Creating Caring Communities: Putting Mental Health on the Agenda

Dr. James Irvine

Health Promotion Summer SchoolPrairie Region Health Promotion Research Unit

Mental Health Promotion: Identity, Culture and PowerAugust 2005

Mental Health a state of balance between

physical, mental, cultural, spiritual and other personal factors, and between the self, others and the environment

Sartorius

Positive Mental Health

A value in its own right; contributes to the individual’s well-being and quality of life; and also contributes to society and the economy by increasing social functioning and social capital.

Jané-Llopis E, Barry M, Hosman C, Patel V.

Why the interest in mental health promotion?

Why the interest from ‘health’?Why the interest from other

sectors?

Increasing interest in population’s mental health

Increasing awareness of mental disorders being common & disabling

Economic consequences clearer Links between physical & mental health better

appreciated Links between education, labour, justice, etc &

mental health more understood Increasing recognition of the link needed between

economic & social development

Mental Illness Impact

Neuropsychiatric disorders account for 13% of Global Burden of Disease; (Moodle and Jenkins)

Predictions that by 2020, depression will be the 2nd leading cause of disability in the world;

Poor mental health also contributes to poor physical health;

One in four persons will develop a mental or behavioural disorder throughout their lifetime. Prevalence ~10% of adults (WHO)

Mental Illness Impact

20% of adolescents under the age 18 suffer from developmental, emotional or behavioural problems; 1 in 8 has a mental disorder; from poor communities this increases to 1 in 5.

Economic costs substantial 30-40% of workplace sickness absence is

attributable to mental disorders (Jenkins)

Socio-economic & Life Stress

Impact on Physical Health

Social Risk Factors Adverse childhood experiences (ACE) Lower childhood socio-economic status

Leads to increased: Cardiovascular risk Lipids (cholesterol) Insulin resistance Obesity

Dong M et al Circulation 2004; Lawlor, Ebrahim, Smith. BMJ 2002

Mental health status is associated with risk behaviours at all stages of the life cycle. Young people with depression and low

self-esteem are linked with smoking, binge drinking, eating disorders and unsafe sex.

Vicious circle

Links between physical health and mental health are bidirectional

Malnourishment in infants – increased risk of cognitive and motor deficits

Heart disease and cancer can increase risk of depression

Mood disorders can lead to increased risk of injuries, poor physical and role function

Learned helplessness, hopelessness and depression associated with decreased immunologic activity and increased risk of tumor growth and infections.

Many of the interventions designed

to improve mental health will also

promote physical health and vice

versa.

(when mental health promotion is thought of in a

broader sense than previously understood)

Promoting mental health has the potential to reduce a whole range of risk behaviours and their consequences such as loss of productivity, crime, drop-out from school, disrupted family relationships

(Moodle and Jenkins)

Similarities in the conditions for different health and social outcomes

Same risk factors (low attachment to one’s community, school, family and workplace; parental alcohol and drug use; family conflict; inconsistent parenting; marital instability) and

Absence of protective factors

Can result in

increased crime, drop out from school, increased risk of alcohol abuse, sexual activity, depression and suicide, drug addition

What we spend on policing and courts

and jails is not available to be spent on

affordable housing, school systems, or

income security.

Feather

Mental Well-Being: the foundation of a healthy individual, family & community

The Health of the Population

Prerequisites peace shelter education food income stable ecosystem sustainable resources social justice and

equity

Determinants child development working conditions education choices and coping income and social

status physical environments health services social support network

Social, environmental & economic determinants of mental health

Isolation / alienation Lack of education, transport,

housing Neighourhood disorganization Peer rejection Poor social circumstances Poor nutrition Poverty Racial injustice /

discrimination Violence Work stress Unemployment Access to drugs / alcohol Displacement War

Empowerment Positive interpersonal

interactions Social participation Social responsibility /

tolerance Social services Social support / community

network Cultural integration

Williams, Saxena, McQueen

Risk Factors Protective Factors

Societal or community-level characteristics: Culture, Language, Cohesion, Control

Aboriginal Youth Suicide by Cultural Continuity Factors

0 20 40 60 80 100 120 140 160

Suicide Rate / 100,000

S elf-Government

Land Claims

Education

Health

Cultural Facilities

Y es No

Cultural Continuity Factors

Source: Chandler & Lalonde, 1998

Post-Traumatic Stress Response

Popular explanations of health inequities of the

Aboriginal communities are limited (its more than

health behaviours, more than socio-economic),

The enduring impact of colonization and loss of

culture are identified as critical health issues –

concepts of historical and intergenerational trauma

need to be recognized

Mental health and social problems linked to social and

cultural disruption over the lifespan and across

generations

Mitchell, Maracle

Post-Traumatic Stress Response

arises from external trauma and terrifying experiences that break a person’s sense of predictability, vulnerability, and control.

Mentally: negative beliefs about themselves and the

world,

Emotionally: cycles of denial and anxiety

Physically: sleep disturbances, anxiety, nightmares,

flashbacks

Behaviourally: avoidance, isolation, drinking, drugging,

increasingly aggressive.

PTSR is a useful model for understanding and addressing health inequities:

Provides a social / historical context for what has been incorrectly viewed as individual/cultural weaknesses, or illness,

Confirms holistic understanding of well-being and cultural renewal

Compassionately validates stress responses as appropriate human reaction to trauma;

Offers access to proven psycho-educational and therapeutic approaches

Points to use of group/community models for collective mourning, support and healing.

Mental Health Promotion

Enhances positive mental health Contributes to the reduction of risk

behaviours such as tobacco, alcohol, and drug misuse, unsafe sex

Reduction of social and economic problems such as drop out from school, crime, absenteeism from work and intimate partner violence

Reduction of rates, severity of, mortality from physical and mental illness.

How do we approach mental health

promotion?

Diet

Sexual Activity

Drugs

Smoking

Early Childhood Development

Social Supports

Unemployment

Education

Poverty

Principles of Health Promotion

Health education Policy analysis Community development and

organization Health advocacy Legislation

World Health Organization (1984)

Ottawa Charter for Health Promotion

Building Healthy Public Policy Creating supportive environments Strengthening community action Developing personal skills Reorienting health services

World Health Organization (1986)

Key Population Health Promotion Ideas

Meaningful participation

Meaningful Participation

Participation by local people is

recognized as having the greatest

and most sustainable impact when

solving local problems and setting

local norms

Multi-sector collaboration and partnerships

The health sector has to pick up the pieces resulting from poor mental health, but it has little effect on the determinants of mental wellbeing

Expand the traditional view about who ‘owns’ mental health promotion, and who actually does, or can, promote mental health in most populations. Moodle/Jenkins

Finding ways to shift emphasis from a sector-by-sector approach to a broader and more cohesive problem approach

Community as the focus!

Partnerships Within communities Between communities Within health organizations

Mental health promotion & health promotion

Treatment and promotion services Between health organizations With other sectors

Conditions for success: Intersectoral action for Population Health

Seek shared values and interest; alignment of purpose; common vision

Ensure political support Engage key partners Ensure horizontal and vertical linking Invest in alliance building Focus on concrete objectives and visible results Ensure leadership, accountability and rewards are

shared among partners Build stable teams of people skilled

transformative action adapted from FPT Adv C on PH

Housing

Good housing acts as a mitigating factor against the negative effects of low SE status on health and well-being (Dunn, 2002).

Community focus versus jurisdictional

“if jurisdiction is your starting point, you’re not going to solve anything…Start from a

community issues standpoint, set aside jurisdictional and policy issues, and commit

some resources to it. You’ll see things happen” (Hanselmann, Gibbins)

Intersectoral partnerships

Individuals and organizations in business and industry, housing, local gov’t, sports, recreation, arts and culture, education, and justice already are promoting and in some cases demoting mental health

May not be aware of the effect they have on mental health and can be further encouraged to either expand their health promoting work, or reduce the health damaging effects of their work

Challenge is to work out how to create effective partnerships with these indiv and organizations.

Take action on a variety of determinants

Multiple StrategiesMultiple Levels

Reduce individual, socio-economic, and environmental risk factors, and

Promote protective factors

Supportive environments to reduce inequities & remove barriers

Making healthy choices, easier choices.

Creating supportive environments

Policy Economic development Social action Community schools Early childhood supports

Creating Supportive Environments

High/Scope Perry Preschool Project Targeted 3-4 year old children from

impoverished backgrounds

Cost $1000 per child

Cost-benefit - $7,000 to $8,000 per child

Barnett WS. AJ Orthopsych 1993

Government Healthy Public Policy

The way services are provided Environmental policy Policy on housing, transportation,

etc Economic policy Taxation policy Social policy

Healthy Policy is also for you & I

School boards Recreation centers First Nations Band councils Municipal governments Committees and organizations Families Workplaces

Capacity building and empowering practices

Capacity building

Increased awareness & knowledge

Skill development Knowing how to access

resources Developing social networks Learning from others

Actions that focus on the health of the population

Focus upstream on taking action earlier

Evidence based decision making

Not only doing things right, but the right things.

The delivery of mental health

promotion programs in an

empowering, collaborative and

participatory manner is central to

mental health promotion activity. (Barry M)

Four crucial settings for intervention

Home, School, Workplace, and Community.

Jané-Llopis/Barry MM

Home

During the first period of life,

there is more development in

mental, social, and physical

functioning than in any other

period across the lifespan

UNICEF, 2002

School Enormous potential – no other setting where

such a large proportion of children can be reached

WHO “Child-friendly schools” promotes sound psychosocial environment; encourages tolerance and equality between genders, ethinic,

religious and social groups. Promotes active involvement and co-op; avoids use of physical

punishment; does not tolerate bullying. Supporting and nurturing environment; providing education

which responds to the reality of the children’s lives. Establishes connections between school and family life,

encourages creativity as well as academic abilities, and promotes self-esteem and self-confidence of children.

Workplace Unemployment Work stress

Noise, overload, time pressures

Repetitive tasks Interpersonal conflicts Job insecurity Low sense of control Balance with personal life

Community

Change is more likely to come about when the people it affects are involved in the change process.

Participation by local people is recognized as having the greatest and most sustainable impact when solving local problems and setting local norms

Support Multi-outcome interventions

One of remaining problems is the categorical approach to mental, social, educational, behavioural and legal problems.

Many of these problems have commonalities that can be addressed simultaneously and that impact on many areas of functioning.

Addressing the determinants

Partner - Who can we work with, to do it better together?

Advocate - What needs to be done at policy legislative

level?

Cheerlead - Encouraging and not getting in the way.

Enable - What we do directly to change the determinants

Mitigate - Picking up some of the pieces, so it isn’t worse

Solutions?

Will be found in:.. thinking, planning and working...

across sectors and levels of government from multiple perspectives, including social,

psychological, justice, education, and economic, from prevention and promotion through to

treatment and care, using the expertise of many disciplines and engaging communities as partners in

potential solutions.

David’s Population Health Traps

Macro Avoidance

Micro Paralysis

Many Small Steps

“Almost anything you do will seem insignificant, but it is very important that you do it anyway”

Mahatma Ghandi

Why would a small group of dedicated individuals believe that by working together we

can change the world?

Because throughout history, it is the only thing that ever

has.

Other sources of further information: Moodle R and Jenkins R. Mental health promotion. I’m

from the government and you want me to invest in mental health promotion. Well why should I? Promotion and Education 2005; S-2:37-41.

Jané-Llopis E, Barry M, Hosman C, Patel V. Mental health promotion works: a review. Promotion and Education; 2005; ProQuest Nursing Journals, supplement 2: 9-25

Sask Health. Supporting mental well-being and decreased substance use and abuse. 2005

McCubbin M, Labonte R, Sullivan R, Dallaire B. Mental health is our collective wealth – a discussion paper. Submitted to Federal/Provincial/Territorial Advisory Network on Mental Health. Accessed online: http://www.spheru.ca/www/html/Reports/Reports_other.htm

Dr. James IrvineProfessor, Dept of Family Medicine, U of S

Medical Health Officer, Population Health Unit, Northern Health Authorities

Box 60002nd Floor, Lac La Ronge Indian Band Office,

LaRonge, Sk S0J 1L0

James.Irvine@mcrrha.sk.ca