Prepared for the Mental Health Promotion Working Group of the Provincial Wellness Advisory Council by Heather Pollett, Policy Analyst, Canadian Mental Health Association (Excerpt: June 18, 2007 )
As a state of complete physical, mental and social well-being, health is influenced by many interconnecting factors. Mental health is an essential component of toand is a resource to help us deal with the stresses and challenges of everyday life. Good mental health contributes to the quality of our lives as individuals, as communities, and as a society in general.
Mental health is created in our interactions with the world around us, and is determined by our sense of control in dealing with our circumstances and by the support we have to help us cope (CMHA-NL, 2001). An individual who has good mental health is able to realize his or her own abilities, cope with the stress of everyday life, work productively, and contribute to the community (WHO, 2001). Good mental health protects us and helps us to avoid risktaking behaviours that contribute to poor mental health (Moodie & Jenkins, 2005; NeLMH, 2004).
While individuals and communities have the capacity for good mental health, they require support in order to achieve and maintain it. The process of enhancing protective factors that contribute to good mental health is called mental health promotion. The following is a review of recent mental health promotion literature that synthesizes current general concepts, evidence of effective interventions, and practice in this growing field.
What is Mental Health Promotion?
Mental health promotion builds individual and community capacity by enhancing people’s own innate ability to achieve and maintain good mental health, and by creating supportive environments that reduce barriers to good mental health. As an approach to wellness, it focuses on the positive aspects of health such as assets and strengths rather than focusing on deficits and needs, and it emphasizes the value inherent in good mental health. It aims to achieve wellness for the entire population by addressing the determinants of mental health by applying the health promotion strategies of the Ottawa Charter. It relies on the collaboration of all sectors of society with meaningful participation of those most affected– individuals, families and communities–and by intervening and taking action at each of these levels to build capacity, including the structural or policy level (Jané-Llopis, Barry, Hosman, & Patel, 2005).
Health promotion and illness prevention are distinct concepts, but they are complementary and overlapping (Lahtinen, Joubert, Raeburn, & Jenkins, 2005). The focus of health promotion is to strengthen and enhance the capacity for health that already exists; the focus of prevention is to avoid illness, which is seen as a lack of health. Within the field of mental health promotion, there are differing views about the degree to which promotion and prevention overlap and the point at which these concepts converge. Good mental health is not the absence of mental illness, and preventing illness will not guarantee good mental health. Some people are more mentally healthy than others, regardless of whether or not one has a diagnosis of a mental illness (CMHA, “Meaning of Mental Health”; WHO, 2001).
Health and illness are not mutually exclusive and can coexist. People with mental illness have resources and skills to draw on to protect them against poor mental health, and are affected by the same factors as those without mental illness (MHPU, 2003; Pape & Galipeault, 2002).
While some groups are more vulnerable to poor mental health than others, the population health approach to mental health promotion aims to reduce the burden of mental health problems by improving the mental health of the whole population. The health of the whole population is determined by the following: income and social status, social support networks, education, employment/working conditions, social environments, physical environments, personal health practices and coping skills, healthy child development, biology and genetic endowment, health services, gender, and culture (PHAC, 2002). These determinants can then be grouped into the following three themes for mental health promotion:
• Social inclusion (supportive relationships, involvement in community and group activity; and civic engagement);
• Freedom from discrimination and violence (valuing diversity, physical security, self determination and control of one’s life);
• Access to economic resources (work, education, housing, money) (Victorian DHS, 2006)
EVIDENCE OF EFFECTIVE INTERVENTIONS
A population health approach also uses evidence-based decision-making (PHAC, 2002). In mental health promotion, evidence is necessary for policy makers to justify their spending, for practitioners to plan and implement programmes, and for those affected to know if the interventions will benefit them (Barry & McQueen, 2005). Mental health promotion interventions aim to reduce the risk factors that contribute to poor mental health and enhance the protective factors, which contribute to good mental health, but they also produce many other health, social, and economic benefits. Examples of effective interventions to promote good mental health include: strengthening parenting skills in early childhood; preventing or reducing bullying in schools; addressing workplace stress and creating a work-life balance; and providing opportunities for meaningful community involvement through volunteering.
However, the evidence of mental health promotion effectiveness is still emerging, and while there is no consensus on what works best, there are recognized groups of risk and protective factors that can be reduced or enhanced by interventions (Barry, 2005). Both the theoretical and the evidence bases need to be broadened to help inform and expand work in this area. Research studies and reviews mainly focus on outcomes, and not on the process of implementation or programme quality, which are necessary to understand positive outcomes (Barry, Domitrovich & Lara, 2005). Even though the evidence base is not well developed, practitioners, policy makers and researchers have moved ahead with mental health promotion practice because of the burden of suffering and costs related to mental health problems, and because the evidence that is emerging indicates that the interventions are effective (Zubrick & Kovess-Masfety, 2005).
Risk behaviours, social and economic problems, and rates and severity of physical and mental illness can be reduced by strengthening protective factors for good mental health (Moodie, 2005; NeLMH, 2004). The absence of protective factors in the presence of risk factors can result in behaviours associated with poor mental health, such as increased crime, low educational attainment, problematic substance use, depression and suicide, all of which have broader social and economic consequences (Moodie, 2005). Both risk and protective factors can exist at the individual, community, and structural levels, as well as in different settings and situations (NeLMH, 2004). For example, some of the protective factors at the individual level for the entire population include self-esteem, a sense of coherence, personal coping skills, social support, sense of mastery or control, ability to form and sustain satisfying relationships, resilience, sense of belonging, and optimism. (MHPU, 2003; Moodie & Jenkins, 2005). These are also indicators of good mental health.
The population health approach to mental health promotion looks at mental health across the lifespan, from birth to death. The determinants of health affect everyone but there are different issues related to each stage of development that can create vulnerabilities for poor mental health. Interventions are generally focused on the settings where these populations create and maintain health: at home, at school, at work, and in the community.
While there is no clear age distinction that divides adults from seniors, this later stage of adulthood brings unique challenges to achieving and maintaining mental health. One of these challenges is the myth that declining mental health is related to dementia or Alzheimer’s and is a natural, and therefore inevitable, part of the aging process. This misconception makes seniors vulnerable to developing poor mental health as other determinants of mental health such as illness, abuse, and social and economic disadvantage may not be recognized or addressed (Sturgeon & Orley, 2005). The reality is that good mental health is possible in the later years of life. Given respect and support, seniors have the capacity for positive overall health, even as they deal with the challenges of aging (HCS, 2006).
As people age, they experience a range of physical and cognitive changes that may affect mental health. Protective factors change with age and, at the oldest ages, as social, economic and health circumstances change, poor resources and less adaptability increase vulnerabilities for loneliness and depression, especially for older women who outlive men and live alone with less support (Pushkar & Arbuckle, 2002). The wealth of wisdom and knowledge gained across the lifespan are protective factors, but there is a decline in the speed of cognitive functioning. Retirement or loss of employment can also negatively affect level of income, sense of identity and meaning, and the level of social support.
For older adults, social loneliness and isolation are key risk factors for poor mental health. Social isolation refers to the number of contacts and measures separation from social environment objectively; social loneliness is related to one’s negative feelings about the quantity and quality of social contact, with quality defined as meaningful and satisfying relationships (Hall & Havens, 2002). Having a positive sense of self, being flexible and using adaptive strategies and personal coping skills for changes, health problems and difficult life events are protective against poor mental health for older adults (Pushkar & Arbuckle, 2002).
However, individual coping skills alone do not effectively address the need for social contact for older adults. The number of social contacts becomes smaller as people retire,move, as family and other contacts die, and as people select a condensed but high quality network of friends (Hall & Havens). There is a strong link between loneliness and health problems, but the direction of the link is not clear. Social isolation and loneliness also negatively affect health, which may, in turn, lead to further social isolation and loneliness. (Hall & Havens, 2002). Risk factors for loneliness include: being widowed; living alone; and a decline in eyesight or hearing, as these might limit social interaction and independence (Pushkar & Arbuckle, 2002).
Although seniors are diverse as a population, there are some general themes for promoting mental health. Because seniors have the wisdom, skills and the time to make contributions to society, volunteering is an intervention that can enhance individual well-being and build community capacity at the same time (Keleher & Armstrong, 2005). While physical exercise is important for all ages in enhancing mental health, exercise interventions that encourage regular physical activity in supportive, age-friendly environments are effective for helping older adults to manage physical ailments and reduce the risk of depression (Keleher & Armstrong, 2005; Hosman & Jané-Llopis). Interventions that support people with hearing loss or visual impairments can promote independence, and interventions such as community befriending programmes can provide social support, thus reducing loneliness and depression. Evidence shows that friendship is important for well-being, particularly for older women. Meaningful friendships provide companionship and support, and help maintain a sense of self through difficult times (Hosman & Jané_Llopis, 2005).
PRACTICING MENTAL HEALTH PROMOTION
Evidence of effectiveness is used to inform the practice of mental health promotion in the settings where people live, work, learn and play, the physical and social environments in which health is created. Interventions delivered in the settings where people create health are more effective than interventions delivered in isolation from their contexts. Based on WHO’s Ottawa Charter for Health Promotion, there are five areas for action in mental health promotion, and they are as follows:
1. Build health public policy: Health promotion requires coordinated action from all policy makers in all sectors, and at all levels, to ensure that those who make decisions take responsibility for policies that promote health, and requires that obstacles to the adoption of healthy public policies outside the health sector are identified and removed.
2. Create supportive environments: Because our health is closely connected to our environments, health promotion takes into account that our health cannot be separated from the places where we live. Thus, creating and maintaining environments at home, school, work and in our communities that support our health is key.
3. Strengthen community action: By drawing on its own resources, both human and material, communities are able to enhance their capacity for self-help and social support that contribute to good health. Therefore, communities must be supported in their development efforts through funding, access to information, and opportunities to learn about health promotion, all of which enable public participation in matters of health.
4. Develop personal skills: Helping people through the provision of health information and education allows them to learn ways to cope with the health challenges they may encounter, thus enabling them to develop a sense of control over their own lives.
5. Reorient health services: The health sector must shift and expand its services to include health promotion alongside clinical and curative services, and this responsibility is shared with individuals, community groups, health professionals, health institutions and governments, all of whom must work together in the pursuit of health and well-being.
These five strategies address the determinants of health and from the interventions discussed in the previous section, it becomes clear that these are the directions for mental health promotion. Multifaceted programmes that are designed to take action in more than one area and at different levels are more effective at promoting mental health than individual interventions focusing solely on the development of personal coping skills.
Mental health treatment at the individual level does not always mean improvements for population mental health (Lahtinen et al., 2005). Most health systems and organizations still focus spending on diagnosing and treating symptoms of illness rather than focusing on a person as a whole, whose health is influenced by many social and economic factors.
Considering the significant burden of mental health problems and its economic costs, and despite the investment of the health care sector, the solution to achieving good mental health lies in reorienting health services and collaborating with many other sectors (Lahtinen et al., 2005).
Mental health promotion is everyone’s responsibility, and stakeholders from all sectors of society have a role to play. There are better health outcomes when different sectors work together because mental health is determined by many factors. Intersectoral collaboration requires that the sectors that work in the areas of the various health determinants work together to achieve wellness. The health sector participates in mental health promotion by lending expertise to develop, implement, evaluate, research and provide resources for actions within a population health approach (PHAC, “Health is Everyone’s Business”).
Therefore, needs assessments should involve those most affected at the centre to ensure that programmes are suited to those who will benefit from them and to encourage empowerment of individuals and communities as they participate in the decision-making process. It is the opinions of these individuals in each country and community, in combination with evidence of effectiveness, which will shape the practice of mental health promotion (Herrman, Saxena, Moodie, & Walker, 2005).
Interventions at the structural level allow practice at the community and individual level. Building healthy public policy involves making policy makers accept responsibility for promoting good mental health through legislation, fiscal measures, taxation, organizational change, and by increasing access to education, housing, nutrition and health care (WHO, 1986; Jané-Llopis et al., 2005). Examples of effective interventions at the policy level include measures to reduce poverty, improving high-quality affordable housing, access to high quality education, improving nutrition, taxation of addictive substances, and regulatory policy in workplaces (Jané-Llopis et al., 2005).
What does mental health promotion look like in practice in settings where we create health? The following is an examples of an effective mental health promotion programmes for seniors.
Seniors’ Medicine Wheel, Portage Aboriginal Friendship Centre, Manitoba:
This project was initially developed to address the needs of Aboriginal seniors in urban Manitoba, many of whom were still dealing with the trauma of childhood abuse in residential schools. The marginalization and isolation of living in urban areas had led them to lose touch with their traditional culture. When these seniors came together, they identified problems in their community that related both to their own health and to the health of Aboriginal children and youth, who were vulnerable to entering the same cycle of abuse. By partnering with Aboriginal Head Start, a community programme that fosters spiritual, emotional, intellectual and physical growth in children while supporting their parents and guardians, the seniors were able to share their wisdom and knowledge of traditional culture with Aboriginal children. Through this process, these seniors became valued Elders and increased their own feelings of self-worth. The children’s own mental health was promoted through their relationships with the Elders; they developed confidence, respect, self-worth, and learned traditional Aboriginal culture and language that was at risk of being lost if it was not passed on to younger generations (CMHA, “Took Kit”).
A review of the current literature on mental health promotion reveals the many complex interrelationships between the individual, community, and structural levels of society and the various determinants of mental health. Addressing these issues requires commitment from the sectors aligned with these different determinants, as it is their responsibility to ensure that their work does not negatively affect mental health. Most of the interventions combine building personal skills with the creation of supportive environments to enhance protective factors in the settings where people spend most of their time.
However, there is little focus in the literature on mental health promotion for older adults, and little explanation as to why this problem exists. While the determinants of health apply to the entire population, there is generally limited discussion of interventions to enhance the mental health of seniors, despite a growing body of effective interventions focusing specifically on children and adults. Given that there are many negative stereotypes around aging and older people in our society, and that concepts of mental health issues in older adults are characterized by misconceptions, there is a need for more mental health