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Why "Mental" Health Promotion?

Posted on: Tuesday, 28 June 2005, 03:00 CDT

Key words

* mental disorder prevention

* mental health promotion

At the time I drafted this commentary, I was in attendance at the WHO European Ministerial Conference on Mental Health, in Helsinki, Finland (12-15 January 2005). The conference is the first of its kind in Europe, and very welcome indeed. The conference culminated with a Mental Health Declaration for Europe and an Action Plan that will undoubtedly be useful tools to European mental health advocates. Virtually all who are informed and concerned about mental health are in agreement about one objective at least: we seek to influence political processes to replace rhetoric with action, and not surprisingly, the lack of funding to back up ambitious mental health policy was a recurring theme at the Conference.

I came away from the conference more convinced than ever of the importance of health promotion's involvement in mental health, and of the need for information and advocacy for effective mental health promotion, such as this special issue of Promotion & Education. The Conference reminded me forcefully that different constellations of mental health advocates are circling about in Europe, usually not colliding and blissfully unaware of one another. They do collide occasionally at the edges, but the collisions are glancing - the constellations do not otherwise meet, and quickly regain their insularity.

The much larger of these constellations is medically-oriented and treatmentfocussed, concerned with the primary, secondary and tertiary prevention of mental disorders. Its conversational agenda tends to be dominated by mortality, morbidity and disability related to mental illness, alcohol and substance abuse, health budgets and mental health's too small piece of the pie, psychiatry's need for expansion and its responsibility to train other health professionals in screening, early detection and referral to appropriate care, numbers and types of facilities and beds, and policy and legislation related to the prevention and treatment of mental disorder.

The much smaller of these constellations is community health- oriented, and focussed on mental health promotion for the entire population. It is deeply concerned with tackling mental disorder, too, but its perspective is that of the patient, the family, the informal carer, and the community. This constellation's conversational agenda is dominated by talk of empowerment through participation and rights to health, the need to break health professionals' stranglehold over policy-making and resource allocation, primordial prevention (prevention of the conditions that give rise to rise to risk factors for mental disorder) and mental health as a resource for robust living for all people in the community, not just vulnerable sub-groups.

As heavenly constellations more in different orbits, but nevertheless influence one another despite great distances, these earth-bound constellations stay mostly in their own orbits, and have rather weak magnetic attractions for one another. Strengthening that magnetism has been an obsession of Professor Clemens Hosman, Head of the Prevention Research Centre at University of Nijmegen, The Netherlands. His advocacy to stimulate and connect mental disorder prevention and mental health promotion has had a profound effect on the International Union for Health Promotion and Education. Mental health promotion has become a priority of the organisation, it is a featured theme at our conferences, it is among the priorities of the Global Programme on Health Promotion Effectiveness, the International Journal of Mental Health Promotion has become a partner in the Health Promotion Journals' Equity Project... and it has resulted in this special issue of Promotion & Education on mental health promotion.

There are other promising developments for mental health promotion. The WHO will soon release an authoritative text on mental health promotion, and the influence of adherents of both constellations on its contents is clearly evident. Textbooks on mental health promotion are multiplying. Seminars, conferences and symposia on mental health promotion are on offer almost continuously. University's offer courses and specialities in mental health promotion. A new and rapidly growing academic field called positive psychology is quickly advancing the knowledge base for mental health promotion. Public health surveillance systems in Europe will soon include health promotion and mental health promotion indicators, alongside the sickness indicators that have long been tracked.

My assessment is that the two constellations' attraction for each other is strengthening, but from a very weak level to only to a slightly stronger level. This is understandable; there exist natural forces that oppose the attraction - professional competitiveness, differences in understanding of what health means, competition for political attention and for funding. At the Helsinki conference, one vocal mental health advocate called for a stop to professional jealousy, unfathomable bickering and territory defending, loosening one of the Conference's few spontaneous bursts of enthusiastic applause. But as applause does, it quickly exhausted itself. At this conference, dominated by the larger constellation, the term 'mental health promotion' was used mostly as a euphemism for mental disorder prevention. And the conversational agenda of the mental disorder constellation was stoutly defended and clearly dominant.

Assuming I have got all this right, what is a small constellation to do? We now have quite a few Clemens Hosman clones running about (including me), thanks to his legendary perseverance - he once drove me to an airport several hours distant, knowing a good opportunity to capture one's undivided attention when he saw one! I think we just have to carry on, and that is what this collection of papers does, most effectively in my opinion. Mental health promotion, as all health promotion, is effective when done with seriousness of purpose and in a sustained way. And today, there is considerable momentum for mental health promotion. This is taken up in the paper by Marshall Williams, Saxena, and McQueen. Particularly important is emerging emphasis on protective as well as risk factors as determinants of mental health, on the need for including mental health indicators in health surveillance systems, and the proof that this is feasible. The US' nationwide Behavioral Risk Factor Surveillance system demonstrates how measures such as the Health- related Quality of Life indicators can be introduced into existing surveillance efforts and provide for the simultaneous tracking of positive as well as poor mental health.

On the intervention side, Jan-Llopis, Barry, Hosman and Patel's contribution is a most welcome update of what works for mental health promotion, must reading for anyone wishing to know the state- of-art in this rapidly advancing arena. I think it particularly fortunate that they chose to organise the material using the Ottawa Charter action areas as the framework. They illustrate convincingly that each of the five action areas provides opportunity for effective mental health promotion, reaching all population segments in a wide range of settings. I am struck particularly by the evidence on effective action to reorient health services, thought by many to be the Ottawa Charter action area in which least progress has been made. However true that may or may not be, this paper shows that brief (read feasible) interventions in primary care can pay large dividends. If only more primary care providers were aware that their interventions need not necessarily be costly and time consuming, their inclination to try such interventions would undoubtedly be strengthened.

Patel's contribution addresses the influences on health of two intertwined macro factors: gender and poverty. Biological differences between men and women play a certain role in defining distinct health and illness experiences, but Patel focuses rightly on gender as socially constructed, not biologically constructed reality. The significance of this for mental health promotion is illustrated by evidence cited by Patel. A particularly instructive example is that of the economic and social interventions carried out by the Bangladesh Rural Advancement Committee, resulting in demonstrable improvements in nutritional status, child survival, educational attainment, and reduce domestic violence. This and other examples of successful intervention discussed by Patel show how women and the poor, too often mutually inclusive groups, may be empowered to take increased control of their own mental health, however deprived of resources they may be.

Barry, Domitrovich and Lara take on a critical issue - how can mental health promotion programmes that are proven in research be disseminated with high quality and effectiveness? There is often scholarly discussion of this issue, but this paper adds a new level of rigour, by systematically addressing and integrating literature on factors that both assist and retard quality dissemination of programmes. Most usefully, they propose a checklist that can be used by funders, programme managers and quality monitors to determine if appropriate steps are taken before, during and after implementation of a programme, to ensure the hi\ghest possible quality and effectiveness, when programmes are disseminated beyond their point of origin. Of special value are the paper's admonitions to policy makers and researchers, nicely presented as recommendations, to use energy, time and resources to produce knowledge, not just about programme effectiveness, but also about critical programme processes. If a fine, research-tested communitybased mental health intervention has certain magic ingredients and/or Achilles' tendons, it is vital to illuminate them for the benefit of those who will disseminate the programme.

Moodie and Jenkins signal something different right from the start, with their provocative title Tm from the government and you want me to invest in mental health promotion. Well, why should I?' The message of this paper is of special importance to the researchers among the readership, who have wellhoned expertise in telling audiences what we don't know, and why yet more research is needed on virtually all aspects of mental health promotion. That is appropriate in scholarly discourse, but the kiss of death in dialogues with policymakers, who recognise an opportunity to say 'no' the instant they see it. There are times and places where one puts one's best foot forward, and this paper provides a blueprint of just how to do that. It makes a factual and a persuasive case for investment in mental health promotion, with example after example that shows how virtually every sector of society can promote mental health. Perhaps most importantly, the paper illustrates that one does not need necessarily to launch formal mental health promotion programmes to obtain good results. As stimulating examples, the authors cite the Women's Circus, the Somebody's Daughter Theatre Company, and Vocal Nosh - arts and culture projects not launched with mental health promotion explicitly in mind, but with major health promotion impact nonetheless.

Herrman and Jan-Llopis' contribution is to secure in readers'minds connections that are sometimes lost by mental health promoters - the reciprocal connection between mental and physical health, and the professional and research connections between mental health promotion, mainstream health promotion and public health. The similarity of discourses in all three arenas is solid evidence that the underlying values of empowerment and participation, and concern with structural determinants of health, closely unite these arenas, despite any surface differences. At the same time, the authors add important nuance to their argument, maintaining, for example, that in advocacy, the activities of mental health promotion should remain distinct. The same is true for many aspects of health promotion, because of the way that society chooses to govern itself. As long as funding streams, professional education programmes, and services delivery systems are defined by disease, by risk factor, by target group, we will need to show that our work is relevant to various actors' vested interests. Advocating for health promotion in general cannot be near as effective as focussed advocacy for patients'rights, for tobacco control, for safe streets, for inclusive schools, among many other specialised interests that all fall somewhere under an umbrella we call health promotion.

The final paper in this issue by JanLlopis and Barry makes a strong case for using the concept of health promotion settings to establish a framework for a comprehensive European strategy for mental health promotion. This idea makes great sense. Regardless of cultural and other differences, informal and formal social institutions are remarkably similar across Europe, enough so that national and international networks devoted to setting- based health promotion flourish (e.g., health promoting schools, work places, hospitals). Without necessarily claiming to promote mental health per se, better mental health is a sure outcome in community settings where participation and empowerment processes are set into motion to improve social, psychological and physical functioning. To be explicit about the positive mental health outcomes of health promotion is to strengthen the argument that all settings need to be health promoting settings. Also worthy of note is the section of the paper that relates to quality. There, the authors elucidate principles of practice, which when adhered to, increase the likelihood that interventions will work like they are supposed to work.

That is why we need the label 'mental health promotion', even though just under the skin, virtually all health promotion in Europe today shares the same touchstone of the Ottawa Charter and the developments it stimulated. This brings me back to the Helsinki Conference, and to the constellations of mental disorder prevention and mental health promotion with which this commentary opened. For many - too many - in the constellation of mental disorder prevention, the term mental health promotion is but a euphemism for mental disorder prevention. The terms are frequently used interchangeably and without thought, and this is indeed unfortunate. The vulnerable population sub-groups with which the mental disorder constellation is occupied require all the attention and care that can be mustered. But we need also a mental health promotion for the entire community, and a vision of mental health as a resource for robust living, not merely the absence of mental disorder.

That explains the need for the mental health promotion constellation, for the term mental health promotion, and for information and advocacy efforts of which this special issue of Promotion & Education is a fine example.

Pourquoi la promotion de la sant mentale ?

Deux constellations de dfenseurs de la promotion de la sant coexistent sans beaucoup interagir. La plus large est oriente vers la mdecine et axe sur les traitements, et se proccupe principalement de la prvention primaire, secondaire et tertiaire des troubles mentaux. La plus petite est oriente vers la sant communautaire, et axe sur la promotion de la sant mentale pour l'ensemble de la population. Elle met l'accent sur l'empowerment du patient, de la famille, du soignant informel, et de la communaut. Mais ceux qui plaident pour une action qui rduise le fardeau des troubles mentaux tendent, eux aussi, utiliser les termes 'promotion de la sant mentale'pour dcrire leurs efforts. Ainsi, les deux constellations utilisent la mme expression - promotion de la sant mentale - pour dsigner des concepts bien distincts quoique complmentaires. Il serait souhaitable de renforcer la connexion entre ces deux constellations afin que chacune connaisse mieux la perspective de l'autre, ce qui dvelopperait leur motivation travailler en synchronie pour rduire les troubles mentaux et amliorer la sant mentale.

Por qu salud "mental"?

Dos constelaciones de profesionales que abogan por la promocin de la salud coexisten con escasa interaccion entre ellos. La mayor de estas la forman la orientacin mdica y el enfoque al tratamiento, que se concentran en la prevencin primaria, secundaria y terciaria de los trastornos mentales. La menor de las constelaciones se orienta hacia la salud comunitaria con un enfoque en la promocin de la salud mental de la poblacin en general. El nfasis de esta ultima est en empoderar al paciente, la familia, el curador informal y la comunidad. Aquellos que abogan por reducir el peso de los trastornos mentales describen sus esfuerzos como "promocion de la salud mental". Con lo cual, ambas constelaciones utilizan el mismo trmino, promocion de la salud mental, para describir dos interpretaciones complementarias, pero distintas. Aumentar el vinculo entre ambas constelaciones es deseable, para que estn ms al corriente de las perspectivas de cada una, con el fin de incrementar la motivacin para trabajar sincronizadamente para reducir los trastornos mentales y mejorar la salud mental.

References

Barry, M., Domitrovich, C, & Lara, MA (2005). The implementation of mental health promotion programmes. Promotion & Education, Suppl. 2,30-36,

Herrman, H., & Jane-Llopis, E. (2005). Mental health promotion in public health. Promotion & UucaSon, Suppl. 2,42-47

Jan-Llopis, E., Barry, M., Hosman, C., & Patel, V., (2005). What works in mental health promotion. Promotion & Education, Suppl. 2,9- 25.

Jan-Llopis, E. & Barry, M. (2005), What makes mental health promotion effective?. Promotion & Education, Suppl. 2,47-55.

Marshall Williams S., Saxena, S., & McQueen, D. (2005). The momentum for mental health promotion. Promotion & Eaucation, Suppl. 2,6-9.

Moodie, R. & Jenkins, R. (2005), "I'm from the government and you want me to invest in mental health promotion. Well why should I?". Promotion & Education, Suppl. 2,37-41.

Patel, V. (2005). Poverty, gender and mental health promotion in a global society. Promotion & Education, Suppl, 2, 26-29.

Professor Maurice B. Mittelmark

Research Centre for Health Promotion, University of Bergen

President, International Union for Health Promotion and Education

Christiesgt. 13, 5015 Bergen, Norway

Tel: +47 55 58 32 51

Fax: +47 55 98 87

Mobile: +47 95 13 92 25

Email: mbmittelmark@iuhpe.org

Copyright International Union for Health Promotion and Education 2005

Source: Promotion & Education

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