We congratulate the journal and editors in highlighting the importance of “happiness” in terms of understanding conceptions of health (that is, what it means to be healthy) and the importance of the link between unhappiness and social exclusion for the pervading and widening inequalities in health.^1,2

These themes fit almost exactly with findings from a qualitative study we completed in 2003, which centred on understanding the health care needs of residents in a materially deprived, ethnically mixed locality in northern England. The study involved undertaking five focus groups with Pakistani and white residents (total of 28 Pakistani and 19 white residents). The focus groups with Pakistani residents were undertaken with the aid of an interpreter. All focus groups were transcribed and independently analysed by both authors using interpretive analysis.³

Two of the important themes to emerge from the focus groups were the holistic definition of health and the importance of “happiness” in maintaining and improving health. Many participants talked about a symbiotic relation between health and happiness, whereby happiness was a pre-requisite for good health and vice versa. Both health and happiness were conceptualised in holistic terms, and were not seen as the sole provenance of public health or primary care services. Participants often spoke vociferously about a long history of dis-investment in services in their locality and “broken promises” from government agencies and also about general feelings of distrust of statutory sector institutions and exclusion from mainstream society. This had lead to general feelings of unhappiness and therefore reduced levels of health. Therefore, to be healthy, respondents talked about the need for a cleaner physical environment (for example, clean streets, parks, and other public spaces), reduced traffic noise and pollution, reduced industrial pollution, more jobs, and better local services (for example, schools and advice centres in addition to healthcare services).

While none of these findings will come as a great shock to many people working within a social model of health, what they do is reinforce the importance of structural forces in shaping feelings of happiness (qua health) and suggest a heightened and widened advocacy role for public health practitioners within and across a number of statutory sector agencies, in terms of representing the “voice” of excluded and marginalised groups.