Mental Health Promotion: Overcoming the challenges to 'focusing upstream'
Health promotion, as it is currently practised, focuses primarily on physical health and the prevention of chronic conditions, such as cancer, diabetes, stroke and heart disease. Yet there is another critical dimension of health that is often overlooked, as noted in the following extracts from the 2001 World Health Report compiled by the World Health Organization:
* Over 450 million people worldwide are affected by mental, neurological and behavioural problems at any given time. These problems are expected to increase considerably in years to come.
* Mental health problems are common to all countries, cause immense suffering, social exclusion, disability and poor quality of life. Mental health problems also cause staggering economic and social costs.
* One in four persons utilizing health services has at least one mental, neurological or behavioural disorder. In many cases, these are neither diagnosed or treated.
* Cost-effective treatments for most mental health disorders do exist and, if used correctly, could permit affected individuals to be functioning members of the community. Yet, in most countries, there are major barriers to the prevention of mental health disorders, as well as the care and reintegration of people with mental health issues. Decision makers, insurance companies, health and labour policies and the public at large all discriminate between physical and mental problems. This discrimination leads to stigmatization against people who need help. (1)
Last year I was invited to facilitate a workshop on mental health promotion for the Centre for Addiction and Mental Health Summer Institute. To illustrate the importance of preventing health problems before they arise, I fell back on the old "upstream-downstream" story: frantic efforts to pull drowning people out of the river are called into question by a perceptive individual asking why people were falling into the water in the first place. I had not regarded this anecdote as anything more than a useful analogy for teaching purposes until I read the newspaper headlines on the morning of the workshop.
"Work Starts on Suicide Barrier"
"After five years and at least 30 deaths, construction of a suicide barrier on the Bloor Street Viaduct is finally beginning. Tomorrow, the first bolts will be screwed into place to support a luminous veil of stainless steel rods that is expected to end the Viaduct's era as a suicide magnet." (2)
Could anything else be done to prevent these deaths?
There is a branch of health promotion practice devoted to meeting this challenge.
II Understanding Mental Health Promotion
Mental health promotion is the process of enhancing the capacity of individuals and communities to take control over their lives and improve their mental health. Mental health promotion uses strategies that foster supportive environments and individual resilience while showing respect for equity, social justice, interconnections and personal dignity. (3)
A recent "train the trainers" manual on mental health promotion, published by Health Canada and the Canadian Mental Health Association, lists the following key principles of mental health promotion practice:
* Applies to the whole population in the context of everyday life
* Aims to enhance control and resiliency
* Builds on individual and community capacity
* Focuses on the individual, family and community levels
* Addresses issues that affect everyone
* Aims to enhance participation
* Increases social cohesion and builds social support (4)
Like health promotion, mental health promotion uses a broad range of strategies, including community mobilization, education, policy development and organizational change, to prevent mental illness and foster an optimal state of mental and emotional well-being. A participatory action research project conducted with newcomer female youth at two Toronto high schools illustrates how mental health promotion strategies can be applied to address the risk factors and conditions affecting the self-esteem and mental well-being of young people.
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III Promoting Mental Health Among Newcomer Female Youth
Fifteen years ago, the Canadian Task Force on Mental Health Issues Affecting Immigrants identified young immigrant women as a group with special needs. Recognizing the impact of racism, cultural dislocation and other socio-environmental factors on the self-esteem of young people, the Task Force report noted that "policies have not yet addressed the needs of migrant children as comprehensively as necessary" (5). Recognizing the additional risk factors experienced by young immigrant women, compared to those experienced by their male counterparts, the report observed that "policies and programs that address these factors are of even greater importance for women than for men." (5)
To guide the development of appropriate mental health promotion policies and program initiatives for newcomer female youth, a group of researchers at the Centre for Addiction and Mental Health conducted a participatory action research study with immigrant female youth at two secondary schools in Toronto (6). Over 60% of the students at both schools spoke a primary language other than English. Information was collected through focus groups with the female students and school educators and through interviews with parents and school and community health centre workers.
The study paid particular attention to influences promoting or challenging the self-esteem of the young women. Participating students identified multiple sources of influence determining how they felt about themselves. Not surprisingly, relationships with friends and parents played an important supportive role. Systems issues, specifically issues related to the education, social services and settlement service systems that created barriers for young people and their parents in Canadian society were also identified.
One major concern of the students was a lack of proficiency in English, which was viewed as a major factor inhibiting self-esteem and positive social interaction. As one focus group participant noted, "We pretend to be quiet or not there, nobody knows us, something like that. We don't speak English very well at first, right, so nobody wants to talk to us. Actually, though they don't even want to talk to us, we don't want to answer. Because we make wrong answer, and they're going to laugh so we just pretend to be quiet." (6)
Drawing on the feedback provided by participants, the report concludes with fifteen recommendations for mental health promotion policies and services to better serve the needs of newcomer youth. These include recommendations for the education, health and social services and resettlement services systems, as well as cross-cutting recommendations across systems. Recommendations included expanding school-based ESL programs; promoting inclusive educational curricula encompassing multicultural, anti-racist and anti-sexist values; providing comprehensive resettlement services to the entire family unit of newcomer female youth; and developing and coordinating partnerships (including health, education, social and resettlement services) across systems. As part of this process, the study suggested that the explication of values underlying policies be a necessary component of mental health promotion initiatives for newcomer female youth.
While the focus of the study was on female newcomer youth, the mental health promotion principles and recommendations can contribute to the health and well-being of all young people attending school in Canada's multicultural communities. For example, school-based anti-racism initiatives promote a more just society where all young people, whether Canadian-born or immigrant, develop and learn to embrace differences. The ways in which differences are viewed in society are significant for youth. If differences are looked down upon or feared, then youth can experience differences as a vulnerability; if diversity is celebrated, youth will view their uniqueness as a source of strength and pride.
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"The protection and promotion of mental health should be a matter of compelling priority for every community in Canada..Mental health issues are of unquestionable importance to our collective and individual lives. As such, they call for intense reflection and vigorous policy initiatives by all sectors in our society." (7)
These were the concluding statements in Striking a Balance, the national mental health promotion strategy released by the Canadian government in 1988. Sadly, the vision outlined in this document was never realized due to a lack of resources for implementation. In the fifteen years since the release of Striking a Balance, the chronic underfunding of programs and services to prevent mental health problems remains a key barrier to realizing the promise of mental health promotion. This is a world-wide problem that is by no means unique to Canada: the World Health Organization notes that most countries devote less than 1% of their total health expenditure to mental health. (1) To illustrate this point (and taking a cue from a popular credit card commercial), I leave you with the following facts and figures. Hopefully a renewed emphasis on mental health promotion will result in a more positive balance between costs and values.
Ontario's 2002 health care budget = $23 billion per year (approx)
Percentage of budget earmarked for prevention = 1.5%
Annual cost of Health Canada's Diabetes Prevention Strategy = $23 million per year
Annual cost of Health Canada's AIDS prevention strategy = $42.2 million per year
Annual cost of Health Canada's breast cancer prevention strategy = $10 million per year
Annual cost of Health Canada's mental health promotion initiative = $250,000 per year
Cost of erecting a suicide barrier on Bloor Street Viaduct = $5.5 million
Length of time taken to approve Viaduct barrier proposal = 3.5 years
Number of suicides on Viaduct during delay in approval of barrier = 30
Number of suicides on Viaduct during construction = 18
Value of mental health promotion strategies to prevent suicides and other mental health problems = priceless
(1) World Health Organization World Health Report 2001. Geneva: WHO, 2001.
(2) "Work Starts on Suicide Barrier." Toronto Star. April 15, 2002
(3) Centre for Health Promotion. "Proceedings from the International Workshop on Mental Health Promotion, University of Toronto." In C. Willinsky and B. Pape (Eds.), Mental Health Promotion. Toronto: Canadian Mental Health Association, 1997.
(4) Willinsky, C. Mental Health Promotion Train the Trainers Manual. Toronto: Canadian Mental Health Foundation, 2003.
(5) Beiser, M. After the door has been opened: Mental health issues affecting immigrants and refugees in Canada. Report of the Canadian Task Force on Mental Health Issues Affecting Immigrants and Refugees. Ottawa: Minister of Supply and Services Canada, 1988.
(6) Khanlou, N. et al. Mental Health Promotion Among Newcomer Female Youth: Post-Migration Experiences and Self-Esteem. Ottawa: Status of Women Canada, 2002.
(7) Health and Welfare Canada. Mental Health for Canadians: Striking a Balance. Ottawa: Minister of Supply and Services Canada, 1988.