Taking a Population Health
Approach to Mental Well-being:
Identity, Culture & Power
Dr. Lewis Williams, Director
Prairie Region Health Promotion Research Centre
August 15, 2005
Mental Health Promotion: Identity, Power & Culture Summer School 2005
“Biotechnology Could
Destroy Rural Social
Fabric”
StarPhoenix April 14, 2005, A11
StarPhoenix July 16, 2005, A11
StarPhoenix July 8, 2005, C1
StarPhoenix July 16, 2005, A11
Globalization
“A Canada More
Strong and Free:
The Key to
Greater
Prosperity and
Well-being is
Reducing
Government’s
Role…”
“… I thought I should tell someone before I die why.
I can’t breathe. I can’t get enough air. So I’m
planning on killing myself. No one cares. No one
will care once I’m gone either”.
- Globe and Mail
Globe and Mail April 14,
2005, A25
Macdonald’s
India
Coca Cola
China
Wal-mart China
Poverty and Employment
“Poverty Major Health Determinant”
StarPhoenix April 28,, 2005, A13
“Canada’s Biggest
Employer to Strengthen
Workplace mental
Health Programs”
“Stress Follows Some
People into Holidays”
StarPhoenix July 31, 2004, F18
Community Action vol. 20, p. 7
“Sask. Residents Too Reluctant to Take
Holidays”
StarPhoenix August 23, 2004, A10
“Many Suffer
‘Vacation
Deprivation’ ”
StarPhoenix August
21, 2004, E17
Current/Local Issues
“Crystal Meth Devastates Users…”
StarPhoenix June 15, 2005, A1
Regina Leader Post June 11, 2005
“ ‘Very early births tend to occur among young people
whose lives don’t hold many possibilities for them.’ ”
– Regina Leader Post July 13, 2005
“Regina Activist
Distributes Flyers
Targeting Gays,
Lesbians”
StarPhoenix June 8, 2005,
A9
StarPhoenix
StarPhoenix June 11, 2005
What Influences Mental
Health?
The Evidence……….
Colonization
Indigenous / Non Indigenous Suicide
Rates by age & gender
Economic Globalization
Yalnizyan, A. (1998). The Growing Gap: A Report on growing
inequality between the rich and poor in Canada. Toronto Centre for
Social Justice.
Income
Vozoris, N. & Tarasuk, V. (2004). The health of Canadians on Welfare.
Canadian Journal of Public Health. Mar/Apr; 95, 2, 115-120
Food
Security
Vozorris, N. & Tarasuk, V. (2002).
Household food insufficiency is
associated with poorer health.
Journal of Nutrition 133: 120-126.
Town Planning
Social connection
“Loneliness is bad for your health”
GLOBE AND MAIL JUNE 11TH 2005
Women experiencing a major stressor in their lives who lacked intimate
emotional support experienced a nine-fold increase in risk for breast
cancer.
Stress and personal control
• Continuing anxiety, social isolation and
lack of control over work and home life
have powerful effects on health. People
become vulnerable to a wider range of
conditions including high blood
pressure, stroke, depression and
aggression.
Wilkinson, R and Marmot, M. (2003). Social Determinants of
Health. The Solid Facts. WHO: Geneva.
Cultural identity and expression
And others..
• Organic basis of disease
• Healthcare services
Population Health Promotion
• Strives to improve the health of an entire
population
• Sees health as the function of individual
capacities, environmental supports and equity
in the distribution of environmental supports.
• Builds on the potential of whole populations.
• Wholistic conception of health
• Self-determination
Why identity, culture and
power?
Clue – the distribution of
mental wellbeing
Aboriginal
Mental
Health
Overall mental health status of Aboriginal
people’s is significantly worse of that that
of non aboriginal peoples by almost every
Measure.
Suicide rates for First Nation youth, for
example, are roughly five to six times
higher than for non aboriginal youth
Kirmayer, L. et al, (2003). Canadian Journal of
Psychiatry: 45: 607-616. Advisory Group on
Suicide Prevention (2003). Acting on what we
know: Preventing Youth Suicide in First Nations.
FNIHB, Canada.
Migrant Mental Health
• A recent study found that suicide rates for Canada’s immigrant
population are about half of those for Canadian born people.
However, among immigrants, suicide rates increase with age,
while among the Canadian born, suicide is a ‘younger’
phenomenon
• ‘Healthy migrant effect’, the superior health status of many
migrants to native-born Canadians, tends to erode over time.
• For marginalized migrant groups in particular mental health
tends to worsen over time in response to pressures such as
poverty, racism, class inequities and social exclusion.
Bhugra, D. (2001). Migration and Mental Health. Acta Psychiatrics Scandinavia
109: 243-258. Hyman, I. (2002). Immigration and Health. Applied Research and
Analysis Directorate, Health Canada.
GLBT
mental
health
• Rates of depression, anxiety
disorders and suicidal
ideation 2-3 x higher than
women in the general
population.
• Over 50% of transgendered
people have experienced
some form of violence
during their life time.
McNair, R. (2003). Lesbian health
inequalities: a cultural minority issue for
health professional. Medical Journal of
Australia; 178: 643-645
Sexual minority youth are more likely to
engage in self-endangering behaviors
such as:
GLBT Youth
and Mental
Health
•
•
•
Abusing alcohol and other drugs
Vomiting or taking laxatives to loose
weight
Thinking about planning and
attempting suicide
Jones, B. & Hill, M. Mental Health
Issues in Lesbian, Gay, Bisexual and
Transgender Communities. Review of
Psychiatry, Volume 21
Same sex attracted young people have
higher rates of homelessness & cannot
necessarily rely on support and
protection of family of origin.
McNair, R. (2003). Lesbian health inequalities: a
cultural minority issue for health professional. Medical
Journal of Australia; 178: 643-645
The Gender Paradox:
A Canadian child born in 1997
can expect to live just under 76
years if male or over 81 years if
female – however the girl child is
more likely to experience those
years as unhealthy ones.
11% of women compared to 4%
of men suffer from chronic
conditions.
Control in the workplace is socially
distributed and women generally
have less of it. Women in low
control work environments have
40% increased risk of developing
depression.
Spitzer, D. (2005). Engendering health disparities. Reducing
Health Disparities in Canada. Canadian Journal of Public
Health, 96 (2) 78-96
Ability (deafness) and mental
health
• 38% of Deaf people surveyed were
experiencing some sort of emotional distress
• Deaf people are more likely to be diagnosed
with depression or anxiety
• Deaf people who are proud of deaf identity
and are part of a deaf community experience
less psychological problems than those who
aren’t.
Ridgeway, S. (1997). Deaf People and
Psychological Health, University of
Manchester.
Equity - because
• Access to mental health determinants
• Subjective experiences of power and
powerlessness
Being Aboriginal and access to
adequate housing
In need of major repairs
2x as many
No piped water supply
90 x as many
No bathroom facilities
5 x as many
No of persons per dwelling
30% higher
Owner occupied dwellings
34% fewer
owners
No flush toilet
10 x as many
Adelson. N. (2005). The embodiment of inequity. Health disparities in
Aboriginal Canada. Canadian Journal of Public Health. Mar/Apr, Vol 96, S 2:
45-61
Immigration and access to
employment
Labour Force Participation (employment rate %
1981
1991
2001
Total Labour
Force
75.5%
78.2%
80.3%
Canadian
born
74.6%
78.7
81.1%
All
immigrants
79.3%
77.2%
75.6%
Recent
immigrants
75.7%
68.6%
65.8%
Galabuzi, G. 2004. Social exclusion. Social Determinants of Health.
Canadian Perspectives. Canadian Scholars Press: Ontario.
Sexual identity & access
to….
Women and access to income
• Statistics Canada report that in 1997 the
average annual income for women was 67%
of men
• Among seniors 29% of women versus 12.9%
of men were poor for at least one year
• Over 33% of women with disabilities live
below the poverty line compared with 28.2%
of men
Spitzer, D. (2005). Engendering Health Disparities. Canadian
Journal of Public Health, Mar/Apr, 96 (2), 78-96.
Experiences of power
• 4th national Survey of ethnic minorities (UK) finds an
association between interpersonal racism and mental
illness – Those who had experienced racial attack, 3x
more likely to suffer from depression and 5 x more
likely to suffer from psychosis
• A review of US literature found that 92% of studies
reported a positive association between psychological
distress and the experience of racism.
McKenzie, K. (2004). Tackling the root cause. Mental Health Today, Nov, 30-32.
Williams, D. Racial/ethnic discrimination and health: findings from community
studies. American Journal of Public Health, 93 (2), 200-208.
Experiences of power
The Case for Equity
• Identity refers to our thoughts and
feelings about ourselves, who we
are, our sense of belonging and
relationships with others.
IDENTITY
• An individual self-identity can be
influenced by and influences
beliefs, habits, attitudes and ideas.
• People have both a self-identity
and group identities. Identity is a
key aspect of self-determination
and mental well-being.
•
Culture refers to attitudes, behaviours
and beliefs shared by a social group.
•
Culture can be developed within any
community, e.g. ethnic, sexual
identity, gender, work or age group.
•
Culture influences identity and is
influenced by it.
•
Culture is fluid, changing and
contested.
CULTURE
• Personal power – power
within
POWER
• Group power – power
with
• Institutional power power over
• None are inherently
good or bad – depends
on how used.
Power-culture
• A power-culture lens conceptualizes
mental health promotion work as
centralizing practices that actively build
equitable power-culture relations
• We must actively build concepts such as
equity and social justice into our
practice
Mental Health Promotion could
be thought of as
“A process of enabling individuals and
communities to express aspirations and
consciously shaped (cultural) identities
through access to capacities such as land,
language, housing, economic resources and
decision-making institutions in ways that
are mutually empowering.”
THE
PROGRAM
Monday, August 15
11:001:00
Registration Place Riel
Room 241
1.002:15
Welcome and Opening
keynote, Dr. Lewis
Williams
2:153:00
3:003:45
Entertainment
3:455:00
6:308:30
Discussion groups
Break
Formal Banquet and
Keynote: Ovide Mercredi
“The Impact of
Colonization on Mental
Well Being”
Theory
8:309:30
9:3010:30
10:3011:00
11:0012:00
12:001:00
1:002:15
2:152:45
2:453:15
3:154:15
4:305:30
7:30
Tuesday, August 16
Key note # 3 Willie Ermine:
“Ethical Space”
Open discussion with Ovide
Mecredi & Willie Ermine,
facilitated by Dr Lewis
Mehl-Madrona
Nutrition Break
Keynote by Dr. Lewis
Williams, “Landscapes of
Self-determination:
Power, Culture & Equity”
Lunch
Panel discussion:
“Landscapes of selfdetermination: Power,
culture & equity: Migrant,
Rural, and Service Users”
Open discussion
Open discussion
Practice
Wednesday, August 17
Keynote by: Dr, Caroline
Tait “Sticks and Stones:
Why is Understanding
Power and Politics of Words
Important for Mental health
promotion?”
9:30Keynote by Dr. Allyson
10:30
McCollum “Unpacking
Mental Health Promotion”
10:30Break
10:45
10.45Discussion groups
12:00
12:00Lunch
1:00
1:00Best Practices by Elaine
3:00
Malbeuf, “Integrating
Addictions and Mental
Health” and by Dr. Judith
Martin “Mental Health in
the Workplace”
3:00Break
3:15
8:309:30
Break
Panel Discussion :
Expanding our
Understanding of Culture:
Sexuality, Gender & Mental
Health
Discussion groups:
Integrating the Keynotes,
Several topic streams
available, see our website
After Dinner Invitation
Presentation by: Dr. Lewis
Mehl-Madrona “Coyote
Medicine: Contributors of
Aboriginal Culture to
Health Care”
3:155:00
Discussion groups:
Developing Mental Health
Promotion Initiatives
Praxis
8:309:15
9:159:45
9:4510:15
10:1511:15
11:1511.30
11:3012.30
1:00
Thursday, August 18
Keynote by Dr. Allyson McCollum
“Making the links between policy,
practice and organizational
capacity”
Panel response
Nutrition Break
Round table discussions: “Local
challenges: policy, practice and
organizational capacity.
Implications for Practice and
Research”
Nutrition Break
Closing plenary by Dr. James
Irvine: “Creating Caring
Communities Through
Intersectoral Partnerships”
Celebration lunch and farewells
“Wrestling with the Difficult
Questions”
Taking a Population Health
Approach to
Mental Well-being:
Identity Power and Culture
Question 1: Illness and health – according to whose definitions?
Question 2: Identity, culture and health are fluid concepts – how do we
work with moving targets?
Questions 3: How do I name what I do?
Question 4: Mental health promotion involves personal and structural
change – how do I hold this tension in my practice?
Question 5: How can I exercise my agency as a practitioner – i.e. make
the best use of my cultural, professional, and organizational power to
increase self-determination/mental well-being?
Question 6: Mental health is distributed inequitably amongst populations.
By virtue of having more, other have less. How do we extend our
ethical terrain – i.e. move from individual to collective ethics?
Question 7: Given the validity of Indigenous and population health
promotion approaches to mental well-being, how do we tackle the
issues of evidence- based practice and funding?