practice mindfulness.

Other steps to take

It is also important to take care of physical health to improve your emotional well-being. Things you can do include:

• Eat healthy .
• Get enough sleep . 
• Be active .
• Limit alcohol use.
• Avoid smoking , vaping, and using other tobacco products.

Find tips for managing your emotions at How Right Now and for improving your emotional health at Emotional Wellness Toolkit .

• National Center for Chronic Disease Prevention and Health Promotion

Positive emotional well-being is when people manage emotions well and sense meaning, purpose and supportive relationships, which can lower sickness, injury risk

This paper is in the following e-collection/theme issue:

Published on 21.5.2024 in Vol 8 (2024)

This is a member publication of Open University

A Web-Based Intervention to Support the Mental Well-Being of Sexual and Gender Minority Young People: Mixed Methods Co-Design of Oneself

Authors of this article:

Original Paper

• Katherine Brown 1 , PhD   ; 
• Mathijs F G Lucassen 2 , PhD   ; 
• Alicia Núñez-García 3 , PhD   ; 
• Katharine A Rimes 4 , DPhil, DClinPsy   ; 
• Louise M Wallace 3 , PhD   ; 
• Rajvinder Samra 3 , PhD  

1 Centre for Research in Psychology and Sports Science, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom

2 School of Health & Psychological Sciences, City, University of London, London, United Kingdom

3 School of Health, Wellbeing & Social Care, The Open University, Milton Keynes, United Kingdom

4 Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, United Kingdom

Corresponding Author:

Katherine Brown, PhD

Centre for Research in Psychology and Sports Science

School of Life and Medical Sciences

University of Hertfordshire

College Lane

Hatfield, AL109AB

United Kingdom

Phone: 44 1707 284 615

Email: [email protected]

Background: Sexual and gender minority youth are at greater risk of compromised mental health than their heterosexual and cisgender peers. This is considered to be due to an increased burden of stigma, discrimination, or bullying resulting in a heightened experience of daily stress. Given the increasing digital accessibility and a strong preference for web-based support among sexual and gender minority youth, digital interventions are a key means to provide support to maintain their well-being.

Objective: This paper aims to explicate the co-design processes and underpinning logic of Oneself , a bespoke web-based intervention for sexual and gender minority youth.

Methods: This study followed a 6-stage process set out by Hagen et al (identify, define, position, concept, create, and use), incorporating a systematic scoping review of existing evidence, focus groups with 4 stakeholder groups (ie, sexual and gender minority youth, professionals who directly support them, parents, and UK public health service commissioners), a series of co-design workshops and web-based consultations with sexual and gender minority youth, the appointment of a digital development company, and young adult sexual and gender minority contributors to create content grounded in authentic experiences.

Results: Oneself features a welcome and home page, including a free accessible to all animation explaining the importance of using appropriate pronouns and the opportunity to create a user account and log-in to access further free content. Creating an account provides an opportunity (for the user and the research team) to record engagement, assess users’ well-being, and track progress through the available content. There are three sections of content in Oneself focused on the priority topics identified through co-design: (1) coming out and doing so safely; (2) managing school, including homophobic, biphobic, or transphobic bullying or similar; and (3) dealing with parents and families, especially unsupportive family members, including parents or caregivers. Oneself’s content focuses on identifying these as topic areas and providing potential resources to assist sexual and gender minority youth in coping with these areas. For instance, Oneself drew on therapeutic concepts such as cognitive reframing, stress reduction, and problem-solving techniques. There is also a section containing relaxation exercises, a section with links to other recommended support and resources, and a downloads section with more detailed techniques and strategies for improving well-being.

Conclusions: This study contributes to research by opening up the black box of intervention development. It shows how Oneself is underpinned by a logic that can support future development and evaluation and includes diverse co-designers. More interactive techniques to support well-being would be beneficial for further development. Additional content specific to a wider range of intersecting identities (such as care-experienced Asian sexual and gender minority youth from a minority faith background) would also be beneficial in future Oneself developments.

International Registered Report Identifier (IRRID): RR2-10.2196/31036

Introduction

Worldwide, it is estimated that up to 10% of the adolescent population identifies as being either a sexual or gender minority youth; that is, they identify as lesbian, gay, bisexual, transgender, queer, or another sexual or gender minority (lesbian, gay, bisexual, transgender, and queer [LGBTQ+]) [ 1 - 3 ]. Sexual and gender minority youth are known to be at greater risk of poor mental health than their heterosexual and cisgender peers [ 1 , 4 ]. This elevated risk is suggested to be largely related to an increased burden of stigma, discrimination, or bullying resulting in a heightened experience of stress in their day-to-day lives [ 5 , 6 ]. Clearly, work needs to continue to improve social environments for sexual and gender minority youth to reduce the additional stress they experience, but this will take time. In parallel, research is needed to identify what can be done to support sexual and gender minority youth to protect their mental health and well-being and help them build the skills and resilience they will need to thrive. This is increasingly important for the youngest sexual and gender minority youth as there is evidence suggesting that they are coming out at an earlier age than previous generations [ 6 , 7 ]. Their younger age may mean that they have had less time and opportunity to develop strong support networks and coping skills compared with those who come out at an older age [ 6 , 8 ].

Current and recent generations of young people have grown up in the digital age. Often referred to as digital natives [ 9 ], they have only experienced a world with access to the internet [ 9 ]. The latest data suggest that almost all homes in the United Kingdom have access to the internet [ 10 ] and 97% of individuals aged 12 to 15 years have their own mobile phone, with the vast majority using it to access the internet [ 11 ]. Young people are also known to spend much of their time in web-based spaces, which can assist their early attempts to seek information or obtain support on the issues they face. Similarly, a UK Department of Health and Social Care–commissioned report highlighted a strong preference among sexual and gender minority youth to access help on the internet, whereby 82.3% (n=572) of sexual and gender minority youth participants reported being “likely” or “very likely” to choose support in this format [ 12 ]. For this reason, providing web-based resources to support sexual and gender minority youth and the adults who assist them could be a widely accessible and relatively low-cost public health approach to improving their health and well-being.

In this paper, we present the detailed systematic steps we took to develop Oneself, a bespoke digital web-based resource to support sexual and gender minority youth regarding some of the most pressing challenges associated with growing up and being a sexual and gender minority young person. Drawing on the “identify, define, position, concept, create, and use” stages set out by Hagen et al [ 13 ] for participatory design with young people in mental health promotion, the process initially involved a scoping review of the strategies used in existing interventions [ 14 ]; in-depth interviews with adult experts who support sexual and gender minority youth, including parents; and focus groups with sexual and gender minority youth. We then engaged in a co-design process involving workshops with sexual and gender minority youth to determine priorities for the focus of the content and the look and feel of the resource and develop aspects of the content itself.

In addition to drawing on evidence from the scoping review, we drew on the firsthand expertise of sexual and gender minority youth as participatory research and co-design with intended end users of interventions are essential for their optimization in pragmatic terms. For example, knowledge about the needs of unique subpopulations may be limited, and co-design processes can help enhance an intervention’s acceptability [ 15 - 18 ]. In instances in which a group is frequently marginalized, such as sexual and gender minority youth, co-design is especially important because it represents a way to empower and democratize research and its outputs [ 19 ]. Co-design with underserved populations, including sexual and gender minority youth, allows pertinent diversity considerations to be addressed, for instance, factors regarding language, symbols, and character use in digital mental health technologies [ 20 ]. Hence, co-design processes are an attempt to help inform the creation of acceptable resources and assist in not only avoiding further alienating populations such as sexual and gender minority youth but also offering them a voice and greater inclusion. The approach applied by Hagen et al [ 13 ] was specifically chosen because it has been applied successfully in the past to support sexual and gender minority youth in terms of their mental health. Making intervention development processes replicable and transparent in how they are intended to bring about change for end users is also recognized as important for developing the science of health and well-being [ 21 ]. With this in mind, we outlined what we planned to do at the start of our project in our published study protocol [ 6 ]. This protocol was submitted in June 2021, before the project officially commenced.

This paper sets out the systematic stages involved in developing Oneself for sexual and gender minority youth and describes how the findings or outcomes from each stage fed into content development and refinements. It also aims to clearly explicate how each feature and its content are intended to support sexual and gender minority youth and promote change so that any future research involving Oneself can incorporate evaluation against the logic that underpins it.

In accordance with our published protocol [ 6 ], we set out to follow the stages in intervention co-design as outlined by Hagen et al [ 13 ]. Intervention development and co-design are rarely a straightforward, linear process. In practice, some tasks need to happen in parallel, and researchers and coproducers may need to cycle back and repeat elements of the process as additional challenges emerge and new insights arise. The 6 stages of co-design involving adult experts and sexual and gender minority youth are set out below with a brief description of project activities involved in developing the resource aligned to that stage and links to the relevant methods section where more detail is provided ( Textbox 1 [ 13 ]).

• Focus groups with sexual and gender minority youth (see the Interviews and Focus Groups With Sexual and Gender Minority Youth, Adult Experts, and Parents: Identify and Define Stages section)
• Systematic scoping review (see the Systematic Scoping Review: Identify and Define Stages section)
• Interviews with adult experts and parents (see the Interviews and Focus Groups With Sexual and Gender Minority Youth, Adult Experts, and Parents: Identify and Define Stages section)
• Team co-development to finalize decisions and solutions (see the Findings of the Research Team’s Co-Design Meetings in June 2022: Design, Position, and Concept Stages section)
• Initial co-design workshops with sexual and gender minority youth and email and web-based consultation (see the Initial Co-Design Workshops With Sexual and Gender Minority Youth and Email or Web-Based Consultations: Position and Concept Stages section)
• Appointment of digital developer (see the Appointment of Digital Developer [Preparation for Delivering the Concept, Create, and Use Stages] section)
• Team co-development to finalize decisions and solutions (see the Research Team Co-Development to Finalize Decisions on the Focus and Topic Areas [Define, Position, and Concept Stages] section)
• Initial co-design workshops with sexual and gender minority youth and email or web-based consultation (see the Initial Co-Design Workshops With Sexual and Gender Minority Youth and Email or Web-Based Consultations: Position and Concept Stages section)
• Questionnaire to assess look and feel design options (see the Initial Co-Design Workshops With Sexual and Gender Minority Youth and Email or Web-Based Consultations: Position and Concept Stages section)
• Appointment of sexual and gender minority community members through specialist media and modeling agencies (see the Appointment of Sexual and Gender Minority Contributors Through Specialist Media and Modeling Agencies: Concept Stage section)
• Further co-design workshops with sexual and gender minority youth (see the Further Co-Design Workshops With Sexual and Gender Minority Youth: Create Stage section)
• Filming with sexual and gender minority contributors (see the Introducing the Sexual and Gender Minority Contributors: Create Stage section)
• Development work by appointed digital provider (see The Oneself Resource section)
• Feedback from think aloud user interviews (MFG Lucassen, unpublished data, 2024)
• Feedback from adult expert interviews (MFG Lucassen, unpublished data, 2024)

Ethical Considerations

Ethics approval for the aspects of the study involving human participation was granted by the Human Research Ethics Committee at The Open University (OU) before data collection began (ethics approval HREC/4059/Lucassen). All participants, both adults (eg, professionals who directly support sexual and gender minority youth) and adolescents, gave full informed consent to participate and signed a consent form to indicate this. Young people aged <16 years also required written parental consent to participate. Study data were anonymized before analysis, and all consent records were stored separately. Following the anonymization of interview and focus group transcripts, recordings and transcripts with person-identifiable information were deleted. Where applicable, participants were reimbursed for any transport costs associated with taking part and given a £20 (US $25.56) gift voucher per interview or focus group as a token of gratitude for their involvement.

Systematic Scoping Review: Identify and Define Stages

The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines [ 22 ] were followed, and studies were included if they contained primary data on psychosocial coping strategies for sexual and gender minority youth, were conducted with adolescents (aged 10-19 years), and were published in English. The MEDLINE, Embase, and PsycINFO databases were searched. Search terms included a range of terms to capture a sexual and gender minority focus (eg, “gender minorit*” or “LGB*”) and a range of terms for psychosocial coping strategies (eg, “Coping*,” “adaptive,” and “resilience”). No date restrictions were applied, and the searches ran up to January 19, 2022. A descriptive approach to synthesizing the evidence, as recommended by Arksey and O’Malley [ 23 ], was used. The methods and findings of the scoping review have been published elsewhere [ 14 ]. The systematic scoping review ran in parallel to the focus groups with sexual and gender minority youth and interviews with adult experts and parents, which are reported in the following section.

Interviews and Focus Groups With Sexual and Gender Minority Youth, Adult Experts, and Parents: Identify and Define Stages

A total of 6 focus groups, each with between 3 and 10 sexual and gender minority youth participants, were conducted between November 2021 and February 2022. To reach and recruit participants in the applicable age range from the target communities, we worked with 3 organizations supporting LGBTQ+ youth to advertise the opportunity. Focus groups were run in conjunction with these organizations, with their staff also attending to help young people feel comfortable and supported. Staff also assisted in the process of obtaining informed consent from sexual and gender minority youth and, for those aged <16 years, from their parents or guardians. Due to COVID-19 restrictions, all focus groups were hosted via videoconference. The sessions were audio recorded and transcribed. Once accurate transcripts were approved (by MFGL or ANG) and fully anonymized, the focus group electronic audio recordings were deleted. Participants were all secondary school-aged, primarily between the ages of 12 and 20 years, with those aged ≤15 years in a separate focus group. In total, 4 participants aged ≤25 years took part in the focus groups with the older participants because they had special educational needs (eg, learning disabilities) and, as such, were still engaged in secondary-level education or training. Table 1 provides demographic information about sexual and gender minority youth focus group participants; 81% (29/36) of the sexual and gender minority youth were gender minority youth (ie, their gender identity was not the same as their sex as recorded at birth). Many participants (14/36, 39%) were bisexual or pansexual. Approximately 1 in 5 sexual and gender minority youth (7/36, 19%) were of dual heritage (eg, European and West African) or from a migrant background (eg, the other White participants who were not White British).

In parallel, 16 one-to-one interviews were conducted with adult experts based in England, with 6% (1/16) of the participants in Wales, including parents of sexual and gender minority youth, between October 2021 and January 2022. A total of 25% (4/16) of the adults held posts as commissioners of public health services relevant to sexual health and well-being, roles that included consideration of the needs of sexual and gender minority youth. In total, 25% (4/16) of the experts worked in frontline practitioner roles supporting the health and well-being of young people, including sexual and gender minority youth (eg, clinicians working in child and adolescent mental health services). In total, 25% (4/16) of the experts were community-based professionals, such as sexual and gender minority youth workers and policing staff focused on reducing the mistreatment of sexual and gender minority individuals. A total of 25% (4/16) of the adults were parents of a sexual and gender minority adolescent interested in better supporting sexual and gender minority youth. As with the sexual and gender minority youth focus groups, interviews were conducted using videoconference software and audio recorded, and transcripts of the interviews were produced. Once anonymized and approved as accurate (by MFGL or ANG), the electronic audio recordings were deleted.

a 6 focus groups in total with between 5 and 11 participants each; 44 participants in total (including 8 youth workers).

b This item was an open-ended question; as such, 3 gender minority youths wrote Male or Female (ie, Male and Female here does not necessarily equate to being cisgender and male or female).

c N/A: not applicable.

Appointment of Digital Developer (Preparation for Delivering the Concept, Create, and Use Stages)

In January 2022, a tender specification for a digital developer was created based on the outcomes at that time from the identify, define, and position work outlined previously. A range of commercial developers were notified of the tender, and after a competitive process involving an assessment of providers’ submissions and web-based interviews, Bluestep Solutions Limited (Bluestep for brevity) were appointed. They supported the research team in the task of translating the findings that emerged from the preceding evidence-gathering stages (ie, the scoping review, interviews, and focus groups) to content for the digital resource. Bluestep’s expertise resided in developing engaging and user-friendly content aligned with the research team’s evidence-informed approach. Co-design workshops with sexual and gender minority youth participants were conducted to refine the pilot content and improve its look and feel (described in the Findings of the Co-Design Workshops With Sexual and Gender Minority Youth: Position and Concept Stages section). Bluestep provided a map of the potential structure and parameters of the digital resource that could be developed within the available budget. The original budget was £41,000 (approximately US $50,000). Some savings were made in the project’s overall budget, and additional funds were also sourced through the OU, resulting in a final budget of nearly £50,000 (approximately US $61,000). To remain within budget, Bluestep indicated that the research team should focus on 3 core sections of content and have only 1 full day of filming.

Initial Co-Design Workshops With Sexual and Gender Minority Youth and Email or Web-Based Consultations: Position and Concept Stages

Two initial co-design workshops were held with (1) older sexual and gender minority youth aged ≥16 years (May 2022) and (2) younger sexual and gender minority youth aged 12 to 15 years (June 2022). The main aim of these workshops was to identify the priority issues and challenges faced by sexual and gender minority youth on which to focus and the preferred solutions and strategies that should be highlighted. To achieve this, 10 possible topics or issues and 11 possible solutions or strategies were presented to them based on data from the scoping review and the earlier interviews with adults and focus groups with sexual and gender minority youth. A modified nominal group technique [ 24 ] was used to facilitate this process. This involved structured voting before group discussions on the possible topics for inclusion, where all attendees were given an opportunity to express their views and preferences.

In June 2022, Bluestep created a selection of visual concepts ( Multimedia Appendix 1 ) with different color palettes and visual tones of voice represented by imagery. For example, the inclusive visualized toolkit included a bright rainbow color palette, and the message toning was intended to represent inclusivity and messaging that “we’re all in it together.” The overall concepts were also set out alongside some suggested names (created from a marketing perspective) from Bluestep for the digital resource. The suggested names, which drew on commercial marketing expertise from Bluestep, included the following:

• MEE: Mindful Education & Enlightenment for LGBTQ+
• Oneself: Defined by you, allied by us
• Free to be: Mindful tools for your journey

These visual concepts and suggested names were shared with our sexual and gender minority youth workshop participants, and they gave their feedback with support from youth workers via email and in a web-based consultation session via videoconference. The ultimate decisions about concepts, color schemes, and names were strongly informed by the sexual and gender minority youth’s views and we were led by their preferences. A set of questions to prompt discussions regarding preferences was provided to the youth workers supporting the consultation process.

Research Team Co-Development to Finalize Decisions on the Focus and Topic Areas (Define, Position, and Concept Stages)

Following the second sexual and gender minority youth co-design workshop, the research team met to reflect on the voting decisions of sexual and gender minority youth and discuss their own ideas for the priority content and sections in the resource and its features (eg, video clips and animations). In addition to professional expertise, members of the team also have lived experience from their personal lives on which to draw (eg, MFGL is a White migrant, queer male individual and gender role nonconformer; RS is from an ethnic minority group and has lived experience of mental illness [ 25 ]; and KB is White British, grew up with a sibling who identifies as a gay cisgender male, and has lived experience of mental illness). The team held 2 meetings 1 week apart in June 2022.

Questionnaire to Assess the Look and Feel of the Design Options: Concept Stage

Parallel to the co-design and development work outlined previously, Bluestep produced a number of design concepts for consideration by our sexual and gender minority youth workshop attendees and the research team ( Multimedia Appendix 1 ). A questionnaire was developed that asked sexual and gender minority youth workshop attendees to consider the designs and some other key features related to the look and feel of the resource, such as whether the characters featured should be real people or fully animated or whether the characters should be acting out scenarios versus sharing their own personal experiences as sexual and gender minority individuals ( Multimedia Appendix 2 ).

Appointment of Sexual and Gender Minority Contributors Through Specialist Media and Modeling Agencies: Concept Stage

On the basis of our understanding of the need for credible sources to deliver messages in our intervention, and because the dramatizations we had initially envisaged for Oneself in our original study protocol were deemed too contrived and artificial by sexual and gender minority youth, we made a notable decision. In particular, it was identified that real sexual and gender minority young adults, who can talk authentically about their own experiences growing up as sexual and gender minority individuals, would be an important feature of Oneself . In July 2022, the process of recruiting 3 sexual and gender minority young adult contributors or community members was initiated. We applied to modeling and talent agencies given that we wanted contributors who were comfortable in front of cameras. We were provided with a dozen portfolios of different potential sexual and gender minority contributors and short introductory video clips on why they were interested in being involved in the development of Oneself . The research team and sexual and gender minority youth considered the clips separately, and the sexual and gender minority youth voted on their preferred contributors or community members. Feedback on the initial possible contributors highlighted that there was a lack of diversity, particularly regarding ethnicity and body size (ie, they looked “too much like models”). In our attempts to ensure a broader representation, we went back a second time to the agencies to obtain further potential contributor options.

Further Co-Design Workshops With Sexual and Gender Minority Youth: Create Stage

In total, 2 additional co-design workshops were held in September 2022 and January 2023. Co-design workshops were hosted in person with MFGL, Bluestep, or ANG present. Audio recordings were transcribed, and once accurate transcripts were approved (by MFGL or ANG) and fully anonymized, the co-design workshop audio recordings were deleted. Participants were all secondary school-aged, primarily between the ages of 12 and 20 years, with those aged ≤15 years in a separate workshop. Demographic information about workshop participants is presented in Table 2 . A total of 93% (14/15) of the participants were gender minority youth (ie, their gender identity was not the same as their sex as recorded at birth), and 60% (9/15) were bisexual or pansexual. Approximately one-quarter of sexual and gender minority youth (4/15, 27%) were of a dual heritage (eg, Asian and Black) or from a migrant background (eg, White participants who were not White British). An in-person consultation also bridged co-design workshops 3 and 4. This was not recorded.

a 4 co-design workshops in total (with between 5 and 8 youth participants each); 19 participants in total (including 4 youth workers).

Results of the Systematic Scoping Review: Identify and Define Stages

The findings of the scoping review have been published previously [ 14 ]; however, a summary is presented in this section of what we learned that fed into our thinking about the content for Oneself . A total of 68 articles were identified as meeting the review criteria. The oldest paper dated from 2008, and more than half (25/68, 51%) were published from 2017 onward. Most studies (40/68, 59%) were small scale (ie, with <50 participants), and more than two-thirds (47/68, 69%) were conducted in the United States. In total, 26 studies included sexual minority youth only, a further 28 included sexual and gender minority young people, and 14 studies included only gender minority young people.

A total of 24 of the included articles focused on 17 unique interventions to support sexual and gender minority youth. More than half of the intervention papers (13/24, 54% studies) focused on both sexual and gender minority youth. In total, 9 studies included only sexual minority young people, and 2 studies focused on gender minority youth only. Of the 17 interventions, the most frequently cited therapeutic modality was cognitive behavioral therapy (11/24, 46% studies and 6/17, 35% interventions). Common features described in these interventions, including those with CBT-based modalities, are summarized in Table 3 [ 14 ].

Most of the interventions involved in-person delivery (14/24, 58% studies). In total, 5 (56%) out of 9 interventions were delivered in a digital format. In addition to the strategies and techniques outlined in Table 3 , it was also noted that interventions often sought to affirm sexual and gender minority youth identities and give a message of hope to intervention users (eg, “I won’t always feel this way” in the Rainbow SPARX intervention [ 26 ]).

A total of 44 of the included studies did not focus on interventions per se. Instead, they were mainly qualitative studies (with some mixed methods studies combining survey and qualitative data) that explored the experiences of sexual and gender minority youth and the strategies they used to cope with the challenges they face. Table 4 [ 14 ] summarizes the commonly identified strategies and tools for sexual and gender minority youth drawn from these studies and applied to Oneself .

Taken together, the strategies listed in Tables 3 and 4 gave us a comprehensive list of potential contenders to make up the core content and features of Oneself . We drew on this information and the findings we present in the following section from our focus groups and interviews to develop the content of the 3 topic areas identified as most important.

a CBT: cognitive behavioral therapy.

Results of Interviews and Focus Groups With Sexual and Gender Minority Youth, Adult Experts, and Parents: Identify and Define Stages

To expedite drawing out the relevant data from the focus group and interview transcripts and inform Oneself’s development, the data were divided between the research team and examined carefully. Detailed notes were made regarding the sorts of issues that the various stakeholders identified as important to address. Details on strategies and tools that were deemed useful in participants’ experiences were also extracted. The issues and strategies identified were revised during 2 team meetings in June 2022. A more detailed framework analysis [ 27 ] of the data is underway and will be published in due course.

The rapid data extraction process provided us with a series of initial issues and potential areas or populations of focus. MFGL and ANG then met to construct a long list of the main issues (n=10) and the potential solutions or strategies (n=11) that emerged from the findings of the scoping review and the interviews and focus groups with stakeholders. These are summarized in Textboxes 2 and 3 .

• How to deal with unsupportive parents or other family members
• How to deal with bullying at school (eg, name calling)
• How to deal with the challenges associated with coming out
• How to deal with negativity directed at lesbian, gay, bisexual, transgender, and queer people (eg, from a religion)
• How to deal with misgendering
• How to deal with feeling isolated or alone
• How to deal with stigma (eg, homo-, bi-, or transphobia)
• How to deal with web-based abuse (eg, trolls saying nasty things)
• How to explore and make sense of your sexuality or gender
• How to deal with people not believing you about your sexuality or gender
• Educate teachers and others on how to better support lesbian, gay, bisexual, transgender, and queer (LGBTQ+) youth so that school environments can be improved for LGBTQ+ youth
• Educate parents (and other people in the community) on how to better support LGBTQ+ youth so that communities can be improved for LGBTQ+ youth
• Help young people with practical issues—in particular, finding a toilet that they can safely use
• Allow the young person to connect directly with other LGBTQ+ young people so that they can talk to someone else who understands
• Coming out and how to do this safely—highlight that it is OK not to come out (and it is also OK to change one’s mind)
• Up-to-date and accurate information on sexuality and gender to help them make sense of their identity
• How to find supportive people via web-based environments so that they have a better support network
• Help young people figure out what they can and cannot change themselves so that they know what to focus their energy on
• Use affirmations (positive messages) about the young person (eg, “I deserve kindness” and “my gender is not an inconvenience”) to help people feel even better about themselves
• Help young people engage in creative activities (eg, art and music) to make them feel better
• Provide the contact phone numbers and details for supports available to LGBTQ+ youth so that they know where to go for extra help

First Proposed Structure and Designs After Appointing the Digital Developer: In Preparation for the Concept, Create, and Use Stages

Bluestep provided a map of the potential structure and parameters of the digital resource that it would be possible to develop within the available budget, specifically a wireframe. A copy of the structure is provided in Multimedia Appendix 3 . This illustrates the inclusion of 3 core features or sections of content and a “free” (all content is free to access, but the main content requires the user to create an account with a username or email address and password) taster section of content proposed as important to engage potential users and educate the wider public (eg, teachers).

Findings of the Co-Design Workshops With Sexual and Gender Minority Youth: Position and Concept Stages

Table 5 shows the average rank order preferences from the adapted nominal group technique voting in relation to priority issues or topics to cover within the Oneself resource. Participants ranked their highest-priority topic as rank 1 and their lowest-priority topic as rank 10. The lowest average rank order identifies the highest preference among the group. Dealing with unsupportive parents or other family members and dealing with bullying were the highest-ranked topics to cover. Table 6 presents the average rank order preferences for possible solutions or strategies to include in Oneself . The highest-ranking content included educating parents and teachers to help improve the quality of the environments they live in.

a LGBTQ+: lesbian, gay, bisexual, transgender, and queer.

Findings of the Research Team’s Co-Design Meetings in June 2022: Design, Position, and Concept Stages

The first co-design meeting with the research team began by reflecting on the rank order preferences of the sexual and gender minority youth (presented previously). It was acknowledged that, although clear priorities emerged from the data, there was also considerable variability in the rank order preferences. With the budget and practical limits to the amount of content that we could include, we could not create an ideal resource to suit all sexual and gender minority youth needs. However, given the identification by Bluestep that we could have three main sections with featured content, the selection of the top three topic areas was straightforward: (1) coming out and doing so safely; (2) managing school, including homophobic, biphobic, or transphobic bullying or similar; and (3) dealing with parents and families, especially unsupportive family members, including parents or caregivers. We found the favored focus area or population being about educating parents, teachers, and other community members to be outside the scope given our budget to date and as the resource was always intended to be primarily for sexual and gender minority youth themselves rather than adults who support them. The resource is designed to center the experiences of sexual and gender minority youth, but we expect that Oneself will ultimately support parents, teachers, and other community members by increasing awareness and visibility of sexual and gender minority youth experiences. We do acknowledge that there are important challenges in balancing (individual-focused) support for sexual and gender minority youth with promoting social justice through education of adult stakeholders. As was done in this study, it is important to consider these elements in parallel because they are interactive. While we decided not to explicitly target adults at this stage, we acknowledged this request as being part of sexual and gender minority youth’s desire for the environments they live in to be better and more supportive of them, hence the decision to prioritize the educational animation about pronouns, intended for a wider audience (including parents and teachers). We also reflected on the fact that, while the main purpose of the content should be to help young people cope with situations independently, it could also be useful for educating parents, teachers, and other members of the community. Specifically, the resource could help them understand the unique challenges of growing up as a sexual and gender minority youth and how they can act and respond supportively to promote positive social change. At this stage, we thought that the formats we might use to present content could be videos or animations depicting narratives of sexual and gender minority youth everyday experiences, possibly with some interactive content or features for the user.

Sexual and gender minority youth understandably had a range of perspectives and ideas about what should be covered in Oneself . We identified 9 such specific suggestions. For instance, we were cautioned against educating Oneself users on the various sexuality and gender “labels” used by a young person given that the terminology is continually evolving (and frequently contested). Another sexual and gender minority youth felt strongly that we should acknowledge the difficulties associated with challenging environments; for example, “you cannot change everyone,” and therefore, a sexual and gender minority youth must know how (and when) to “walk away.” They also wanted us to ensure that our sexual and gender minority contributors would represent as much diversity as possible. By the end of the research team discussions, there was a growing sense that we could cover, to some degree, many of the preferred solutions or strategies that had been discussed and voted on by sexual and gender minority youth in their co-design workshops, with a focus on the top 3 topics or issues.

It was beyond the scope and resources of Oneself to provide a web-based community space where sexual and gender minority youth could connect with each other safely in real time as this would likely require constant monitoring and ongoing administration. However, advice on where or how to do this elsewhere could be included, along with links to other supportive resources. It was decided that the resource would focus on supporting sexual and gender minority youth directly. We aimed to center the young person in this resource, with Oneself often talking directly to them and trying to focus on them and their needs, for instance, by using language or terms and concepts that map to the concerns they have raised with us as the research team. This act of centering is in direct contrast to the marginalization that they may face daily. It was also intended to have a dual purpose of potentially serving to educate the wider community, including parents and teachers. It was felt that, because the 3 main topics focused on dealing with challenges that can have a detrimental effect on well-being, the resource needed to include evidence-based tools and resources known to support and enhance mental well-being, such as relaxation techniques and other relevant means of coping. It also needed to include content that felt empowering of developing and evolving identities to support and develop users’ self-esteem.

Findings of the Questionnaire to Assess the “Look and Feel” Design Options: Concept Stage

The wireframe structure of Oneself (which was designed to include some introductory content) was confirmed first. This included a log-in feature to access the 3 main content sections and recommended additional resources and sources of help and support. The log-in feature, with the associated gathering of demographic data, was deemed necessary to capture future user information related to Oneself. Next, Bluestep worked with the research team to develop a questionnaire posing different design concepts and options for the look and feel of the resource. The full questionnaire and the options posed are presented in Multimedia Appendix 2 . The preferences that this process helped identify are briefly summarized in the following paragraph.

Although the idea for having full animations with voice actors was rated favorably by many sexual and gender minority youth participants, a clear overall preference emerged for using real people talking about their firsthand experiences growing up as sexual and gender minority youth, as well as the inclusion of sexual and gender minority youth “influencers” or public figures. There were also clear indications that the resource would most likely be accessed on a smartphone by sexual and gender minority youth and that video clips should include audio subtitles (to enable viewing without sound on; however, this is also valuable for accessibility reasons), and most indicated that they would use headphones to listen to content, too. On the basis of sexual and gender minority youth feedback, video-based content should ideally not exceed 60 seconds; some were willing to watch longer clips when the content was engaging. Downloadable information sheets, for access again offline, were identified as useful, and sexual and gender minority youth participants favored a color palette that was pastel and informed by the “progress rainbow flag.”

Team Consultation Based on the Questionnaire Feedback Led to Plans for Inclusion of Sexual and Gender Minority Contributors: Concept and Create Stages

The feedback we obtained about the inclusion of sexual and gender minority contributors (ie, not actors playing a role) led to further consultation about the format of the resource and a decision to focus the main content on testimonial or account footage from sexual and gender minority young adults who could reflect on their experiences with the topics selected when they were growing up. We set out to identify individuals from modeling and talent agencies who would be willing to provide this kind of content, as described in the Appointment of Sexual and Gender Minority Contributors Through Specialist Media and Modeling Agencies: Concept Stage section.

The process of assessing potential sexual and gender minority content contributors resulted in the appointment of 3 people who identified as sexual and gender minority individuals who were willing to be involved for a set fee. Between them they represented diversity in terms of gender and sexual identity, body shape and size, ability, and ethnicity. More details about those selected are provided in the following section.

Design Concept Selection via Email and Web-Based Consultation With Sexual and Gender Minority Youth and Outcomes From Co-Design Workshops 3 and 4: Position, Concept, and Create Stages

Concept 1 ( Figure 1 ) was a clear favorite in terms of the color scheme, and it was described as more “friendly” and inclusive than concept 2 ( Figure 2 ). There was a question regarding the icons in both concepts (ie, symbols transposed over certain images); sexual and gender minority youth did not feel that the icons represented the topics adequately, and therefore, wording or text would be needed, which would defeat the purpose of using icons. In concept 1, a “share” function was seen as more understandable as it was interpreted as a speech bubble, though this could be made even clearer.

From concept 2, sexual and gender minority youth liked the “squiggly lines” in the designs if they could be incorporated into concept 1’s color scheme. It was preferred that design elements from both concepts could be used in the final resource, although sexual and gender minority youth were clear not at the same time as it would be too much on one image.

The sexual and gender minority youth participants were asked if they thought that including the OU (lead university for the project) logo on the resource was a good idea. Most participants felt that it would give people confidence in the quality of the resource as OU is a well-known brand in the United Kingdom. The preferred name for the resource, of the 3 suggestions, was Oneself , but they considered the inclusion of the originally proposed taglines to be too long. Consequently, we did not use a subsequent lengthy tagline in combination with the name Oneself across the whole resource.

Table 7 provides a summary of the workshops and consultations by date, including what was covered and how it aligns with the co-design stages by Hagen et al [ 13 ].

a OU: The Open University.

Introducing the Sexual and Gender Minority Contributors: Create Stage

Bluestep shortlisted 10 candidate sexual and gender minority young adult contributors for the research team, who in turn shortlisted 5 to present to the young people in co-design workshop 3. There were some unforeseen recruitment difficulties. For example, the selected racial and ethnic minority gay man and a transgender woman (who was one of the sexual and gender minority youth’s top choices) were unfortunately not able to participate as initially agreed. For instance, one of them became concerned about how publicly accessible Oneself would be once released (ie, they could be “outed” to a whole range of people known to them). Thus, 2 female contributors were selected from the initial shortlist, and both were rated very favorably by the sexual and gender minority youth. As it was important for the project to reflect diversity across gender identity, sexuality, race, and disability, a further search for a third contributor was carried out in October 2022. Finally, 3 contributors were selected and approved by the young people: Chloe, Lilly, and Georgie.

Georgie, also known as Triple Minor, uses they, she, or he pronouns and is transgender nonbinary. Georgie wanted to contribute to Oneself because they were keen to be the much needed representation that is often lacking within LGBTQ+ communities.

Lilly uses she or her pronouns and is pansexual. Lilly wanted to contribute to Oneself because, when she was younger, she would have loved to have heard more about queer perspectives. This is why she wanted to talk about her own experiences.

Chloe uses she or her pronouns and is a lesbian. Chloe wanted to contribute to Oneself because she believes it is important for the younger LGBTQ+ community to feel supported and comfortable in their sexuality and be able to hear the voices and perspectives of queer people.

Bluestep developed and circulated a creative brief for the 3 sexual and gender minority contributors explaining the requirements for filming ( Figures 3 and 4 ).

Filming took place on November 29, 2022, in a London-based studio. On the day, all 3 sexual and gender minority contributors were asked the same questions on the topics of school, coming out, and friends and family ( Multimedia Appendix 4 ). Filming was done against a green screen so that animations could be added later. Rough-cut footage included approximately 35 minutes of Chloe, Lilly, and Georgie each and 10 minutes of a group recording. ANG transcribed these rough cuts, which comprised 28 pages in total, and summarized their content into key points and quotes that could be shared with the young people. These were given to the sexual and gender minority youth in co-design workshop 4, who rated the points and quotes, adding their own reflections. For instance, the sexual and gender minority youth found Lilly’s advice to cope if someone reacts negatively to coming out helpful—she said the following: “Remember you are not alone. It may take time, but you’ll find your community and people that get you and understand you.” However, the sexual and gender minority youth found Georgie’s advice for teachers and students to manage bullying at school (ie, “zero tolerance” for this) too vague as most schools should have zero tolerance policies but there is still a need for proactiveness to enforce them. A summary of these points, organized by topic (coming out, school, and family and friends) and divided into challenges and solutions and strategies with key quotes to include, was then given to Bluestep to create 2- to 3-minute–long rough cuts of each video, which combined live footage and animation. This resulted in a total of 6 videos— Parents and Families: Some Common Challenges , Parents and Families: Some Strategies , School: Some Common Challenges , School: Some Strategies , Coming Out: Some Common Challenges , and Coming Out: Some Strategies . These were reviewed several times for content, design, storyline, accessibility, and subtitles and finally refined before approval by MFGL and ANG.

The Oneself Resource

Oneself was divided into 7 web pages: a home page ( Figure 5 ); the 3 topics of parents and families, school, and coming out; downloads; chilling out; and resources. To access the entire toolkit, the user needs to log in and complete a brief baseline measure of well-being (ie, the 5-item World Health Organization Well-Being Index). The home page is free to access for anyone, although images of the contributors are reserved for the logged-in user.

The home page includes a description of Oneself ; quotes; and extracts of what the user could find in the resource, for instance, the 3 topics. These were designed to prompt the user to log in to access the content. The home page also features an animation of the meaning and use of pronouns created in collaboration with sexual and gender minority youth from Rainbow Power (a sexual and gender minority youth group) run by the Free2B Alliance in England.

Each topic area began with two parts: (1) the problems and challenges that sexual and gender minority youth face in relation to that topic and (2) potential strategies and solutions to these issues. Each topic area included videos and social polls, which were then followed by activities, downloadable exercises, and external resources (see Multimedia Appendix 5 for an example).

Each topic area had 2 live footage videos: the first with sexual and gender minority contributors talking about common challenges on the topic based on their own experiences and the second with sexual and gender minority contributors talking about solutions, strategies, and advice on the topic based on their own experiences. Live footage was mixed with an animated background, highlighting what contributors were speaking about with color, illustrations, or additional text.

Each topic area also had 2 social polls, the first of which asked users to reflect on their own experiences on the topic. For example, for Coming Out , the question was as follows: “have you come out to others about your sexuality or gender yet?” A second social poll question asked users to reflect on which contributor’s experience was most similar to their own. After answering, the percentage of responses to the question became visible to the user. This was designed so that the user could understand others’ experiences and feel part of the Oneself community.

In total, 2 exercises or activities per topic area were designed to help the user reflect on the topic in greater depth and learn more about how to implement strategies and advice in managing challenges. For instance, an exercise in “Parents and Families” is framed as follows: “Some LGBTQ+ young people have repeatedly described online environments as ‘lifesaving’ at times. Reflect on your experiences of creating an online support network for yourself.” This is followed by an “Explore More” button that takes the user to another page where they can read through several strategies and choose the ones that fit them best ( Figure 6 ).

Downloads or downloadable exercises for each topic area were drafted by MFGL and ANG and then checked and refined by other research team members. Downloads were designed to tackle the problems and challenges described in each of the topics—2 downloadable guides addressing issues relevant to each topic provide detailed written information on strategies and solutions regarding them. In the case of Parents and Families , these look at standing up for yourself (communication) and problem-solving. In the case of School , they focus on finding allies and rejecting negativity (ie, the ABCD method). In the case of Coming Out , they support the coming out journey and finding hope. Downloads can also be found grouped together under the Downloads tab. An overview of the logic underpinning the development and content of Oneself is depicted in Figure 7 .

Finally, each topic area provided 2 external resources leading to organizations and web pages that can offer sexual and gender minority youth further support, such as advice, community resources, or helplines. These were chosen in agreement with the research team. External resources can also be found grouped together under the Resources tab.

All content was interspersed with quotes from our sexual and gender minority youth participants and the 3 sexual and gender minority contributors as well as short comments and advice linked to the social polls.

Finally, a Chilling Out section was included promoting relaxation exercises as well as 2 additional external resources. These exercises consisted of 3 recordings, each led by a sexual and gender minority contributor following a script provided by the research team ( Figure 8 ). A stress levels scale of 1 to 10 was available to complete before and after listening to each recording to help the user reflect on whether it had been a useful and calming exercise for them. Oneself was designed so that users can rate content with between 1 and 5 stars as they work through it, providing the research team with feedback.

Principal Findings

This study aimed to set out the systematic and iterative approach undertaken to develop a web-based resource to support the mental well-being of sexual and gender minority youth so that they can deal effectively with the specific challenges of growing up LGBTQ+. Providing this kind of support was identified as important because sexual and gender minority youth are at greater risk of poor mental health outcomes than their cisgender and heterosexual peers [ 1 , 4 , 6 , 14 ]. This study demonstrated how project activities are mapped against the 6 stages of co-design set out by Hagen et al [ 13 ]. In particular, it showed how extant research evidence and engagement with a range of stakeholders and representatives of end users were drawn on to make decisions about the content and design of the final resource, named Oneself . The logic underpinning the content of the resource is also set out to support the design of future process and outcome evaluations of Oneself . Initial usability and end-user feedback has been gathered through a set of “think aloud” interviews and post use reflection interviews with sexual and gender minority youth and adult stakeholders. The findings of the latter study will be reported in detail elsewhere (MFG Lucassen, unpublished data, 2024). The feedback to date has been largely positive, with all sexual and gender minority youth testers saying they would recommend the resource to others. There have also been some points of constructive and critical feedback, in particular from adult stakeholders, which will need to be considered in future development work (eg, that a greater range of experiences should be included, such as those of cisgender gay male individuals and individuals from minority faith backgrounds).

Strengths and Limitations of Oneself

There are several strengths and limitations to Oneself in its current format. Strengths include the fact that Oneself represents one of the first digital mental well-being–related resources reported on that is designed specifically to meet the needs of sexual and gender minority youth. The design drew on the evidence base for techniques to support their well-being [ 14 ] and was developed in collaboration with 4 different stakeholder groups: sexual and gender minority youth, adults who work with sexual and gender minority youth, parents of sexual and gender minority youth, and commissioners of public health services focused on their needs. In doing so, the process of development included a wide variety of relevant perspectives and looked to build on what is already known about supporting the well-being of this population. It is also a strength of the resource that its development included adolescents aged <16 years and was inclusive of gender and sexual minority groups rather than focusing solely on gender or sexual minority groups. This is a departure from previous interventions that have typically focused on those aged >16 years only and selected to focus on either gender or sexual minority groups [ 14 ]. Although there are important differences between sexual and gender minority experiences, there is also considerable overlap, including compromised mental well-being for many. Some young people will ultimately identify as being both a sexual and gender minority, which makes the resource’s recognition of both groups important.

Limitations of the resource include the fact that, given the budget constraints, much of the available funding had to be channeled into creating basic initial functionality that would be likely to engage and sustain interest from the target end users. This meant that much of the evidence-informed content that we might expect to have the greatest effect on mental health and well-being had to be included within the more text-heavy “downloads” section. Although, in early consultation work, sexual and gender minority youth suggested that these “downloads” were a good way to provide additional resources for use offline, it was later acknowledged that young people do not want to have to read a lot of text when engaging with the content (MFG Lucassen, unpublished data, 2024). Common evidence-based features for supporting mental health and well-being include relaxation exercises [ 28 ], behavioral activation [ 29 ], problem-solving [ 28 - 30 ], helping people recognize problematic cognitions [ 26 ], and cognitive restructuring [ 26 ]. Future iterations will need to focus on bringing more of this content into the interactive elements of Oneself. However, in doing so, it will also be important to consider whether such features are best delivered via pure self-help or whether optimal delivery requires engagement with an adult who can help structure what are often quite complex therapeutic activities (eg, sexual and gender minority youth can feasibly be supported by “e-coaches” to complete resources such as Oneself ).

The sexual and gender minority youth involved in co-designing Oneself included almost one-quarter of individuals who were of dual heritage (eg, European and West African) or from a migrant background (eg, several of the White participants). Furthermore, gender minority youth, who have been traditionally underrepresented in LGBTQ+ research [ 31 ], were very well represented, as were bisexual and pansexual participants. Nonetheless, content could have been improved in relation to intersectionality, such as the fact that there is a need to represent sexual and gender minority youth more complexly in terms of sexual and gender minority youth’s social positions (eg, across ethnicity, religion, and social class). Future iterations need to look at making the resource more relatable to additional underrepresented groups, as was suggested during co-design processes (eg, for care-experienced Asian sexual and gender minority youth from a minority faith background), who may face different and complex challenges growing up as sexual and gender minority youth.

Self-help digital resources and interventions have the potential to be very cost-effective [ 32 ]. They can be relatively low cost to produce, with the potential for very high reach given evidence of increasing digital access and capability, particularly among young people [ 10 , 11 ]. Despite this, it is likely that those with the greatest vulnerabilities and at the most risk of poor mental well-being may be the least likely to access suitable web-based spaces with ease (eg, those with limited funds to purchase data for a mobile phone). Therefore, reaching these individuals needs to be carefully considered by those who are responsible for identifying and tackling such needs, including youth support organizations, schools, and commissioners of services. In addition, digital resources such as Oneself need to keep up with the rapid pace of progress and evolution in the web-based world. Young people have high expectations and are savvy consumers of web-based media, and they anticipate polished and engaging products. Keeping a resource such as Oneself comprehensive, up-to-date, and relevant in terms of content and look and feel requires ongoing funding. Relatedly, sexual and gender minority youth highlighted the importance of educating others, in particular teachers and parents, as this would bolster their overall mental well-being. In future funded work, we would like to develop resources specifically for adults, potentially within the overall Oneself intervention. Finally, something we identified that we would not be able to achieve with Oneself , at least for now, was direct access to support and interaction from a sexual and gender minority youth peer group. Although this was desired, providing it would involve considerable resources to monitor and approve content and messaging and avoid harm that could be caused by web-based bullying and harassment. Investigating how to provide this sense of community more fully in a web-based space warrants further attention. Ideally, such spaces should be structured in such a way that the experiences of sexual and gender minority youth can be shared without any pressure to divulge information that could identify a young person or lead to instances of “oversharing” (which sexual and gender minority youth may regret at a later stage). Case studies, as presented in Oneself with the contributors, could offer a safe means to discuss personal issues without the need for self-disclosure. We think that establishing and maintaining web-based community spaces in the context of digital mental health technologies requires further study to ensure that such spaces are both acceptable and viable. However, a noteworthy shortcoming of direct access to ongoing human support and interaction given the associated costs and practical considerations (eg, whether an intervention can realistically be provided 24 hours a day, 7 days a week) are limitations in terms of an intervention’s likely reach.

Strengths and Limitations of the Research

The research we have conducted in developing Oneself, and this paper specifically, makes an important contribution to needed literature that opens the “black box” of intervention development [ 33 ]. Attempting to record the process of development, including the co-design stages, as accurately and comprehensively as possible and placing it within the public domain via open access publishing contributes to the Open Science Agenda by making it accessible, inclusive, and transparent [ 34 ]. Being explicit about the logic that underpins the intervention content in terms of how it is intended to have an effect on factors associated with maintenance (or not) of mental well-being is also important to support the design of future evaluation studies [ 35 ].

Co-design work is complex and challenging to do well. We believe that aspects of our co-design efforts were of merit, in particular our inclusion of younger sexual and gender minority youth (which included participants as young as 12 years of age) and our engagement of sexual and gender minority youth from the “Identify” all the way through to the “Use” stages of the process [ 13 ]. We drew heavily on sexual and gender minority youth’s views to decide on the topic areas to focus on and in deciding on the “look and feel” of Oneself . We also made key changes to the resource in response to sexual and gender minority youth feedback, such as not using dramatizations, as was initially envisaged. Challenges to the co-design processes included the COVID-19 pandemic at the start of the project, which meant that work with sexual and gender minority youth was conducted using videoconference software at a time when adolescents were frequently fatigued by web-based forms of communication. Connected to this was our awareness that assisting in the creation of Oneself was one of the many demands placed on the sexual and gender minority youth involved in co-design, and as such, we sought to use sexual and gender minority youth’s time efficiently. Consequently, we limited the number of workshops conducted and carried out some consultations via email, which was less robust. In the future, we could enhance our co-design efforts and move closer to partnership (as opposed to consultation as defined by Arnstein [ 36 ] in her ladder of participation) by helping a number of older sexual and gender minority youth learn more about evidence-based techniques for supporting mental well-being and subsequently getting them to design features of the content. These older adolescents could be employed as coresearchers, and they could draft and further develop content with our ongoing support.

Most sexual and gender minority youth involved in the co-design of Oneself were gender minority young people, which is a strength given that these youth are underserved by mental health services [ 4 ]. However, a limitation of our research was that we struggled to recruit cisgender adolescents to join the co-design workshops and, as such, may have underrepresented the views or specific needs of certain youth (eg, cisgender lesbian and gay youth). Relatedly, it is likely that some groups or individuals who may need intervention support the most are among those least likely to get involved in co-design or research activities (eg, sexual and gender minority youth who do not feel safe to “come out”) leading to intervention development and associated research more generally, which misses the perspective of those who are “not out.” Acknowledging this potential issue is important, and striving to reach the underheard and underserved must remain a priority of future research.

Summary, Conclusions, and Next Steps

This study aimed to set out the process involved in co-designing and developing Oneself , a digital resource to support sexual and gender minority youth in building and maintaining their resilience to cope with the everyday challenges of growing up LGBTQ+ and support their mental health and well-being more generally. It is hoped that, in the future, this resource will be extended so that it is also of use for educating adults who wish to support sexual and gender minority youth. We have explained the included content and the logic that underpins its use and acknowledged a range of strengths and limitations of what has been achieved so far. Priorities for future efforts will be to specifically address critique and feedback provided by adults and sexual and gender minority youth during their “think aloud” interviews (MFG Lucassen, unpublished data, 2024); build in additional characteristics translating evidence-based content into interactive features; and continue to incorporate diverse voices in co-design, including consideration of how intersectionality may need to be more integrated. The next steps include applying for further research funding to continue our evaluation and development activities.

Acknowledgments

The authors would like to thank all the study participants, academic advisors, and organizational partners for this project, such as the lesbian, gay, bisexual, transgender, and queer organizations, specifically Free2B Alliance and METRO Charity. The authors also thank their other partners, which include 2 county councils, a clinical commissioning group, and the Centre for Policing Research and Learning (at The Open University). The authors would also like to thank Lauren Walker for her feedback on earlier drafts of this paper. Funding for this project was provided by the UK Medical Research Council (grant MR/V031449/1).

Data Availability

The data sets generated during and analyzed during this study are not publicly available due to their sensitive nature but are available from the corresponding author on reasonable request.

Conflicts of Interest

The authors are the codevelopers of Oneself but do not stand to gain financially from its future use and have no further conflicts of interest to declare.

Concept design options for Oneself.

Questionnaire for sexual and gender minority youth as part of co-design of Oneself.

Wireframe website map for Oneself.

Instructions given to sexual and gender minority contributors for filming video content.

Screenshots from Oneself.

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Abbreviations

Edited by A Mavragani; submitted 20.11.23; peer-reviewed by E Layland; comments to author 07.02.24; revised version received 23.02.24; accepted 26.02.24; published 21.05.24.

©Katherine Brown, Mathijs F G Lucassen, Alicia Núñez-García, Katharine A Rimes, Louise M Wallace, Rajvinder Samra. Originally published in JMIR Formative Research (https://formative.jmir.org), 21.05.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.

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Role of Physical Activity on Mental Health and Well-Being: A Review

Aditya mahindru.

1 Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND

Pradeep Patil

Varun agrawal.

In addition to the apparent physical health benefits, physical activity also affects mental health positively. Physically inactive individuals have been reported to have higher rates of morbidity and healthcare expenditures. Commonly, exercise therapy is recommended to combat these challenges and preserve mental wellness. According to empirical investigations, physical activity is positively associated with certain mental health traits. In nonclinical investigations, the most significant effects of physical exercise have been on self-concept and body image. An attempt to review the current understanding of the physiological and psychological mechanisms by which exercise improves mental health is presented in this review article. Regular physical activity improves the functioning of the hypothalamus-pituitary-adrenal axis. Depression and anxiety appear to be influenced by physical exercise, but to a smaller extent in the population than in clinical patients. Numerous hypotheses attempt to explain the connection between physical fitness and mental wellness. Physical activity was shown to help with sleep and improve various psychiatric disorders. Exercise in general is associated with a better mood and improved quality of life. Physical exercise and yoga may help in the management of cravings for substances, especially in people who may not have access to other forms of therapy. Evidence suggests that increased physical activity can help attenuate some psychotic symptoms and treat medical comorbidities that accompany psychotic disorders. The dearth of literature in the Indian context also indicated that more research was needed to evaluate and implement interventions for physical activity tailored to the Indian context.

Introduction and background

Physical activity has its origins in ancient history. It is thought that the Indus Valley civilization created the foundation of modern yoga in approximately 3000 B.C. during the early Bronze Age [ 1 ]. The beneficial role of physical activity in healthy living and preventing and managing health disorders is well documented in the literature. Physical activity provides various significant health benefits. Mechanical stress and repeated exposure to gravitational forces created by frequent physical exercise increase a variety of characteristics, including physical strength, endurance, bone mineral density, and neuromusculoskeletal fitness, all of which contribute to a functional and independent existence. Exercise, defined as planned, systematic, and repetitive physical activity, enhances athletic performance by improving body composition, fitness, and motor abilities [ 2 ]. The function of physical activity in preventing a wide range of chronic illnesses and premature mortality has been extensively examined and studied. Adequate evidence links medical conditions such as cardiovascular disease and individual lifestyle behaviours, particularly exercise [ 3 ]. Regular exercise lowered the incidence of cardiometabolic illness, breast and colon cancer, and osteoporosis [ 4 ]. In addition to improving the quality of life for those with nonpsychiatric diseases such as peripheral artery occlusive disease and fibromyalgia, regular physical activity may help alleviate the discomforts of these particular diseases [ 5 ]. Exercise also helps with various substance use disorders, such as reducing or quitting smoking. As physical exercise strongly impacts health, worldwide standards prescribe a weekly allowance of "150 minutes" of modest to vigorous physical exercise in clinical and non-clinical populations [ 6 ]. When these recommendations are followed, many chronic diseases can be reduced by 20%-30%. Furthermore, thorough evaluations of global studies have discovered that a small amount of physical exercise is sufficient to provide health benefits [ 7 ].

Methodology

In this review article, a current understanding of the underlying physiological and psychological processes during exercise or physical activity that are implicated in improving mental health is presented. Search terms like "exercise" or "physical activity" and "mental health", "exercise" or "physical activity" and "depression", "exercise" or "physical activity" and "stress", "exercise" or "physical activity" and "anxiety", "exercise" or "physical activity" and "psychosis," "exercise" or "physical activity" and "addiction" were used as search terms in PubMed, Google Scholar, and Medline. An overwhelming majority of references come from works published within the past decade.

The impact of physical health on mental health

There is an increasing amount of evidence documenting the beneficial impacts of physical activity on mental health, with studies examining the effects of both brief bouts of exercise and more extended periods of activity. Systematic evaluations have indicated better outcomes for mental diseases with physical activity. Numerous psychological effects, such as self-esteem, cognitive function, mood, depression, and quality of life, have been studied [ 8 ]. According to general results, exercise enhances mood and self-esteem while decreasing stress tendencies, a factor known to aggravate mental and physical diseases [ 9 ]. Studies show that people who exercise regularly have a better frame of mind. However, it should be highlighted that a consistent link between mood enhancement and exercise in healthy individuals has not been established.

Additionally, human beings produce more of these two neurochemicals when they engage in physical activity. Human bodies manufacture opioids and endocannabinoids that are linked to pleasure, anxiolytic effects, sleepiness, and reduced pain sensitivity [ 10 ]. It has been shown that exercise can improve attention, focus, memory, cognition, language fluency, and decision-making for up to two hours [ 11 ]. Researchers state that regular physical activity improves the functioning of the hypothalamus-pituitary-adrenal (HPA) axis, lowering cortisol secretion and restoring the balance of leptin and ghrelin (Figure ​ (Figure1) 1 ) [ 12 ].

HPA: hypothalamus-pituitary-adrenal

This image has been created by the authors.

Regular exercise has immunomodulatory effects such as optimising catecholamine, lowering cortisol levels, and lowering systemic inflammation. Physical activity has been shown to increase plasma brain-derived neurotrophic factor (BDNF), which is thought to reduce amyloid-beta toxicity linked to Alzheimer's disease progression [ 13 ].

Although no causal correlations have been proven, methodologically sound research has discovered a related improvement in mentally and physically ill populations. These findings are based on research and studies conducted all across the globe, particularly in the Western Hemisphere. In order to address a widespread health problem in India, it is useful to do a literature review that draws on research conducted in a variety of settings. In addition, the prevalence of these mental illnesses and the benefits of exercise as a complementary therapy might be made clear by a meta-analysis of research undertaken in India [ 14 ].

This review also analysed published literature from India to understand the effects of exercise on mental health and the implications for disease management and treatment in the Indian context. Results from Indian studies were consistent with those found in global meta-analyses. The Indian government has made public data on interventions, such as the effects of different amounts of physical exercise. Exercising and yoga have been shown to be effective adjunct therapies for a variety of mental health conditions [ 12 ]. Though yoga may not require a lot of effort to perform, other aspects of the program, such as breathing or relaxation exercises, may have an impact on a practitioner's mental health at the same time. Due to its cultural significance as a common physical practice among Indians and its low to moderate activity level, yoga would be an appropriate activity for this assessment [ 15 ].

Yoga as an adjunctive treatment 

Although yoga is a centuries-old Hindu practice, its possible therapeutic effects have recently been studied in the West. Mind-body approaches have been the subject of a lot of studies, and some of the findings suggest they may aid with mental health issues on the neurosis spectrum. As defined by the National Center for Complementary and Alternative Medicine, "mind-body interventions" aim to increase the mind's potential to alter bodily functions [ 16 ]. Due to its beneficial effects on the mind-body connection, yoga is used as a treatment for a wide range of conditions. Possible therapeutic benefits of yoga include the activation of antagonistic neuromuscular systems, stimulation of the limbic system, and a reduction in sympathetic tone.

Anxiety and depression sufferers might benefit from practising yoga. Yoga is generally safe for most people and seldom causes unintended negative consequences. Adding yoga to traditional treatment for mental health issues may be beneficial. Many of the studies on yoga included meditation as an integral part of their methodology. Meditation and other forms of focused mental practice may set off a physiological reaction known as the relaxation response. Functional imaging has been used to implicate certain regions of the brain that show activity during meditation. According to a wealth of anatomical and neurochemical evidence, meditation has been shown to have far-reaching physiological effects, including changes in attention and autonomic nervous system modulation [ 17 ]. Left anterior brain activity, which is associated with happiness, was shown to rise considerably during meditation. There's also some evidence that meditation might worsen psychosis by elevating dopamine levels [ 18 - 20 ]. We do not yet know enough about the possible downsides of meditation for patients with mental illness, since this research lacks randomised controlled trials.

Physical activity and schizophrenia

Schizophrenia is a debilitating mental disorder that often manifests in one's early years of productive life (late second decade). Remission of this disorder occurs in just a small fraction of cases. More than 60% will have relapses, and they might occur with or without noticeable deficits. Apart from delusions, hallucinations, and formal thought disorders, many patients exhibit cognitive deficits that emerge in the early stages of the disease and do not respond adequately to therapy [ 21 ].

Treatment for schizophrenia is challenging to master. Extrapyramidal side effects are a problem with first-generation antipsychotic drugs. Obesity and dyslipidemia have been related to second-generation drugs, which may cause or exacerbate these conditions. The majority of patients do not achieve complete remission, and many do not even experience satisfactory symptom relief. Even though certain antipsychotic medications may alleviate or even exacerbate negative and cognitive symptoms, these responses are far less common. This means that patients may benefit from cognitive rehabilitation. Because of their illness or a negative reaction to their medicine, they may also have depressive symptoms. This would make their condition even more disabling. Many patients also deal with clinical and emotional complications. Tardive extrapyramidal illnesses, metabolic syndromes, defect states, and attempted suicide are all in this category. Patient compliance with treatment plans is often poor. The caregivers take on a lot of stress and often get exhausted as a result.

Evidence suggests that increased physical activity can aid in attenuating some psychotic symptoms and treating medical comorbidities that accompany psychotic disorders, particularly those subject to the metabolic adverse effects of antipsychotics. Physically inactive people with mental disorders have increased morbidity and healthcare costs. Exercise solutions are commonly recommended to counteract these difficulties and maintain mental and physical wellness [ 22 ].

The failure of current medications to effectively treat schizophrenia and the lack of improvement in cognitive or negative symptoms with just medication is an argument in favour of utilising yoga as a complementary therapy for schizophrenia. Even without concomitant medication therapy, co-occurring psychosis and obesity, or metabolic syndrome, are possible. The endocrine and reproductive systems of drug abusers undergo subtle alterations. Numerous studies have shown that yoga may improve endocrine function, leading to improvements in weight management, cognitive performance, and menstrual regularity, among other benefits. In this context, the role of yoga in the treatment of schizophrenia has been conceptualized. However, yoga has only been studied for its potential efficacy as a therapy in a tiny number of studies. There might be several reasons for this. To begin with, many yoga academies frown against the practice being adapted into a medical modality. The second misconception is that people with schizophrenia cannot benefit from the mental and physical aspects of yoga practised in the ways that are recommended. Third, scientists may be hesitant to recommend yoga to these patients because of their lack of knowledge and treatment compliance.

In a randomised controlled experiment with a yoga group (n = 21) and an exercise group (n = 20), the yoga group exhibited a statistically significant reduction in negative symptoms [ 2 ]. In accordance with the most recent recommendations of the National Institute for Health and Care Excellence (NICE), the above research provides substantial evidence for the use of yoga in the treatment of schizophrenia. According to a meta-analysis of 17 distinct studies [ 23 ] on the subject, frequent physical activity reduces the negative symptoms associated with schizophrenia considerably.

Physical activity and alcohol dependence syndrome

Substance abuse, namely alcohol abuse, may have devastating effects on a person's mental and physical health. Tolerance and an inability to control drinking are some hallmarks of alcoholism. Research shows that physical activity is an effective supplement in the fight against alcohol use disorder. In addition to perhaps acting centrally on the neurotransmitter systems, physical exercise may mitigate the deleterious health consequences of drinking. Evidence suggests that persons with alcohol use disorder are not physically active and have low cardiorespiratory fitness. A wide number of medical comorbidities, like diabetes mellitus, hypertension, and other cardiovascular illnesses, occur with alcohol use disorders. Physical exercise may be highly useful in aiding the management of these comorbidities [ 24 ].

Physical exercise and yoga may help in the management of cravings for substances when other forms of therapy, such as counselling or medication for craving management are not feasible or acceptable. Physical exercise has been shown to have beneficial effects on mental health, relieve stress, and provide an enjoyable replacement for the substance. However, the patient must take an active role in physical activity-based therapies rather than passively accept the process as it is, which is in stark contrast to the approach used by conventional medicine. Since most substance use patients lack motivation and commitment to change, it is recommended that physical activity-based therapies be supplemented with therapies focusing on motivation to change to maximise therapeutic outcomes.

One hundred seventeen persons with alcohol use disorder participated in a single-arm, exploratory trial that involved a 12-minute fitness test using a cycle ergometer as an intervention. Statistically, significantly fewer cravings were experienced by 40% [ 24 ]. Exercise programmes were found to significantly reduce alcohol intake and binge drinking in people with alcohol use disorder in a meta-analysis and comprehensive review of the effects of such therapies [ 25 ].

Physical activity and sleep

Despite widespread agreement that they should prioritise their health by making time for exercise and sufficient sleep, many individuals fail to do so. Sleep deprivation has negative impacts on immune system function, mood, glucose metabolism, and cognitive ability. Slumber is a glycogenetic process that replenishes glucose storage in neurons, in contrast to the waking state, which is organised for the recurrent breakdown of glycogen. Considering these findings, it seems that sleep has endocrine effects on the brain that are unrelated to the hormonal control of metabolism and waste clearance at the cellular level. Several factors have been proposed as potential triggers for this chain reaction: changes in core body temperature, cytokine concentrations, energy expenditure and metabolic rate, central nervous system fatigue, mood, and anxiety symptoms, heart rate and heart rate variability, growth hormone and brain-derived neurotrophic factor secretion, fitness level, and body composition [ 26 ].

After 12 weeks of fitness training, one study indicated that both the quantity and quality of sleep in adolescents improved. Studies using polysomnography indicated that regular exercise lowered NREM stage N1 (very light sleep) and raised REM sleep (and REM sleep continuity and performance) [ 22 ]. As people age, both short- and long-term activities have increasingly deleterious effects on sleep. In general, both short- and long-term exercise were found to have a favourable effect on sleep quality; however, the degree of this benefit varied substantially among different sleep components. On measures of sleep quality, including total sleep time, slow-wave sleep, sleep onset latency, and REM sleep reduction, acute exercise had no effect. But both moderate and strenuous exercise has been shown to increase sleep quality [ 27 ]. According to a meta-analysis of randomised controlled trials, exercise has shown a statistically significant effect on sleep quality in adults with mental illness [ 28 ]. These findings emphasise the importance that exercise plays in improving outcomes for people suffering from mental illnesses.

Physical activity in depressive and anxiety disorders

Depression is the leading cause of disability worldwide and is a major contributor to the global burden of disease, as per the World Health Organization. However, only 10%-25% of depressed people actually seek therapy, maybe due to a lack of money, a lack of trained doctors, or the stigma associated with depression [ 29 ]. For those with less severe forms of mental illness, such as depression and anxiety, regular physical exercise may be a crucial part of their treatment and management. Exercise and physical activity might improve depressive symptoms in a way that is comparable to, if not more effective than, traditional antidepressants. However, research connecting exercise to a decreased risk of depression has not been analysed in depth [ 30 ]. Endorphins, like opiates, are opioid polypeptide compounds produced by the hypothalamus-pituitary system in vertebrates in response to extreme physical exertion, emotional arousal, or physical pain. The opioid system may mediate analgesia, social bonding, and depression due to the link between b-endorphins and depressive symptoms (Figure ​ (Figure2 2 ).

The "endorphin hypothesis" states that physical activity causes the brain to produce more endogenous opioid peptides, which reduce pain and boost mood. The latter reduces feelings of worry and hopelessness. A recent study that demonstrated endorphins favourably improved mood during exercise, and provided support for these theories suggested that further research into the endorphin theory is required [ 31 ].

Physical activity and exercise have been shown to improve depressive symptoms and overall mood in people of all ages. Exercise has been implicated in lowering depressive and anxious symptoms in children and adolescents as well [ 32 ]. Pooled research worldwide has revealed that physical exercise is more effective than a control group and is a viable remedy for depression [ 33 ]. Most forms of yoga that start with a focus on breathing exercises, self-awareness, and relaxation techniques have a positive effect on depression and well-being [ 34 ]. Despite claims that exercise boosts mood, the optimal kind or amount of exercise required to have this effect remains unclear and seems to depend on a number of factors [ 35 ].

Exercise as a therapy for unipolar depression was studied in a meta-analysis of 23 randomised controlled trials involving 977 subjects. The effect of exercise on depression was small and not statistically significant at follow-up, although it was moderate in the initial setting. When compared to no intervention, the effect size of exercise was large and significant, and when compared to normal care, it was moderate but still noteworthy [ 36 ]. A systematic evaluation of randomised controlled trials evaluating exercise therapies for anxiety disorders indicated that exercise appeared useful as an adjuvant treatment for anxiety disorders but was less effective than antidepressant treatment [ 37 ].

Conclusions

The effects of exercise on mental health have been shown to be beneficial. Among persons with schizophrenia, yoga was shown to have more positive effects with exercise when compared with no intervention. Consistent physical activity may also improve sleep quality significantly. Patients with alcohol dependence syndrome benefit from a combination of medical therapy and regular exercise since it motivates them to battle addiction by decreasing the craving. There is also adequate evidence to suggest that physical exercise improves depressive and anxiety symptoms. Translating the evidence of the benefits of physical exercise on mental health into clinical practice is of paramount importance. Future implications of this include developing a structured exercise therapy and training professionals to deliver it. The dearth of literature in the Indian context also indicates that more research is required to evaluate and implement interventions involving physical activity that is tailored to the Indian context.

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The authors have declared that no competing interests exist.