ii. Public information campaigns

PROJECT EVIDENCE for Mental Health Promotion. The project coordinator is Dr Allan Mawdsley. The version can be amended by consent. If you wish to contribute to the project, please email admin@mhyfvic.org

[9] Mental Health Promotion

a) Community awareness programs

i Involvement of Consumers and Carers
ii Public information campaigns

b) Mental Health consultation to agencies
c) Training

[9 a ii ] Public Information campaigns

Mental Health problems are the largest cause of lost productivity in the community and one of the largest causes of loss of life. Most mental disturbances of adulthood begin in childhood and adolescence. Although treatment programs are reasonably effective, only a small minority of persons with mental health problems engage with formal treatment programs. In the case of children this shortfall is greater because participation is only mediated through adult (usually parental) involvement.

Whilst logic dictates that prevention and early intervention would greatly reduce the burden of morbidity and mortality, participation remains low despite greater public awareness of the burden. This is partly explained by difficulties in accessing services, but the major component is found in public resistance to participation. MHYFVic advocates improvements in the delivery of Community Mental Health services (see Policy 7a) but changes are also needed to reduce resistance.

Most public information campaigns in Australia have been trying to reduce this resistance by ‘normalising’ mental disorders as equivalent to other health disorders and by encouraging empathic concern for others to facilitate their entry to treatment. This ‘cultural change’ process is necessary and commendable because it is directly aimed at reducing stigma.

MHYFVic supports this process but also advocates a range of universal interventions in the community in line with evidence for prevention of mental disorders. These are outlined in the following summary of the paper by Eva Jané-Llopis, Margaret Barry, Clemens Hosman and Vikram Patel “Mental health promotion works: a review” IUHPE – PROMOTION & EDUCATION SUPPLEMENT 2 (2005) p 9, before coming back to the issue of dealing with the stigma of mental disorders.

Mental health promotion targets the whole population and focuses on enabling and achieving positive mental health. This multidisciplinary area of practice aims to enhance well-being and quality of life for individuals, communities and society in general. Mental health promotion conceptualises mental health in positive rather than in negative terms and delivers effective programmes designed to reduce health inequalities in an empowering, collaborative and participatory manner.

Mental health promotion endorses a competence enhancement perspective and seeks to address the broader determinants of mental health. This is in keeping with the fundamental principles of health promotion as articulated in the Ottawa Charter (W HO, 1986), There is a growing theoretical base and accumulating body of evidence to inform Positive mental health is a value in its own right; it 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.

Positive mental health refers to human qualities and lite skills such as cognitive functioning, positive self-esteem, social and problem solving skills, the ability to manage major changes and stresses in life and to influence the social environment, the ability to work productively and fruitfully and to make contributions to the community, and a state of emotional, spiritual and mental well-being (Hosman, 1997; WHO, 2001).

Mental health is an integral part of overall health and well-being and in a broad sense, reflects the equilibrium between the individual and the environment (Lethinen et al., in press) lack of positive mental health, mental health problems, and mental disorders are not exclusive to any special group, and are found in people of all regions, countries and societies (WHO, 2001).

The lack of access to education, health care or environmental resources, or even at a more basic level, the lack of food, water or shelter contribute to mental health strain in populations around the world. Not only individuals suffering from mental health problems but also their families, have to bear the negative impact of stigma, discrimination and social exclusion.

Mental health promotion targets the whole population and focuses on enabling and achieving positive mental health. This multidisciplinary area of practice aims to enhance well-being and quality of life for individuals, communities and society in general. Mental health promotion conceptualises mental health in positive rather than in negative terms and delivers effective programmes designed to reduce health inequalities in an empowering, collaborative and participatory manner.

Mental health promotion endorses a competence enhancement perspective and seeks to address the broader determinants of mental health. This is in keeping with the fundamental principles of health promotion as articulated in the Ottawa Charter (W HO, 1986), There is a growing theoretical base and accumulating body of evidence to inform the development of mental health promotion practice (Barry, 2001, 2002; WHO 2004a: WHO 2004b; Jané-Llopis and Anderson, in press).

Evidence from systematic reviews of mental health promotion and preventive interventions shows long-lasting positive effects on multiple areas of functioning, leading to outcomes such as improving mental health (Durlak and Wells, 1997; WHO, 2004a), reducing risks of mental disorders (Mrazek and Haggerty, 1994; Jané-Llopis et al., 2003; WHO 2004b) and producing social and economic benefits (Hosman and Jane-Llopis, 1999).

The Ottawa Charter for health promotion (WHO, 1986) provides a framework for improving the populations` health in a holistic manner tackling health determinants at different levels, Mental health promotion is based on the fundamental principles of the Ottawa Charter, and this paper aims to review and present some of the evidence of mental health promotion under the five headings of the Charter.

This is not a systematic review but an overview presenting some examples that illustrate the efficacy of mental health promotion. The paper draws on different sources of evidence from across a number of levels i.e. from systematic reviews, randomised controlled trials (RCTs), quasi-experimental and process evaluations. Specific efforts have been undertaken to include initiatives or programmes from middle and low-income countries by inviting practitioners to submit descriptions of their work.

To continue gathering and disseminating practices from all over the world, professionals in this field are encouraged to contact the first author of this paper if any of their work could be included in a worldwide database of programmes for mental health promotion (www.imhpa.net).

Effective interventions:

The Ottawa Charter and mental health promotion

The evidence of the efficacy of interventions for mental health promotion is presented under the five headings of the Ottawa Charter. ln presenting the evidence in the framework of the Ottawa Charter, the authors propose to consider the inclusion of mental health promotion as an integral part of health promotion interventions and policies.

1. Building healthy public policy
   Building healthy public policies puts health on the agenda of policy makers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept responsibilities for health. Such policies include legislation, fiscal measures, taxation, and organisational change. Existing public policies in some health and social domains have also proven to promote mental health, such as policies aiming to increase access to education, housing, nutrition or health care. These are particularly relevant in low income settings, where conditions for health are compromised, as further described by Patel (2005) in this volume,
   1. Nutrition
   2. Housing
   3. Access to education
   4. Taxation of addictive substances
   5. Regulatory Policy at the workplace
2. Creating supportive environments
   The Ottawa Charter advocates tor the creation of supportive environments which puts the emphasis on a socio-ecological approach to health, promoting the change of home, work and community environments with the aims oi improving control over the determinants of health.The creation of supportive environments has received increasing attention in mental health promotion as mental health is mediated by the interaction between the individual, the environment and wider social forces. This perspective moves mental health beyond an individualistic focus to consider the influence of broader social, cultural and economic factors.

   The socio-ecological perspective underscores the importance of mediating structures such as home, schools, workplaces and community settings as providing key contexts for mental health promotion interventions operating from the micro to the macro levels.

   1. Creating supportive home environments for early development {Home visiting for families at risk; Communities supporting early parenthood]
   2. Parenting interventions
   3. Pre-school interventions
   4. Schools as a supportive environment to learn and grow
   5. Supportive environments in the workplace
3. Strengthening community action
   Based on empowerment principles, strengthening community action emphasizes enabling local communities to actively participate in setting priorities, making decisions, planning strategies and implementing them in order to achieve better health, Effective community interventions focus on the development of building a sense of ownership and social responsibility through the empowerment of community members, and have led to health and social outcomes around the world.
   1. Strengthening community networks
   2. Community action against substance dependence
   3. Schools as a gateway for the community
   4. Media campaigns
4. Developing personal skills
   Developing personal skills supports personal and social development through providing information, education for health and enhancing life skills. This increases the options available to people to exercise more control over their own health and over their environment to make choices conducive to health.
   1. Enhancing resilience and promoting social competence
   2. Targeting the prevention of depression
   3. Addressing the negative impact of unemployment
5. Reorienting health services
   Reorienting health services emphasises that health is a shared responsibility among individuals, community groups, health professionals, health service institutions and governments. The reorientation oi health services includes attention to health research, changes in professional education and training and a change in the organisation of health services including the needs of the individual as a whole person.
   1. Including brief interventions in primary health care
   2. Interventions for new mothers
   3. Hearing aids
   4. Early intervention for people with mental disorders

Conclusions

This overview of programmes, although not a systematic review aims to illustrate that, to date, there is a large range of initiatives that can be efficacious in promoting mental health. However, it is crucial to highlight, that there are also non-effective programmes, and meta-analyses have shown a large variation in outcomes of existing mental health promotion and prevention programmes (Durlak and Wells, 1997; Brown et al., 2000; Jane-Llopis el al., 2003; WHO, 2004b).

In addition, the evidence for many programmes is still lacking robustness through confirmation by the outcomes of replication studies. This large variation in outcome and in quality of evidence urgently calls for formal evaluations (including cost-effectiveness studies) of existing programmes across countries, including low- and middle-income countries.

ln spite of the low resources in those countries, individual studies, partnerships between research institutes and practitioners, and seeking the support of international organisations and researchers in high-income countries, have proven to facilitate the so needed evaluations, as Patel (2005) further describes in this volume.

When considering adoption and implementation of programmes across cultures, it is essential to have evidence-based knowledge and information on what programmes have proven to be efficacious and why. ln this volume, Jane-Llopis and Barry (2005) expand on what ingredients make programmes effective, and what principles should be taken into account when deciding to adopt a given programme, Barry and colleagues (2005), present in this issue a discussion of the implementation conditions and principles that should be taken into account to ensure improved quality implementation.

Patel (2005) underlines some key determinants of mental health in low income countries, identifying key areas for implementation. Moodie and Jenkins (2005) illustrate how the choices for implementation should be relevant for policy making, and Herrman and Jane-Llopis (2005) present the relationship between mental and physical health and suggest strategies for increasing intervention efficiency.

There is enough mental health promotion knowledge to move evidence into practice. However, this translation should be based on what works and should stimulate continuous evaluation and improvement of existing practices.

Although the promotion of evidence-based practice and policy is needed worldwide, special attention and support should be provided to those countries where these types of strategies are less developed and needed most.

STIGMA

The main element of public resistance is the stigma of mental illness. Everybody aspires to be healthy. Whilst there is some inhibition about acknowledging physical illnesses, the reluctance to acknowledging mental disorders is considerably greater. There is a serious threat to the positive regard by other people and to self-esteem by acknowledging mental disorders.

This is also the case in acknowledging mental disturbances of children because they are extensions of the parental self.

When problems are noted and a suggestion is made for mental health service referral, there is often denial and normalisation based on avoidance of stigma. The image of mental health service is linked with serious mental illness, hospitalisation, drugs and ongoing impairment, and “my child is not like that”. Reassurances alone are not enough to dispel the stigma. We need to develop a different public perception of mental health services.

At the core of stigma is perception of an “in-group” to be supported and an “out-group” that is feared and rejected in a range of ways from caricature to destruction. Reducing stigma involves broadening the “in-group” to include many previously in the “out-group”, by seeing them as “just like us”. In the case of mental disorders this means moving away from a dichotomy “Crazy vs healthy” to a spectrum of problems, most of which are “just like us”. The language of the discourse is important.

Although mental health is a state of wellbeing and resilience, not merely the absence of mental illness, the term “Mental Health Services” is generally a euphemism for “mental illness services”. It is certainly perceived by the public that way and although preferable to madness, lunacy and insanity, the term does not currently convey the promotion of wellbeing and resilience that it should.

Other steps are needed to change public perception. One of the most important would be to normalise mental health services by integration with other health services. Victoria has done this to some extent by including mental health services under the administration of general hospital services, but more needs to be done. MHYFVic advocates that community-based infant, child, adolescent and family mental health services should be provided within Community Health Centres that also include a range of other health services.

Information campaigns that aim to reduce stigma by broadening the public perception of services must make careful use of language to strengthen the sense of “just like us”. Hence, instead of the dichotomy “healthy vs mental disorder” the community health service would recognize children who were “not stressed”, “coping” (to be monitored), “struggling” (in need of assessment), “unwell” (in need of treatment). This categorisation could be made by parents or any of the Tier One or Tier Two professionals. It uses non-stigmatising lay language but is explicit in service expectations.

Last updated 21 October 2019

POLICIES for Mental Health Promotion

[9] Mental Health Promotion

a) Community awareness programs

i Involvement of Consumers and Carers
ii Public information campaigns

b) Mental Health consultation to agencies
c). Training

[9 a ii ] Public information campaigns

MHYFVic advocates that Infant, Child, Adolescent and Family Mental Health Services should be provided through Community Health Centres, alongside other health services. Consultancy expertise, admission to inpatient facilities and specialist training should be provided from Tier Three specialist services of the region.

MHYFVic advocates that Information campaigns make careful use of language recognizing children who are “not stressed”, “coping” (to be monitored), “struggling” (in need of assessment), “unwell” (in need of treatment).

MHYFVic advocates that in keeping with the Ottawa Charter, public health policy specifically includes measures to improve 1) general health, nutrition and wellbeing, 2) housing, 3) access to education, 4) taxation of addictive substances, 5) regulatory policy at the workplace.

MHYFVic advocates that public policy includes provision of early development services, parenting interventions, pre-school interventions, school-based interventions, and workplace interventions.

MHYFVic advocates that public policy includes provisions for strengthening community networks, enhancing community action against substance dependence, promoting schools as hubs for the community, and enhanced media campaigns promoting positive mental health.

MHYFVic advocates that public policy includes programs for individuals to enhance resilience and promote social competence, programs to target prevention of depression and address the negative consequences of unemployment.

MHYFVic advocates that Medicare improves access to 1) brief psychotherapeutic interventions in primary health care, 2) interventions for new mothers, 3) improved services for hearing impairments.

Last updated 21 October 2019

BEST PRACTICE MODELS for Mental Health Promotion

[9] Mental Health Promotion

a) Community awareness programs

i Involvement of Consumers and Carers
ii Public information campaigns

b) Mental Health consultation to agencies

[9 a ii] Public information campaigns

Information campaigns that aim to reduce stigma by broadening the public perception of services must make careful use of language to strengthen the sense of “just like us”. Hence, instead of the dichotomy “healthy vs mental disorder” the community health service would recognize children who were “not stressed”, “coping” (to be monitored), “struggling” (in need of assessment), “unwell” (in need of treatment).

This categorisation could be made by parents or any of the Tier One or Tier Two professionals. It uses non-stigmatising lay language but is explicit in service expectations.

Community Health Centres are coordinated through local government administration albeit receiving funding from the State Government Health Department.

Best practice programs are not only about cultural change to reduce stigma but also about strengthening all public health and welfare services which improve general health, nutrition, housing, education, employment, reduction of addictive substances, strengthening of community networks and provision of improved access to treatment programs.

Last updated 21 October 2019