Research Findings

Issue 11 February 2006

Health and Resilience:

What does a resilience approach offer health research and policy?
Health research often focuses on illness, rather than on positive health or well-being and it is clear that adverse life circumstances usually lead to a much greater chance of bad health. However, there are people and places which seem to get by, cope, or even thrive, despite the adversity they experience. More people in public health and health-related social science are now asking: What can be learnt from these people and places? This brieng presents ndings on resilience from a number of studies, to explore the value of a resilience approach in understanding health and well-being.

Key points:

The term resilience is applied to both the status of adapting or reacting positively to adversity, and to the social processes and practices which seem to foster these positive reactions. We have identied two different types of resilient practices (things people do to cope in difcult circumstances) : incidental and reactive.

An incidental source of resilience might be a something someone has been doing anyway for a long time which promotes health and well-being but which becomes a very important part of coping when difculties arise. A reactive source of resilience is something someone does as a direct response to difcult circumstances.

Sometimes, adopting a risky (i.e. potentially health damaging) behaviour can in itself be a resilient practice. Examples include children stealing food to eat when none is provided by parents, or adults staying unemployed to maintain eligibility for a valued support service. Policy makers may be able to learn how to help people face adversity by studying those who have managed to get by or do better than expected in difcult circumstances.

Other RUHBC Research Findings available from the address below:

Issue 10 Issue Issue Issue Issue 9 8 7 6 Evaluating Healthy Living Centres in Scotland: lessons for policy, practice and research Pakistani and Indian Patients experiences of Scottish diabetes services: a qualitative study Food, eating, health and fatness: the perceptions and experiences of young teenagers from disadvantaged families Women and health technologies: views and experiences of women at midlife Recovering from coronary heart disease: patients views and experiences

Research Unit in Health, Behaviour and Change, School of Clinical Sciences and Community Health, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG. www.chs.med.ed.ac.uk/ruhbc/

RUHBC

RUHBC Research Findings 11

Background
The term resilience is applied to positive adaptation or reaction to adversity. Those who get by, or even thrive, in a situation where most would suffer or do badly can be called resilient. The term has been widely used within psychology (with a particular focus on child development), social policy and ecology. The concept is now being explored in medical sociology, public health and health geography. In these disciplines, related concepts such as well-being and salutogenesis (literally, health creation) have already led to understanding the conditions and contexts which enhance and create health and happiness, and away from the more conventional focus on pathology, risk and deciency. In this Findings we draw on three RUHBC research projects to explore and illustrate the utility and value of a resilience approach to exploring health and wellbeing. Project 1)a identied deprived areas in Britain which have relatively low mortality rates compared to others of a similar socioeconomic status. In-depth case studies were then carried out to try and establish what features of the areas and their populations might have led them to being healthier than expected. Project 2)b conducted in-depth interviews with a sample of young people who had at least one parent with a drug or alcohol problem. They were asked about their childhoods, current lives and plans and hopes for the future. Factors, practices and processes which had helped, or not helped, them to deal with adverse circumstances were explored. Project 3)c investigated the range and content of 11-15 year olds calls to ChildLine Scotland. Analysis focused on how the health and well-being of parents and signicant others affected the young peoples own lives, and the strategies they developed for getting by in difcult circumstances. conventional approaches to understanding health and well-being. A common way to structure our understanding of health and well-being is to consider the balance between the risk and protective factors affecting people or communities, and social processes that affect these. We already know that certain practices are good for us, or can help to promote or protect health and well-being (protective factors), and that others may increase the chances of poor health or reduce well-being (risk factors). Smoking, for example, is a risk factor for many diseases, whilst supportive social networks have been shown to promote better health and well-being in individuals and communities. Health research has tended to focus attention much more on risk factors and is generally less adept at recognising and measuring protective factors. So, are resilient people or places appearing healthier, or to be doing better than we expect, simply because we observe the risk factors more readily than the protective factors? Perhaps the urge to ask this question is the rst really useful feature of a resilience approach; greater attention is directed towards health and well-being, as opposed to disease and dysfunction. Yet, the very denition of resilience as unexpected adaptation to adversity, or healthier than expected, implies that most people or places do not achieve a resilient outcome. The vast majority of poor places have high mortality rates, for example. If resilience is rare, why should it warrant attention? First, a focus on the balance between observed and/or hidden risk and protective factors doesnt constitute the

The Research Team

This Findings was written by Richard Mitchell and Kathryn Backett-Milburn, with input from colleagues at RUHBC and edited by Sarah Morton. The views expressed here are those of the authors and do not necessarily reect those of the funding body. Richard Mitchell gratefully acknowledges the support of the ESRC in funding Resilient populations: a geographical perspective and the contributions of Helena Tunstall, Julia Gibbs, Danny Dorling and Steve Platt. More information on the research network is available from http://www.ucl.ac.uk/ capabilityandresilience/ Kathryn Backett-Milburn gratefully acknowledges the support of the Joseph Rowntree Foundation for Surviving Parental Drug and Alcohol Use Experiences of Older Children of Drug and Alcohol Using Parents: Risk and Resilience (with A. Bancroft, S. Wilson, S. Cunningham-Burley, H. Masters) and the ESRC for Childrens concerns about parents and signicant others health and well-being (with S. Ogilvie-Whyte, L. Jamieson, S. Morton (University of Edinburgh), A. Houston , A. Wales (ChildLine Scotland).

What could a resilience approach offer?

It is important to think critically about what the concept of resilience might offer researchers, policy makers and practitioners that is not currently available within
a

Resilient populations: a geographical perspective. (ESRC Research Network, Development and persistence of human capability and resilience in their social and geographical context).
b

Surviving parental drug and alcohol use: experiences of older children of drug and alcohol using parents: risk and resilience. With the Centre for Research on Families and Relationships (CRFR) (Joseph Rowntree Foundation)
c

Childrens concerns about parents and signicant others health and well-being. (ESRC) With the Centre for Research on Families and Relationships (CRFR)
d

Gilligan R. (2003) Promoting childrens resilience - some reections. Paper presented at the launch event for the Glasgow Centre for the Child and Society, University of Glasgow

(See RUHBC website for further details of these projects and research teams)

whole of the resilience approach. Resilience theorists from other disciplinesd urge that we step back from simply identifying risk or protective factors and their interrelationships, and examine the underlying social processes and practices by which positive outcomes may be achieved. While resilience promoting processes may not always achieve a denably resilient outcome, we can nevertheless learn more about how resilience can be supported and fostered by studying these processes. Second, whilst resilient outcomes may be rare, adversity is widespread. Further understanding of the means by which some people and places apparently do better in such circumstances may have policy relevance for planning to help others in the future.

and well-being under adverse circumstances than under benign circumstances. To continue the example of the children supported by aunts or grandparents, ordinarily their contact may have little impact on, or signicance for, that young persons health and well-being, but under adverse circumstances it may become tremendously important. Similarly, free coal may have a much greater protective effect when offered to an unemployed family than when the family is in work. In this way, a resilience approach can extend the more conventional risk and protective factor approach by recognising that the context and timing in which a protective factor operates might be signicant for its value in promoting resilience.

What kinds of resilient practices and processes are there?

We have identied two different kinds of resilient practices through our research: incidental and reactive. In project 2, for example, several participants reported that, as children living with a substance misusing parent, they continued to draw on support from relatives, particularly aunts and grandparents with whom they had always had a close relationship. This continuing support was portrayed as helping the young person to get by in difcult circumstances. We see this support as an incidental source of resilience because the protective practice was always present, but was still an important part of coping with the adversity. In project 3, on the other hand, callers to ChildLine with similar family problems often reported specically seeking help or advice from a friend or relative as a response to the adversity. This might be considered a reactive resilient practice. We also identied incidental and reactive practices in project 1. In some communities which suffered the closure of their coal mine, the longstanding provision of free coal to miners families continued even after the miner had lost his job, helping to keep his family warm in winter and out of fuel poverty. This is an example of an incidental source of resilience because it was the continuation of a longstanding protective practice. In some other areas where jobs were lost, those who owned their own homes could no longer afford their upkeep. As a direct response, new regeneration schemes were introduced to renovate all the houses in a neighbourhood, whether or not they were rented or owner occupied. Such schemes are an example of reactive resilient practice because they were specically introduced to tackle economic adversity. This example also shows how social policies, as well as individual behaviours, can form resilient practices. It seems reasonable to call the specically reactive actions resilient practices because they are a direct response to adversity and may lessen the impacts. However, it is debateable whether new understanding is gained by calling incidental activities a source of resilience and hence different just because they continue under adverse circumstances. It has been suggested that the denition of a resilient practice might rest on whether it holds greater signicance for the maintenance of health

When can unhealthy practices become resilient?

A resilience framework also offers the possibility of challenging conventional perspectives on risk factors and risky or unhealthy behaviour. Involvement in crime, for example, is usually seen as a bad thing, and an important risk factor for later social and health problems. However, projects 2 and 3 found that, in order to deal with challenging family circumstances, children sometimes truant, steal and sleep rough. Project 1 (resilient areas) and other literature on unemployment illustrate how choosing to remain unemployed or on sickness benet, rather than seeking and taking work, can have clear benets for some members of the community. By staying out of work or sick, people remain eligible for greater levels of nancial support and for other local support schemes. It is reasonable to view these strategies as resilience promoting practices for some, despite the fact that unemployment is a strong risk factor for poor health in later life. Thus, in extremely adverse contexts, risky or socially unacceptable behaviours can become resilient practices. Of course, these behaviours remain risk factors for poor health and development. Smoking is unhealthy, even if it helps people to get through tough times, and stealing food still carries a risk of punishment, even if it also carries the benet of nourishment. However, the resilience perspective allows us to see the importance of context for re-evaluating the meanings and value of these risky practices.

Is resilience a permanent thing?

The transience of risk and protective factors has long been recognised. Peoples behaviours and circumstances rarely remain either healthy or unhealthy at all times across the life course. For example, many young people start smoking, but most eventually give up, and there is considerable change in leisure-time physical activity rates as spare time and family commitments change. Of course, the nature of areas can change over time too. London docklands was once a polluted, derelict, violent place. Today it is home to some of Britains richest people. If the balance between risk and protective factors in an individual or area is transient, resilience may be too. In project 1 we found some areas in which the older population appeared resilient, but the younger population

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did not. One area in Birmingham had a high percentage of rst generation immigrants from South Asia and the Caribbean in adult age groups. They had relatively low mortality rates, particularly from cancer, compared to other disadvantaged populations. There were several cultural practices which may have mitigated, at least in part, the impact of living in a poor area, including diet, attitude to alcohol, and family and community support structures. However, the younger population, many of whom were born in the area, appeared vulnerable to adverse socio-economic circumstances to the same extent as other disadvantaged groups. They were growing up in a social and cultural environment that was markedly different from that of their parents. We also observed that individuals or families who achieved economic success in the face of adversity often chose to move away from the poorer neighbourhoods. Such processes suggest that an adverse area can foster and develop resilient individuals, but in achieving this may ultimately lose them from its population. sometimes hard to predict and to manipulate. The loss of control over personal and social circumstances is a feature of adversity, and the accompanying loss of control over practices which enhance health or well-being may be one reason why resilience is so hard to achieve and maintain. Resilience can thus be very fragile.

Summary and conclusions

This Findings has introduced an emerging concept which helps us learn about surviving or adapting to adversity and which may also increase our general understanding of how positive health and well-being occur. Resilience is about both the state of positive adaptation to adversity and the processes by which, and contexts in which, this takes place. Results from three projects in RUHBC have suggested that resilience can be identied, may be transient and fragile, and often asks us to reassess our understanding of risky and protective practices. Much work remains to be done in assessing the value of resilience as a framework for researching and understanding health and for policy generation. However, just as policy makers in Scotland (and the rest of UK) often try to learn from successful policies developed abroad, a focus on resilience may eventually offer the potential for policy makers to learn from those who are already practicing adaptation in their own everyday lives.

Resilience can be elusive: the value of control and access.

The absence of control over resilient practices was a common nding in our research. In project 1 we heard examples of areas and residents working hard to regain a positive economic trajectory following deindustrialisation, but seeing early success in attracting new business turning to failure when those businesses collapsed or moved away. The economic welfare of an area (and thus the residents welfare) is often subject to the inuence of regional, national and global markets something hard to predict and hard to manipulate. Similarly, in projects 2 and 3, the reports from children and young people showed how sources of support, advice and friendship could easily end with the break-up of adult relationships or their own friendships, or with supportive siblings moving away. Equally, access to basic social supports which might foster resilience cannot be assumed. It was chastening to learn that 14% of the callers in the ChildLine project reported having no-one to talk to about their problems. The welfare of young people is often subject to the inuence of adults around them again,

Implications
It is perhaps too soon in our programme of research into resilience to offer policy recommendations. We can however, offer some implications of our work for future research which we (and we hope others) will focus on.

There is a great need to focus on the well in addition to the sick in all health research. There is a need to understand more about the factors and contexts which determine whether a resilient practice helps in the face of adversity, or not. A resilience approach helps research on risk and risky behaviours by placing them in the context of peoples lives.

RUHBC was established in 1983 to improve understanding of the processes and mechanisms which inuence the health and well-being of the Scottish population, and to enhance the contribution of knowledge to the development of policy and practice interventions for health. RUHBC is funded by the Chief Scientist Ofce (Scottish Executive Health Department). There are around 20 staff and four PhD students in the unit. It forms part of the Division of Community Health Sciences in the School of Clinical Sciences and Community Health, within the College of Medicine & Veterinary Medicine at the University of Edinburgh.

Research Unit in Health, Behaviour and Change

Research Unit in Health, Behaviour and Change, School of Clinical Sciences and Community Health, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG. www.chs.med.ed.ac.uk/ruhbc/