Department of Health Promotion National University of Ireland ...

1. Advancing the Implementation of Best Practice in Mental Health Promotion Professor Margaret Barry Department of Health Promotion National University of Ireland, Galway Ollscoil na hÉireann, Gaillimh

2. Introduction • Mental health is fundamental to good health, wellbeing and quality of life resource for everyday life which enables us to manage our lives successfully • Importance of promoting mental health in its own right, as well as its role in reducing the risks of mental ill-health • Demand for effective mental health promotion strategies - raise the standard of mental health promoting policy and practices worldwide

3. Overview • What do we know about effective mental health promotion? • Applying the existing knowledge base concerning mental health promotion and its effectiveness • what makes mental health promotion programmes work? • translate from research into effective programme implementation • Evidence-based principles of effective practice • Implications for future development of practice and policy

4. Effective Mental Health Promotion • WHO Reports (2004/5) Promoting Mental Health: Concepts, Emerging Evidence, Practice. Prevention of Mental Disorders: Effective Interventions and Policy Options. - clarify concepts of promotion and prevention - review the evidence of effectiveness - public health policy and practice implications • Cost-effectiveness of mental health promotion and prevention (Friedli and Parsonage, 2007) • Knapp et al., 2008 - mental health economics

5. IUHPE Special Issue, 2005“there is sufficient knowledge to move evidence into practice” Jané-Llopis, E., Barry, M.M., Hosman, C. and Patel, V. (Eds.) (2005) The Evidence of Mental Health Promotion Effectiveness • Momentum for mental health promotion • Review of the international evidence base on effectiveness • Principles of successful programme implementation and adoption • Determinants - poverty and gender in a global society • Why governments should promote mental health • Integration into health promotion and public health

6. Promotion and Prevention • Mental health promotion • focus on positive mental health and quality of life across populations • building strengths, competencies and resources • Prevention of mental disorders • concern with specific disorders - reducing incidence, prevalence or seriousness of a targeted problem • mortality, morbidity and risk behaviours

7. Standard treatment for known disorders Case identification Indicated Compliance with long-term treatment Selective After-care (including rehabilitation) Strategies for promoting well-being & quality of life Universal Competence Empowerment Resilience Supportive Environments Barry, M.M. (2001) International Journal of Mental Health Promotion, 3(1) 25-34.

8. Positive concepts of mental healththe absence of mental ill-health does not equal mental health • Mental health and mental disorder - continuum or separate entities? • Conceptualisations of positive mental health (Keyes, 2002; Huppert, 2005; Ryff et al., 2006) • Hedonic - subjective well-being and life satisfaction • Eudaimonic - positive functioning, engagement, fulfilment and social wellbeing • Population approach - distribution of mental health and mental disorder across the population • Mental health as an integral part of health and wellbeing (Lancet series on Global Mental Health 2007)

9. Current definitions of mental healthmore than the absence of mental illness • Mental health may be defined as; • “a state of emotional and social well-being in which the individual realises his or her own abilities, can manage the normal stresses of life, can work effectively, and is able to play a role in his or her community” (WHO, 1999) “Mental health is the embodiment of social, emotional and spiritual wellbeing .. provides individuals with the vitality necessary for active learning, to achieve goals and to interact with one another in ways that are respectful and just” (VicHealth, 2005)

10. Aspects of Well-being • Emotional well-being - affect/feeling • Psychological well-being - positive functioning • Physical well-being - physical health and fitness • Social well-being - relations with others and society • Spiritual well-being - meaning and purpose in life

11. Positive mental health • Barry and Friedli (2008) - review of the determinants of positive mental health for the UK Government’s Foresight Project on Mental Capital and Wellbeing • few studies have focused on analysing the determinants of positive mental health among whole populations • existing evidence is drawn from epidemiological studies of mental disorders and interventions studies • Measuring positive mental health (Kovess-Masfety et al., 2005) • Sense of Coherence scale (Antonovsky, 1993) • Affectometer 2 scale (Kammann & Flett ,1983) • Warwick Edinburgh Mental Wellbeing scale (Tennant et al., 2006) • Energy and Vitality Index (SF-36) • Keyes (2002, 2005) -suite of measures

12. The Emergence of Positive Psychology • “The scientific study of the strengths and virtues that enable individuals and communities to thrive”(Positive Psychology Centre, University of Pennsylvania, 2007) • Psychological aspects of what makes life worth living - optimism, love, emotional intelligence, hope, wisdom, creativity, humour • Focus on happiness - positive emotion, engagement and meaning - how we establish meaningful social relations, and our ability to find coherence and deeper meaning in our lives

13. Positive Psychology • Writings of Seligman, Peterson, Csikszentmihalyi, Zautra, Synder et al. • Seligman - 3 pillars of positive psychology • Positive subjective experiences • Positive individual characteristics (strengths and virtues) • Positive institutions and communities • Is happiness the appropriate construct? • Link up with a positive sociology and positive economics?

14. Economics of happiness • Richard Layard (2005)- ‘Happiness: Lessons from a New Science?’ • Income and happiness - no direct correlation • Relative income - ‘hedonic treadmill’ • Economic growth produces many unwanted side-effects - diminishing returns (Sustainable Development Commission, 2003) • Rethinking economic policy - how the economy affects our well-being • Object of public policy - maximising the sum of human well-being? • Policy making centred on economic growth or well-being?

17. A policy focus on well-being “What would politics look like if promoting people’s well-being was one of the government’s main aims?” New Economics Foundation - A Well-being Manifesto for a Flourishing Society • Measure what matters - set of national well-being audits • Well-being economy - employment, meaningful work and environmental taxation • Reclaim our time • Education system that promotes flourishing • Health service that promotes complete health • Invest in the early years and parenting • Discourage materialism and promote authentic advertising • Strengthen active citizenship social well-being and civil society • Integration of social, economic and ecological policies

18. Adopting a Mental Health Promotion Approach

19. A process view of mental health • Mental health is fundamental to good health, well-being and quality of life • a resource for everyday life which enables us to manage our lives successfully • not a static entity - dynamic equilibrium • contributes to the functioning of individuals, families, communities and society • influenced by the broader determinants of health • importance of promoting positive mental health in its own right

20. Mental Health Foundation “Mental health promotion works to enable individuals, whanau, organisations and communities to improve and sustain their mental health and realise their full potential.”

21. The importance of mental health‘there is no health without mental health’ • Mental health promotion - socio-ecological model • Builds on the basic concepts and principles of health promotion • Mental health promotion concepts are positive, dynamic and empowering - focus on enhancing the strengths and competencies of individuals, communities and society • Multidisciplinary - theories and methods

22. Assessment Evaluation Planning Implementation Health Promotion action areas Build healthy public policy Create supportive environments Reorient health services Strengthen community action Develop personal skill combined into Health Promotion strategies Systems Policies environmentorganisationcommunityperson Systems scale Health PromotionModel (WHO Ottawa Charter) The process of enabling people to increase control over their health and the determinants of health micro - macro Health Promotion Principles(participation, empowerment, equity)

23. Determinants of mental health • Healthy structures - economic, political, social and cultural framework for developing and maintaining positive mental health • Citizenship - social support, sense of social integration and inclusion • Emotional Resilience - self-esteem, coping , life skills, sense of control

24. Generic principles of mental health promotion Adopt a socio-ecological approach • Bring about change at the level of the individual, the family, social group/community and broader society • Programmes need to be able to influence the enduring environments in which the individual, family, group or community is functioning • The importance of supportive environments or settings - homes, schools, workplaces, communities, health services

25. Generic principles of mental health promotion Embracing an empowerment philosophy • engage the active participation of programme participants • build on existing strengths and skills of the programme participants • enhance their sense of control over their lives • address systems of socialisation and control (poverty, social injustice, discrimination) • Multilevel construct - role of mediating structures

26. Generic principles of mental health promotion Engaging in Consultation and Collaboration • Partnership working and participation at all stages • Hauf and Bond (2002) - community-based collaboration • Promotes greater ownership • Facilitates capacity building • Supports development of inter-sectoral structures • Improves chances of sustainability

27. Generic principles of mental health promotion Addressing Social Equity • Social inequalities in the distribution of mental health problems - markers of social disadvantage are all associated with poorer mental health (Melzer et al., 2004; Prince et al., 2007) • Mental health is both a consequence of and contributor to health inequalities • Multi-sectoral initiatives tackling sources of disadvantage and inequalities for poor and marginalised groups • education, standards of living, employment, childcare, community supports, discrimination, social exclusion

28. Evidence of Effectiveness

29. Evidence Reviews • Mrazek and Haggerty (1994) - systematic review; Institute of Medicine Report Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. • Durlak & Wells (1997) - meta-analytic review • American Journal of Community Psychology 25(2),115-152 • Tilford et al. (1997) Effectiveness of Mental Health Promotion Interventions: A Review. HEA (UK) • IUHPE Report (1999) The Evidence of Health Promotion Effectiveness, Chapter 3 • Friedli (2003) Making it Effective: A guide to evidence based mental health promotion. Mentality, UK

30. Conclusions from Evidence Reviews “Effective interventions have been identified which promote the mental health of the population at large and those known to be at risk of mental health problems” (Tilford et al., 1997) IUHPE Report (1999) The Evidence of Health Promotion Effectiveness. • mental health promotion programmes not only improve mental health and quality of life but also reduce the risk for mental disorder • lasting positive effect on functioning in multiple domains • clusters of risk and protective factors - cost-effective • strategies - effective across diverse groups and across the lifespan

31. IUHPE Special Issue, 2005Mental Health Promotion Works: A Review • Draws on different sources of evidence - systematic reviews, process evaluations, ‘grey literature’ - case studies from high, middle and low-income countries • Reviews the evidence of effectiveness in terms of health, social and economic impacts - interventions across key settings - home, school, community, workplace and health services • Positive outcomes across multiple areas of health and social functioning • Sufficient knowledge to move evidence into practice

32. Research Principles of Efficacy What makes mental health promotion effective?Eva Jané-Llopis and Margaret Barry - IUHPE Special Issue, 2005 • Adoption and implementation ofevidence-based interventions - efficacy and effectiveness • Evidence-based principles underpinning programme success • sound theoretical and research base • clarifying key goals and objectives • programme provider training and support • evaluation and high quality research methods • infrastructural support from management • programme fidelity versus reinvention • transferability across countries and cultures

34. Characteristics of successful programmes (Barry & Jenkins, 2006) • Programme development based on underpinning theory, research principles of efficacy and needs assessment • A focused and targeted approach to programme planning, implementation and evaluation • Address a range of protective and risk factors

35. Characteristics of successful programmes (Barry & Jenkins, 2006) • Adopt a competence enhancement approach and an implementation process that is empowering, collaborative and participatory, carried out in partnership with key stakeholders • Employ a combination of intervention methods operating at different levels

36. Characteristics of successful programmes (Barry & Jenkins, 2006) • Comprehensive approaches that intervene at a number of different time periods rather than once off • Include the provision of training and support mechanisms that will ensure high quality implementation and sustainability

37. Theoretical base of effective programmes Clear articulation of programme theory • Attachment theory • Self-efficacy • Resilience • Stress and coping • Social support • Social learning theory • Organizational theory

38. Theoretical base of effective programmes • Causative and prescriptive theories (Chen,1998) • Causative theories - mechanisms underpinning the intervention • Prescriptive theories - dynamic process of change • JOBS depression prevention programme (Vinokur, Price & Schul, 1995) - causative theory based on models of stress and coping - prescriptive theory based on active learning and building of self-efficacy • Adoption of the JOBS programme in Ireland (Barry et al., 2007 Journal of Public Mental Health)

39. Needs Assessment • Tailored to the needs of the participants and the local setting - ecological fit • Age, gender and culturally sensitive programmes • Example: Lara et al. (1997, 2003) - adapting a depression prevention programme for women in Mexico city • Balancing programme fidelity and adapting to local needs • Rural Mental Health Project (Barry et al., 2005)

40. Focused approach to programme planning, implementation and evaluation • Example: Communities that Care initiative (Hawkins et al., 2002) • Readiness phase - capacities and barriers • Involving the community - organizational structure • Compiling a community baseline profile • Developing a comprehensive action plan • Implementation and evaluation of the plan

41. Competence enhancement approach Promotion of resourcefulness and generic coping and competence skills • Greenberg et al (2001) promoting alternative thinking strategies (PATHS) • Kellam et al (1994) Good Behaviour Game • Gillham et al (1995) Penn Resiliency programme • Resourceful Adolescent programme (Shochet et al, 2001) • Depression prevention & mood management (Munoz, 1997; Clarke et al. 1995)

42. Competence enhancement approach Implementation approach that is empowering, collaborative and participatory • Programme Examples: • Community Mothers Programme (Johnson et al., 2000; Molloy, 2002) - parent empowerment • Widow-to-Widow peer support programme (Silverman, 1986, 1988) - mutual help • Patel et al. (2005) - poverty, gender equality, violence, literacy - community development and economic empowerment

43. Address a range of protective and risk factors • High/Scope Perry Preschool Programme (Schweinhart et al., 2005) - intellectual and social development in 3-4 year olds from disadvantaged backgrounds • Cognitive and social co-operation skills • Educational model - active learning, effective learning environment • Positive long-lasting effects (ages 39-41) school success - literacy, grades and completion rates socioeconomic success - employment, earnings, home ownership social responsibility - reduced crime levels marriage and parenthood • Cost effectiveness - solid investment

44. Multi-component comprehensive programmes • The Midwestern Prevention Project (Pentz et al., 1997) - comprehensive community-based programme • School component - student skills and school policies • Parental programme - skills training, communication • Community component- community leaders engaged in service planning • Health policy change - local government leaders • Mass media - supportive messages

45. Adopt a comprehensive approach • Effective school programmes - whole school approach - the school curriculum and pupils’ knowledge and skills, the school ethos and environment, involving the parents and the local community (Lister-Sharp et al., 1999; Well et al., 2003) Australian MindMatters programme (Wynn et al., 1999) Olweus et al. (1998) Bullying Prevention programme - school, classroom and individual level • Workplace stress - organizational wide approaches - legislation on bullying and harassment - sense of control, social support and involvement in decision-making

46. Quality implementation support system • Adopting a best practice programme does not in itself guarantee success • Provide adequate resources for good quality planning and implementation - staff skills, training, supervision, organisational support • Mobilise support of key stakeholders

47. Quality implementation support system • Identify core components of the programme • Quantity and quality of programme delivery • Invest in process as well as outcome evaluation • Sustainability - organizational and system-level practices and policies that will ensure the long-term impact of high quality programmes (Barry et al., 2005 IUHPE Special Issue)

48. Research Challenges for the Future • Development and refinement of measures of positive mental health - mental health status and well-being; determinants • Evaluating ‘upstream’ interventions addressing the broader determinants of mental health • Documenting wider health and social gain - integration of mental health in health promotion and public health initiatives; cost-effectiveness studies • Developing methodologies that seek to capture dynamic interactions in context - process and outcomes - evaluation of programme implementation

49. Research into Practice and Policy • Building and disseminating the knowledge and evidence base - identifying and filling the gaps • Translating the evidence into policy and practice - databases, evidence briefings, best practice guidelines • Translational process - more active dissemination - evidence needs to be contextualised and usable • IUHPE Getting Evidence into Practice project • Methodologies for integrating the evidence into the realities of current practice - technical assistance and capacity building

50. Practice Challenges for the Future • Capacity building in programme adoption and implementation training in evidence-based programme planning and evaluation • Collaboration and shared learning • Two way process - capturing knowledge and learning from best practice and the policy making process • Models of best practice - effective, feasible and sustainable in the local context • Making knowledge work for improved mental health • Wider community participation • ‘removing the shadows’ - stigma reduction and community awareness, media