Wellbeing, resilience and inequalities Lynne Friedli 17th Annual Conference of the WHO Regions for H

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Wellbeing, resilience and inequalitiesLynne
Friedli17th Annual Conference of the WHO
Regions for Health NetworkManchester10th
November 2009
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Summary
Can we achieve wellbeing in ways that combine a
healthy economy, sustainable communities and a
reduction in health inequalities?

• Mental wellbeing contributes to the money
  economy, the core economy and health equity
• How do we achieve wellbeing interventions that
  make a difference
• Resources equitable access to valued assets
• Relationships social solutions/social outcomes
• Meaning valued roles/occupations/contribution

Respectful responses to misfortune
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Dimensions of mental health
If I am not for myself, who will be for me? And
if I am only for myself, what am I? If not now,
when?
Emotional resources e.g. coping style, mood,
emotional intelligence
Cognitive resources e.g. learning style,
knowledge, flexibility, innovation, creativity
Mental health (capital)
Meaning and purpose e.g. vision, goals,
connectedness
Social skills e.g. listening, relating,
communicating, co operating
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Mental wellbeing and a healthy (money) economy
Its better to be roughly right than precisely
wrong
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Outcomes associated with positive mental health

• A worthwhile goal in itself and leads to
  better outcomes
• reduces prevalence of mental illness
• physical health mortality/morbidity
• health behaviour
• employability, productivity, earnings
• educational performance
• crime / violence reduction
• pro-social behaviour/social integration/relations
  hips
• quality of life

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Life course benefits

• 
  crime smoking drugs depression
  suicide no quals
• top 50
• (no conduct problems) 1.00 1.00
  1.00 1.00 1.00 1.00
  
• middle 45
• (some problems) 1.95 1.24
  1.51 1.24 1.69 1.18
  
• bottom 5
• (conduct disorder) 4.13 1.59
  2.39 1.57 3.00 1.45

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Reducing behavioural problems life course
savings

• 
  per case total for
  1-year Scotland
• 
  cohort in UK
• 
  million
  million
• Prevention
• (move bottom 5
• to middle 45 ) 150,000
  5,250 4.2
• Promotion
• (move middle 45
• to top 50) 75,000
  23,625 18.9
• (Friedli Parsonage 2007)

Annual UK birth cohort 700,000
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Cost of interventions

•  Typical cost of parenting programmes (2003 )
• Group programme community 1,350
• Individual programme home 6,000
•  
• Success rate needed 1 in 25 and 1 in 55
• (effect size of 2-4)

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Cost benefits other examples

• Health promoting schools (life skills, social
  skills)
• 25 - 45 return per dollar invested
• Adult education increase education of women
  from no qualifications to basic qualifications
• 230m per year saving in cost of depression
• Access to green open spaces 50 reduction in
  health gap (all cause and circulatory disease
  mortality )
• (US DHHS 2007 Chevalier Feinstein 2006
  Mitchell Popham 2008)

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Mental wellbeing and rebuilding the core
economyPSA 21 to build cohesive, empowered and
active communities
It gets so lonely around here that I phone
myself seven or eight times a day, just to see
how I am (Phantom Tolbooth)
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Economic policy, sustainability and wellbeing

If being poor once derived its meaning from
being unemployed, today it draws its meaning
primarily from the plight of a flawed
consumer. Zygmunt Bauman
environmental instability
Economic/ fiscal policy
Social recession
psycho-social instability
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Return to the social....

To value the contribution of those whom the
market excludes or devalues and whose genuine
work is not acknowledged or rewarded
Edgar Cahn
I am, because we are...
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Resilience, health assets and capabilities
Towards an Index of Multiple Assets...
doing better than expected in the face of
adversity extent to which communities are able
to exercise informal social controls or come
together to tackle common problems bouncing
back

• Resilient places
• Resilient communities
• Resilient individuals

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Mental wellbeing and achieving health equity
The importance of mental health is directly and
indirectly related at every level to human
responses to inequalities
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Mental health and deprivation

• Not every family in the land
• Findings from 9 large scale population based
  studies
• Material and relative deprivation
• Childhood socio-economic position
• Low educational attainment
• Unemployment
• Environment poor housing, poor resources,
  violence
• Adverse life events
• Poor support networks
• (Melzer et al 2004 Rogers Pilgrim 2003
  Stansfeld et al 2008 APMS 2007)
• Cycle of invisible barriers
• Poverty of hope, self-worth, aspirations

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Contribution of mental health to inequalities

• Key domains education/employment/behaviour
  /health/ consequences of illness /services
• (Whitehead Dahlgren 2006)
•  Mental health is a significant determinant in
  each case, influencing
• readiness for school/learning
• employability
• capacity, motivation and rationale for healthy
  behaviours
• risk for physical health (e.g. coronary heart
  disease),
• chronic disease outcomes (e.g. diabetes)
• relationship to health services, including
  uptake/treatment

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How do we achieve wellbeing interventions that
make a differenceresources, relationships,
meaning, respect
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Untangling the determinants
I do worry about this emphasis on individual
psychology You cant separate thoughts,
feelings, self esteem, motivation from the
material circumstances of peoples lives. Is it
great to be positive? Maybe people are right
to be pissed off. Positive steps
interviews

• Individual skills and attributes
• Social relationships, support and networks
• Material resources
• Inequalities in distribution of resources

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...the Greeks and Romans lived, I suppose, very
comfortably though they had no linen. But in the
present times, through the greater part of
Europe, a creditable day labourer would be
ashamed to appear in public without a linen
shirt, the want of which would be supposed to
denote that disgraceful degree of poverty which,
it is presumed, nobody can fall into without
extreme bad conduct. Custom in the same manner
has rendered leather shoes a necessary of life in
England. The poorest creditable person of either
sex would be ashamed to appear in pubic without
them (Adam Smith Wealth of Nations 1776 cited
in Zaveleta 2008)
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Scope of public mental health
Social and material outcomes
Material resources Increasing equitable access
to assets that support mental wellbeing
Relationships Increasing social support as a
buffer against adversity
Interventions to promote mental wellbeing
Meaningful activity Opportunities to contribute
Inner resources Strengthening psycho-social, life
skills and resilience
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Increase equitable access to valued assets

• Money, learning, culture, space, opportunities
• income maximisation benefits debt credit
  training pay
• green/blue space access food landshare
  forest schools
• public space resist privatisation of traffic
  reduction transport stop and chat young
  people friendly
• asset transfer social enterprise community
  right to buy

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Develop social solutions
Rebuilding the core economy.........

• Collective opportunities for healthy lifestyles
• Social prescribing/community referrals
• Support for parenting free range children
• Bridging capital (parents) and social capital
  (older people)
• Reduce barriers to social contact e.g. MVT,
  street level incivilities

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Expand opportunities to contribute

• life long learning literacy basic education,
  training
• home learning environment (HLE), life skills
• valued social roles for children and young
  people
• Co-production time banking volunteering
  (person to agency)
• Acknowledge and value those who contribute to the
  core economy

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A (wider) framework for effective action
And what I shall endure, you shall endure For
every atom belonging to me as good belongs to
you...... Walt Whitman
Reduce poverty and the impact of poverty
Respectful policy responses to misfortune
Mental health and Mental Capital
Opportunities for meaningful activity
education, training, volunteering
Quality of social relationships (family, schools,
workplace, communities)
Reduce material inequalities
Build capacity for collective action (collective
efficacy)
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What if?
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