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Implementation Principles in Mental Health Promotion

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Title: Implementation Principles in Mental Health Promotion


1
Promoting Mental Health and Wellbeing Concepts,
Practice and Policy Professor Margaret Barry
World Health Organisation Collaborating Centre
for Health Promotion Research National
University of Ireland, Galway Ollscoil na
hÉireann, Gaillimh
2
Overview
  • Concepts of positive mental health and wellbeing
  • Adopting a mental health promotion approach
  • generic principles of practice
  • Addressing the determinants of mental health
  • implications for research, practice and policy

3
Concepts of mental health
  • Concepts of mental health vary as a function of
    time, place, culture and context
  • changing and competing perspectives concerning
    the nature of mental health and ill-health
  • Mental health has been conceived as a medical,
    psychological and sociological phenomenon
  • - disease entity approach
  • - normality and abnormality ideal self
  • - social construct - deviance and social
    causation - impact of poverty, social position,
    poor housing, unemployment, social stressors
  • The merging of perspectives - biopsychosocial
    model

4
Concepts of mental health
  • Relationship between mental health and mental
    disorder
  • continuum or separate entities?
  • Population approach - continuous distribution of
    mental health and mental disorder across the
    population
  • Mental health is fundamental to good health and
    quality of life
  • complete physical, mental and social
    well-being
  • a resource for everyday life which enables us
    to manage our lives successfully
  • Mental health as an integral part of health and
    wellbeing (Lancet series on Global Mental Health
    2007)

5
Current definitions of mental health more than
the absence of mental illness
  • Mental health may be defined as
  • a state of emotional and social well-being in
    which the individual realises his or her own
    abilities, can manage the normal stresses of
    life, can work effectively, and is able to play a
    role in his or her community (WHO, 1999)
  • The capacity of the individual, the group, and
    the environment to interact in ways that promote
    subjective well-being, the optimal development
    and use of mental abilities (cognitive,
    affective, and relational), the achievement of
    individual and collective goals consistent with
    justice and, the attainment and preservation of
    conditions of fundamental equality (Striking a
    Balance, Epp, 1988)

6
Aspects of wellbeing
  • Emotional wellbeing - affect/feeling
  • Psychological wellbeing - positive functioning
  • Spiritual wellbeing - meaning and purpose in life
  • Physical wellbeing - physical health and fitness
  • Social wellbeing - relations with others and
    society

7
Concepts of mental health
  • Emergence of positive psychology - the
    scientific study of the strengths and virtues
    that enable individuals and communities to
    thrive (Positive Psychology Centre, University
    of Pennsylvania, 2007)
  • optimism, love, emotional intelligence, hope,
    wisdom, creativity and humour
  • focus on happiness- positive emotion, engagement
    and meaning
  • Cowens concept of wellness resilience,
    competence, social change and empowerment
  • Overlaps with the wider population health and
    wellbeing agenda
  • social and economic prosperity will depend on
    improving mental health and wellbeing
  • rethinking of public policy

8
Mental health and wellbeing
  • Mental Health Action Plan for Europe (WHO, 2005)
  • mental health is an essential component of
    social cohesion, productivity and peace and
    stability in the living environment, contributing
    to social capital and economic development in
    societies
  • UK Foresight Project on Mental Capital and
    Wellbeing (2008)
  • A key message is that if we are to prosper and
    thrive in our changing society and in an
    increasingly connected and competitive world,
    both our mental and material resources will be
    vital. Encouraging and enabling everyone to
    realise their potential throughout their lives
    will be crucial for our future prosperity and
    wellbeing (www.foresight.gov.uk)

9
Economics of happiness and wellbeing
  • Richard Layard (2005)- Happiness Lessons from a
    New Science?
  • income and happiness - no direct correlation -
    hedonic treadmill
  • Economic growth produces many unwanted
    side-effects - diminishing returns (Sustainable
    Development Commission, 2003)
  • Rethinking economic policy - how the economy
    affects our well-being
  • is the object of public policy maximising
    economic growth or the sum of human wellbeing?

10
A policy focus on wellbeing
  • New Economics Foundation - A Well-being Manifesto
    for a Flourishing Society
  • What would politics look like if promoting
    peoples well-being was one of the governments
    main aims?
  • Integration of social, economic and ecological
    policies

11
A policy focus on wellbeing
  • Measure what matters - set of national well-being
    audits
  • Well-being economy - employment, meaningful work
    and environmental taxation
  • Reclaim our time
  • Education system that promotes flourishing
  • Health service that promotes complete health
  • Invest in the early years and parenting
  • Discourage materialism and promote authentic
    advertising
  • Strengthen active citizenship social well-being
    and civil society

12
Adopting a mental health promotion approach
  • A socio-ecological model of mental health
  • Mental health promotion concepts are positive,
    dynamic and empowering - focus on enhancing the
    strengths and competencies of individuals,
    communities and society
  • Multidisciplinary - theories and methods
  • Builds on the basic concepts and principles of
    health promotion
  • Where mental health is created - contexts and
    settings

13
Health Promotion action areas Build healthy
public policy Create supportive
environments Reorient health services Strengthen
community action Develop personal
skill combined into Health Promotion
strategies
Systems Policies environment organisation com
munity person Systems scale
Health Promotion Model (WHO Ottawa Charter) The
process of enabling people to increase control
over their health and the determinants of health
micro - macro
Health Promotion Principles (participation,
empowerment, equity)
14
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15
Generic principles of effective mental health
promotion
  • Adopt a socio-ecological approach - bring about
    change at the level of the individual, family,
    group/community and broader society
  • Adopt a competence enhancement approach -
    resourcefulness and competence
  • Implementation approach that is empowering,
    collaborative and participatory
  • Adopt a comprehensive approach - integrated
    strategies
  • Address social inequity - multi-sectoral
    initiatives tackling sources of disadvantage and
    inequalities
  • Theory base, research principles of efficacy,
    needs assessment and high quality implementation

16
Standard treatment for known disorders
Case identification
Indicated
Compliance with long-term treatment
Selective
After-care (including rehabilitation)
Strategies for promoting well-being quality
of life
Universal
Competence
Empowerment
Resilience
Supportive Environments
Barry, M.M. (2001) International Journal of
Mental Health Promotion, 3(1) 25-34.
17
Concepts of positive mental health
  • Conceptualisations of positive mental health
    (Keyes, 2002 Huppert, 2005 Ryff et al., 2006)
  • Hedonic - subjective well-being and life
    satisfaction
  • Eudaimonic - positive functioning, engagement,
    fulfilment and social well-being
  • Keyes concept of optimal mental health or
    flourishing

18
Concepts of positive mental health
  • Measuring positive mental health - more than the
    absence of mental ill-health (Kovess-Masfety et
    al., 2005)
  • Sense of Coherence scale (Antonovsky, 1993)
  • Affectometer 2 scale (Kammann Flett, 1983)
  • Energy and Vitality Index (SF-36)
  • Keyes (2002, 2005) -suite of measures
  • WHO Wellbeing Index (2004)
  • Warwick Edinburgh Mental Wellbeing scale (Tennant
    et al., 2006)
  • Wellbeing Indicators at country level
  • - National Accounts of Well-being (New Economics
    Foundation, 2008)
  • - measure and act on well-being within the
    broader context of societal and
  • environmental stability

19
Determinants of mental health
  • Healthy structures - economic, political, social
    and cultural framework for developing and
    maintaining positive mental health
  • Citizenship - social support, sense of social
    integration and inclusion
  • Emotional resilience - self-esteem, coping ,
    life skills, sense of control

20
Determinants of positive mental health
  • Barry and Friedli (2008) - review of the
    determinants of positive mental health for the UK
    Governments Foresight Project on Mental Capital
    and Wellbeing
  • Existing evidence is drawn from epidemiological
    studies of mental disorders and intervention
    studies
  • Few studies have focused on analysing the
    determinants of positive mental health among
    whole populations

21
Findings from European studies
  • Eurobarometer study (Lehtinen et al., 2005)
  • 2002 survey of 10, 878 people over 15 years
    across 11 European countries using the
    recommended set of mental health indicators for
    the European Union (1999-2001)
  • Energy Vitality Index (SF-36) - measure of
    positive mental health
  • Positive mental health was higher for those with
    higher levels of social support
  • Gender and social and economic factors
  • Lowest income quartile had the poorest mental
    health status in all countries

22
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23
Findings from SLÁN 2007 study (Barry et al., 2009)
  • Mental health and social wellbeing of 10, 364
    Irish adults
  • Positive and negative mental heath as part of the
    national health survey
  • Lower levels of loneliness and higher levels of
    social support are associated with positive
    mental health
  • Gender and social and economic factors
  • Markers of social advantage - higher income,
    employed, higher education - associated with
    better mental health

24
Positive Mental Health
25
Psychological Distress
26
Psychological Distress and Energy and Vitality by
Income
27
Psychological Distress and Energy and Vitality by
Social Support
28
Flourishing by Health Behaviour
29
Psychological Distress by Health Behaviour
30
Determinants of mental health and wellbeing
  • Dolan et al., 2006 - review of causative factors
    associated with subjective wellbeing (analysis of
    British Household Panel Survey)
  • Identified relationships and neighbourhood social
    contact, income, health, and employment as being
    positively associated with mental health and
    well-being
  • direction of causality
  • within group variance
  • distribution across different population
    sub-groups

31
Addressing the determinants of mental health
  • Markers of social disadvantage are all associated
    with poorer mental health
  • Association between mental health, social
    wellbeing and physical health
  • Promoting mental health is central to population
    health and wellbeing

32
Addressing the determinants of mental health
  • Strengthening individuals - cognitive and
    emotional resources, identity, social
    relationships, life skills
  • Social networks - social support, exchange, sense
    of social belonging and inclusion
  • Community level - civic engagement, leisure,
    membership of clubs etc., volunteering,
    neighbourhoods, physical environment
  • Societal level - role in wider society, work,
    citizenship, democratic participation
  • Access to resources and opportunities
  • supportive relationships, education, employment,
    opportunities for social inclusion
  • Multilevel action

33
Effectiveness of mental health promotion
  • Growing international evidence base on the
    effectiveness of mental health promotion practice
  • (Hosman Jané-Llopis, 1999 WHO, 2004
    Jané-Llopis et al., 2005 Herrman et al., 2005
    Keleher Armstrong, 2005 Barry Jenkins, 2007
    Barry et al., 2009)
  • Evidence sources
  • Health Evidence Canada
  • Cochrane database of systematic reviews
  • US Mental Health and Substance Abuse (SAMSHA)
  • UK NICE - evidence briefings
  • There is sufficient knowledge to move evidence
    into practice (Jané-Llopis, Barry, Hosman and
    Patel (IUHPE Special Issue, 2005)

34
The evidence on social determinants of mental
health
  • Social exclusion and isolation have a negative
    impact on mental health
  • racism, discrimination, stigmatisation and
    hostility
  • unemployment
  • lower levels of education
  • lower levels of income and poverty
  • Research - interaction of indicators of
    deprivation and social inclusion
  • Practice - opportunities for social engagement,
    remove structural barriers to social inclusion
  • Policy - higher levels of education, freedom from
    discrimination, access to quality employment,
    improved standards of living - enhance mental
    health and wellbeing

35
The evidence on social determinants of mental
health
  • Social cohesion - quality of social relationships
    and existence of trust, mutual obligation and
    respect - protective of health
  • Inequality is corrosive of good social relations
  • Societies with higher levels of income inequality
    tend to have lower social capital (Putnam, 2001)
    and higher levels of mental ill-health (Pickett
    et al., 2006 Wilkinson Pickett, 2010)
  • Research - interaction between social cohesion,
    equality and positive mental health impact of
    inequality on mental health
  • Practice - strengthen community ties, social
    organisations and civil society
  • Policy - reducing social and economic
    inequalities population mental health and social
    and economic policies

36
The evidence on social determinants of mental
health
  • Social support and strong networks play a
    significant role in protecting mental health
  • Positive impact of supportive social
    relationships in maintaining resilience
  • Research - interaction with material living
    conditions and socioeconomic status - offset the
    effects of deprivation?
  • Practice - strengthen levels of social support
    and remove structural barriers to social contact
  • Policy implications - transport, housing,
    regeneration, community development, social care

37
Promoting mental health intervention studies
  • Individual level determinants - life skills and
    social competencies - protective of mental health
  • Sense of self -control, efficacy and esteem
  • Relationship skills
  • Coping skills
  • Communication
  • Cognitive style
  • Emotional literacy
  • Problem solving skills
  • Sense of connectedness - home, school, community

38
Promoting mental health across the lifespan
  • Children - close relationships contribute to
    resilience in adulthood
  • Early attachment, warm and affectionate
    parenting secure and safe home, informal sources
    of community support
  • Positive effect of parenting on child development
  • Relationships with peers and wider community -
    social support from at least one caring adult is
    protective from a wide range of adversities

39
Promoting mental health across the lifespan
  • High-quality early-childhood interventions
  • home visiting programmes parenting programmes
  • Pre-school education, school-based approaches
  • Robust evidence base - cost of not putting these
    programmes in place
  • Marked socioeconomic gradients in social and
    emotional adjustment across childhood (Graham and
    Power, 2004)
  • Part of a wider range of public policy measures -
    reduce health inequalities and eliminate poverty

40
Promoting mental health across the lifespan
  • Adults and the role of work and paid employment
  • Mental health impact of unemployment is well
    documented
  • Evidence-based interventions to facilitate
    re-employment, job retention, supported
    employment
  • Workplace - interventions and legislation on
    bullying and harassment
  • Organizational approaches - management and
    decision-making, social support, demand-control,
    effort-reward balance

41
Promoting mental health across the lifespan
  • Older people
  • Loss of social support, loneliness, lack of
    social participation - exclusion
  • Limited evidence base on effective interventions
    - befriending, peer support (Widow-to-Widow
    programme), targeted outreach, intergenerational
    programmes
  • Interaction with material and social inequalities

42
Implications of addressing social determinants
of mental health
  • Evidence-based interventions addressing proximate
    or individual level determinants
  • Targeted interventions - vulnerable,
    disadvantaged and marginalised groups
  • Broader social determinants - more evidence of
    impact of structural level interventions and of
    population-level patterns and interactions
  • Relative importance of material factors -
    housing, income, employment - and psychosocial
    factors - social position, relationships, social
    competency skills
  • Community level - need for more evidence of
    effectiveness of interventions at this level

43
Conclusions
  • Development and refinement of measures of
    positive mental health
  • - mental health status and well-being
    determinants
  • Implementing and evaluating upstream
    interventions addressing the broader determinants
    of mental health
  • Documenting wider health and social gain
  • - integration of mental health in health
    promotion and public health initiatives
    cost-effectiveness studies
  • Mental health as a consequence of and contributor
    to inequality (WHO Commission on the Social
    Determinants of Health, 2008)

44
Conclusions
  • Addressing the social determinants of mental
    health
  • co-ordinated multi-sectoral policy - deliver on
    improved mental health at a population level
  • Engaging the political will to promote mental
    health at a policy level
  • Mobilising a public demand for a mentally healthy
    society
  • - concern with emotional and social wellbeing,
    social values, culture, economic and social
    policies

45
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