On the Promotion of Human Flourishing. Tyler J. VanderWeele Harvard T.H. Chan School of Public Health Departments of Epidemiology and Biostatistics

Transcription

1 On the Promotion of Human Flourishing Tyler J. VanderWeele Harvard T.H. Chan School of Public Health Departments of Epidemiology and Biostatistics 1

2 Plan of Presentation (1) Academic Disciplines and Human Flourishing (2) Measurement of Flourishing (3) Empirical Properties of Measures (4) Pathways to Flourishing (5) Implications for Research and Practice Paper: VanderWeele, T.J. (2017). On the promotion of human flourishing. Proceedings of the National Academy of Sciences, U.S.A., 31:

3 Academic Disciplines and Human Flourishing Our disciplines often aspire to grand visions of human flourishing: World Health Organization (1948): Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity Economics: Maximization of expected utility, taking into account all aspects of an agent s preferences Positive Psychology (Penn): the scientific study of the strengths that enable individuals and communities to thrive 3

4 Academic Disciplines and Human Flourishing In actual practice they often focus on narrow questions Public Health: Determinants of specific diseases Economics: Income, or production and consumption of goods and services Psychology: Very specific psychological states in very controlled settings These more specific inquiries are important but we also need, from time-to-time at least, to step back and look at the bigger picture of human flourishing 4

5 Flourishing Flourishing (OED): Grow or develop in a healthy or vigorous way Flourish (AHD): To do or fare well Etymology: from Latin florere "to bloom, blossom, flower Translation: Often used to translate Aristotle s Eudaimonia (sometimes also translated as happiness ) Working Definition: Flourishing (or complete human well-being): A state in which all aspects of a person s life are good This is arguably what we are after as individuals and should be after as a society 5

6 Subjective Well-being Positive psychology has perhaps most tried to broaden our scope Various conceptions of subjective well-being Ø Hedonic: Positive affective state e.g. In general, how happy or unhappy do you usually feel? Ø Evaluative: Overall life satisfaction e.g. Overall, how satisfied are you with life as a whole these days? (OECD, 2013) Ø Eudaimonic (composite psychological well-being): inclusive of positive affect, life satisfaction, meaning, purpose, autonomy, self-acceptance, optimism, positive relationships, mastery, selfdetermination, resilience, personal growth, vitality, engagement, and self-esteem (cf. Ryff, 1989; Hyde et al., 2003; Keyes et al., 2008; Diener et al., 2010; Huppert and So, 2013; Su et al., 2014) 6

7 Subjective Well-being Notably absent from the eudaimonic psychological well-being list are Ø Virtue or Character contra to Plato, Aristotle, etc. Ø Health are we flourishing if not healthy? Flourishing: A state in which all aspects of a person s life are good; this should include health, and virtue So how do we measure flourishing? Conceptions of what this includes will differ across persons Can we achieve consensus? 7

8 Measurement of Flourishing Whatever else might be included I would argue the following domains would be included as well: (1) Happiness and life satisfaction (2) Mental and physical health (3) Meaning and purpose (4) Character and Virtue (5) Close social relationships These things do not exhaust flourishing but are arguably a part of it Each of these domains satisfies the following two criteria: Ø Nearly universally desired Ø An end in itself These criteria might be useful on shaping consensus on what to measure 8

9 Measurement of Flourishing For a short scale, two questions chosen in each domain based on what is already regularly in use (for comparison) and has received some validation cf. NRC, 2013; OECD, 2013; Diener, 1985; Lyubomirsky and Lepper, 1999; Steger et al., 2006; CEL, 2015; Prawitz et al., 2006 Virtue questions were newly proposed based on philosophical and psychological literature cf. Pieper, 1966; Petersen and Seligman,

10 Measurement of Flourishing Life satisfaction - How satisfied are you with life as a whole these days? (0-10) Affective happiness - In general, how happy or unhappy do you usually feel? (0-10) Physical health In general, how would you rate your physical health? (0-10) Mental health - How would you rate your overall mental health? (0-10) Worthwhile Activities - Overall, to what extent do you feel the things you do in your life are worthwhile? (0-10) Purpose in life - I understand my purpose in life (0-10) Seeking to do good - I always act to promote good in all circumstances, even in difficult and challenging situations (0-10) Delayed Gratification - I am always able to give up some happiness now for greater happiness later (0-10) Content with Relationships - I am content with my friendships and relationships (0-10) Satisfying relationships - My relationships are as satisfying as I would like them to be (0-10)

11 Measurement of Flourishing Such measures could perhaps be used to measure flourishing at a given point in time (Sum of 10 Questions = Flourish Index 0-100) For flourishing over time, financial and material resources should be such that the other dimensions can be sustained Two Additional Questions (Financial and Material Stability): How often do you worry about being able to meet normal monthly living expenses? (0-10) How often do you worry about safety, food, or housing? (0-10) Sum of 12 Questions = Secure Flourish Index (0-120) Less satisfactory conceptually (financial and material stability are means not ends) But perhaps more satisfactory in practice (flourishing over a longer period) 11

12 Measurement Validation Data were obtained from the Health and Well-Being Survey conducted in June and July 2017, with responses from 4210 residents of North Carolina, USA (members of Allegacy Credit Union) Mean Age: 46.4 Race: 73% White, 17% Black, 10% Other Martial Status: 57% Married, 14% Divorced, 18% Never Married Cf. Węziak-Białowolska, D, McNeely, E., VanderWeele, T.J. (2017). Flourish Index and Secure Flourish Index development and validation. Under Review. 12

13 Means and Standard Deviations Domain Mean Std. dev. D1. Life Satisfaction D1. Happiness D2. Physical Health D2. Mental Health D3. Worthwhile Activities D3. Purpose D4. Doing Good D4. Delayed Gratification D5. Content with Relationships D5. Relationships are Satisfying D6. Financial Stability D6. Material Stability

14 Exploratory Factor Analysis Factors separated across proposed dimensions except More difficult to separate happiness/life satisfaction from meaning and purpose Distinctions are however clear from other empirical literature (e.g. Baumeister et al., 2013) Fit statistics for confirmatory factor analysis for proposed second order model across dimensions was also very good 14

15 Convergent and Discriminant Validity Factors separated across proposed dimensions except Flourish and Secure Flourish Index correlated well with days full of energy and inversely with days couldn t do usual activities Comparatively only very slight correlation with fruits and vegetable or consumption of tobacco products 15

16 Measurement Validation General Conclusions: Ø Psychometric properties generally satisfactory Ø Evidence that the indices can be obtained via sum of scores Ø Reasonable to use in analysis Limitations: Ø Only two questions per domain Ø Purpose or virtue are very difficult to measure Ø Subject to self-report biases Ø The five/six domains do not cover all aspects of flourishing Nevertheless: Ø Some measurement of flourishing is better than none Ø The proposed domains would have near universal consensus: universally desired each constitutes its own end 16

17 Pathways to Flourishing Public Health Impact: Function of (i) prevalence of exposure and (ii) size of the effect What pathways are there that are (i) common and (ii) have large effects on Ø Happiness and life satisfaction Ø Physical and mental health Ø Meaning and purpose Ø Character and virtue Ø Close social relationships Based on literature review I would propose four 17

18 Pathways to Flourishing Major Pathways to Flourishing: 1) Family 2) Work 3) Education 4) Religious Community Each of these (i) is relatively common in the population and (ii) has large effects across the domains of flourishing Note: Ø These four are not exhaustive (other pathways may have important effects but may be less common) Ø The four are not necessary (one can flourish even in the absence of one or more of these pathways) Ø But each powerfully affects the domains of flourishing and is common Ø If public policy contributed to these pathways flourishing would increase 18

19 Literature Review Restriction to longitudinal, experimental, quasi-experimental designs Cross-sectional designs (data on all variables collected at the same time) are excluded as they are generally useless for assessing causality E.g. Marriage may cause happiness, but happy people are more likely to marry (Stutzer and Frey, 2006) E.g. Religious service attendance may protect against depression, but those who become depressed are more likely to stop attending (Li et al., 2016) We cannot assess causal effects unless we have data over time Ideally we have longitudinal data controlling for baseline outcomes Ideally evidence is robust to potential unmeasured confounding Ideally evidence comes from multiple sources and meta-analyses of longitudinal studies Sometimes almost all the studies in a given area are cross-sectional and actual evidence may only come from very few (e.g. 1 of 100+ on religious community and happiness/life satisfaction is longitudinal) 19

20 Literature Review 20

21 Family Vast majority grow up within some family context Approximately 80% of Americans 25 and older at some point are married Marriage itself is associated with Happiness and life satisfaction: some evidence Physical and mental health: strong evidence Meaning and purpose: some evidence Character and Virtue: reduction in crime for those at risk Close social relationships: lower loneliness, greater social support Financial: Better financial outcomes (controlling for baseline finance) Divorce is associated with worse outcomes on these dimensions Outcomes of children across these dimensions are worse when parents are divorced or otherwise with unmarried parents Efforts to support marriage, and provide marital support and counseling before problems become too severe may be an important pathway for flourishing 21

22 Work About 81% of civilian non-institutionalized Americans aged are employed (88% of men, 73% of women) Employment is associated (on average) with Happiness and life satisfaction: relatively strong evidence Physical and mental health: relatively strong evidence Meaning and purpose: plausible, but few rigorous studies Character and Virtue: vocational training programs reduce crime Social relationships: increases marriage likelihood, reduces divorce Financial: Source of income The evidence comes from averages of transitions of unemployment to employment and vice versa Of course any given context can be problematic: occupational hazards for health, excessive work, etc. 22

23 Education Some education is near universal but varies dramatically in extent Educational attainment is associated with Happiness and life satisfaction: when not controlling for mechanisms Physical and mental health: maybe stronger in US than Europe Meaning and purpose: plausible, but few rigorous studies Character and Virtue: lower crime, more civic engagement Social relationships: community involvement, delayed but more likely to marry; less likely to divorce Financial: Substantial return on income 23

24 Religious Community Within the United States (Gallup Poll, ): 89% believe in God or a universal spirit 78% consider religion a very important or fairly important part of life 79% identify with a particular religious group 36% report having attended a religious service in the last week Religious service attendance is associated with Happiness and life satisfaction: some evidence Physical and mental health: strong evidence on large effects on mortality, depression, suicide Meaning and purpose: some evidence Character and Virtue: greater charitable giving, forgiveness, volunteering, civic engagement Social relationships: more likely to marry, less divorce, greater social support, more likely to make new friends 24

25 Policy Implications Policies, laws, structures, and incentives, financial or otherwise, that contribute to family, work, education, and religious community will likely be important ways in which society itself can better flourish Family and Marriage: Eliminate marriage penalties in welfare system (Rand, 2015) Offer online early marital counseling (Doss et al., 2016) Alter norms on costs of entering marriage Positive parenting practices Work: Welfare policy should not disincentivize work Supportive employment programs for disadvantaged / mentally ill (Kashner, 2002; Modini et al., 2016; van Rijn et al., 2016) 25 Better understanding of positive work conditions

26 Policy Implications Education: Access to good teachers for all students (Chetty et al., 2014) Need system to let go of poor teachers Disconnect education funding and real estate taxes Higher differential pay for those teaching in disadvantaged neighborhoods Religious Community: Religious liberty Retain tax-exempt status Correct unbalanced portrayals in media and academy 26

27 Research Implications (1) Incorporate broader flourishing measures (other outcomes) into studies (2) Examine numerous outcomes simultaneously ( outcome-wide epidemiology, VanderWeele, 2017) (3) Better research support (in term of government and university funding, hiring, promotion) for broader outcomes (e.g. life satisfaction, meaning-purpose, character-virtue) (4) Stop funding and conducting cross-sectional studies (5) Governments could start tracking flourishing measures (e.g. UK, OECD) and not just GDP 27

28 Societal Flourishing Focus here has been on individual-level determinants of flourishing However, well-functioning government and society is necessary to sustain the pathways that promote individual flourishing Ø Efficient and effective government Ø Well-functioning financial system Ø Absence of corruption Ø Civic Stability All are important to promote family, work, education, religious community But effects are likely in both directions: Ø Health, relationships, life satisfaction, purpose, and perhaps especially virtue, are needed for individuals to act rightly to strengthen, serve and support political and civic structures that themselves allow society to thrive 28

29 Future Research Directions (1) Building consensus on what to measure (workshop in spring) (2) Promote broader use of flourishing questions in the workplace (Howard Koh s Culture of Health Initiative) (3) Development of longer 40-question index (work with Aetna) (4) More longitudinal empirical research on the flourishing pathways (5) Effects of well-being/flourishing on work outcomes 29

30 Work and Well-Being Number of absent days due to sickness Work injury Life satisfaction Things done in life are worthwhile Understanding purpose in life Feeling happy Seeking to do good Satisfying relationships Being ontent with friendships and relationships Physical health Mental health Life satisfaction Things done in life are worthwhile Understanding purpose in life Feeling happy Seeking to do good Satisfying relationships Being ontent with friendships and relationships Physical health Mental health Job engagement Quality of work Job satisfaction Life satisfaction Things done in life are worthwhile Understanding purpose in life Feeling happy Seeking to do good Satisfying relationships Being ontent with friendships and relationships Physical health Mental health 0 Life satisfaction Things done in life are worthwhile Understanding purpose in life Feeling happy Seeking to do good Satisfying relationships Being ontent with friendships and relationships Physical health Mental health 0 Life satisfaction Things done in life are worthwhile Understanding purpose in life Feeling happy Seeking to do good Satisfying relationships Being ontent with friendships and relationships Physical health Mental health Results are from cross-sectional analyses using data from three factories in Mexico (N=2000); further research will examine associations in longitudinal designs Only standardized estimates with p<0.01 are displayed Controlling for gender, age, being married, having children, taking care for an elderly, job tenure (up to one year, more than 1 year and up to 5 years, more than 5 years), job position including the chief/manager title and factory

31 Conclusions (1) We should examine a broader range of flourishing outcomes in research, in the workplace, in government indices, and in personal reflection (2) Measurement across these broader domains (e.g. purpose, virtue, relationships) will always be imperfect but something is better than nothing (3) We should identify pathways and interventions that enhance flourishing across domains (e.g. family, work, education, religious community) and support these (4) A reallocation of human and financial resources is necessary to support this work (5) Focus on these questions would likely contribute to not only greater individual flourishing but a better functioning society as well 31