Creating Caring Communities:
Putting Mental Health on the
Agenda
Dr. James Irvine
Health Promotion Summer School
Prairie Region Health Promotion Research Unit
Mental Health Promotion: Identity, Culture and Power
August 2005
Mental Health
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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
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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
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Increasing awareness of mental disorders being common &
disabling
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Economic consequences clearer
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Links between physical & mental health better appreciated
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Links between education, labour, justice, etc & mental
health more understood
Increasing recognition of the link needed between
economic & social development
Mental Illness Impact
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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
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20% of adolescents under the age 18 suffer from
developmental, emotional or behavioural problems;
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1 in 8 has a mental disorder;
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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
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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
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Mental health status is associated with risk
behaviours at all stages of the life cycle.
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Young people with depression and low selfesteem are linked with smoking, binge
drinking, eating disorders and unsafe sex.
Vicious circle
Links between physical health and mental
health are bidirectional
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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.
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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)
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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
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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
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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
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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
Risk Factors
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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
Protective Factors
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Empowerment
Positive interpersonal
interactions
Social participation
Social responsibility / tolerance
Social services
Social support / community
network
Cultural integration
Williams, Saxena, McQueen
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Societal or community-level characteristics:
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Culture,
Language,
Cohesion,
Control
Aboriginal Youth Suicide by
Cultural Continuity Factors
Cultural Continuity
Factors
Cultural Facilities
Health
Education
Land Claims
Self-Government
0
Yes
No
20
40
60
80
100
120
Suicide Rate / 100,000
Source: Chandler & Lalonde, 1998
140
160
Post-Traumatic Stress Response
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Popular explanations of health inequities of the
Aboriginal communities are limited (its more than health
behaviours, more than socio-economic),
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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
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Mental health and social problems linked to social and cultural
disruption over the lifespan and across generations
Mitchell, Maracle
Post-Traumatic Stress Response
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arises from external trauma and terrifying
experiences that break a person’s sense of
predictability, vulnerability, and control.
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Mentally: negative beliefs about themselves and the world,
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Emotionally: cycles of denial and anxiety
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Physically: sleep disturbances, anxiety, nightmares, flashbacks
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Behaviourally: avoidance, isolation, drinking, drugging,
increasingly aggressive.
PTSR is a useful model for understanding
and addressing health inequities:
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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
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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?
Poverty
Sexual Activity
Drugs
Diet
Smoking
Education
Unemployment
Social Supports
Early Childhood Development
Principles of Health Promotion
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Health education
Policy analysis
Community development and
organization
Health advocacy
Legislation
World Health Organization (1984)
Ottawa Charter for Health
Promotion
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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
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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
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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
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Finding ways to shift emphasis from a
sector-by-sector approach to a broader
and more cohesive problem approach
Community as the focus!
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Partnerships
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Within communities
Between communities
Within health organizations
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Mental health promotion & health promotion
Treatment and promotion services
Between health organizations
With other sectors
Conditions for success: Intersectoral
action for Population Health
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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
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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
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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 Strategies
Multiple Levels
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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
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Policy
Economic development
Social action
Community schools
Early childhood supports
Creating Supportive Environments
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High/Scope Perry Preschool Project
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Targeted 3-4 year old children from
impoverished backgrounds
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Cost $1000 per child
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Cost-benefit - $7,000 to $8,000 per child
Barnett WS. AJ Orthopsych 1993
Government Healthy Public Policy
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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
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School boards
Recreation centers
First Nations Band councils
Municipal governments
Committees and organizations
Families
Workplaces
Capacity building and
empowering practices
Capacity building
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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.
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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
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Home,
School,
Workplace, and
Community.
Jané-Llopis/Barry MM
Home
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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
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Enormous potential – no other setting where such
a large proportion of children can be reached
WHO “Child-friendly schools”
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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
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Unemployment
Work stress
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Noise, overload, time pressures
Repetitive tasks
Interpersonal conflicts
Job insecurity
Low sense of control
Balance with personal life
Community
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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
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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
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Partner - Who can we work with, to do it better together?
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Advocate - What needs to be done at policy legislative level?
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Cheerlead -
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Enable -
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Mitigate -
Encouraging and not getting in the way.
What we do directly to change the determinants
Picking up some of the pieces, so it isn’t worse
Solutions?
Will be found in:..
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thinking, planning and working...
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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:
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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 Irvine
Professor, Dept of Family Medicine, U of S
Medical Health Officer,
Population Health Unit, Northern Health Authorities
2nd
Box 6000
Floor, Lac La Ronge Indian Band Office,
LaRonge, Sk
S0J 1L0
James.Irvine@mcrrha.sk.ca