Promoting Mental Health
Promoting Mental Health
CONCEPTS ■ EMERGING EVIDENCE ■ PRACTICE
A Report of the
World Health Organization,
Department of Mental Health and Substance Abuse
in collaboration with
the Victorian Health Promotion Foundation
and
The University of Melbourne
Promoting Mental Health
CONCEPTS ■ EMERGING EVIDENCE ■ PRACTICE
A Report of the
World Health Organization,
Department of Mental Health and Substance Abuse
in collaboration with
the Victorian Health Promotion Foundation
and
The University of Melbourne
Editors:
Helen Herrman
Shekhar Saxena
Rob Moodie
WHO Library Cataloguing-in-Publication Data
Promoting mental health: concepts, emerging evidence, practice : report of the World Health Organization,
Department of Mental Health and Substance Abuse in collaboration with the Victorian Health Promotion Foundation
and the University of Melbourne / [editors: Helen Herrman, Shekhar Saxena, Rob Moodie].
1.Mental health 2.Health promotion 3.Evidence-based medicine 4.Health policy
5.Practice guidelines 6.Developing countries I.Herrman, Helen. II.Saxena, Shekhar. III.Moodie, Rob.
ISBN 92 4 156294 3
(NLM classification: WM 31.5)
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Foreword
The World Health Organization (WHO) embraces a definition of health as “physical, mental, and
social well-being”. Of these elements, mental well-being historically has been misunderstood and
often forgotten. WHO has spent the last five years actively addressing the barriers that prevent
access to mental health care and campaigning for the full incorporation of mental health in world-
wide public health. Thanks greatly to their hard work, mental health now ranks as a priority within
the international health and development agenda. Governments across the world and health pro-
fessionals across the disciplines are now more aware of the importance of mental health issues to
the overall health of individuals, communities, cities, and even entire nations.
Promoting Mental Health: Concepts, Emerging Evidence, Practice clarifies the concept of mental
health promotion and is a potent tool for guiding public officials and medical professionals in
addressing the behavioural health needs of their societies. It presents striking evidence that there
is a strong link between the protection of basic civil, political, economic, social, and cultural rights
of people and their mental health. In these times, when conflicts between individuals and com-
munities are on the increase and economic disparities are widening, this message is especially
relevant. Good mental health goes hand in hand with peace, stability and success, and Promoting
Mental Health presents a powerful case for including mental health promotion in the public
health policies of all countries.
WHO recognizes that besides the vital need for expanding services to those who currently receive
none, prevention of mental disorders and vigorous promotion of healthy behaviours are critical
for decreasing the international burden of mental illnesses and for helping people to realize their
full potential. WHO’s efforts include international reviews of scientific evidence for interventions;
wide dissemination of evidence, particularly in lower and middle income countries; and assisting
governments and non-governmental organizations in using the evidence to develop actual pro-
grammes.
Promoting Mental Health: Concepts, Emerging Evidence, Practice emphasizes that everyone has
a role and responsibility in mental health promotion and encourages integrated participation
from a variety of sectors such as education, work, environment, urban planning and community
development as the best way to make the most positive improvement in people’s mental health.
It appropriately focuses on resource-poor settings; however, money is not the key determinant to
ensure good mental health. Awareness and active involvement by each member of the commu-
nity often have the greatest impact.
I congratulate WHO on this excellent work and urge policy-makers the world over to use this
important information to effect real improvement in the mental health and well-being for all their
people.
Rosalynn Carter
Chair, Mental Health Task Force
The Carter Center
Atlanta, Georgia
USA
Foreword
“… not merely the absence of disease or infirmity.”
“… attainment by all people of the highest possible level of health.”
“… to foster activities in the field of mental health, especially those affecting the harmony of human
relations.”
These objectives and functions of the World Health Organization (WHO) are at the core of our
commitment to mental health promotion.
Unfortunately, health professionals and health planners are often too preoccupied with the imme-
diate problems of those who have a disease to be able to pay attention to needs of those who
are “well”. They also find it difficult to ensure that the rapidly changing social and environmental
conditions in countries around the world support rather than threaten mental health. This situa-
tion is only partly based on the lack of clear concepts or of adequate evidence for effectiveness
for health promoting interventions. This has much to do with how the professionals and planners
are trained, what they see as their role in society and, in turn, what society expects them to do. In
the case of mental health, this also has to do with our reluctance to discuss mental health issues
openly.
Promoting Mental Health: Concepts, Emerging Evidence, Practice is WHO’s latest initiative to over-
come these barriers. It describes the concept of mental health and its promotion. It tries to arrive
at a degree of consensus on common characteristics of mental health promotion as well as
variations across cultures. It also positions mental health promotion within the broader context
of health promotion and public health. The evidence provided for the health and non-health
interventions for mental health benefits is likely to be useful to health policy planners and public
health professionals. The emphasis, however, is on the urgent need for a more systematic genera-
tion of evidence in the coming years, so that a stronger scientific base for further planning can be
developed.
Prevention of mental disorders and promotion of mental health are distinct but overlapping aims.
Many of the interventions discussed in this report are also relevant for prevention. However, the
scope as well as the target audience is considered much wider for mental health promotion. For
this reason, WHO is releasing this report on promotion separately from a forthcoming report on
the evidence for prevention of mental disorders.
I trust that the present full report, along with the summary report released earlier, will create a
more definite place for mental health promotion within the broader field of health promotion and
will be useful for the countries that WHO serves.
Dr Catherine Le Galès-Camus
Assistant Director-General
Noncommunicable Diseases and Mental Health
World Health Organization, Geneva
Table of Contents
Forewords
Rosalynn Carter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III
Catherine Le Galès-Camus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV
Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XI
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XIV
Key Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XVIII
Part I: Concepts
1. Introduction: Promoting Mental Health as a Public Health Priority . . . . . . . . . . . . . . . . . . . . . 2
Helen Herrman, Shekhar Saxena, Rob Moodie, Lyn Walker
What is mental health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Towards a new public health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
A new enthusiasm for promoting mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Promoting mental health is an integral part of public health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Mental health is more than the absence of mental illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
No health without mental health: mental health and behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Objectives and actions of mental health promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
International collaboration and the role of WHO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Mental health is everybody’s business . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Additional comments
Thomas R Insel
Promoting Mental Health: Lessons from Social Brain Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2. Health Promotion: A Sketch of the Landscape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Maurice B Mittelmark, Pekka Puska, Desmond O’Byrne, Kwok-Cho Tang
Concepts of health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Determinants of health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Health inequalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Health promotion responds to the challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Health promotion practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Politics of health promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Health promotion successes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Health promotion in low income countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
The nature of evidence of health promotion’s effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Innovative funding strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
VI • PROMOT
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3. Evolution of Our Understanding of Positive Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Vivianne Kovess-Masfety, Michael Murray, Oye Gureje
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Concepts of mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Quality of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4. The Intrinsic Value of Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Ville Lehtinen, Agustin Ozamiz, Lynn Underwood, Mitchell Weiss
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Conceptualization and measurement of values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Mental health as an individual capacity and experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Mental health and social interaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Mental health contributes to social capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Cultural values and mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Spiritual dimensions of mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Additional comments
Bengt Lindstrom, Monica Eriksson
The Salutogenic Perspective and Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
5. Concepts of Mental Health Across the World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Shona Sturgeon, John Orley
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Who promotes mental health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Who defines mental health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Approach of this chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Concepts of mental health in infancy and early childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Concepts of mental health and the school context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Concepts of mental health and under-age soldiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Concepts of mental health and HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Concepts of mental health and palliative care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Concepts of mental health and older people . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
PROMOT
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6. Social Capital and Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Harvey Whiteford, Michelle Cullen, Florence Baingana
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Conceptualizing social capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Deconstructing social capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Social capital, health and mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Mental health promotion and social capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Building social capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
7. Mental Health and Human Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Natalie Drew, Michelle Funk, Soumitra Pathare, Leslie Swartz
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
The link between mental health and human rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
The international human rights framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Vulnerable groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
8. Responding to the Social and Economic Determinants of Mental Health:
A Conceptual Framework for Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Lyn Walker, Irene Verins, Rob Moodie, Kim Webster
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
The VicHealth framework to promote mental health and well-being . . . . . . . . . . . . . . . . . . . . . . . 89
Key aspects of the framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
The framework in action: mental health promotion in refugee communities . . . . . . . . . . . . . .100
Future challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105
VIII • PROMOT
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Part II: The Emerging Evidence
9. The Nature of Evidence and its Use in Mental Health Promotion . . . . . . . . . . . . . . . . . . . . . .108
Margaret M Barry, David V McQueen
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108
Evaluating the promotion of positive mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108
Adopting an evidence-based approach: issues and challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . .110
Evaluating the process of programme implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113
Widening the evidence base: applying the evidence to low income countries . . . . . . . . . . . . .115
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .118
Additional comments
Jodie Doyle
The Cochrane Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110
10. Social Determinants of Mental Health and Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . .120
James C (Jim) Anthony
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120
Social mobilization of resources to prevent, reduce or ameliorate suffering . . . . . . . . . . . . . . .123
Uncertainty of presently available evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124
Future directions in research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131
11. Links Between Mental and Physical Health and Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132
Beverley Raphael, Margit Schmolke, Sally Wooding
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132
Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133
Interrelationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135
Developing mental health promoting health care systems and environments . . . . . . . . . . . . .144
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .144
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145
Additional comments
Corey LM Keyes
A Mental Health Continuum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
12. Indicators of Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148
Stephen R Zubrick, Vivianne Kovess-Masfety
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148
Positive mental health and the absence of disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148
PROMOT
O ING MENTA
T L HEALT
L H • IX
A social-ecological framework for positive mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .149
Criteria for selecting indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .152
Macro-level indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .153
Individual indicators of positive mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155
Individual indicators of mental health distress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157
Determinants of mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .161
Capacity building in mental health promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .163
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .164
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166
Additional comments
Elise Maher, Elizabeth Waters
Indicators of Positive Mental Health for Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .159
13. The Evidence of Effective Interventions for Mental Health Promotion . . . . . . . . . . . . . . . .169
Clemens MH Hosman, Eva Jané-Llopis
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .169
Macro interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .169
Meso and micro interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .172
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .184
14. The Evidence for Mental Health Promotion in Developing Countries . . . . . . . . . . . . . . . . . .189
Vikram Patel, Leslie Swartz, Alex Cohen
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189
Human development and mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189
The evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .191
Building the evidence base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .199
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .201
15. Evidence: The Way Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .203
Mark Petticrew, Dan Chisholm, Hilary Thomson, Eva Jané-Llopis
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .203
The current evidence on policy interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .203
Mental health impact assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .206
Health economics and mental health promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .207
Improving the availability of evidence: an Internet-based system . . . . . . . . . . . . . . . . . . . . . . . . .211
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .212
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213
X • PROMOT
O ING MENTA
T L HEALT
L H
Part III: Policy and Practice
16. Mental Health Promotion:
An Important Component of National Mental Health Policy . . . . . . . . . . . . . . . . . . . . . . . . . . .216
Michelle Funk, Elizabeth Gale, Margaret Grigg, Alberto Minoletti, M Taghi Yasamy
Investing in mental health promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .216
What is mental health policy and why is it important? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .216
Components of policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .217
Intersectoral collaboration – making health promotion work . . . . . . . . . . . . . . . . . . . . . . . . . . . . .220
Examples of strategies for mental health promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .220
Evaluation of mental health promotion policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .224
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .224
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .225
17. Strategies for Promoting the Mental Health of Populations . . . . . . . . . . . . . . . . . . . . . . . . . . .226
Eero Lahtinen, Natacha Joubert, John Raeburn, Rachael Jenkins
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .226
Mental health and its promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .227
Three levels of action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .228
The Ottawa Charter for Health Promotion as a guide to population strategies . . . . . . . . . . . . .230
Healthy public policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .232
Supportive environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .234
Community action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .235
Personal skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .236
Reorientation of health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .239
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .240
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .240
18. Community Development as a Strategy for Promoting Mental Health:
Lessons from Rural India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .243
Rajanikant Arole, Beth Fuller, Peter Deutschmann
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .243
Everyday life in a village – the impact on mental well-being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .243
The process of community development in Jamkhed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .246
The impact of community development at Jamkhed on mental health . . . . . . . . . . . . . . . . . . . .248
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .251
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .251
PROMOT
O ING MENTA
T L HEALT
L H • XI
19. Developing Sustainable Programmes: Theory and Practice . . . . . . . . . . . . . . . . . . . . . . . . . . .252
Penelope Hawe, Laura Ghali, Therese Riley
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .252
What is programme sustainability? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .252
What makes a programme likely to be sustained? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .253
Theories informing programme sustainability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .254
Beyond programmes: how the thinking about “what” gets sustained has evolved . . . . . . . . .256
Issues and challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .257
Implications for building sustained interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .259
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .261
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .262
20. Intersectoral Approaches to Promoting Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .264
Louise Rowling, Alison Taylor
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .264
Conceptualization of mental health and intersectoral collaboration . . . . . . . . . . . . . . . . . . . . . . .264
Frameworks and action for mental health promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .267
Settings for intersectoral collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .272
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .280
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .282
Additional comments
Mason Durie
Indigenous Health Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .265
Chris Bale, Brian Mishara
Zippy’s Friends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .269
Arabinda Chowdhury, Sohini Banerjee, Mitchell G Weiss
An Intersectoral Approach to Mental Health and Pesticide Safety . . . . . . . . . . . . . . . . . . . . . . . . .271
21. Conclusions and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .284
Shekhar Saxena, Helen Herrman, Rob Moodie, Benedetto Saraceno
What do we know? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .284
What can we do now? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .285
What do we need to know and do further? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .286
Key recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .288
Preface
Promoting Mental Health: Concepts, Emerging Evidence, Practice aims to bring to life the mental health
dimension of health promotion. The promotion of mental health is situated within the larger field
of health promotion, and sits alongside the prevention of mental disorders and the treatment and
rehabilitation of people with mental illnesses and disabilities. Like health promotion, mental health
promotion involves actions that allow people to adopt and maintain healthy lifestyles and create
living conditions and environments that support health. This book describes the concepts relating
to promotion of mental health, the emerging evidence for effectiveness of interventions and the
public health policy and practice implications. It complements the work of another major WHO pro-
ject focusing on the evidence for prevention of mental illnesses.
Many within and outside the fields of mental health and health promotion recognize a need to
assemble, review and generate evidence about the tangible benefits of mental health promotion.
This includes evidence on the relationship between social and cultural factors and the mental health
of individuals and communities. This book reviews the available evidence from a range of countries
and cultures. It documents how actions such as advocacy, policy and project development, legisla-
tive and regulatory reform, communications, research and evaluation may be achieved and monito-
red in countries at all stages of economic development. It considers strategies for continued growth
of the evidence base and approaches to determining cost-effectiveness of actions. International
cooperation and alliances will play a critical role in generating and applying the evidence by encou-
raging the social action required and monitoring the impact on mental health of a range of policies
and practices.
Promoting Mental Health: Concepts, Emerging Evidence, Practice has been written for people working
in health and non-health sectors whose decisions affect mental health in ways that they may not rea-
lize. It is also a sympathetic account for people in the mental health professions who need to endorse
and assist the promotion of mental health while continuing to deliver services for people living with
mental illnesses. It is relevant to people working to develop policies and programmes in countries
with low, medium and high levels of income and resources, as well as those concerned with guideli-
nes for international action. It uses a public health framework to address the dilemma of competing
priorities that concerns planners and practitioners in low income as well as affluent settings.
Promoting Mental Health: Concepts, Emerging Evidence, Practice is the result of collaboration with
scientific contributors from sectors outside as well as within health. The editors consulted a group of
senior project advisers and contacted a wide group of interested people and organizations: profes-
sional, government, nongovernment and others. The aims of the project were to facilitate a better
understanding of the evidence and approaches to gathering local evidence, activation of the scien-
tific community and growth in international cooperation and alliances.
The book is divided into three parts. Part One introduces the topic and describes a number of con-
cepts associated with health, health promotion and mental health, as well as their use across diffe-
rent cultures, countries and subpopulations. In Chapter 1, the introduction, we identify a new enthu-
siasm for mental health as a public health priority, and describe how international collaboration
is crucial to stimulate much needed interest in mental health promotion. Chapter 2 sketches the
landscape of health promotion. Since we consider mental health promotion as a subset of health
promotion, this information is likely to be useful in our examination of the concept of mental health
promotion. Chapter 3 discusses the concept of positive mental health and how our understanding
of it has changed over time. The intrinsic value of mental health to individuals, families, communi-
ties and nations is discussed in Chapter 4, which also includes a discussion on the spiritual dimen-
sions of mental health. How the concepts of mental health and mental health promotion may differ
PROMOTING MENTAL HEALTH • XIII
in different contexts across the world is taken up in Chapter 5, where the point is made that before
engaging in mental health promotion in any community it is first necessary to understand that par-
ticular community’s understanding of mental health. The concept of social capital has been of great
interest to researchers across a number of disciplines in recent years, and the relationship between
social capital and mental health is the focus of Chapter 6. Our view is that mental health is inextrica-
bly linked with human rights and these links are discussed in Chapter 7, which gives an overview of
the international human rights framework and discusses some of the groups particularly vulnerable
to human rights violations. Chapter 8 describes how a framework for mental health promotion can
bring the concepts already discussed together to guide actions to address the determinants of men-
tal health.
Part Two focuses on evidence for mental health promotion. It begins with examining the nature of
evidence in mental health promotion (Chapter 9) and then considers the available evidence in two
specific areas – social determinants (Chapter 10) and the interface with physical health and illness
(Chapter 11). Chapter 12 reviews the literature on indicators for mental health promotion and iden-
tifies their strengths and weaknesses. The next chapter (13) reviews the evidence on effectiveness
of interventions using available information from the published literature. Since this evidence most
often comes from high income developed countries, a separate chapter (14) focuses on evidence
accumulating in developing countries where interventions are most urgently needed. Since it is clear-
ly recognized that the available evidence is limited in scope, even while sufficient to prompt national
and international action, Chapter 15 describes the way forward for generating further evidence on
determinants of mental health and the effectiveness and cost-effectiveness of interventions.
Part Three takes the concepts and evidence forward to examine and suggest actions for policy and
practice that serve the needs of mental health promotion. Since national mental health policy often
forms the blueprint for all actions in this area, Chapter 16 describes how mental health promotion
can and should be an important component of policy. This is followed by a chapter (17) that traces
the historical basis for mental health promotion within international charters and comments on
the relevance and limitations of these approaches for policy and practice. Since community deve-
lopment can provide an important strategy for promoting mental health, Chapter 18 describes
one such model being implemented in a low income country to illustrate a successful example.
Sustainability of interventions is a serious issue in all health promotion programmes; it is examined
with relevance to mental health promotion in Chapter 19 and some lessons drawn. Chapter 20
emphasizes the importance of intersectoral approaches in developing and implementing mental
health promotion programmes by giving examples from several relevant sectors.
Finally, Chapter 21 draws conclusions and key messages from the material presented in the earlier
chapters and proposes a way forward to make evidence-based mental health promotion a reality.
As we worked on this project, we became aware of the richness of information available about
programmes of proven effectiveness in the area of mental health promotion, as well as the limita-
tions and shortcomings of the evidence in areas of greatest need. We believe there is much that
can be done by countries and communities within the available financial and human resources to
advance mental health promotion. We will feel rewarded in our efforts if the information provided
in the chapters that follow encourages action and programmes to enhance mental health across the
world, as well as stimulates further research.
Helen Herrman, Shekhar Saxena, Rob Moodie
Editors
Acknowledgements
The editors compiled Promoting Mental Health: Concepts, Emerging Evidence, Practice in collabo-
ration with Ms Lyn Walker, Victorian Health Promotion Foundation. The editors gratefully ack-
nowledge the work of the contributors and advisers listed below.
The editors also most sincerely thank Ms Christine Hayes for her assistance with editing,
Ms Jean Cameron and Ms Rosemary Westermeyer for their administrative assistance, and
Ms Tushita Bosonet for the graphic design of the report. Ms Rosemary Westermeyer also supported
production at WHO.
WHO gratefully acknowledges financial assistance from the Government of Finland in the produc-
tion of this book.
Editors
Dr Rajanikant Arole
Director, Comprehensive Rural Health Project
Professor Helen Herrman
Jamkhed, Maharashtra, India
St Vincent’s Health Melbourne and
Department of Psychiatry
Dr Florence Baingana
The University of Melbourne
Senior Health Specialist (Mental Health)
Victoria, Australia
The World Bank
Washington, DC, USA
Dr Shekhar Saxena
Coordinator, Mental Health: Evidence and Research
Mr Chris Bale
Department of Mental Health and Substance Abuse
Director, Partnership for Children
World Health Organization
London, United Kingdom
Geneva, Switzerland
Ms Sohini Banerjee
Professor Rob Moodie
Swiss Tropical Institute, Department of Public Health
Chief Executive Officer
and Epidemiology and University of Basel
Victorian Health Promotion Foundation
Switzerland
Victoria, Australia
Dr Margaret Barry
Director, Centre for Health Promotion Studies
Advisers
National University of Ireland, Galway
Ms Beverley Long
Ireland
World Federation for Mental Health
Dr Dan Chisholm
Atlanta, GA, USA
Economist, Mental Health: Evidence and Research
Professor Norman Sartorius
Department of Mental Health and Substance Abuse
University of Geneva
World Health Organization
Geneva, Switzerland
Geneva, Switzerland
Dr Dusica Lecic Tosevski
Professor Arabinda N Chowdhury
Director, Institute of Mental Health and
Professor of Psychiatry, University of Calcutta and
Chair, World Psychiatric Association Section
Superintendent, Institute of Psychiatry
on Preventive Psychiatry
Kolkata, India
Belgrade, Serbia and Montenegro
Dr Alex Cohen
Assistant Professor of Social Medicine
Contributors
Harvard Medical School
Boston, MA, USA
Dr James C (Jim) Anthony
Professor and Chairman, Department of Epidemiology
Ms Michelle Cullen
College of Human Medicine
Consultant, Post-Conflict Unit
Michigan State University
The World Bank
Michigan, USA
Washington, DC, USA
PROMOTING MENTAL HEALTH • XV
Dr Peter Deutschmann
Professor Penelope Hawe
Executive Director, Australian International
Centre for the Study of Social and Physical
Health Institute
Environments and Health
The University of Melbourne
University of Calgary
Victoria, Australia
Canada
Ms Jodie Doyle
Professor Clemens Hosman
Field Coordinator, Cochrane Health Promotion
Prevention Research Centre on Mental Health
and Public Health Field
Promotion and Mental Disorders Prevention
Victorian Health Promotion Foundation
Faculties of Social Sciences and Health Sciences
Victoria, Australia
Radboud University Nijmegen and Maastricht
Ms Natalie Drew
University
Technical Officer
The Netherlands
Mental Health Policy and Service Development
Dr Thomas R Insel
Department of Mental Health and Substance Abuse
Director, National Institute of Mental Health
World Health Organization
Bethesda, MD, USA
Geneva, Switzerland
Dr Eva Jané-Llopis
Professor Mason Durie
Head of Science-Based Knowledge and Policy
Head of School, Te Pütahi-ä-Toi, School of Mäori
Prevention Research Centre on Mental Health
Studies, Massey University
Promotion and Mental Disorder Prevention
Palmerson North, New Zealand
Academic Centre for Social Sciences
Ms Monica Eriksson
Radboud University Nijmegen
Project Leader, Nordic School of Public Health
The Netherlands
Sweden
Professor Rachael Jenkins
Ms Beth Fuller
Institute of Psychiatry
Senior Program Development Officer
London, United Kingdom
Australian International Health Institute
The University of Melbourne
Professor Natacha Joubert
Victoria, Australia
Head, Mental Health Promotion Unit
Health Canada
Dr Michelle Funk
Canada
Coordinator
Mental Health Policy and Service Development
Dr Corey Keyes
Department of Mental Health and Substance Abuse
Department of Sociology and Department of
World Health Organization
Behavioural Sciences and Health Education
Geneva, Switzerland
The Rollins School of Public Health
Emory University
Ms Elizabeth Gale
Georgia, USA
Chief Executive, Mentality
London, United Kingdom
Professor Vivianne Kovess-Masfety
Directrice, Fondation MGEN pour la Sante Publique
Dr Laura Ghali
Paris, France
Centre for the Study of Social and Physical
Environments and Health
Dr Eero Lahtinen
University of Calgary
Senior Medical Officer
Canada
Ministry of Social Affairs and Health in Finland
Helsinki, Finland
Ms Margaret Grigg
Technical Officer
Professor Ville Lehtinen
Mental Health Policy and Service Development
National Research and Development Centre for
Department of Mental Health and Substance Abuse
Welfare and Health (STAKES)
World Health Organization
Mental Health Unit
Geneva, Switzerland
Helsinki, Finland
Professor Oye Gureje
Professor Bengt Lindstrom
Department of Psychiatry, University of Ibadan
Nordic School of Public Health
Ibadan, Nigeria
Goteborg, Sweden
XVI • PROMOT
O ING MENTA
T L HEALT
L H
Dr David McQueen
Dr Mark Petticrew
Associate Director for Global Health Promotion
MRC Social and Public Health Sciences Unit
Centers for Disease Control and Prevention
Glasgow, United Kingdom
Atlanta, GA, USA
Dr Pekka Puska
Ms Elise Maher
Director-General, National Public Health Institute
Research Fellow
(KTL)
School of Health and Social Development
Helsinki, Finland and
Deakin University
Former Director, Communicable Disease Prevention
Victoria, Australia
and Health Promotion
World Health Organization
Dr Alberto Minoletti
Geneva, Switzerland
Director, Mental Health Unit
Ministry of Health
Associate Professor John Raeburn
Santiago, Chile
University of Auckland
Auckland, New Zealand
Professor Brian Mishara
Director, Centre for Research and Intervention on
Professor Beverley Raphael
Suicide and Euthanasia (CRISE)
Director, Centre for Mental Health,
University of Quebec
New South Wales Health Department
Montreal, Canada
New South Wales, Australia
Dr Therese Riley
Professor Maurice Mittelmark
VicHealth Centre for the Promotion of Mental Health
President, International Union for Health Promotion
and Social Wellbeing; and
and Education
School of Population Health
Research Centre for Health Promotion
The University of Melbourne
University of Bergen
Victoria, Australia
Bergen, Norway
Associate Professor Louise Rowling
Mr Michael Murray
School of Policy and Practice
Chief Executive, The Clifford Beers Foundation
University of Sydney
University of Central England
New South Wales, Australia
Birmingham, United Kingdom
Dr Benedetto Saraceno
Dr Desmond O’Bryne
Director
Coordinator of Health Promotion
Department of Mental Health and Substance Abuse
Health Education and Health Promotion Unit
World Health Organization
World Health Organization
Geneva, Switzerland
Geneva, Switzerland
Dr Margit Schmolke
Dr John Orley
International Centre for Mental Health
Former Programme Manager in the Department of
Mt Sinai School of Medicine
Mental Health
New York, USA
World Health Organization
Geneva, Switzerland
Ms Shona Sturgeon
Department of Social Development
Professor Agustin Ozamiz
University of Cape Town
Department of Sociology
Republic of South Africa
University of Deusto
Bilbao, Spain
Professor Leslie Swartz
Professor, Department of Psychology
Dr Vikram Patel
University of Stellenbosch and
Reader in International Mental Health
Director, Child Youth and Family Development
London School of Hygiene and Tropical Medicine
Human Sciences Research Council
London, United Kingdom
Cape Town, Republic of South Africa
Dr Soumitra Pathare
Dr Kwok-Cho Tang
Consultant Psychiatrist
Senior Professional Officer
Ruby Hall Clinic
World Health Organization
Pune, India
Geneva, Switzerland
PROMOT
O ING MENTA
T L HEALT
L H • XVII
Dr Alison Taylor
Professor Mitchell Weiss
Chief Executive Officer, Mental Health Foundation
Professor and Head
Auckland, New Zealand
Department of Public Health and Epidemiology
Swiss Tropical Institute
Ms Hilary Thomson
Basel, Switzerland
MRC Social and Public Health Sciences Unit
University of Glasgow
Professor Harvey Whiteford
Glasgow, United Kingdom
Kratzmann Professor of Psychiatry
University of Queensland
Dr Lynn Underwood
The Park Centre for Mental Health
Fetzer Institute
Queensland, Australia
Kalamazoo, MI, USA
Dr Sally Wooding
Ms Irene Verins
Senior Project Officer
Senior Project Officer
Centre for Mental Health – Policy Division
Victorian Health Promotion Foundation
NSW Health Department
Victoria, Australia
New South Wales, Australia
Ms Lyn Walker
Dr Mohammad Taghi Yasamy
Director, Mental Health and Wellbeing Unit
Department of Psychiatry
Victorian Health Promotion Foundation
Shahid Beheshti University of Medical Sciences
Victoria, Australia
Tehran, Islamic Republic of Iran
Professor Elizabeth Waters
Professor Stephen R Zubrick
Chair in Public Health
Head, Division of Population Sciences
School of Health and Social Development
Curtin University of Technology Centre for
Faculty of Health and Behavioural Sciences
Developmental Health
Deakin University
Telethon Institute for Child Health Research
Victoria, Australia
Perth, WA, Australia
Ms Kim Webster
Senior Project Officer
Victorian Health Promotion Foundation
Victoria, Australia
Key messages
There is no health without mental health
The World Health Organization (WHO) defines health as:
… a state of complete physical, mental and social well-being and not merely the absence of
disease or infirmity.
Mental health is clearly an integral part of this definition. The goals and traditions of public health
and health promotion can be applied just as usefully in the field of mental health as they have
been in heart health, infectious diseases and tobacco control.
Mental health is more than the absence of mental illness: it is vital to individuals, families and
societies
Mental health is described by WHO as:
… a state of well-being in which the individual realizes his or her own abilities, can cope
with the normal stresses of life, can work productively and fruitfully, and is able to make a
contribution to his or her community.
In this positive sense mental health is the foundation for well-being and effective functioning for
an individual and for a community. This core concept of mental heath is consistent with its wide
and varied interpretation across cultures.
Mental health is determined by socioeconomic and environmental factors
Mental health and mental illnesses are determined by multiple and interacting social, psychologi-
cal and biological factors, just as health and illness in general. The clearest evidence for this relates
to the risk of mental illnesses, which in the developed and developing world is associated with
indicators of poverty, including low levels of education, and in some studies with poor housing
and low income. The greater vulnerability of disadvantaged people in each community to mental
illnesses may be explained by such factors as the experience of insecurity and hopelessness, rapid
social change, and the risks of violence and physical ill-health.
Mental health is linked to behaviour
Mental, social and behavioural health problems may interact so as to intensify their effects on
behaviour and well-being. Substance abuse, violence, and abuses of women and children on the
one hand, and health problems such as heart disease, depression and anxiety on the other, are
more prevalent and more difficult to cope with in conditions of high unemployment, low income,
limited education, stressful work conditions, gender discrimination, unhealthy lifestyle and human
rights violations.
Mental health can be enhanced by effective public health interventions
The improvement in heart health in several countries has had more to do with attention to envi-
ronment, tobacco and nutrition policies than with specific medicines or treatment techniques.
The malign effects of changing environmental conditions on heart health have been reversed to
varying extents by actions at multiple levels.
Similarly, research has shown that mental health can be affected by non-health policies and prac-
tices, for example in housing, education and child care. This accentuates the need to assess the
effectiveness of policy and practice interventions in diverse health and non-health areas. Despite
PROMOTING MENTAL HEALTH • XIX
uncertainties and gaps in the evidence, we know enough about the links between social expe-
rience and mental health to make a compelling case to apply and evaluate locally appropriate
policy and practice interventions to promote mental health.
Collective action depends on shared values as much as the quality of scientific evidence
In some communities, time-honoured practices and ways of life maintain mental health even
though mental health may not be identified as the outcome, or identified by name. In other com-
munities, people need to be convinced that making an effort to improve mental health is realistic
and worthwhile.
A climate that respects and protects basic civil, political, economic, social and cultural rights is
fundamental to the promotion of mental health
Without the security and freedom provided by these rights it is very difficult to maintain a high
level of mental health.
Intersectoral linkage is the key for mental health promotion
Mental health can be improved through the collective action of society. Improving mental health
requires policies and programmes in government and business sectors including education,
labour, justice, transport, environment, housing and welfare, as well as specific activities in the
health field relating to the prevention and treatment of ill-health.
Mental health is everybody’s business
Those who can do something to promote mental health, and who have something to gain,
include individuals, families, communities, commercial organizations and health professionals.
Particularly important are the decision-makers in governments at local and national levels whose
actions affect mental health in ways that they may not realize. International bodies can ensure
that countries at all stages of economic development are aware of the importance of mental
health to community development. They can also encourage them to assess the possibilities and
evidence for intervening to improve the mental health of their population.
XX • PROMOTING MENTAL HEALTH
Part I
Concepts
S
T
P
E
C
N
O
C
Chapter 1 • Introduction:
Promoting Mental Health as a Public Health Priority
Helen Herrman, Shekhar Saxena, Rob Moodie, Lyn Walker
Public health is the science and art of promoting health, preventing disease, and prolonging
life through the organized efforts of society (WHO, 1998a, p. 3).
Health polices in the 21st century will need to be constructed from the key question…”What
makes people healthy?” (Kickbusch, 2003, p. 386).
What is mental health?
Since its inception, WHO has included mental well-being in the definition of health. WHO famous-
ly defines health as:
… a state of complete physical, mental and social well-being and not merely the absence
of disease or infirmity (WHO, 2001b, p.1).
Three ideas central to the improvement of health follow from this definition: mental health is
an integral part of health, mental health is more than the absence of mental illness, and mental
health is intimately connected with physical health and behaviour.
Defining mental health is important, although not always necessary to achieving its improve-
ment. Differences in values across countries, cultures, classes and genders can appear too great to
allow a consensus on a definition (WHO, 2001c). However, just as age or wealth each have many
different expressions across the world and yet have a core common-sense universal meaning, so
too can mental health be understood without restricting its interpretation across cultures. WHO
has recently proposed that mental health is:
… a state of well-being in which the individual realizes his or her own abilities, can cope
with the normal stresses of life, can work productively and fruitfully, and is able to make
a contribution to his or her community (WHO, 2001d, p.1).
In this positive sense, mental health is the foundation for well-being and effective functioning for
an individual and for a community. It is more than the absence of mental illness, for the states and
capacities noted in the definition have value in themselves. Despite this, mental health is still por-
trayed by some as a luxury. The misunderstandings on which this view is based are now clearer than
they were in the past, and WHO and other international organizations identify the improvement of
mental health as a priority concern for low and middle income countries as well as for wealthier
nations and people (WHO, 2001b).
Neither mental nor physical health can exist alone. Mental, physical and social functioning are
interdependent. Furthermore, health and illness may co-exist. They are mutually exclusive only
if health is defined in a restrictive way as the absence of disease (Sartorius, 1990). Recognizing
health as a state of balance including the self, others and the environment helps communities and
individuals understand how to seek its improvement.
Towards a new public health
Public health in modern times has a broad scope as the organized global and local effort to
promote and protect the health of populations and to reduce health inequalities. This ranges
from the control of communicable diseases – the original impetus for public health work – to the
leadership of intersectoral efforts to promote health (Beaglehole, 2003). The new public health is
CHAPTER 1 • PROMOTING MENTAL HEALTH AS A PUBLIC HEALTH PRIORITY • 3
a social and political concept, aimed at improving health, prolonging life and improving the qual-
ity of life among whole populations. It works through health promotion, disease prevention and
other forms of health intervention (WHO, 1998a).
Health promotion has had new prominence in recent decades. Its strategies are based on the
question of how health is created, and it aims to offer people more control over the determinants
of their health. The priority this gives to investing in the determinants of health is matched by the
increasing focus on health outcomes around the world. The concept of ecological public health
has also emerged. It emphasizes the common ground between achieving health and sustain-
able development, focusing on the economic and environmental determinants of health (WHO,
1998a).
Several key thinkers in the last two decades have influenced public health practice. Marmot, in
his work with Wilkinson on the social determinants of health, noted that it is possible to alter
“the impact of the social environment on health, as represented by social inequalities in health”
(Marmot & Wilkinson, 1999, p. 3). Specific social determinants of health can be characterized and
their effects studied. It is then potentially possible to affect these determinants with a consequent
impact on health. Syme (1996) noted the importance of distinguishing between individual risk
factors and environmental causes of disease. Rose (1992) suggested that the causes of individual
differences in disease may not be the same as the causes of differences between populations.
These population determinants are the focus of much of the new public health and health pro-
motion work.
The report of the Commission on Macroeconomics and Health, published by WHO in 2001, sup-
ports the economic as well as humanitarian value of improving the health of poor and disadvan-
taged populations in all countries. Since the determinants of health and the most powerful means
for health improvement are located at the global and regional levels, and since most public
health work lies outside the conventional market framework and remains the responsibility of
government, its “public good” nature can be stressed and is gaining acceptance. Reducing health
inequalities requires action on the underlying structural determinants of social and economic
deprivation and serious intersectoral action is required (Beaglehole & Bonita, 2003). Beaglehole
and Bonita call for better education of public health practitioners to give them the skills for this
type of work.
A new enthusiasm for promoting mental health
Along with enthusiasm for the new public health, over the past 20 years the interest in promot-
ing mental health has grown (Friedli, 2002; Secker, 1998; Trent & Reed, 1992–6; Tudor, 1996; WHO,
1981, 2002). The fields of mental health and public health have a long history of weak interac-
tions, despite the possibilities for a stronger working relationship (Cooper 1990; Goldberg &
Tantam, 1990; Goldstein, 1989). This relates mainly to the stigma of mental illness, and vagueness
in the concepts of mental health and mental illness. The interest has grown recently for two main
reasons. First, mental health is increasingly seen as fundamental to physical health and quality
of life and thus needs to be addressed as an important component of improving overall health
and well-being. The concept of health enunciated by WHO as encompassing physical, mental
and social well-being is more and more seen as a practical issue for policy and practice. In par-
ticular, there is growing evidence to suggest interplay between mental and physical health and
well-being and outcomes such as educational achievement, productivity at work, development
4 • PROMOT
O ING MENTA
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L H
of positive personal relationships, reduction in crime rates and decreasing harms associated with
use of alcohol and drugs. It follows that promoting mental health through a focus on key determi-
nants should not only result in lower rates of some mental disorders and improved physical health
but also better educational performance, greater productivity of workers, improved relationships
within families and safer communities.
Second, there is wide acknowledgement of an increase in mental ill-health at a global level.
The authoritative work undertaken by WHO and the World Bank indicates that by the year 2020
depression will constitute the second largest cause of disease burden worldwide (Murray & Lopez,
1996). The global burden of mental ill-health is well beyond the treatment capacities of developed
and developing countries, and the social and economic costs associated with this growing bur-
den will not be reduced by the treatment of mental disorders alone (WHO, 2001c). Evidence also
indicates that mental ill-health is more common among people with relative social disadvantage
(Desjarlais et al., 1995).
The global focus on mental ill-health has sparked interest in the possibilities for promoting mental
health as well as preventing and treating illness. There is a need to ensure that appropriate care
and treatment is in place for those experiencing mental ill-health while at the same time develop-
ing a greater focus on promotion of mental health and prevention of illness, and giving priority to
each of these in global, national and local policy and practice. Many policy-makers, practitioners
and academics working in public health are committed to addressing health inequalities result-
ing not only from biological and behavioural characteristics but also from a maldistribution of
resources. Consequently, health promotion, including the promotion of mental health and well-
being, is as much an emerging political and social project as a health project (Mittelmark, 2003).
Promoting mental health is an integral part of public health
Mental health and mental illness are determined by multiple and interacting social, psychological
and biological factors, just as are health and illness in general. The clearest evidence relates to the
risks of mental illness, which in the developed and developing world are associated with indica-
tors of poverty, including low levels of education. The association between poverty and mental
disorders appears to be universal, occurring in all societies irrespective of their levels of develop-
ment. Factors such as insecurity and hopelessness, rapid social change and the risks of violence
and physical ill-health may explain this greater vulnerability (Patel & Kleinman, 2003). Economic
levels also have important implications for family functioning and child mental health (Costello et
al., 2003; Rutter, 2003).
Mental, social and behavioural health problems may interact to intensify each other’s effects on
behaviour and well-being. Substance abuse, violence and abuses of women and children on the
one hand, and health problems such as heart disease, depression and anxiety on the other, are
more prevalent and more difficult to cope with in conditions of high unemployment, low income,
limited education, stressful work conditions, gender discrimination, unhealthy lifestyle and human
rights violations (Desjarlais et al., 1995, p. 6).
Mental health for each person is affected by individual factors and experiences, social interaction,
societal structures and resources and cultural values. It is influenced by experiences in everyday
life, in families and schools, on streets and at work (Lahtinen et al., 1999; Lehtinen, Riikonen &
Lahtinen, 1997). The mental health of each person in turn affects life in each of these domains
CHAPTER 1
1 • •PROMOT
O ING MENTA
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L H AS A PUBLIC HEALT
L H PRIORITY • 5
and hence the health of a community or population. Some of the newest research across the dis-
ciplines of genetics, neuroscience, the social sciences and mental health involves elaborations of
ideas about the impact societies have on human life over and above the sum of the impact of the
individual members of the society (as discussed in Chapter 10).
Ethnographic studies show how people living in adverse environments and social settings such as
the slums of Mumbai are faced with problems such as migration and displacement, poor condi-
tions, unequal distribution of amenities, demolition of housing, homelessness and communal and
ethnic disharmony. These in turn shape local experience and affect the mental health of the inha-
bitants and the community. Hopelessness, demoralization, addictions, distress, anger, depression,
hostility and violence can all be linked back to these experiences and problems (Parkar, Fernandes
& Weiss, 2003).
Despite this, mental health and mental illness are largely viewed as residing outside the public
health tradition with its fundamental concepts of health and illness as multifactorial in origin
(Cooper, 1993) and of there being a continuum between health and illness (Rose, 1992). The con-
sequences are twofold. First, the opportunities for improving mental health in a community are
not fully exploited. Second, organized efforts by countries to reduce the social and economic bur-
den of mental illnesses tend to focus mostly on the treatment of ill individuals.
Mental illnesses are common and universal. Worldwide, mental and behavioural disorders repre-
sented 11% of the total disease burden in 1990, expressed in terms of disability-adjusted life years
(DALYs). This is predicted to increase to 15% by 2020. Depression was the fourth largest contribu-
tor to the disease burden in 1990 and is expected to be the second largest after ischaemic heart
disease by 2020 (WHO, 2001c). Mental health problems also result in a variety of other costs to the
society (WHO, 2003). Yet mental illness and mental health have been neglected topics for most
governments and societies. Recent data collected by WHO demonstrates the large gap that exists
between the burden caused by mental health problems and the resources available in countries
to prevent and treat them (WHO, 2001a). In contrast to the overall health gains of the world’s
populations in recent decades, the burden of mental illness has grown (Desjarlais et al., 1995;
Eisenberg, 1998).
This neglect is based at least in part on confusion and false assumptions about the separate con-
cepts of mental health and mental illness. Until now, the prevailing stigma surrounding mental
illness has encouraged the euphemistic use of the term “mental health” to describe treatment and
support services for people with mental illness. This usage adds to confusion about the concept
of mental health as well as that of mental illness.
In most parts of the world the treatment of mental illness was alienated from the rest of medicine
and health care at least until recently. In the isolated setting of asylums, practitioners saw many
seemingly incurable patients. The supposed incurability of insanity and melancholy made practi-
tioners believe the causes were entirely biological. The idea has since persisted that prevention of
mental illness is “all or none” (Cooper, 1990). This concept of an irreversible process once a person
becomes ill leads to a sense of therapeutic nihilism as well as a belief that prevention is either
absolute and one-dimensional or unlikely to succeed at all. Furthermore, the promotion of men-
tal health is sometimes seen as far removed from the problems of the “real world” and there are
concerns it could shift resources away from the treatment and rehabilitation of people affected by
mental illness.
6 • PROMOT
O ING MENTA
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L H
The twin aims of improving mental health and lowering the personal and social costs of mental
ill-health require a public health approach.1 Within a public health framework, the activities that
can improve health include the promotion of health, the prevention of illness and disability, and
the treatment and rehabilitation of those affected. These are different from one another, even
though the actions and outcomes overlap. They are all required, are complementary, and no one
is a substitute for the other.
Mental health is more than the absence of mental illness
As already noted, mental health implies fitness rather than freedom from illness. In 2003, George
Vaillant in the USA commented that mental health is too important to be ignored and needs to
be defined. As Vaillant pointed out, this is a complex task. “Average mental health” is not the same
as “healthy”, for averaging always includes mixing in with the healthy the prevailing amount of
psychopathology. What is healthy sometimes depends on geography, culture and the historical
moment. Whether one is discussing state or trait also needs to be clear – is an athlete who is
temporarily disabled with a fractured ankle healthy or unhealthy? Similarly, is an asymptomatic
person with a history of bipolar affective disorder healthy or unhealthy? There is also “the two-fold
danger of contamination by values” (Vaillant, 2003, p. 1374) – a given culture’s definition of mental
health can be parochial, and, even if mental health is “good”, what is it good for? The self or the
society? For fitting in or for creativity? For happiness or for survival? Even so, Vaillant advocates
that common sense should prevail and that certain elements have a universal importance to men-
tal health; just as despite every culture having its own diet, the importance of vitamins and the
five basic food groups is universal.
No health without mental health: mental health and behaviour
Physical health and mental health are closely associated through various mechanisms, as studies of
the links between depression and heart and vascular disease are demonstrating (see Chapter 11).
Many studies since the 1950s support the idea that medically ill patients with negative attitudes
have worse outcomes than those with more positive attitudes. Now studies demonstrate that
healthy people who are optimistic have lower death rates from heart disease than those who are
pessimistic, even taking other risk factors into account (Giltay et al., 2004). The relevance of emo-
tional status to the maintenance of good physical health and recovery from physical illness is now
well substantiated, as is the converse.
Physical ill-health is detrimental to mental health as much as poor mental health contributes to
poor physical health (Herrman & Jané-Llopis, in press). For example, malnourishment in infants
can increase the risks of cognitive and motor deficits, and heart disease and cancer can increase
the risk of depression (Blane et al., 1996; Marmot & Wilkinson, 1999). Strong evidence establishes
depression as a risk factor for heart disease, and some national health policies now assert that
the causal link is undeniable. The importance of short-term mental stress as a trigger for the
1 A number of books and articles have discussed this point. For example: CDHAC, 2000; Christodoulou, Lecic-Tosevski
& Kontaxakis, 1999; Goldberg & Tantam, 1990; HEA, 1997; Healthy Living, 2003; Herrman, 2001; Hosman, 2001;
Jenkins, 2001; Jenkins & Ustun, 1998; Lehtinen, Riikonen & Lahtinen, 1997; Mrazek & Haggerty, 1994; Newton, 1988;
Paykel & Jenkins, 1994; Rowling, Martin & Walker, 2002; Sartorius, 1998, 2002; Secker, 1998; VicHealth, 1999, 2005;
Walker, Moodie & Herrman, 2004; and WHO, 1998b.
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development of myocardial infarction and sudden death in people with heart disease is no longer
questioned. The notion that hypertension may arise through psychological stress, in turn related
to occupational and other adverse factors in the environment, remains contentious, but the idea
is an old one (Esler & Parati, 2004). Low control at work and poor social support have important
influences on both physical health (e.g. cardiovascular morbidity) and psychological health (e.g.
depression) (Kopp, Skrabski & Szedmák, 2000). Many of the people living with HIV/AIDS and their
families experience stigma and discrimination as well as depression and anxiety and other mental
illnesses (WHO, 2001c). Persistent pain is linked with suffering and lost productivity around the
world. A WHO study across 15 centres in Asia, Africa, Europe and the Americas examined the rela-
tionship between pain and well-being in over 5000 individuals. Those with persistent pain were
over four times more likely to have an anxiety or depressive disorder than those without pain
(Gureje et al., 1998).
Research has pointed to two main pathways through which a person’s mental and physical health
and functioning mutually influence each other over time (WHO, 2001c), interacting with social
and environmental influences on health. The first pathway is directly through physiological sys-
tems, such as neuroendocrine and immune functioning. The second pathway is through health
behaviour. The term health behaviour covers a range of activities, such as eating sensibly, getting
regular exercise and adequate sleep, avoiding smoking, engaging in safe sexual practices, wear-
ing safety belts in vehicles and adhering to medical therapies. The physiological and behavioural
pathways are distinct yet interact with one another and the social environment: health behaviour
can affect physiology (for example, smoking and sedentary lifestyle decrease immune function-
ing) and physiological functioning can influence health behaviour (for example, tiredness leads
to accidents). In an integrated and evidence-based model of health, mental health (including
emotions and thought patterns) emerges as a key determinant of overall health. Anxious and
depressed moods, for example, initiate a cascade of adverse changes in endocrine and immune
functioning and increase susceptibility to a range of physical illnesses. For instance, stress is
related to the development of the common cold (Cohen, Tyrrell & Smith, 1991) and delays wound
healing (Kielcot-Glaser et al., 1999).
While many questions remain concerning the specific mechanisms of these relationships, it is
clear that poor mental health plays a significant role in diminished immune functioning, the
development of certain illnesses and premature death. As WHO points out:
Understanding the determinants of health behaviour is particularly important because of
the role that health behaviour plays in shaping overall health status. Noncommunicable
diseases such as cardiovascular disease and cancer … are strongly linked to unhealthy
behaviour such as alcohol and tobacco use, poor diet and sedentary lifestyle. Health
behaviour is also a prime determinant of the spread of communicable diseases such as
AIDS, through unsafe sexual practices and needle sharing …
The health behaviour of an individual is highly dependent on that person’s mental
health. Thus, for example, mental illness or psychological stress affect health behaviour
(WHO, 2001c, p. 9).
In young people, depression and low self-esteem are linked with smoking, binge drinking, eating
disorders and unsafe sex, putting them at risk of a range of diseases including sexually transmit-
ted diseases such as AIDS (Patton et al., 1998; Ranrakha et al., 2000). Depression in other age
groups is linked with social isolation, alcohol and drug abuse and smoking (Hemenway, Solnick
8 • PROMOT
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& Colditz, 1993). Mood disorders can lead to an increased risk of accidents and injuries and poor
physical and role function (Wells et al., 1989). Other factors such as learning through experience
or observation also have an effect on health behaviour. For example, it has been established that
drug use before the age of 15 years is highly associated with the development of drug and alco-
hol abuse in adulthood (Jaffe, 1995). Environmental influences, such as poverty or societal and
cultural norms, also affect health behaviour (WHO, 2001c).
There are complex interactions between the determinants of health, behaviours and mental
health at all stages of life. A body of evidence indicates that the social factors associated with
mental ill-health are also associated with alcohol and drug use, crime and dropout from school.
An absence of the determinants of health and the presence of noxious factors also appears to
have a major role in other risk behaviours, such as unsafe sexual behaviour, road trauma and
physical inactivity. For example, a lack of meaningful employment may be associated with depres-
sion and alcohol and drug use. This may in turn result in road trauma, the consequences of which
are physical disability and loss of employment (Walker, Moodie & Herrman, 2004). Kleinman
(1999) describes the clustering of mental and social health problems in “broken communities” in
shantytowns and slums and among vulnerable and marginal migrant populations: civil violence,
domestic violence, suicide, substance abuse, depression and post-traumatic disorder cluster and
coalesce. He calls for a research agenda and innovative policies and programmes “that can pre-
vent the simply enormous burden that mental illness has on the health of societies resulting from
the variety of forms of social violence in our era” (Kleinman, 1999, p. 979). The corollary is the need
for the development and evaluation of programmes that on the one hand control and reduce
such clusters and on the other hand assist people and families to cope in these circumstances.
A life-course approach helps in understanding social variations in health and mental health.
Exposure to experiences and environments accumulate throughout life, increasing the risk of
adult morbidity and premature death if they are disadvantageous. Exposure to health-damaging
environments during adulthood may accumulate on top of health disadvantage during childhood
(Holland et al., 2000). This approach takes into account the complex ways in which biological, eco-
nomic, social and psychological factors interact in the development of health and disease. Such
an approach reveals biological and social “critical periods” during which policies that will defend
individuals against an accumulation of risk are particularly important. The policies of modern
“welfare states” can be seen to contribute in many ways to present-day high standards of health
overall in developed countries (Bartley, Blane & Montgomery, 1997).
The evidence is clear: mental health is fundamentally linked to physical health outcomes. Mental
health status is a key consideration in changing the health status of a community. Health and
behaviour are influenced by factors at multiple levels, including biological, psychological and
social. Interventions that involve only the individual, such as training in social skills or self-control,
are unlikely to change long-term behaviour unless family, work and broader social factors are
aligned to support a change (Institute of Medicine, 2001).
Objectives and actions of mental health promotion
This [20th] century has seen greater gains in health for the populations of the world than at any
other time in history. These gains have been made partly as a result of improvements in income
and education, with accompanying improvements in nutrition, hygiene, housing, water supply
and sanitation. They are also the result of new knowledge about the causes, prevention and
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treatment of disease and the introduction of policies that have made intervention programmes
more accessible. The greatest advances in health have been made through a combination of
structural change and the actions of individuals (Nutbeam, 2000, p.1).
Effective health promotion leads to changes in the determinants of health (Nutbeam, 2000, p. 3).
Health promotion is an approach to improving public health that requires broad participation.
It may be understood as actions and advocacy to address the full range of potentially modifiable
determinants of health, including actions that allow people to adopt and maintain healthy lives
and those that create living conditions and environments that support health (WHO, 1998a).
Mental health promotion is an integral part of health promotion theory and practice. The inter-
ventions can be applied at population, subpopulation and individual levels, and across settings
and sectors within and beyond the health field (Walker & Rowling, 2002).
The personal, social and environmental factors that determine mental health and mental illness
may be clustered conceptually around three themes (HEA, 1997; Lahtinen et al., 1999; Lehtinen,
Riikonen & Lahtinen, 1997):
■ the development and maintenance of healthy communities
This provides a safe and secure environment, good housing, positive educational experien-
ces, employment, good working conditions and a supportive political infrastructure; mini-
mizes conflict and violence; allows self-determination and control of one’s life; and provides
community validation, social support, positive role models and the basic needs of food, war-
mth and shelter.
■ each person's ability to deal with the social world through skills like participating, tolerating
diversity and mutual responsibility
This is associated with positive experiences of early bonding, attachment, relationships, com-
munication and feelings of acceptance.
■ each person's ability to deal with thoughts and feelings, the management of life and emotional
resilience
This is associated with self-esteem, the ability to manage conflict and the ability to learn.
The fostering of these environmental, social and individual qualities, and the avoidance of the
converse, are the objectives of mental health promotion. In each nation or community, local opin-
ion about the main problems and potential gains as well as evidence about the social and per-
sonal determinants of mental health will shape the activities of mental health promotion.
As noted earlier, health promotion and prevention are necessarily related and overlapping activi-
ties: the former is concerned with the determinants of health and the latter focuses on the causes
of disease. The evidence for prevention of mental disorders (Hosman & Jané-Llopis, 2005; Jane-
Llopis, in press) contributes to the evidence for the promotion of mental health. The evidence
for effectiveness of mental health promotion is also being extended through evaluation of expe-
rience in different countries and settings. This gives growing confidence to develop and evaluate
interventions, even while the principle of prudence (see Chapter 2) recognizes that we can never
know enough to act with certainty.
The actions that promote mental health will often have as an important outcome the prevention
of mental disorders. The evidence is that mental health promotion is also effective in the pre-
vention of a whole range of behaviour-related diseases and risks. It can help, for instance, in the
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prevention of smoking or of unprotected sex and hence of AIDS or teenage pregnancy. Indeed,
the potential contribution of mental health promotion to the prevention of health-damaging and
anti-social behaviours is probably greater than its potential to prevent mental disorders (Orley &
Weisen, 1998).
As already discussed, many of the activities of mental health promotion are sociopolitical: reduc-
ing unemployment, improving schooling and housing and working to reduce stigma and discrim-
ination of various types. Other policy initiatives such as wearing seat belts to avoid head injury are
designed to prevent illness and injury. The key agents are politicians, educators and members of
nongovernment organizations. The job of mental health practitioners is to remind these agents of
the evidence showing the importance of these key variables (Goldberg, 1998) and to assist them
in introducing policies that lead to better mental health. Health practitioners may be more direct-
ly involved in prevention of illness, devising and applying programmes in primary health care and
other settings, as well as working with communities to promote awareness of mental health.
A combined approach to health promotion and prevention of illness categorizes interventions
according to the levels of risk of illness (or scope for improving health) in various population
groups and makes it clearer what type of collective action is required (Eaton & Harrison, 1996;
Mrazek & Haggerty, 1994). Interventions are categorized as either universal (directed to whole
populations, e.g. good prenatal care), selected (targeted to subgroups of the population with
risks significantly above average, e.g. family support for young, poor, first pregnancy mothers) or
indicated (targeted at high-risk individuals with minimal but detectable symptoms, e.g. screening
and early treatment for symptoms of depression and dementia).
The approach to gathering evidence is influenced by recognizing that (1) the evidence for direct
causal pathways is generally strongest for the most immediate influences on health or disease;
(2) most health states have multiple causes interacting over time (Desjarlais et al., 1995); and
(3) important factors such as family environment will influence the level of physical and mental
health as well as the risk for several types of illness in later life. Other life events and circumstances
will interact favourably or unfavourably to contribute to health and resilience or the development
of illness.
Mental health promotion has been seen to ask for peace, social justice, decent housing, education
and employment. The call for intersectoral action has sometimes been diffuse (Kreitman, 1990)
or characterized as lacking an evidence base. Specific evidence-based proposals with measurable
outcomes are required. However, asking individual health promotion projects to demonstrate
long-term changes in ill-health, productivity or quality of life is often unrealistic and unneces-
sary. What is required instead is a marshalling of the evidence linking mental health with its criti-
cal determinants (etiological research) and programme design and evaluation to demonstrate
changes in the same determining or mediating variables. Programmes and policies can aspire, in
other words, to produce changes in indicators of economic participation, levels of discrimination
or social connectedness. Further work is required to identify and document the mental health
benefits of these changes, especially in the face of the complex interactions, and to develop indi-
cators of these determinants. As discussed throughout the following chapters, an evidence base
for mental health promotion does exist but it needs boosting with etiological research and pro-
gramme and policy evaluation of various types.
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International collaboration and the role of WHO
International collaboration is crucial for vigorous and successful advocacy as well as for the
actions that follow. WHO is the lead international agency responsible for health and is increasingly
recognizing the value of mental health. Its activities emanate from the definition of health given
earlier. The WHO Constitution stipulates a number of core functions that include:
■ “To foster activities in the field of mental health, especially those affecting the harmony of
human relations”; and
■ “To assist in developing an informed public opinion among all peoples on matters of health”.
Numerous World Health Assembly (WHA) Resolutions have urged Member States to take steps to
prevent mental illness and to promote mental health, and have requested the Director-General
to provide information and guidance regarding suitable strategies (WHO, 2002). A resolution
adopted in 2002 urged WHO to “facilitate effective development of policies and programmes
to strengthen and protect mental health” (WHA55.10). It called for “coalition building with civil
society and key actions in order to enhance global awareness-raising and advocacy campaigns on
mental health”.
The role of WHO in mental health promotion can be briefly summarized as follows.
■ To generate, review, compile and update evidence on strategies for mental health promotion,
especially from low and middle income countries
Although there are numerous published studies on mental health promotion and from time
to time efforts have been made to assimilate them, a comprehensive review of the literature
related to evidence-based research in this area has not been available. This volume and the
accompanying work on prevention of mental disorders are an attempt to fill this gap. The
evidence for the effectiveness of mental health promotion is least available in areas that have
the maximum need, such as in low and middle income countries and conflict areas where
mental health is especially compromised. More efforts are needed to generate evidence from
these settings. Attention also needs to be paid to strategies that have been found to be inef-
fective or inappropriate on the basis of all kinds of evidence. Information on these is useful in
order to prevent wastage of precious resources.
■ To develop appropriate strategies and programmes
WHO can assist countries to develop and introduce appropriate strategies and programmes.
Some of the factors to be considered are:
■ evidence of effectiveness
■ the principle of prudence
■ cultural appropriateness and acceptability
■ financial and personnel requirements
■ level of technological sophistication and infrastructure requirements
■ overall yield and benefit
■ potential for large-scale application.
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■ To facilitate partnerships and collaboration
Mental health promotion requires the collective efforts of all organizations and sectors that
may have a direct or indirect impact on mental health. At the international level these include
professional associations, international organizations, national governments, nongovernment
organizations, the health industry and prospective donors. WHO is well positioned to forge
strategic links with all these bodies and to develop effective programmes for mental health
promotion. International organizations with which WHO regularly collaborates in this area are
the International Labour Office (ILO), the United Nations Children’s Fund (UNICEF), the Office
of the United Nations High Commissioner for Refugees (UNHCR) and the World Bank.
Mental health is everybody’s business
The scope and outcomes of mental health promotion activities are potentially wide and difficult
to grasp. At the conceptual level, mental health can be and should be defined broadly. At a more
practical level, however, it is useful to distinguish between interventions that have the primary
goal of improving the mental health of individuals and communities and others that are mainly
intended to achieve something else but which enhance mental health as a side-benefit. Examples
of the former are policies and programmes that improve parenting skills and encourage schools
to prevent bullying. Policies and resources that ensure girls in a developing country attend school
and programmes to improve public housing could be considered examples of the latter. This dis-
tinction helps allocate responsibilities. Monitoring the effect on mental health of public policies
relating to housing and education is, for instance, becoming feasible (see Chapter 15). The mental
health promotion programme or interests in a country or locality would need to advocate for this,
watch that it occurs and help use the findings. Other groups will need to do the work, however,
and ensure that policies and practices are shaped by the findings.
The activities of mental health promotion can be usefully mainstreamed with health promo-
tion, although the advocacy needs to remain distinct. Bearing in mind the intimate connection
between physical and mental health, many of the interventions designed to improve mental
health will also promote physical health and vice versa. Health and mental health are affected by
policies of many different kinds and by a range of community interventions.
Various types of evidence suggest that mental health and its determinants can be improved in
association with planned or unplanned changes in the social and physical environment. As will
be discussed in the chapters that follow, sufficient justification exists for the implementation of
programme and policy interventions to promote mental health. These need to be accompanied
by evaluations of process and outcomes in countries of varying income levels. It is also clear that
there is a need to monitor the effects on mental health of social, economic and environmen-
tal changes in any country. These actions in turn will continue to expand the evidence base to
encourage further prudent interventions designed to improve or maintain mental health that will
be suited to each unique time, country, locality and population.
Countries now have the technical base on which to build the political commitment to promote
mental health. This also has a strong ethical foundation, an important pre-requisite for health
action (Lee, 2003) at global and other levels. The moral values of equity and human rights, as well
as humanitarianism and utilitarianism, can guide the policy choices and shape the programmes
(Alkire & Chen, 2004), as described in the chapters to follow.
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Promoting Mental Health: Lessons from Social Brain Research
Thomas R Insel
Over the past two decades, neuroscience research has transformed our understanding of the
brain. Three insights have been fundamental. First, we now recognize the brain as a dynamic
organ, capable of remarkable changes in how cells are connected and even in the number of
cells available throughout life. Second, we recognize considerable individual variation in the
relationship between brain anatomy and function. Classic maps of the cortex with specific
areas for motor and sensory fields are still useful but only as a broad generalization that varies
greatly across individuals. And finally, we now appreciate a stunning level of modularity in the
brain, with circuits dedicated to highly specific functions, such as verbs versus nouns or ani-
mate versus inanimate objects.
While all three aspects of brain function are pertinent to the promotion of mental health, I
will focus on the high degree of modularity with specific reference to how the brain processes
social information. We tend to consider social information among the most highly complex
forms of knowledge, requiring visual, auditory and even somatosensory processing. In fact,
recognizing friend from foe, kin from predator, and mate from stranger are among the most
basic forms of information for survival in the animal kingdom. No wonder then that many spe-
cies, including many mammals, have developed extraordinary abilities to detect social infor-
mation, usually in the olfactory domain (Insel & Fernald, 2004).
Humans, like other primates, are primarily visual rather than olfactory creatures. One particular
area of the visual cortex appears to be essential for face recognition. Most people activate the
fusiform area when looking at pictures of faces, but those with autism do not and those with
schizophrenia appear to have a reduced volume of this region. People with strokes infarcting
this region develop prosopagnosia, an inability to recognize faces. Connections from this area
to a subcortical nucleus, the amygdala, are believed to be important for higher order decoding
of faces, including the reading of emotion, non-verbal expressions and gaze.
In the past couple of years, a surprising set of studies in mice suggest that there may be a
specific molecular as well as anatomic basis for social information. Studies in mice lacking the
gene for oxytocin show a specific loss of social memory apparently without loss of any other
aspect of cognition (Ferguson et al., 2000). Mice lacking oxytocin cannot distinguish familiar
from novel mice. This neuropeptide hormone has been implicated in social behaviour includ-
ing maternal care and pair bonding or attachment. Replacing oxytocin into the amygdala
completely restores social cognition in mice lacking the oxytocin gene.
Few would doubt the importance of social interaction and in particular maternal bonding
for the development of the mental health of the newborn. There may be critical time periods
for development of bonding or attachment. The Nobel Laureate ethologist Konrad Lorenz
described a critical period for social attachment in Greylag geese. In the hours after hatching,
goslings form a preference for the first object they follow, usually the mother but, as Lorenz
demonstrated, they can imprint on a human almost as easily. Studies of human orphans raised
with a variety of institutional caretakers have reported persistent social deficits, akin to autism
(Rutter et al., 2004). If these children are provided with a consistent caring foster parent in the
first two years, there is no evident long-term deficit. Children who remain institutionalized for
14 • PROMOT
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longer periods may fail to recover full social abilities, just as infants who do not have their cata-
racts repaired in their first six months may not develop normal vision.
We do not know the brain mechanisms for critical periods in either the visual domain or the
circuits for social information. However, recent studies in infant rats have suggested a poten-
tial mechanism by which the quality of infant care influences the “mental health” of offspring.
Studies by Michael Meaney and his students have linked high levels of licking and grooming
given by mothers to their pups to less stress responsiveness when they become adults com-
pared to pups receiving less licking and grooming after birth (Meaney, 2001). Of course, this
difference could reflect a genetic difference in the rats. Perhaps mothers with more licking and
grooming behaviour gave birth to pups genetically less responsive to stress. However, cross-
fostering experiments showed that it was indeed the maternal behaviour and not the biologi-
cal mother that determined adult behaviour (Francis et al., 1999).
This decrease in stress responses seems to be due to increased numbers of receptors for glu-
cocorticoids in the hippocampus. These receptors, which sense the circulating stress hormone
corticosterone, serve as a brake on the brain’s stress circuit. Therefore, more receptors mean
less stress responsiveness (higher tolerance to stress). Licking and grooming appears to cause
an enduring change in the glucocorticoid receptor gene – an “epigenetic modification” of
the gene. Amazingly, this state change appears to occur within a critical period. Licking and
grooming in the first six days postnatal, in ways we still do not understand, remove the meth-
ylation tag from this region of the receptor gene and allow the induction of gene expression,
with a resulting lifelong increase in receptors and decrease in stress responsiveness (Weaver et
al., 2004).
In this case, we are beginning to understand the molecular mechanisms by which early experi-
ence confers lasting changes in behaviour. It is certainly possible that an opposing process
occurs in children who have been physically or sexually abused. We know that these children
have increased stress responsiveness and have high baseline levels of stress hormones, such
as corticotrophin releasing hormone (CRH). It seems highly likely that the chronic elevation
of stress hormones has deleterious effects on the central nervous system, and this includes
increasing the risk for major depressive disorder. A recent comparison of the outcome of drug
treatment and cognitive behaviour therapy in depression found no significant effect of medi-
cation in the subgroup with a history of abuse, although this subgroup responded to psycho-
therapy (Nemeroff et al., 2003).
In summary, social neuroscience is revealing the mechanisms by which social experience
influences the developing brain and how the brain, in turn, can process social information.
Although one is tempted to suspect that molecular and cellular studies will only prove reduc-
tionistic, failing to capture the richness of behaviour, our experience in the past decade sug-
gests just the opposite. Studies of the molecular and cellular mechanisms of social information
have begun to reveal previously unexpected, counter-intuitive insights, from unique molecules
for social memory to molecular consequences of maternal care. We have unprecedented
traction in modern neuroscience. The task for the next decade will be to translate this trac-
tion towards the study of the treatment and prevention of mental disorders as well as mental
health and its promotion.
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L H PRIORITY • 17
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Chapter 2
Health Promotion: A Sketch of the Landscape
Maurice B Mittelmark, Pekka Puska, Desmond O’Byrne, Kwok-Cho Tang
Concepts of health
Health promotion is an emerging field of action, often referred to as the “new” public health (Baum,
1998). However, the term health promotion can have many meanings, depending on one’s perspec-
tive (Tones & Tilford, 2001). The term “health” is itself imprecise (Naidoo & Wills, 2000). Health can
refer both to absent and present states. It is often used to mean the absence of disease or disability
but, just as often, may refer to a state of fitness and ability or to a reservoir of personal resources
that can be called on when needed (Naidoo & Wills, 2000). People with different backgrounds may
hold different conceptions of health and an individual may have different ideas about the meaning
of health depending on the circumstances under which the matter is raised. It is beyond the scope
of this chapter to review the discourses on the meanings of health and in any case excellent dis-
cussions are readily available (Baum, 1998; Lupton, 1995; Seedhouse, 1986; Seedhouse, 1997; WHO,
1998b). Here some of the main viewpoints on general health are mentioned to establish the context
for this chapter. The more specific concept of “mental health” is discussed in more detail in the chap-
ters that follow.
In prestige and command of resources a medical model of health is dominant (Lupton, 1995;
Naidoo & Wills, 2000). It assumes that health is a property of beings that can be reduced to the
smallest components of the body. It approaches the body and its parts as a machine that in its heal-
thy state functions as designed. When the body malfunctions the person is said to be ill, the reasons
for the malfunction are investigated and treatment to restore functioning is undertaken. Internal
processes that have gone awry are classified as diseases and the correction of these through medi-
cal treatment processes restores health. The prevention of diseases is valued because it maintains
health. Public health is work to prevent the spread of diseases in the general population.
There are alternatives to the view that health is defined by the absence of disease and illness, howe-
ver. Seedhouse (1986) illustrates this by describing hypothetical people who each have a different
perspective on what it means to be healthy. The perspective of Seedhouse’s Medic is reflected in
the paragraph above. To his Social Scientist, by way of contrast, to be healthy means to function
in normal social roles. The Medic might well examine a prisoner and find him to be healthy, while
the Social Scientist surely would not. This is because the Social Scientist equates health with
autonomy and role fulfilment. In this view, to be healthy is to live under conditions that permit a
person or a group to achieve realistic ambitions. Thus, while our prisoner is unhealthy in the Social
Scientist’s eyes, a person living their chosen way of life and managing their responsibilities could
be judged to be healthy, even while living with medical diagnoses and treatments.
The most stimulating and controversial efforts to define health are found in the work of WHO. The
WHO Constitution of 1946 defines health in the most general terms as a state of well-being and
not only the absence of disease and disability. Tones and Tilford (2001, p. 2) captured well the spi-
rit in which this has been received:
[It] has served both as an inspiration to those subscribing to a holistic philosophy of life
and an irritant to those faced with the practical and pressing demands of managing and
preventing disease on a day-to-day basis!
CHAPTER 2 • HEALTH PROMOTION : A SKETCH OF THE LANDSCAPE • 19
The WHO Ottawa Charter of Health Promotion provides the most widely cited definition of health
promotion (WHO, 1986). It places emphasis on the idea that the promotion of health is a process
that requires broad participation:
Health promotion is the process of enabling people to increase control over, and to
improve, their health. To reach a state of complete physical, mental and social well-being,
an individual or group must be able to identify and to realize aspirations, to satisfy needs,
and to change or cope with the environment. Health is, therefore, seen as a resource for
everyday life, not the objective of living. Health is a positive concept emphasizing social
and personal resources, as well as physical capacities. Therefore, health promotion is not
just the responsibility of the health sector, but goes beyond healthy life-styles to well-being.
This definition covers wide territory indeed, including as it does environmental and well as indi-
vidual factors in the range of resources that define health. The obvious implication is that the
promotion of health must have foci on both the individual and the environment. This calls for the
involvement of a much broader array of interventions and actors than does the traditional medi-
cal model. Indeed, many of the determinants of health are beyond the control of the health care
system, as described next.
Determinants of health
An individual’s health is affected in part by the person’s way of living – for example, whether or
not they smoke tobacco products, consume too much fatty, sugary and salty food, and so forth
(WHO, 2002b). However, other key determinants of health are not a matter of choice, such as one’s
gender and ethnicity. The Health Survey of England 1993–1996, for example, observed substan-
tially poorer health among all minority ethnic groups compared to whites of working age and
higher morbidity for many minority ethnic women compared to men in the same ethnic group
(Cooper, 2002). In Brazil, black infants experience much worse health than white infants (Barrosa,
Victorab & Hortac, 2001). In Africa, women have higher mortality rates than men and women in
the sub-Saharan region have higher maternal mortality rates than other women in both develo-
ped and developing countries outside the region (Harrison, 1997).
An individual’s health is also influenced by their access to social and development resources, such
as education. Both formal and informal education is a critical factor affecting health. People with
better education in general have better health than those who are poorly educated. An increase
in education level among women improves not only their own health but also the health of their
children (Harrison, 1997).
Housing is also a factor affecting health, with homelessness and housing conditions such as poor
sanitation, crowding and inadequate ventilation clearly associated with respiratory infections,
asthma, lead poisoning, meningitis, injuries and poor mental health (Howden-Chapman, 2002).
Social relations between individuals are also factors that influence or determine their health. An
individual may learn from others and consequently adopt healthy or unhealthy lifestyles. There
is also abundant evidence that social connectedness affects people’s health. Social isolation and
social stress lead to poor health, while social participation enhances health (Eng et al., 2002;
Mittelmark, 1999b; Seeman, 1996).
Health is influenced also by one’s economic and employment status. In Australia, it has been
observed that chronic disease risk factors such as tobacco use, overweight, obesity and excess
20 • PROMOT
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alcohol consumption are more prevalent in the lower socioeconomic status (SES) groups than in
the highest SES group (Hayen et al., 2002). In the USA, income level predicts mortality and poor
people are less healthy than those who are better off (Wagstaff & van Doorslaer, 2000).
Another consistent finding is that unemployed people are less healthy and have higher mortality
rates than those that have employment (Morris, 1994). There are suggestions also that the health
of individuals in occupations with higher prestige is better than that of people in lower prestige
occupations (Marmot et al., 1997). These relationships are complex, and the associations between
employment and health may be confounded by other factors such as income, education and
social class (Morris, 1994).
Poverty is a key factor predicting poor health at the individual and population levels (Fiscella
& Franks, 1997), and health improvement contributes to poverty reduction, economic growth
and development. In recent reviews of the conceptual and empirical linkages between poverty
and poor health in both developing and developed countries, the empirical evidence is con-
vincing that poverty is causally related to poor health at both the individual and societal levels
(Subramanian, Belli & Kawachi, 2002; WHO, 2002a).
Characteristics of the physical environment over which people have little control may also threa-
ten health, including climate and climate change, air pollution, noise, the design of community
infrastructures such as roads and buildings and the presence of hazardous substances. Especially
important is ingestion of and contact with unsafe water as well as lack of access to water and sani-
tation. Water poverty is consistently associated with adverse health outcomes such as diarrhoea
and parasitic diseases such as hookworms and schistosomiasis (WHO, 2002b).
Risky physical environments in workplaces produced by toxic substances, unsafe contact with
machinery and poor ergonomic conditions are associated with a range of diseases and injuries
including skin and respiratory disorders, injuries and work stress leading to psychological disor-
ders (Driscoll et al., 2001; Jin et al., 2000; Leigh & Sheetz, 1989; Loewenson, 1999).
Health inequalities
The examples given above provide a greatly oversimplified, but illustrative, picture of the complex
web of factors that influence people’s health. Inequalities in health are related to a wide range of
factors, including social class, gender, ethnic origin and place of living, among others. Inequalities
in health are due in part to individual differences in genetics, health related behaviour and choices
regarding education, work and play. Part of the work of public health is to inform people about
health issues, to enable them to make healthy choices that raise the level of health for entire popu-
lations and hopefully reduce inequalities in health.
To the degree that inequalities are a consequence of social injustice, there exists not merely inequa-
lity but inequity as well (the contrast between equal shares versus fair shares). Virtually all health
promoters, regardless of their professional area of interest, are united by their dedication to one
overriding aim – improved equity in health. That is, they seek to reduce the “unjust” gap between
those with the best and those with the worst health (Dahlgren & Whitehead, 1992; Whitehead, 1990;
WHO, 1996; Wilkinson, 1996). Alarmingly, this gap seems to be widening (WHO, 2002b).
Health promoters believe the gap between those with the best and the worst health can be
narrowed significantly if underlying injustice is corrected. The principal means to this end is to
improve equality in opportunities for education and employment, access to a safe, nurturing phy-
sical and social environment, opportunity to participate in the governance of society and access
CHAPTER 2
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to high quality health care and social support services. This is in addition to the most fundamental
determinants of health – access to food, water, shelter and freedom from violence – that are not
yet realities for many people.
Perfect equality in life’s chances is an idealized goal, but striving for better equity in health through
improving equality in life’s chances is feasible and socially responsible. Much of the scholastic effort
in this arena has until now gone into descriptive research to document the course and causes of
health inequality. This is vital to understand the relative roles of inevitable individual differences
in health, compared to unjust social circumstances that propel people on poor health trajectories
over which they have little or no control. The evidence on this matter is mixed and several compe-
ting explanations have been advanced.
There is much controversy about possible measurement problems. Trend analyses are quite difficult
because of changes over time in the ways social factors and health are measured. Despite such
measurement problems, so many indictors of social conditions show the same pattern of a widening
health gap that measurement problems alone seem an inadequate explanation (Leon & Walt, 2001).
Other explanations of health inequality suggest that people with poor health are “selected” into
socially disadvantageous situations, and that for others inequalities arise from individuals’ free
choices to engage in activities that carry the risk of damage to health. Both these explanations, to
the degree they are true, might reduce concern about the possibility of inequity as a fundamental
cause of health inequality. It can be argued, however, that a caring society will do its best to pro-
tect those with poor health from the risk of social disadvantage. In addition, individuals’ choices of
lifestyle are made in a social context that may truncate the range of realistic choices. The degree to
which inequalities are inequities turns on these and similar differences in viewpoint about indivi-
duals’ places in a society and the kinds of societies we create. This discourse in the health promo-
tion arena is thus part of a much larger discourse, not the least important of which is taking place
in political arenas.
Another explanation for health differences is that they are caused in part by unequal distributions
of material resources in a society and between societies, including access to health and social
services. Such inequality may or may not be stamped as being inequitable and depends on one’s
viewpoint about the kinds of interpersonal relationships members of a society should maintain
with one another. One thing is clear, however: when poor health is seen as resulting from unfair
distributions of resources, the territory of political philosophy has been entered, and that of practi-
cal politics too. This recurring theme is taken up in later in this chapter.
Though most of the research in this area is descriptive, there is mounting evidence that it is pos-
sible to intervene at several levels in pursuit of improved equality in health (Benzeval et al., 1995;
Black & Mittelmark, 1999). Whitehead’s review of the policy intervention arena reveals that at all
levels, from local to national, examples can be found of policies that assist people living in social
and economic disadvantage to enjoy better health (Benzeval et al., 1995). There is some evidence,
also, that community development and regeneration approaches can be powerful tools for impro-
ving health equity in a variety of community settings (Black & Mittelmark, 1999). The assessment of
WHO, for which improving equity in health is a high priority, is that health promoting policies are
needed not only in the health care sector but also in the economic, environmental and social sec-
tors for positive impact on the determinants of health and improved health equity (WHO, 1998c).
22 • PROMOT
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Health promotion responds to the challenge
By most accounts, the modern health promotion movement dates back only to the mid-1970s, to a
Canadian government document titled A New Perspective on the Health of Canadians (Lalonde, 1974).
Its fundamental message was that contemporary health problems of Canadians could not be solved
by the health services and called for a health promotion strategy that aimed at improving, among
other things, the health related lifestyles of all citizens. Canada began on a path of innovation in
health thinking for which it has become famous.
There were, however, other forces critically significant in the emergence of health promotion as it
is known today. As a result, concern with healthy lifestyle is balanced with regard for environmen-
tal factors that determine health status over which individuals have little or no control and that
require the collective attention of a society. Among the earliest of these forces was the International
Conference on Primary Health Care, held in Alma-Ata, USSR, in 1978. In the Declaration of Alma-Ata,
health was reaffirmed as a human right, the role of the social and economic sectors in promoting
health was illuminated and health inequalities were termed politically, socially and economically
unacceptable (WHO, 1978). This introduced a social model of health promotion that was reinforced
a little more than a decade later in the Ottawa Charter, inarguably the most significant single docu-
ment in the health promotion movement (WHO, 1986). The Ottawa Charter resulted from a confer-
ence that was the first in a series of WHO sponsored conferences that have been “spark plugs” to the
health promotion movement and about which more details are provided in the next section. The
five action strategies of the Ottawa Charter outlined in box 2.1 remain today the basic blueprint for
health promotion in many parts of the world.
Yet other forces responded to the need for holistic approaches. By the early 1990s, nongovernment
organizations, which had long been focused on the development of health education as a public
health tool, had ful y incorporated a social model of health in which health education plays a balan-
ced role with policy interventions and in which health equity is the central goal. Prime among these
organizations is the International Union for Health Promotion and Education (IUHPE), which shares the
mantle of responsibility, together with WHO and many other government organizations and NGOs, for
the further global development of health promotion as an action arena for improved public health.1
Health promotion practice
Clearly, health promotion as characterized above is as much a political and social project as a
health project, hence the reference, by both admirers and detractors, to health promotion as a
new and radical public health. It is important, however, not to over-dramatize the matter. Practical
work in policy and programme planning, implementation and evaluation dominates the day-to-
day work of health promotion practitioners. They use professional tools and approaches that are
science-based and there is a strong emphasis on the importance of quality, effectiveness and
improvement. Most front-line health promoters work in organizations whose missions determine
which health issues are the priorities: safety, food and water, infant care, drug use, exercise, mental
health, community development and so on. Each area has unique features, yet experience shows
1 This brief historical sketch excludes many key developments in health promotion’s evolution. Interested readers are
referred to several texts that provide rich perspectives on health promotion’s historical development: Baum, 1998;
Bracht, 1999; Dines & Cribb, 1993; Downie et al., 1996; Katz & Peberdy, 1997; Kelly, 1988; Raeburn & Rootman, 1998;
Tones & Tilford, 2001.
CHAPTER 2
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Box 2.1
Ottawa Charter of Health Promotion Action Strategies
■ Build healthy public policy
Health promotion goes beyond health care. It 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 their responsibilities for health.
■ Create supportive environments
The inextricable links between people and their environment constitute the basis for a
socio-ecological approach to health. Systematic assessment of the health impact of a rapi-
dly changing environment is essential and must be followed by action to ensure positive
benefit to the health of the public. The protection of the natural and built environments and
the conservation of natural resources must be addressed in any health promotion strategy.
■ Strengthen community action
Health promotion works through concrete and effective community action in setting prio-
rities, making decisions and planning strategies and implementing them to achieve better
health. At the heart of this process is the empowerment of communities, their ownership
and control of their own endeavours and destinies.
■ Develop personal skills
Health promotion supports personal and social development through providing informa-
tion and education for health and enhancing life skills. By so doing, it increases the options
available to people to exercise more control over their own health and over their environ-
ments and to make choices conducive to health.
■ Reorient health services
The responsibility for health promotion in health services is shared among individuals,
community groups, health professionals, health service institutions and governments. They
must work together towards a health care system that contributes to the pursuit of health.
Source: WHO, 1986
that successful health promotion work exhibits certain commonalities that transcend almost any
health topic. These commonalities have to do with the underlying philosophy of how to work with
people and models of good professional practice.
Two models of how health promoters seek to work with people are Tones and Tilford’s (2001)
Empowerment Model of Health Promotion and Raeburn and Rootman’s (1998) People-Centred
Model of Health Promotion. Empowerment is at the heart of both, referring both to the intention
to build people’s capacity to manage and control their own health and to a professional style of
working in which citizens are partners in change processes and senior partners as much as is
feasible. Health promoters have the intention of working with people in a participatory way, with
first-order goals set by the realities of the setting and task and second-order goals of building
capacity and control that have transferability to a wide range of future challenges and opportunities.
24 • PROMOT
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Putting this intention into practice in an ethical and effective manner requires complex professio-
nal skills in conducting recurrent cycles of programme planning, implementation and evaluation
through which the quality and effectiveness of health promotion are enhanced over time (Davies
& Macdonald, 1998; Minkler, 1997). Many practice models are available to assist health promoters,
such as Green and Kreuter’s (1999) PRECEDE–PROCEED model, intended for use in community-
wide applications and also within community settings such as workplaces and schools. A number
of other models are also in wide use (Baum, 1998; Dines & Cribb, 1993; Katz & Peberdy, 1997;
Kemm & Close, 1995; Naidoo & Wills, 2000).
There are a number of generic features common to virtually all health promotion practice models.
First, action is preceded by a considerable period of careful study of a community’s needs, resour-
ces, priorities, history and structure, and this study is done in collaboration with the community.
This style represents an underlying philosophy of “doing with” rather than “doing to”. Second, a
plan of action is agreed, the required resources are gathered, implementation begins and moni-
toring of action and change processes is undertaken. Practice models emphasize the need for
fluidity in planning and implementation to meet the demands of new or changing conditions and
constant surveillance of and reflection over practice, change processes and outcomes to inform
better quality of practice. Third, they stress the importance of evaluation and dissemination of
best practices, with attention to maintaining and improving quality as dissemination unfolds.
Politics of health promotion
Public health and health promotion professionals are naturally inclined to view their chosen fields
as being science-driven, with rational decision-making processes based on the best evidence
available about how to improve health. However, the abstract ideals of positivist science, empha-
sizing a detached, cool and sceptical approach to knowledge development, do not match parti-
cularly well with reality. Science and public health and health promotion are essentially political
activities because they are funded as work for the public good yet there is often visceral disagree-
ment about what the public’s “good” is and how it should be pursued.
Deeply held ideological positions about the individual’s proper relationship to society lie at the
heart of much of this political controversy. Specifically, the dialectic between individualism and
collectivism is reflected in debates about how the helping arts such as health promotion should
be practiced. How much risk, with what degree of certainty, for how many and for what kinds of
people should be manifest before the rights of the few are abrogated for the protection of the
many – and how few and how many? Individualists set high thresholds for mass intervention,
while collectivists argue for prudence. Individualists tend to prefer educational interventions that
permit individual citizens to “take it or leave it”; collectivists tend to prefer legislative or environ-
mental interventions, which soften the landing for everyone.
Few health promoters are purely one type; many anxious discussions about what should be done
turn on the nuances of particular situations in particular places at particular times. Under what
conditions, for example, does a health risk warrant an information campaign, a stern advisory or
a policy of forced containment? Scientific evidence can never provide a fully satisfactory answer
and political considerations enter naturally into the decision-making process.
On these matters, health promotion practitioners tend to take a dual position, advocating both
individualistic and collectivist interventions for social change, arguing that the two taken together
CHAPTER 2
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have synergistic effects. This is essentially the formula given by Tones and Tilford’s (2001, p. 43)
elegantly simple definition:
Health promotion = health education x healthy public policy
Health promotion successes
As you will read in later chapters, the generation of evidence of the effectiveness of health promo-
tion is a hard undertaking. Health promotion is social action that takes place not in the clean labo-
ratory, but out in the messy world. Controlled laboratory experiments, therefore, are never appro-
priate ways to generate evidence of health promotion’s effectiveness. Instead, consensus about
effectiveness is based on the principle of methodological triangulation that leads to a converging
interpretation of evidence of different kinds, from different places, generated by different resear-
chers. The “principle of prudence” recognises that all evidence has weaknesses, that we can never
know enough to act with certainty, but that we can in many cases be reasonably sure enough of
the quality of the existing evidence to make recommendations for action.
Of course, decisions to prioritize various policies and programmes are only partly influenced by
“the facts” and a wide range of concerns and priorities may lead to decisions that are not in con-
cert with the recommendations of professionals. Health promoters have learned that if evidence
is to make a difference, policy-makers and the people that influence them need it to be “served” in
a politically meaningful way (Mittelmark, in press). In recent years, written reviews of the evidence
of health promotion’s effectiveness have been produced as guides for policy-makers on topics
as diverse as community heart health, health promotion in schools and workplaces, oral health,
nutrition and community safety (IUHPE, 1999). Two major successes in health promotion have
been in the arenas of tobacco control and heart health promotion.
Tobacco control
The great health hazards of tobacco began to be known over 50 years ago. Today, the evidence
on a whole range of health hazards is extensive, and tobacco, as a single avoidable issue, presents
the greatest global public health risk. It is therefore most alarming that tobacco use has increased
dramatically in all parts of the world with devastating consequences for public health. The latest
estimates are that annually some 4.9 million people die of tobacco use and this figure is expected
to increase to 10 million per year within the next 20 years (WHO, 2002b).
Tobacco, despite its highly addictive properties and ubiquitous overt and subliminal marketing,
can be defeated. Effective tobacco control strategies have been developed and are undergoing
constant improvement. The challenge is to expand with efficiency and effectiveness the tobacco
control campaign to all parts of the world, especially the markets in Asia, Africa and other regions
that are so tempting to the tobacco industry.
Successful tobacco control has three main aims: prevention of onset (mainly children and youth), ces-
sation of use (mainly adults) and protection from environmental tobacco smoke (especially indoors).
These different objectives call for somewhat different approaches. Preventing smoking among
youth has had relative success, especially in school-based interventions that have been based on
appropriate theoretical frameworks (RCP, 1992). Training in skills to resist the pressures to start
smoking has been an important component.
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Methods for smoking cessation have been based on breaking the strong dependence on nicotine
as well as behavioural and social dependency. In this regard, pharmacological and behaviou-
ral interventions, and their combination, have shown a considerable degree of effectiveness
(USDHHS, 2000). At the same time, issues of cost effectiveness for public health purposes have
stimulated the development of low intensity population-wide interventions, such as education
for physicians on tobacco control for patients and innovative public campaigns like “Quit&Win”
(Korhonen et al., 1996).
Although both individual and community-based interventions have shown effectiveness, succes-
sful tobacco control requires national and international strategies (de Beyer and Brigden, 2003;
USDHHS, 2000; WHO, 1998a). Effective measures for tobacco control, especially those that have
cross-border and global dimensions, are outlined in the WHO Framework Convention on Tobacco
Control that was approved by the World Health Assembly in 2003 (WHO, 2003). This text is a firm
basis for countries to build effective tobacco control programmes, employing an array of effective
measures in the best spirit of the Ottawa Charter.
Heart health
The epidemic of cardiovascular diseases (CVD) grew rapidly in most industrialized countries after
World War II. Epidemiological studies soon identified a few strong, obviously causal, CVD risk
factors: elevated blood cholesterol, elevated blood pressure and smoking. Over time, others, such
as physical inactivity, have been added to the list. Because blood cholesterol and blood pressure
are influenced by diet, preventive efforts have focused on promoting a healthy lifestyle among
patients, people with elevated risk factors and society as a whole. This comprehensive approach is
founded on a public health strategy that has six elements (Rose, 1992). Mittelmark’s (1999a) sum-
mary of these elements is shown in box 2.2.
Box 2.2
Justifying a population approach to public health: Rose’s six principles
■ Risk factors for a large number of diseases and health problems are distributed in popu-
lations in a graded manner.
■ There is often no obvious and clinically meaningful risk factor threshold that differentia-
tes those at risk and those not at risk for a chronic disease.
■ For many chronic diseases there are many more people in a population at a relatively
moderate level of risk than at the highest levels of risk.
■ Addressing only the very high risk (clinically recognized) segment of a population mis-
ses the opportunity to improve the risk profile of the entire population.
■ Modest risk lowering among many people with moderate risk factor levels will shift the
risk factor profile of the entire population in a favourable manner.
■ A population-wide approach to intervention is thus called for, the objectives of which
should be to reduce the average level of the population’s risk through intervention for
all and to intervene intensively for those few at the highest level of risk.
Source: Mittelmark, 1999a
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It was clear that merely providing information on CVD risk factors is not enough to produce desi-
red changes. Furthermore, it was realized that although individuals with high risk benefit from
most of the risk reduction, from a public health point of view a population approach was needed.
Since the vast majority of CVD cases come from the relatively large group of people with only
modest risk factor elevations, the key to prevention is the shifting of the risk factor profile of the
whole population to a lower level (Kottke, Puska & Salonen, 1985; Rose, 1981). This can be accom-
plished only via general lifestyle changes.
Based on these considerations, community-based preventive programmes were started. The first
major one was in the Province of North Karelia in Eastern Finland (see box 2.3), where the heart
disease rates were exceptionally high (Puska et al., 1995). Very soon several others were started
– in the USA, in several European countries and elsewhere (Carleton et al., 1995; Fortmann et
al., 1995; Luepker et al., 1994). These programmes were based on the notion that risk elevating
behaviours are deeply rooted in the community and that a broad prevention approach is needed,
consistent with the principles of health promotion outlined earlier.
Box 2.3
Heart health promotion in North Karelia, Finland
The potential for health promotion as a tool for CVD prevention is illustrated well by a pro-
ject undertaken over 25 years in the province of North Karelia in Finland.
Over the life of this project, smoking has been greatly reduced and dietary habits changed
in the male population. The dietary changes led to a 17% reduction in the mean popu-
lation level of serum cholesterol between 1972 and 1997. Elevated blood pressures were
brought well under control and leisure time physical activity increased. Among women,
similar changes in dietary habits, cholesterol and blood pressure levels took place, althou-
gh smoking increased somewhat from a low level. By 1995, the annual mortality rate of
coronary heart disease in the middle-aged male population (below 65 years) had reduced
by 73% from the pre-programme years (1967–71). During recent years, the decline in CVD
mortality among men and women in North Karelia has been approximately 8% per year.
From the 1980s, favourable changes began to develop also throughout Finland. By 1995,
the annual CVD mortality among men in all of Finland had reduced by 65%. The lung can-
cer mortality had also reduced, by more than 70% in North Karelia and by nearly 60% in
all Finland.
Source: Puska et al., 1995; Puska et al., 1998
Puska (2002) reviewed the experiences of the North Karelia and other CVD programmes and
made a number of recommendations for successful heart health promotion which are outlined in
box 2.4
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Box 2.4
Recommendations for heart health promotion
■ Preventive community programmes should pay attention to the well-established princi-
ples and rules of general programme planning, implementation and evaluation.
■ Preventive community programmes should be concerned with both appropriate medi-
cal/epidemiological frameworks to select the intermediate objectives and with relevant
behavioural/social theories in designing the intervention programme.
■ Good understanding of the community (“community diagnosis”), close collaboration
with various community organizations and full participation of the people are essential
elements of successful community intervention programmes.
■ Community intervention programmes should combine well-planned media and com-
munication messages with broad-ranged community activities involving primary health
care, voluntary organizations, food industry and supermarkets, worksites, schools, local
media and so on.
■ Community intervention programmes should seek collaboration and support from both
formal community decision-makers and informal opinion leaders.
■ Successful community intervention programmes need to combine sound theoretical
frameworks with dedication, persistence and hard work.
■ A major emphasis and strength of a community intervention programme should be
attempts to change social and physical environments in the community to be more
conductive to health and healthy lifestyles.
■ Major community intervention programmes can be useful for a target community and
can also have broader impact as a national demonstration programme. For this, proper
evaluation should be carried out and results disseminated.
■ For national implications, the project should work in close contact with national health
policy-makers throughout the programme.
Source: Puska, 2002
Health promotion in low income countries
Stories of health promotion success are not isolated to regions with highly productive economies.
Indeed, health promotion is suited to the widest imaginable array of social and economic situa-
tions. An excellent illustration of this is WHO’s Healthy Cities project, which aims to disseminate
best health promotion practices to all communities around the globe. As the WHO Regional Office
for Europe describes it, the Healthy Cities approach has at its core the principle that modern
public health must tackle basic health determinants through comprehensive multisector policy,
planning and action:
The health of people living in towns and cities is strongly determined by their living and
working conditions, the quality of their physical and socio-economic environment and
the quality and accessibility of care services.
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Health is everybody’s business and most statutory and non-statutory sectors have a role
to play in health development.
Local governments are in a unique position to promote health and sustainable develo-
pment because they have direct responsibility for sectors that have major impacts on
health (such as environment, housing or social services and public health) and/or becau-
se they represent the natural conveners of locally based agencies and citizens’ groups
and community organizations.
Modern public health calls for comprehensive and systematic efforts that address health
inequalities and urban poverty; the needs of vulnerable groups; the social, economic and
environmental root causes of ill health and the positioning of health considerations in
the centre of economic, regeneration and urban development efforts (WHO, 2004).
A large number of communities in Europe, Asia, Africa, the south-west Pacific and the Americas
have successfully implemented the Healthy Cities model, as exemplified in Latin America:
Healthy municipalities in Mexico have carried out education campaigns to protect the
environment and basic sanitation, projects to improve the quality of life and physical and
social environment, and drug addiction prevention activities. They have also established
investment policies designed to improve the quality of life of special groups affected by
several types of inequities.
In Argentina, healthy municipalities have worked with NGOs, schools, governmental
and educational institutions, ecological groups and the Red Cross to improve the health
of children, adolescents and mothers. They are working to reduce malnutrition, create
micro enterprises and community vegetable gardens, and to establish broadcasting
networks to disseminate health promotion information.
Chile strengthened its health promotion efforts by creating committees for health pro-
motion in 60 per cent of its municipalities. The mayors worked to ensure political sup-
port and mobilize resources.
The creation of healthy spaces in Jamaica was expanded to include an inter-ecclesiasti-
cal grouping, expanding health services of church groups to include health promotion
(PAHO, 2004).
The global political achievement of health promotion, built on successes such as those described
above, is incontestable. Among recent evidence of this is the World Trade Organization’s (WTO) Doha
Declaration on the TRIPS Agreement and Public Health (http://www.wto.org). Signers affirmed that
the Agreement “can and should be interpreted and implemented in a manner supportive of WTO
members’ right to protect public health“. Social clauses that include health protections are becoming
commonplace in trade agreements whereas just a few years ago they were almost non-existent.
The nature of evidence of health promotion’s effectiveness
From the examples given, it is obvious that evidence of health promotion’s effectiveness must
be derived from community-based research. Although such real world research is a very com-
plex undertaking, it is possible to develop a body of dependable knowledge about what works
and what does not. Signifying the importance of this, a resolution to employ an evidence-based
approach to health promotion was adopted by the 1998 World Health Assembly.
30 • PROMOT
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There are two focal issues with regard to evidence of health promotion’s effectiveness: the
strength of evidence and its implications for research, practice and policy development.
The strength of evidence is influenced by the design of interventions and related methodological
issues such as the validity of indicators, the efficacy of the interventions and the effectiveness of
efforts to minimize biases arising from the context in which the interventions are implemented.
Tang, Ehsani and McQueen (2003) provide a useful strength-of-evidence typology that has refe-
rence to three elements of scientific enquiry: falsifiability, predictability and repeatability. Four
types of evidence are the result:
■ Type A: What works is known, how it works is known and repeatability is universal.
■ Type B: What works is known, how it works is known but repeatability is limited.
■ Type C: What works is known, how it works is not known but repeatability is universal.
■ Type D: What works is known, how it works is not known and repeatability is also limited.
Though Type A evidence is the most reliable, it is very difficult to develop in health promotion
research, which operates in an environment where numerous cultural, social, economic and poli-
tical factors interact. Moreover, behaviour and policy change are two concerns of much health
promotion activity. When the behaviour of individuals, organizations and political processes are
the focus, complexities are involved that rarely resolve sufficiently to produce Type A evidence.
Also, the expertise of practitioners determines to a great extent the success of an intervention,
regardless of its earlier successes.
Health promotion strives therefore for Type B evidence, which has important implications for
practice. Because it is unlikely that the effectiveness of any health promotion intervention can
be guaranteed beforehand, there is a strong need for evaluation research to be combined with
health promotion practice. In this regard, the WHO European Working Group on Health Promotion
Evaluation (1998) has published the seven recommendations for policy-makers outlined in box 2.5.
The nature of evidence in the health promotion arena also carries implications for formal research.
The complexity of health promotion interventions precludes total reliance on traditional quanti-
tative public health research methods and necessitates the use as well of research methods from
social sciences. The use of qualitative methods to gain insight into the “anatomy and physiology“
of complex interventions can pay dividends in efforts to achieve greater transferability of pro-
grammes from setting to setting.
Innovative funding strategies
Health promotion is a cost-effective way to improve public health and quality of life and reduce
the economic costs of illness. Governments in general and health and welfare ministries may be
aware of this but national health budgets are targeted inevitably for care and cure services. Thus,
while health promotion is cost-effective, many countries are in need of new resources to promote
health and tackle priority health problems. Secure and long-term funding for health promotion is
essential and innovative funding solutions are urgently needed.
One such solution is the use of earmarked tax income to fund national health promotion founda-
tions. The existence and growth of the International Network of Health Promotion Foundations
demonstrates the viability of this innovative way of mobilizing resources for promoting health.
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Box 2.5
Health promotion evaluation: recommendations for policy-makers
■ Encourage the adoption of participatory approaches to evaluation that provide
meaningful opportunities for involvement by all of those with a direct interest in
health promotion initiatives.
■ Require that a minimum of 10% of the total financial resources for a health promotion
initiative be allocated to evaluation.
■ Ensure that a mixture of process and outcome information is used to evaluate all health
promotion initiatives.
■ Support the use of multiple methods to evaluate health promotion initiatives.
■ Support further research into the development of appropriate approaches to evaluating
health promotion initiatives.
■ Support the establishment of a training and education infrastructure to develop exper-
tise in the evaluation of health promotion initiatives.
■ Create and support opportunities for sharing information on evaluation methods used
in health promotion through conferences, workshops, networks and other means.
Source: WHO European Working Group on Health Promotion Evaluation, 1998
The founding members of the Network are Fonds Gesundes Österreich, Health Promotion
Switzerland, Healthway, Hungarian 21 Foundation, Korea Health Promotion Fund, ThaiHealth and
VicHealth of Australia. These foundations have the ability and the mission to support research
and innovation and the strengthening of health promotion capacities in the health sector and
beyond. They have already established a record of supporting health promotion in sectors such as
education, sport, the arts, the environment and commerce in developed and developing
countries.
A mechanism for financing such foundations is a dedicated tax (hypothecation) on tobacco. The
adoption of the WHO’s Framework Convention on Tobacco Control at the 56th World Health
Assembly in May 2003 provides renewed impetus for examining innovative financing models for
sustained health promotion actions. It reaffirms the advantages of imposing a levy on tobacco
products, resulting not only in extra funds for health promotion actions but also lower tobacco
consumption. There do not appear to be any documented cases of reduced revenues for govern-
ment following tobacco taxes increases. There is therefore plenty of leeway for governments to
increase taxes on tobacco – it is popular with the public and all of society benefits through finan-
cing the work of health promotion foundations.
In addition to the setting up of health promotion foundations, the involvement of public social
insurance programmes and the private health insurance industry can have fortuitous financial
outcomes for health promotion. Social insurance and health promotion share a common value
base, with a strong commitment to protection, equity and solidarity. Over the years, the interde-
pendence between health and social and economic development has been affirmed. The high
and increasing cost of cure and care, and the increasing burden on social insurance provisions,
contrasts with the lower costs of prevention and promotion.
32 • PROMOT
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In recent years, private health funds have been undertaking measures to encourage their mem-
bers to maintain or promote health. For example, they offer financial incentives to members who
take actions to stay healthy by providing rebates for health promoting activities such as t’ai chi
classes or jogging shoes. They may also provide rebates for members to seek prompt and appro-
priate care when they feel unwell or charge non-smoking members a lower premium.
These examples of innovation show that financing models for health promotion can go well
beyond traditional models that have depended on national, regional and local government spen-
ding. This is an underdeveloped area in health promotion and one that holds much promise for
expanding the resource base so that health promotion’s full potential might be realized.
Conclusion
It is clear that simply improving and extending formal health services cannot alone solve con-
temporary health challenges. A comprehensive approach to health promotion is needed. Action
must take place in the health and social sectors; however, this is not sufficient. Real progress can
be made only if action is broad-based. Society at all levels, including individual citizens, families
and the institutions of education, government, business and law must contribute actively if health
promotion action is to be truly effective.
That is why, ideally, health promotion takes place at many levels. Governments and businesses
create policies and practices that support health, institutions from the local to the international
levels create supportive environments, communities increase their capacity to support healthful
living, individuals develop skills that promote their own health and the health services include
health promotion among their priorities.
Perhaps no image has been called upon more often to provide a portrait of health promotion’s
aspirations than that of many people being swept downstream by a mighty river current, shou-
ting for help and clearly near drowning. All rescue attempts must be made, of course, but people
need to be kept safe from falling in the river in the first place, and need to learn self-rescue skills
just in case. Similarly, health promotion calls for the orchestration of multiple strategies for health,
including the assurance of equitable access to health care, the provision of a physical and social
environment that supports health and the opportunity to have control over one’s own health.
There is much that mental health promotion can learn from the experiences of health promotion.
The key lessons are outlined in box 2.6. The following chapters describe the concepts, emerging
evidence, practice and policy associated with the promotion of positive mental health.
Box 2.6
Key lessons from health promotion relevant to mental health
■ Combine individual and structural strategies with advocacy.
■ Work with an array of public and private sectors, not just the health sector.
■ Emphasize positive mental health as well as prevention and treatment.
■ Use professional tools for programme planning, implementation and evaluation.
■ Strive to increase people’s control over their own mental health.
■ Avoid over-dependence on “expert-driven” approaches.
■ Adopt a capacity building approach with individuals and communities.
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based health promotion: recollections, reflections
November 2004.
and reconsiderations. Journal of Epidemiology and
WHO (2004). Healthy cities and urban governance.
Community Health, 57:841–843.
Available at: http://www.who.dk/healthy-cities/.
RCP (1992). Smoking and the young. A report of a working
Accessed 24 Nov 2004.
party of The Royal College of Physicians. London, The
WHO European Working Group on Health Promotion
Royal College of Physicians of London.
Evaluation (1998). Health promotion evaluation:
Tones K, Tilford S (2001). Health promotion: effectiveness,
recommendation to policy-makers. Copenhagen, World
efficiency and equity. Cheltenham, Nelson Thornes Ltd.
Health Organization (EUR/ICP/IVST).
Chapter 3
Evolution of Our Understanding of Positive Mental Health
Vivianne Kovess-Masfety, Michael Murray, Oye Gureje
Introduction
Over the past 30 years, research has contributed to an understanding of what is meant by the
term “mental health” although this understanding has been constrained by the fact that much of
the evidence that is accessible widely is recorded in the English language and obtained in deve-
loped countries. Mental health has been variously conceptualized as a positive emotion (affect),
such as feelings of happiness; as a personality trait inclusive of the psychological resources of
self-esteem and mastery; and as resilience, which is the capacity to cope with adversity. Various
aspects and models of mental health contribute to our understanding of what is meant by posi-
tive mental health.
As discussed in Chapters 1 and 2, WHO defines health as being a complete state of physical, psy-
chological and social well-being. Jahoda (1958) elaborated on this by separating mental health
into three domains. First, mental health involves “self-realization” in that individuals are allowed to
fully exploit their potential. Second, mental health includes “a sense of mastery” by the individual
over their environment and, thirdly, positive mental health means “autonomy”, as in individuals
having the ability to identify, confront and solve problems. Others, like Murphy (1978), argued
that these ideas were culturally based and influenced by the North American culture that favours
individualism and so not reflective of many other cultures where the group may be as important
as the individual. Murphy also warned that a high level of aspiration might even threaten the
mental health of individuals. For example, he found that women living in an affluent suburb of
Montreal were presenting with more negative symptoms than those who were living in the inner
city, a rather deprived area. He concluded that suburban women had aspirations that they could
not fulfil while inner city women were proud to contribute to the survival of their family members.
The definition of mental health is therefore clearly influenced by the culture that defines it and
has different meanings depending on setting, culture and socioeconomic and political influences.
This chapter gives an overview of the history of the development of these concepts of positive
mental health and the closely related concept of “quality of life”.
Concepts of mental health
Positive affect
In the 1960s, Bradburn, building on the earlier conceptual work of Gurin, viewed psychological
well-being as the balance between two independent dimensions which he termed positive and
negative affect. In his view, an individual will experience a high degree of psychological well-
being if positive affect dominates. Likewise, a low degree of well-being is characterized by nega-
tive affect (Bradburn, 1969).
Bradburn proposed a scale to measure the positive and negative facets of psychological well-
being in community surveys. This 10-item Bradburn Scale has been used in a number of large
health surveys including the Alameda County Study and the Canadian Health Survey. Many
questions have been raised concerning the scale, however. For example, some of the items have
been criticized for being linked too strongly to specific situations or being difficult to respond to.
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The meaning of the term “positive affect” was also disputed by Beiser (1974), who proposed it be
renamed “pleasurable involvement”. Nevertheless, according to McDowell and Praught (1982),
Bradburn’s detailed conceptual formulation of the construct of well-being represents a milestone
in attempts to measure it.
A number of other instruments have been used to assess positive affect. One example is the
General Well-Being Scale (GWBS), which was created by Dupuy for the USA National Center for
Health and Statistics and used in major studies such as the Canadian Health Survey and the later
Quebec Health Survey. The Quebec Health Survey found that 75% of the adult population had a
high or very high score on the GWBS independently of their age. Scores were affected, however,
by gender (78% of men scored high or very high compared with 70% of women), matrimonial
state (married people scored higher than divorced, widowed or single people), income, life events
and physical handicap. These findings were very similar to those obtained from the 1978 National
Canadian Health Survey.
A personality trait
Psychological resources such as self-esteem, mastery and sense of coherence fall under this
domain and a number of scales have been developed to assess each of these. The inclination to
be optimistic or pessimistic is also included in this sphere and instruments specifically designed to
measure these have also been constructed. Three views of mental health as a personality trait are
discussed here.
Antonovsky: the salutogenic approach
Antonovsky (1979) proposed the “salutogenic approach”, which focused on coping rather than
stressors and “salutory” factors rather than risk factors. He hypothesized that a sense of coherence,
which is the degree to which a person views their own experience as comprehensible, manageable
and meaningful, is a major explanatory construct and contributes to health. He rejected the
notion that stressors always have pathogenic consequences, since people have to survive tran-
sitions and stress in their daily lives. Rather, he viewed them as having the potential for positive,
neutral or negative consequences. It then became important to understand what the characteris-
tics of those people who cope successfully are and the conditions that facilitate such coping.
As outlined further in Chapter 4, Antonovsky did not think that sense of coherence was a “buf-
fering“ factor in the way that self-esteem, social support, high social class or cultural stability
are sometimes thought to be. Rather, these buffering factors had an impact on health because
of their influence on building a sense of coherence. According to his observations, the sense of
coherence was rather stable, at least in adult life, but could change under some dramatic expe-
riences. He proposed that sense of coherence should be considered as a dispositional orientation
that should be distinguished from personality traits. In his view, the personality traits fixed a beha-
vioural tendency whereas sense of coherence implied a varying capacity to respond to stressors
flexibly. A person with a high sense of coherence will select the coping strategy most appropriate
to the stressor they are being confronted with.
Antonovsky also considered that the sense of coherence was culture-free whereas sense of mas-
tery, hardiness and locus of control were culture-bound since they are valued in societies that
favour individual control over environment. He considered that these latter constructs were based
on the assumption that these were the responses likely to lead to the resolution of problems that
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confront individuals. Although this may be the case in middle-class America, it may be the reverse
in other societies where different patterns are favoured.
The Canadian National Health Survey, which began in 1994–95, collects information about the
health of the Canadian population every two years and uses sense of coherence as a positive
mental health measure. At the first follow-up, men and women who scored low on the sense of
coherence index in cycle 1 had twice the likelihood of experiencing a depressive episode prior to
their cycle 2 interview. Decrease in emotional support and low sense of coherence were the two
indicators associated with depression, the risk being about twice that of those without these cha-
racteristics. This was true for both men and women (Swain, Catlin & Beaudet, 1999).
Optimism/pessimism
In 1985, Scheier and Carver proposed the optimism/pessimism dimension, which they described
as a tendency to believe that one will generally experience either good or bad outcomes in life.
Working on the effect of expectations on actions and affects, they discovered that global expec-
tancies were relatively stable across time and context and formed the basis of an important cha-
racteristic of personality. In order to measure this, they developed the Life Orientation Test (LOT).
The LOT has been used in many studies to evaluate the influence of optimistic expectations on
diverse outcomes, including those associated with health. Although some of these studies are
controversial, most conclude that optimism is beneficial for psychological and physical health.
Better coping with the situation may be the mechanism that explains the benefit to the psycholo-
gical and physical state of the optimists. Carver, Scheier and Weintraub (1989) examined this point
in an undergraduate population and found that optimists were more active copers, less avoidant
and more likely to engage in positive health practices.
Leighton and Murphy
Leighton and Murphy (1987) proposed that non-symptomatic individuals from general popula-
tion surveys could be classified according their personality types and their coping strategies into
three groups:
■ “cabbage”: individuals who have low aspiration and achievement;
■ “Elizabethan”: individuals who have an intense emotional life characterised by periods of
intense happiness and unhappiness; and
■ “hermit crab”: individuals who have built up a shell that protects them against stress emana-
ting from family, social network and professional life. People in this group have a high risk of
breakdown when the protective barrier fails.
Their classification brought to light that individuals who do not exhibit symptoms of poor mental
health might nevertheless be using coping strategies that are unhealthy and that could put them
at risk for mental illness.
Resilience
Rutter’s definition
The capacity to cope with adversity and to avoid breakdown or diverse health problems when
confronted by important stressors differs tremendously among individuals. This phenomenon has
been observed and studied by many researchers following quite diverse theories.
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As Rutter (1985, p. 598) remarked: “Even with the most severe stressors and most glaring difficul-
ties more than half of … children will not succumb”. This view was supported by Paykel’s work on
life events, which found that most people did not become depressed in spite of stressful expe-
riences (in Rutter, 1985). More recently, Cederblad et al. (1995) followed up 148 people selected
from an earlier study (the Lundby study) as being at risk of developing mental disorders. They
found that the great majority of them were doing well.
During the 1970s, some children had been described as “invulnerable”, meaning that they were
thought to be so constitutionally tough that they could not give way under the pressures of stress
and adversity. Rutter considered that this notion was wrongheaded in at least three aspects: in
his view, the resistance to stress is relative, not absolute; the basis of the resistance is both envi-
ronmental and constitutional; and the degree of resistance is not a fixed quality. He proposed the
concept of “resilience” instead of this absolute notion of invulnerability, defining resilience as the
capacity to cope with adversity and to avoid breakdown or diverse health problems when con-
fronted with stressors. A number of factors have been found to increase a person’s resilience.
The role of protective factors and cognition
Influences that modify, ameliorate or alter a person’s response to some environmental hazard that
predisposes to a maladaptive outcome are called protective factors. Rutter warned that protective
factors do not always exist as a result of pleasurable happenings. There is evidence that acute
stress in early life, for example, leads to changes that enhance an animal’s resistance to later stress
experiences; this effect – referred to as the “steeling effect” of stressors – has also been described
in human parachute jumpers. Protective factors may have no detectable effect in the absence of
stressors and may concern a quality of the individual rather than an experience (e.g. girls are less
vulnerable than boys to many adversities). Possessing protective factors may also not always be
a pleasant and desirable trait: people who appear the most immune to stress also appear to be
more self-centred, shallow and labile in their relationships (Rutter, 1985).
Interactive processes can have an important impact on the development of resilience. For exam-
ple, it seems that having a working mother is not a risk as such but rather that the perceived loss
of the mother through her getting a job for the first time can become a stressor if it coincides with
the loss of a father (e.g. through a divorce). Likewise, early parental loss predisposes to depression
only if it leads to inadequate care and to lack of emotional stability in the family. This lack of care
can be influential because it sets in motion a chain of events that in combination predispose to
later disorder. Each of these links in the chain is subject to further influences at the time.
Parental mental health disorder is a particular stress that appears to predict child emotional
disorders through associated family discord, especially if the child is involved in the conflict. The
presence of a mentally healthy spouse, the maintenance of good relationships with one parent
and restoration of harmony have been found to be protective factors. Some child characteristics,
such as an easy temperament or being of the opposite sex to the ill parent also have protective
effects. Some schizophrenic family studies suggest that if the stresses are manageable and of a
kind that give rise to rewarding tasks, the health of the children is preserved and resistance to
stress enhanced. Helping others may lead to heightened morale and the acquisition of problem-
solving skills. However, some traits that are positive in one situation can be negative in another.
For example, compliance that is adaptive in some settings would not be in a situation where child
abuse is occurring.
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Studies on the effects of multiple social adversities on children have established the value of paren-
tal supervision in preventing their children’s involvement in activities and social groups likely to
predispose to delinquency. In a longitudinal study, non-delinquent outcomes were also predicted
by positive parent–child relationships and good support from relatives, especially grandparents
(Werner & Smith, 1982, in Rutter, 1985). Resilience was associated with a good-natured disposition,
a positive self-concept and taking responsibility for younger siblings. It seemed that coping succes-
sfully, accepting productive roles and having close family ties led to personality strengths in such
circumstances (Elder 1974, 1979, in Rutter, 1985).
The importance of appraisal of life situation raises the issue of cognitive sets. A person’s cognitive
set (a sense of self-esteem, self-efficacy) can make successful coping more likely. Even though
some coping mechanisms may be better than others, the existence of at least some coping pro-
cesses is essential and their absence leads to helplessness. Helplessness in turn increases the like-
lihood that one adversity will lead to another. Longitudinal studies show that cognitive set is not
a fixed personality trait but may change with altered circumstances. Resilience is characterised by
some sort of action with a definite aim in mind and a strategy to achieve the chosen objective. It
involves a sense of self-esteem and self-confidence, a belief in one’s own self-efficacy, an ability to
deal with change and to adapt, and a repertoire of social problem-solving skills. Two factors that
appear to foster such a cognitive set are secure and stable relationships and experience of success
and achievement. Neither needs to be generalized but they do have to happen in some aspect of
the person’s life. Distancing yourself from an unalterably bad situation is also a protective factor.
These findings may be relevant to prevention promotion actions for children in difficult situations.
A psychoanalytic approach
Fajardo (1991) noted that many psychoanalysts have treated patients who have surprised or puzz-
led them in their response to treatment: some who in spite of favourable history and disposition
have not made use of the treatment to change or improve and others who have unexpectedly
done very well. It was generally concluded that there were dynamic factors that were not reco-
gnized or that there was something constitutional in the patient that was responsible. Fajardo
felt that constitutional explanations tended to be discredited among psychoanalysts, however,
mainly because there was a limited number of ways to think about constitution in psychoanalysis
and because such an explanation seemed static and alien in light of the contemporary emphasis
on psychoanalysis as process. Among psychoanalytic ideas about constitution is Sigmund Freud’s
original (1916) notion of the individual variability of drive strength. A second idea, also from Freud
(Totem and Taboo and Civilisation and Its Discontents), is that constitution determines certain con-
tents of the unconscious that are universal but which have some individual variation. This view
was expanded by Jung and later by Melanie Klein. Constitutional influences have also been thou-
ght to operate in development through the biological unfolding and maturation of cognitive and
motoric capacities, an idea held by Anna Freud, Hartmann and the ego psychologists.
Some psychoanalytic concepts can be used to explain resilience and adaptive mechanisms and
bridge the various theories. For example, coping could be defined as “the adaptive application of
defence mechanisms”. This views coping as conscious while defence mechanisms are subcons-
cious (Rutter, 1985). Psychoanalysis would suggest there are no good or bad coping mechanisms
but rather distinguish between short and long-term coping mechanisms; the ultimate goal being
a genuine integration of experiences which should make sense to the subject.
Psychoanalytic theory proposes positive mental health as the capacity for a subject to use their
inside energy for realization in emotional, intellectual and sexual domains. The quality of resi-
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lience resides in how people deal with life changes and what they do with situations. This implies
a varying capacity to respond to stessors flexibly. All this is influenced by early life experiences,
by what happens during childhood and adolescence and by circumstances in adult life. None
of these is determinative in itself but each may serve to create a chain of indirect linkages that
fosters escape from adversity. Effective prevention and therapeutic interventions could have an
influence at all of these life stages.
A transcultural approach
The balance between internal and external resources for fostering resilience was also discussed
from the transcultural angle by Rousseau et al. (1998) in their study of unaccompanied minors
from Somalia. They agreed with Rutter’s view that resilience is not a fixed attribute but a balance
between the mechanisms and processes of protection and vulnerability. They also emphasized
the cultural basis to the construction of resilience and protection. Unaccompanied refugee chil-
dren are traditionally considered to have a high risk of mental ill-health. Using ethnographic data,
Rousseau et al. showed how young Somali refugees are protected, however, by the meaning attri-
buted to separation within their nomadic culture and by the establishment of continuity through
lineage and age group structures.
This work, embedded in clinical experience, shows the importance of considering the cultural
background of immigrant people in order to be able to respect their own resilience mechanisms
which otherwise may be destroyed by applying rules of the dominant culture to protect them.
This view has to be especially underlined in a worldwide review of mental health promotion.
Possible negative aspects
Wolff (1995) points out that there can be a price to be paid for negotiating salient developmen-
tal tasks in spite of major stressors. She refers to Luthar’s work, which found social competence
among highly stressed but resilient adolescents was accompanied by increased levels of depres-
sion, anxiety and self-criticism.
Although Wolff acknowledges that behavioural deviance and educational problems have more
ominous consequences than internal suffering, she believes that we have to judge resilience in
terms of both externalizing and internalizing difficulties. She proposes that resilience be defined
as “the process of, capacity for or outcome of successful adaptation despite challenging or threa-
tening circumstances”.
Wolff also identifies the “St Matthew effect”: children with the fewest assets are often those most
likely to be challenged by adverse events. In other words, chronic adversity and stressful events in
children’s lives correlate with low social status and with inadequate parenting. She proposes that
interventions should operate though proximal rather than distal variables. This means helping
families and children to cope with their environments rather than relying on attempts to enhance
protective factors or remove the risk factors themselves through, for example, global employment
or housing policies. Nevertheless, Wolff does advocate well-designed social interventions as well
as raising political awareness of the impact of housing and employment on childhood resilience.
Citing Felsman and Vaillant’s follow-up study of a delinquent boys cohort, she states that the
political and socioeconomic climate of the era into which one is born can affect one’s resilience to
adversity. She also points to the long-lasting benefits of targeted preschool education and other
educational provisions that are well established as fostering resilience.
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Quality of life
Quality of life has to be added to any conceptual framework of positive mental health. Early
attempts to bring “quality of life” and “social well-being” to a discussion about the value of popu-
lation life were made not by health practitioners but by social scientists and philosophers in the
1960s and 1970s (Campbell, Converse & Rodgers, 1976; Erickson, 1974; Katschnig, 1997). Although
the WHO 1948 definition of health was broad and foreshadowed a conceptualization of health
that went beyond physiological, anatomical or chemical dimensions (WHO, 1948), measures of
health at both population and individual levels remained relatively narrow until a few decades
ago. Traditional statistics on births, deaths, life expectancy and survival periods, among others,
remained the accepted indices of health and outcome until questions about their adequacy
began to be raised by consumers and human rights advocates. Part of the motivation for this was
the need to capture indices of social and economic well-being and to address the importance that
consumers attach to things like autonomy, choice, life satisfaction and self-actualization. This was
eloquently expressed by Elkinton when, drawing on Francis Bacon’s view that “the office of medi-
cine is but to tune this curious harp of man’s body and reduce it to harmony”, he asked: “What
is the harmony within a man, and between a man and his world – quality of life – to which the
patient, the physician and society aspires?” (Elkinton, 1966).
Given the broad nature of the construct of quality of life, a need soon arose to define a more
specific range of issues relating directly to health that were distinct from those that were not per-
ceived as being directly related to health. In defining health-related quality of life, therefore, issues
such as housing, income, freedom and social support have traditionally been excluded (Patrick
& Erickson, 1993). The concept of health-related quality of life found early application in physical
medicine, in particular in areas such as oncology and arthritis. The concept had a late entry into
psychiatry, however, even though the assessment of non-disease aspects of patients, such as
impairments, disabilities, social functioning and satisfaction, has had a long tradition in the field
(Katschnig, 1983, 1997).
For psychiatry in particular, and mental health in general, the concept of quality of life has gene-
rated controversy (Barry, Crosby & Bogg, 1993; Gill & Feinstein, 1994; Hunt, 1997). Part of this
controversy relates to the overlap between a number of the dimensions included in quality of life
assessment and traditional psychopathological domains that are generally regarded as indicators
of mental illness. The measurement redundancy raises the question of whether assessing quality
of life in people with mental disorders adds anything of value to the psychiatric evaluation. The
conceptualization of health-related quality of life as excluding things such as housing, social sup-
port and autonomy is also contentious in psychiatry since those issues are of direct relevance to
mental health (Oliver et al., 1996). Also, the emphasis placed on subjective reports of well-being
in quality of life assessments seems tautological in mental health where subjective experience is
a core feature of the exploration of health or ill-health. Indeed, reliance on subjective report as
a way of evaluating quality of life has other important limitations in psychiatry where patients’
reports of the quality of their lives may depart significantly from what may be predicted by objec-
tive or social norms (Atkinson, Zibin & Chuang, 1997). A discussion of what may produce this
counterintuitive evaluation of one’s quality of life has been offered by Katschnig (1997), who iden-
tified several components of what he termed “psychopathological fallacies” as possible causes.
In spite of these limitations, few will question the relevance of quality of life assessment to a
discussion of mental health issues today. For example, the centrality of the need for autonomy,
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human rights and freedom from the experience of stigma to an informed concept of mental
health makes its consideration very relevant.
The importance attached to evaluating quality of life is reflected in the range and number of tools
that have been developed to measure it within the mental health field in the past two decades
(Lehman, 1996). Of particular importance is the focus of many tools not only on negative factors
that may impair quality of life but also on positive factors that may enhance general well-being.
The definition of quality of life provided by WHO (WHOQOL Group, 1995) as “an individual’s per-
ception of his/her position in life in the context of the culture and value systems in which he/she
lives, and in relation to his/her goals, expectations, standards and concerns” reflects a broad view
of well-being encompassing social indicators, happiness and health status. It is a definition to
which many in the field of mental health can relate as it gives voice to the hitherto voiceless men-
tally ill and emphasizes the interaction between personal and environmental factors in health.
It also reflects the utility of the concept of quality of life for describing health, including mental
health, in terms that go beyond the presence or absence of symptoms and signs of disorders and
captures positive aspects of coping, resilience, satisfaction and autonomy, among others.
The mental hygiene movement
Early in the 20th century the mental hygiene movement was successful in putting mental
health promotion on the international agenda. During the 1920s and 30s there was subs-
tantial activity to stimulate “the integration of mental health principles into the practices
of social work, nursing, public health administration, education, industry and govern-
ment” (Beers, 1935, p. 327), views that are still very prevalent today. Despite the efforts of
the pioneers, the movement initially failed to attract sufficient interest from these wider
groups. It was not until the 1970s that the first studies into the value of integrating men-
tal health principles into practice in other fields were initiated. During the past 30 years,
however, some 2000 outcome studies have been published on promotion, prevention and
related fields (Hosman, 2000).
Mental health promotion and the prevention of mental disorders
Although mental health promotion and the prevention of mental disorders have overlap-
ping and related properties, they are derived from different conceptual principles and fra-
meworks. Mental health promotion focuses on positive mental health and, in the main, on
the building of competences, resources and strengths, whereas the prevention of mental
disorders concerns itself primarily with specific disorders and aims to reduce the inciden-
ce, prevalence or seriousness of targeted problems (Barry, 2001). Mental health promotion
is not primarily about the prevention of mental disorders but is a desirable activity in itself
and has a major contribution to make to promoting personal and social development
(Orley & Birrell Weisen, 1998). It can also assist in the prevention of a whole range of beha-
viourally-related diseases, for example by preventing smoking and therefore lung cancer
(Botvin, Eng & Williams, 1980; Errecart et al., 1991) or reducing unprotected sex and conse-
quently teenage pregnancies and AIDS (McLean 1994; Gold & Kelly, 1991).
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A competence enhancement approach to mental health promotion
The competence enhancement approach promotes the goal of enhancing potential rather
than emphasizing the prevention of mental disorders. Mental health is conceptualized in
positive terms and mental health promotion programmes build upon strengths, abilities
and feelings of efficacy (Weissberg, Caplan & Harwood, 1991). The competency model
builds on the lifespan developmental approach (Cowen, 1991) and the ecology perspecti-
ve of community psychology, including the structure of social power and support (Orford,
1992). It assumes that the individual becomes more capable as their psychological well-
being improves. Evidence supports the view that competence enhancement programmes
have the potential to strongly influence multiple positive outcomes across personal and
social health domains (Lazar et al., 1982; Price et al., 1988; Schweinhart & Weikart, 1988).
Conclusion
Positive mental health is a huge domain that has many aspects. Many theories and concepts
are pertinent to it and consequently many indicators could and have been used to measure it.
The public health consequences of positive mental health are many and nearly all public health
measures have effects on mental health.
The various theories and concepts represented in the literature about positive mental health
and quality of life add to the understanding of the ideas and how they may be used to promote
mental health. Each of these perspectives can be used to derive approaches to promoting men-
tal health in settings and populations around the world. Understanding the evolution of these
approaches and their application to promoting mental health, at least in certain parts of the
world, is an important prelude to taking the next steps. The international community is now
encouraging each country to assess and consolidate the evidence for promoting mental health
and to consider new or adapted ways of promoting mental health in policy and practice across
many aspects of community life.
There is now compelling evidence for the need to promote positive mental health through inter-
ventions that promote competence and psychological strengths. Scientific methodologies in
promotion are increasingly sophisticated and the results from high-quality research trials are as
credible as those in other areas of biomedical and psychosocial science. There is a growing reco-
gnition that promotion does work. Although some interventions have been proven to be effective
in some settings there is still much to do to gain a better understanding of the mechanisms that
help people to develop positive mental health and to assess how these may vary across cultures.
Among these, a better knowledge of ways to enhance individual capacities to cope with adversi-
ties appears promising. This should not conflict with the necessity of decreasing social stressors
by raising political awareness of their consequences.
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Chapter 4
The Intrinsic Value of Mental Health
Ville Lehtinen, Agustin Ozamiz, Lynn Underwood, Mitchell Weiss
Introduction
Mental health and well-being are issues of everyday life: in families, in schools, on streets and in
workplaces. Therefore they should be of interest to every citizen, to every politician and to every
employee as well as to all sectors of society. This includes sectors such as education, employment,
environment, housing and transport as well as health and social welfare. Many civil society orga-
nizations have taken an active role in the field of mental health. Mental health, social integration
and productivity are linked: well-functioning groups, societies, organizations and workplaces are
not only healthier but also more effective and productive. However, the main reason for promo-
ting good mental health is its great intrinsic value.
There exist many misconceptions among the general public, politicians and even professionals
regarding the concept of mental health. This is due to the fact that mental health is in many
ways undervalued in our societies. The concept is often confused with severe mental disorders
and associated with societal stigma and negative attitudes. It is also often the case that curative
medicine focusing on health problems attracts more attention than public health questions of
prevention and, even more so, of promotion. The positive value of mental health, contributing to
our well-being, quality of life and creativity as well as to social capital, is not always seen.
Mental health is an indivisible part of general health and well-being. In principle, mental health
refers to the characteristics of individuals, but we can also speak about the mental health of fami-
lies, groups, communities and even societies. Mental health as a concept reflects the equilibrium
between the individual and the environment in a broad sense. This is reflected in figure 4.1 which
shows the so-called “structural” model of mental health. Here the determinants are grouped into
four categories: individual factors and experiences, social support and other social interactions,
societal structures and resources, and cultural values (Lahtinen et al., 1999). As the arrows in the
figure show, the influences between mental health and its determinants are reciprocal. Thus,
one can also speak about a “systemic” model of mental health. Furthermore, physical and mental
health are also tightly connected (as is discussed in detail in Chapter 11).
Spiritual or religious values also contribute to mental health. Although they can overlap with
cultural values, religious or spiritual values are often not the same as those of the specific culture.
They can have both positive and negative effects on mental health in the same way as other
determinants. An example of a positive spiritual value might be the assumption that each indivi-
dual is of great worth apart from their functional capacity.
Mental health can be described in two dimensions:
■ Positive mental health considers mental health as a resource. It is essential to subjective well-
being and to our ability to perceive, comprehend and interpret our surroundings, to adapt to
them or to change them if necessary, and to communicate with each other and have succes-
sful social interactions. Healthy human abilities and functions enable us to experience life as
meaningful; helping us to be, among other things, creative and productive members of the
society.
■ Mental ill-health is about mental disorders, symptoms and problems. Mental disorders are
defined in the current diagnostic classifications mainly by the existence of symptoms. Mental
symptoms and problems also exist without the criteria for clinical disorders being met. These
CHAPTER 4 • THE INTRINSIC VALUE OF MENTAL HEALTH • 47
subclinical conditions are often a consequence of persistent or temporary distress. They, too,
can be a marked burden to individuals, families and societies (Lavikainen et al., 2001).
In theory, the aim of mental health promotion is to increase and enhance positive mental health
and that of mental ill-health prevention is to protect individuals from mental health problems. In
practice, however, many activities have both promotive and preventive effects.
Conceptualization and measurement of values
As already stated, mental health is of intrinsic value. Intrinsic value can be attributed to various
qualities in the abstract by the society, culture or philosophical or religious framework. This
identification of values and acting on those values is influenced by the cultural setting and often
reflects cultural norms. Philosophers and theologians have often stated that some values exist
even apart from societal norms and need to be affirmed in the way we live our lives.
A value that most consider important is human life itself. But even something as basic as this has
qualifiers. An example of this is the weighing of the value of many against the value of enhan-
ced life quality for particular individuals. Having the assumption that a value is important to
the society as a whole can influence legal and government structures and research and health
care choices. Epidemiological studies have moved beyond mortality measures to assess broader
outcomes, to look at quality of life and functional status as outcome measures. This reflects a
judgement of what is of value. Statements of values by religious and philosophical leaders past
and present are often taken as a guide to what is intended to be of value and can move people
beyond merely the summation of collective contentment. One can often pragmatically assess
what a society or culture finds of value by examining various actions, rewards and governmental-
legal structures.
Intrinsic value can also be assessed in a personal way by each individual. Questions that address this
are ones such as, “What is most important to me personally? What makes life worth living?” A variety
of scales have been constructed in the social sciences and psychology to measure this concept. In
behavioural economics, value is often measured in terms of what you would be willing to exchan-
ge for something, either imaginatively in a questionnaire or in an experimental setting.
The WHO Quality of Life Measurement Instrument (WHOQOL Group, 1998) is an excellent exam-
ple of a cross-cultural assessment of what makes life worth living and therefore captures values.
Whereas most instruments that assess quality of life used in the health care field measure purely
physical and mental functioning, the WHOQOL instrument measures mental well-being, social
well-being and spiritual well-being. By examining the contribution of the various dimensions to
the overall ranking of quality of life we can analyse, for example, the valuable contribution of lack
of mental distress, our relationships with others and various spiritual variables to overall happi-
ness and well-being. These can be seen as outcomes to be pursued as we institute health care and
prevention measures.
Mental health as an individual capacity and experience
As outlined in Chapter 1, WHO defines mental health as “a state of well-being in which the indivi-
dual realizes his or her own abilities, can cope with the normal stresses of life, can work producti-
vely and fruitfully, and is able to make a contribution to his or her community” (WHO, 2001).
48 • PROMOT
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Figure 4.1
The structural model of mental health
Social support
Societal structures
and other interactions
and resources
Mental
Health
Individual factors
Cultural values
In lay language the concept of mental health is used in different ways, and rather often it has a
negative connotation because it is connected with severe and chronic mental illnesses. However,
the positive aspects of mental health have been more and more recognized by the general public
and political decision-makers in recent years, partly due to the activities and reports of different
international organizations, including WHO (2001) and the European Commission (Lahtinen et al.,
1999). In the USA, the Office of the Surgeon General also published a comprehensive report on
mental health in 1999 (USDHHS, 1999). Mental health is now seen as an essential element of our
general health, well-being and quality of life.
It seems useful to regard mental health mainly as an individual resource contributing to different
capacities and skills. Mental health has even been compared to natural, renewable resources
(Lehtonen, 1978). Thus, mental health and its renewal must be understood as a continuous pro-
cess which makes up the course of life, consisting of a sequence of phases in which the earlier
always affect those that follow. In favourable circumstances mental health can increase, but men-
tal health resources can also be exploited beyond their natural capacity for renewal or even be
destroyed by inappropriate actions by the society.
The individual value of mental health is realized by positive feelings and different individual skills
and capacities that can be seen as components or consequences of good mental health (Korkeila,
2000). Early research considered positive mental health largely from the viewpoint of life satisfac-
tion. A low level of life satisfaction has been significantly associated with mental health problems.
Life satisfaction refers generally to a personal assessment of one’s condition compared to an
external reference standard or to one’s own aspirations. A second approach records affective reac-
tions to daily experiences and a third screens for psychological distress. Numerous instruments
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exist for measuring “psychological well-being”, “subjective well-being” or “positive mental health”
(McDowell & Newell, 1996; see also Chapter 3).
One aspect of mental health is a sense of personal control over the events of one’s life. Rotter
(1966) launched the concept “locus of control” to assess individuals on a presumed continuum
of internality and externality of control. People who believe that they can themselves influence
events in their lives (internal locus of control) cope better with challenging life events than those
who explain events by such concepts as “luck” or “chance” or who attribute events to other people
(external locus of control). Another relevant aspect of personal control is the concept of self-effi-
cacy, which refers to the belief that one can succeed in what one desires to do. It has been shown
that people with strong sense of self-efficacy show less psychological and physiological strain in
stressful situations. Some authors use the term “sense of mastery” in the same meaning.
The concept of sense of coherence, developed by Antonovsky (1979), has been associated with
mental health by many researchers and authors. Antonovsky’s salutogenic model, which is
discussed in more detail in box 4.1 and in Chapter 3, stresses positive aspects and resources of
health rather than symptoms or disorders. The three components of a sense of coherence are
comprehensibility (ability to find structure in events), manageability (control of environment) and
meaningfulness (importance and value inherent in events and one’s life). A person with a strong
sense of coherence is able to choose between various potential resources available. A low level of
sense of coherence has repeatedly been associated with mental ill-health, suicidal behaviour and
psychosomatic conditions.
One feature of good mental health is resilience, by which is meant resistance towards mental
disorders in the face of life adversities (Rutter 1985; also see Chapter 3). Resilience comes close
to such concepts as hardiness and coping. Resilience may be seen as a dynamic process, greatly
influenced by protective factors, which are the specific competencies necessary for the resilience
process to occur. Competencies are healthy skills and abilities (e.g. problem-solving skills) that the
individual can access. Their main function is resistance to stress, which can vary across time and
circumstances and have both constitutional and environmental determinants. Coping with adver-
sities plays a significant role in protecting from unfavourable health and mental health outcomes.
Mental health and social interaction
Another aspect of good mental health is the capacity for mutually satisfying and enduring rela-
tionships. Social relationships and networks can also act as protective factors against the onset
or recurrence of mental ill-health and enhance recovery from mental disorders. Interaction with
other people is an inevitable prerequisite for human development. Without social interaction the
whole potential for development of the infant remains totally unfulfilled, as has been shown by
studies of children who have been left without any human contact, the so-called wolf children.
Some authors regard the availability of social support as directly contributing to increased mental
health whereas others see its role mainly as a buffering one in face of stressful adversities or life
events.
For most people the childhood home is their most important developmental environment. Family
is also for most adults the important core area of intimate relationships. Family researchers have
developed the concept of “family homeostasis” (Jackson, 1957), by which they describe the fact
that there usually exists a kind of dynamic equilibrium between the relationships of different
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Box 4.1
The Salutogenic Perspective and Mental Health
Bengt Lindstrom, Monica Eriksson
The salutogenic framework
Promoting mental health as a positive concept belongs to the family of salutogenic con-
cepts, that is, concepts that explore the origin of health not disease (Antonovsky, 1979,
1987). Prior to Antonovsky, stress had been seen as a negative event that increased the
risk of people “breaking down”. In contrast, Antonovsky stated that diseases and stress
occur everywhere and all the time and that it was surprising that an organism is able to
survive at all for such a long time. His conclusion was that chaos and stress are part of life
and natural conditions. In his view, health is a relative concept on a continuum and the
really important research question is what causes health (salutogenesis) not what are the
reasons for disease (pathogenesis).
The fundamental concepts of salutogenesis are generalized resistance resources (GRRs)
and sense of coherence (SOC). The GRRs are biological, material and psychosocial fac-
tors that make it easier for people to perceive their lives as consistent, structured and
understandable. Typical GRRs are money, knowledge, experience, social support, culture,
intelligence, traditions and ideologies. These are shaped by life experiences characterized
by consistency, participation in shaping outcome and a balance between underload and
overload. If a person has these kinds of resources available or in their immediate surroun-
dings there is a better chance for them to deal with the challenges of life.
GRRs help the person to construct coherent life experiences. Even more important than
the resources themselves is the ability to use them, the sense of coherence (SOC). The
GRRs lead to life experiences that promote a strong sense of coherence – a way of percei-
ving life and an ability to successfully manage the infinite number of complex stressors
encountered in the discourse of life. The salutogenic concept is a deep personal way of
thinking, being and acting, a feeling of an inner trust that things will be in order indepen-
dent of whatever happens. The inner trust developed by internalising the SOC concept
leads us to identify, benefit, use and re-use the GRRs from our surroundings.
Three types of life experiences shape the SOC: consistency (comprehensibility), load
balance (manageability) and participation in shaping outcomes (meaningfulness)
(Antonovsky 1979, 1987). A fourth experience has been added to the SOC concept – emo-
tional closeness – which refers to the extent to which a person feels emotional bonds and
experiences social integration in different groups (Sagy & Antonovsky, 2000). SOC applies
at the individual, group and societal level. Antonovsky postulated that it mainly is formed
in the first three decades of life and that only very strong changes in life would upset and
change the SOC thereafter.
Salutogenesis and mental well-being
The assessment of SOC has been translated into 33 languages in 32 countries (Eriksson &
Lindstrom, 2004). The evidence shows that SOC is strongly and negatively related to
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anxiety, burnout, demoralization, depression and hopelessness, and positively with hardi-
ness, mastery, optimism, self-esteem, good perceived health, quality of life and well-being.
SOC seems to be relatively stable over time, at least for people with a high initial SOC, but
not as stable as Antonovsky assumed, with fluctuations of more than 10% (Lindstrom,
2004; Nilsson et al., 2003; Smith, Breslin & Beaton, 2003). SOC tends to increase with
age and gender differences are found – men usually score higher on SOC than women
(Eriksson & Lindstrom, 2004).
SOC seems to have a main, moderating or mediating role in the explanation of health,
especially in relation to factors that measure mental health. There is a positive association
with optimism, hope, learned resourcefulness and constructive thinking. One conclusion
of this is that SOC is another expression for mental health. The higher the SOC the more
satisfied people are with their lives and consequently they report a higher level of quality
of life and general well-being (Eriksson & Lindstrom, 2004). Social networks and intimate
relationships are GRRs, both factors enabling development and strengthening of the indi-
vidual SOC and strongly and positively related to SOC. They are essential for all human
beings and provide, if they are stable, deep and favourable social support and create a
climate of social integration for the people involved. Giving support also has the effect of
promoting health related to the meaningfulness component (Folkman, 1997).
Other related concepts which contribute to the understanding of the health process are
hardiness (Kobasa), sense of permanence (Boyce), the social climate (Moos), resilience
(Werner) and the family’s construction of reality (Reiss), all mentioned by Antonovsky
(1987). Additional concepts which he did not discuss and which resemble SOC’s connec-
tion to health are learned resourcefulness (Rosenbaum, 1990), flow (Csikszentmihalyi &
Csikszentmihali, 1998), life control (Soderqvist & Backman, 1988) and theories on welfare/
well-being (Allardt, 1980) and quality of life (Lindstrom, 1994).
Conclusions
The salutogenic approach claims health is open-ended and dependent on the skills to
organize the resources available in society, the social context and self. These skills enable
people and populations to develop their health and deal with the fragmentation and
chaos of reality through using cognitive and emotional perception, behavioural skills and
motivation developed through meaningful frameworks based on culture, tradition and
belief systems. The salutogenic framework could guide public health in a new direction.
This framework suggests that what we perceive as being good for ourselves (subjective
well-being) also predicts our outcome on objective health parameters. In other words, if
we create salutogenic processes where people perceive they are able to live the life they
want to live they not only will feel better but also lead better lives.
The full text of this paper and more references can be requested from the authors on bengt@nhv.se.
52 • PROMOT
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family members. This is related to the needs of the different family members and their mutual
power positions. Homeostasis may not only be healthy and thus flexible and tolerate changes
but may also be rigid and pathologizing. Family researchers have shown that the type of family
homeostasis is clearly associated with the state of mental health of the family members, which
again has an effect on the function of the whole family.
Mental health contributes to our social participation and vice versa. People suffering from men-
tal disorders are easily marginalized and socially excluded. Starting from the work by Faris and
Dunham (1939), it has also been repeatedly shown that social disintegration of a community is
associated with an increased rate of mental disorders in that community. The disintegration of
community is characterized by high rates of lonely people, divorces, abandoned children, lack of
social support, violence, crime, drug and alcohol problems and anomie. Several community inter-
ventions exist in which the main goal is to provide opportunities for social support and mutual
responsibility. One example is the “community diagnosis” approach to enhance social interaction
in socially disintegrated urban environments (Dalgard & Tambs, 1997).
One of the most important areas of social participation through our adult years takes place within
our work life. The relationship between mental health and work is very complex. First of all, to
be able to fully participate in work a certain level of mental health and psychological capacity is
needed. In this sense the value of an individual’s mental health is shown in service to society as
one of its productive members. Work is also a valuable supporter of our mental health. It gives
structure and rhythm to our daily life, it gives the possibility for self-fulfilment, it strengthens our
self-esteem and it provides security and an opportunity for satisfying relationships. On the other
hand, work has become more and more a source of distress and even mental ill-health due to
stressful work conditions, overload, increasing requirements and bad workplace relationships
with bosses and co-workers. In many studies, unemployment has been shown to be associated
with increased rate of mental health problems, although in some cases it can also be a relief from
unbearable work conditions and so prevent mental ill-health.
Undoubtedly, a mentally healthy workforce is important for the present and future of organiza-
tions in the information and knowledge society. Assessment of the mental health of employees
and the implementation of strategies for the promotion of mental health in enterprises should
nowadays be at the core of a company’s success.
Mental health contributes to social capital
One way of looking at the relationship between mental health and the society is through the
concept of social capital (Putnam, 1993). This concept refers to features of social life such as insti-
tutions, networks, norms, reciprocity and social trust that shape the quality and quantity of social
interactions and facilitate collective action, coordination and mutual benefit. Increasing evidence
shows that social cohesion is critical for societies to prosper economically and for their develop-
ment to be sustainable. Aspects of social capital, like trust, social support and social networks, are
also important determinants of the mental health of individuals. Furthermore, it is evident that
social capital can improve access to services for people with mental disorders and so shorten the
duration of these disorders (Sartorius, 2003). The relationship between mental health, its conse-
quences and organizations as part of social capital is demonstrated in figure 4.2.
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Figure 4.2
Modelling the impact of mental health on social capital
CONSEQUENCES
• Level of well-being
• Physical health
• Reciprocity
Mental
• Knowledge and skills
Social
• Quality of relationships
Health
• Sexual satisfaction
Capital
• Use of services
• Productivity
• Trust
• Social cohesion
These relationships between social capital and mental health are more thoroughly discussed in
Chapter 6.
The social capital–mental health relationship should be a key consideration in the promotion
of mental health because mental health is a key input to human productivity. This knowledge
should be used in the development of any social policy aiming to enhance social capital. There
are experiences of the development of mental health service resources and systems that have
had favourable impact in the restructuring of societies in crisis. We need more systematic research
to deepen our knowledge on these associations, however, in order to be able to provide useful
recommendations for planning and implementation of new service strategies.
Cultural values and mental health
The task of explaining the relevance of cultural values is complicated somewhat by the fact that in
most of the world’s cultures mental health is a foreign concept (see Chapter 5). Even so, it is often
possible to identify cultural values directly concerned with the essential features of mental health.
For example, cultural formulations of suffering as an essential feature of the human condition
(e.g. Buddhist) may complement or displace notions of mental illness; positive subjective expe-
rience may refer to a sense of inner and interpersonal harmony (Wig, 1999) or be construed in
religious terms. The interplay and relative priority of personal achievement and independence
in Euro-American cultures may be contrasted with an emphasis on interdependence and family
commitment in Asia, Africa and elsewhere. In a diverse world, many factors outside the individual
produce stress or provide support that directly influence mental health. Cultural values, social
organizations and socioeconomic conditions determine the nature and availability of opportuni-
ties for productive and fulfilling activity.
Like any cultural comparison, ideas about mental health that emerge as products of the world’s
cultures are notable both for shared common features and for striking differences in their empha-
sis and substance. The clinical formulation of health as the condition resulting from successful
treatment that cures illness often proves to be unsatisfactory, especially outside of clinical settings
54 • PROMOT
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where the health of populations rather than individual patients is at stake. Thus, the well-known
WHO definition of health aims to respect the interests of various cultures and avoids the kind of
specificity that would exclude the endorsement or participation of people from any particular
cultural group.
Earlier psychiatric concepts of mental health were mainly concerned with a working model for cli-
nical practice rather than broader population-based interests of mental health; they were also less
concerned with questions of culture. Among the few psychodynamically oriented clinical scholars
and teachers who explicitly addressed a need to define mental health in the context of psychiatric
assessment, Havens (1984) argued that human connectedness and self-protectiveness should be
regarded as key features. On the other hand, Freud’s relative inattention to the concept of mental
health remains a persistent feature of mainstream psychiatry. Although his famous quip “to love
and to work” seems benign and superficially appealing, Erikson’s (1963, p. 264–5) elaboration of
the remark – emphasizing genital sexuality, procreation and a capacity for recreation – specifies
a cultural ideal that would be unacceptable, if not offensive, in many cultures as a working defini-
tion of mental health, and dated as well, even in Europe and America.
Writing from a feminist and mental health advocacy perspective in Pune, India, Bhargavi Davar
analysed a variety of definitions of mental health (including Erikson’s) formulated from the 1950s
through to the 1970s. She dismissed them as essentially bourgeois, concerned primarily with
promoting conformity and suppressing deviance (Davar, 1999). She argued that the unexamined
effort to generalize local cultural ideals as expectations defining “healthy” works to the disadvan-
tage of women and others who lack the entitlements and resources to achieve such ideals. Others
have argued that multicultural populations in America and Europe are also poorly served because
of too little attention being paid to social contexts and cultural values and by relative inattention
to subjective well-being compared with the predominant interest in the field of psychopathology
(Christopher, 1999).
Calling upon evidence from psychiatric epidemiology to make the case yields mixed results. As
discussed in Chapter 12, findings from comparing rates of disorders and suicide rates turn out
to be difficult to interpret, if not misleading (Weiss, 2001). These indicators are relatively blunt
instruments that may obscure as much as they clarify the adverse impact of racism, poverty, urba-
nization and social change, victimization by violence and the displacement of populations. When
rates of psychiatric disorders and suicides fail to show the special needs of disadvantaged groups,
data are too often explained away as inconclusive findings from inadequate studies.
Although mental health problems (in contrast to psychiatric disorders) are regarded by some
as signs and symptoms of “insufficient intensity or duration to meet the criteria for any mental
disorders” (USDHHS, 2001a, box 1-2, p. 7), this formulation is incomplete and therefore flawed.
Mental health problems that do not meet criteria for a psychiatric disorder may nevertheless be
so troubling and persistent that they lead to suicidal behaviour and mortality from suicide. It is
not just limited seriousness and duration but also specific cultural configurations of distress and
suffering that may distinguish mental health problems from psychiatric disorders. Careful atten-
tion to locally significant mental health problems is especially important to guide population-
based mental health policy. Lessons from a study of suicidal behaviour showing substantial self-
harm without a psychiatric diagnosis clearly show that criterion-based disorders should not be
regarded as the only valid outcome variables for mental health research, especially in community
studies. Programmes concerned with social problems recognize this point. For example, mental
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health priorities for addressing community violence (e.g. dowry deaths, marital rape, honour mur-
ders and youth violence) focus more appropriately on problem behaviours, their typical social and
gender contexts and the cultural values that support them rather than the diagnosis of under-
lying disorders (Fishbach & Herbert, 1997; USDHHS, 2001b).
Some initial efforts in this regard have begun to consider the interests of children and families at
risk in a study of urban and rural communities in and near Bangalore, Delhi, and Kanpur, India.
An assessment of indicators of mental health was followed by an intervention and evaluation of
impact with reference to controls (Channabasavanna, Varghese & Chandra, 1995). Additional com-
munity-based innovative studies are needed to develop a population-based mental health agen-
da to promote mental health. The potential gains from effective policy to develop a population
perspective for mental health are vast. Culturally appropriate strategies to identify and assist fami-
lies in need may ultimately provide mental health interventions targeting children with long-range,
non-specific benefits comparable to the positive impact of vitamin A on general health status.
Spiritual dimensions of mental health
Many would agree that to be fully human includes the spiritual dimension of life (Smith, 2003).
Spiritual well-being can be thought of as a component of mental health, but it also stretches
beyond the comfort of the individual and his or her community to aspirations that transcend this.
Spirituality makes an important contribution to quality of life for many people all over the world.
This has been documented in a WHO study of over 4000 people at 18 sites worldwide. Qualities
such as awe, meaning of life, faith and connection to a spiritual being make significant contribu-
tion to the overall rating of quality of life, above and beyond that of psychological well-being or
social connection (Saxena, O’Connell & Underwood, 2002). In the development of a new WHO
instrument to measure quality of life in people living with HIV and AIDS it was concluded that it
was crucial to include measures of the contribution of spiritual factors to life. “Many PLWHA [peo-
ple living with HIV/AIDS] reported experiencing a more intense spiritual life as a result of their HIV
infections” (WHOQOL AIDS Group, 2003). In situations such as these, when the end of life is clearly
in sight, particular elements of the spiritual can promote mental health.
Spirituality can exist independently of religious practice or affiliation, but in most people their
spirituality is nested in a religious context. In an article summarizing the relevance of religion to
public health research and practice, Chatters (2000) states:
Religious doctrines may support positive views of human nature and the self that engen-
der attitudes and emotional states that are associated with better physical and mental
health outcomes. Belief in the intrinsic value and uniqueness of each individual may pro-
mote feelings of self-esteem. Religious injunctions may shape interpersonal behaviours
and attitudes towards others in ways that emphasize a variety of positive and pro-social
goals (e.g. interpersonal warmth and friendliness, love, compassion, harmony, tolerance
and forgiveness) and that reduce the likelihood of noxious and stressful interpersonal
interactions (p. 345).
Hope and hopelessness are important determinants of mental health. For example, in depression
hopelessness is one of the key symptoms. A number of well-conducted clinical and epidemiolo-
gical studies have shown that spirituality can under some circumstances help prevent depression
(Koenig, McCullough & Larson, 2001). Spirituality can provide hope to people in despair, and
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in that sense even prevent suicide which is often the result of a decision that life is not worth
living. In interviews about the role spirituality played in their daily lives, people reported being
able to experience deep peace even in the midst of mental distress (Underwood & Teresi, 2002).
Spirituality can enable people to step outside or beyond the mental distress and experience
comfort and calm. Especially in the midst of crisis, particular kinds of spirituality can prove to
be a powerful resource which can be a real buffer against excessive mental distress and despair
(Pargament, 1997).
A large number of studies have recently been completed looking at the role of spirituality/reli-
giousness in preventing alcohol problems. One of the studies showed that in inner-city African-
American adolescents, those who had a sense that they were “working cooperatively with God”
had fewer alcohol problems than those who did not have such a belief or experience (Goggin et
al., 2003). Pardini et al. (2000) found in a study of 237 recovering substance abusers that higher
levels of religious faith and spirituality predicted a more optimistic life orientation, greater percei-
ved social support, higher resilience to stress and lower levels of anxiety. In addition, in a study of
over 2000 female-female twins, Kendler, Gardner and Prescott (1997) reported that current drin-
king and smoking as well as lifetime risk for alcoholism and nicotine dependence were inversely
associated with personal devotion (such as frequency of praying and seeking spiritual comfort).
Religiousness and spirituality can also improve overall health by encouraging healthy behaviours
and practices (such as healthy dietary practices, sexual regulation and limitations on addictive
substances) that can often improve physical health, and through that improve overall well-being,
including mental health (Koenig, McCullough & Larson, 2001).
Maintaining mental health also has a positive effect on the development of a healthy spiritual life.
It is more difficult to see the positive hopeful view, have faith or face the moral challenges and
demands for ethical behaviours presented by the spiritual life if the mind is clouded by mental
health problems. Religion can also contribute negative features to a person’s spirituality, however,
such as guilt and inappropriate revenge-motivated behaviours. In general, though, the positive
contribution of religion to spirituality is the dominant effect.
One of the most important ways spirituality contributes to human value is that it tends to define
the human being in a way that is beyond merely the ability to function:
The functional world defines people in terms of how effectively they perform functions:
in other words, as ‘human doings’ rather than human beings. The spiritual approach
tends to view the functional aspect as just one part of life, with issues such as root moti-
vations and attitudes such as appreciation, awe and compassion being ultimately more
important (Underwood-Gordon, 1999, p. 60).
Conclusion
There is an urgent need to develop mental health policies and to enhance promotion of mental
health at different levels because of the great value of mental health in different contexts. The
information in this chapter has shown that:
■ Mental health, to which much confusion and many misconceptions are attached, is essential
for the well-being and functioning of individuals.
■ Good mental health is also an important resource for families, communities and nations.
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■ Mental health, as an indivisible part of general health, is often undervalued, although it con-
tributes to the functions of society and has an effect on overall productivity.
■ Mental health can be approached both from professional and lay perspectives. It concerns
everyone as it is generated in our everyday lives in homes, schools, workplaces and in leisure
activities.
■ Positive mental health contributes to the social, human and economic capital of societies.
■ Because culture influences the way people understand mental health and their regard for it,
cultural contexts should be evaluated and considered when designing interventions to pro-
mote mental health.
■ Spirituality can make a significant contribution to mental health promotion, and mental
health positively influences our spiritual life.
Without exaggeration, it is possible to say that mental health contributes to all aspects of human
life. Mental health has both material or utilitarian and immaterial or intrinsic values. Material
values are those that contribute to productivity and can, at least in principle, be measured in
monetary terms. But one must not forget that mental health is also a great value in itself.
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Chapter 5
Concepts of Mental Health Across the World
Shona Sturgeon, John Orley
Introduction
The concept of positive mental health (discussed in detail in Chapter 3) is considered by mental
health practitioners to refer to the individual having a positive sense of well-being, resources such
as self-esteem, optimism, sense of mastery and coherence, satisfying personal relationships and
resilience or the ability to cope with adversities. These qualities enhance the person’s capacity
to make a meaningful contribution to their family, community and society (Lavikainen, Lahtinen
& Lehtinen, 2000). While these qualities of mental health may be universal, the form they take
may well differ individually, culturally and in different contexts. Before engaging in mental health
promotion in any community, therefore, it will be necessary to understand that particular commu-
nity’s concept of mental health, although it is unlikely that their ideas will be couched in mental
health terms.
Who promotes mental health?
Given that mental health is broadly defined, it would be naïve to think that its enhancement
should be the preserve of mental health professionals. Actions which potentially can promote
mental health are usually undertaken by people other than mental health practitioners, whether
through interacting directly with people in ways they consider to be positive, such as is done by
parents and teachers, or indirectly, such as through creating environments which they consider
positive, as do town planners.
It is unlikely, however, that these people will describe the impact of their activities in mental
health terms, and they may not even be aware of such impact. They are more likely to describe
the outcome of their activities in terms derived from their own background and world view.
Having made the point that most of what is done to enhance mental functioning and well-being
falls within the scope of others, perhaps it is helpful to list some of the roles of the mental health
specialist. These include to:
■ identify and point out areas where mental health is not optimal;
■ help develop measures of mental health to monitor the situation;
■ help (if asked) to devise interventions;
■ help with the training of those intervening; and
■ help monitor the effectiveness of interventions.
It is important to note that the “cultural gap” can be just as great when one is engaging with
someone from another discipline as it is when engaging with someone from another culture.
Who defines mental health?
Naturally, if the aim is to make some impact on the mental health of people, it is important for
those involved to have some shared understanding of what is meant by mental health. A chal-
lenge posed in mental health promotion, and perhaps why it has been so difficult to get program-
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mes adopted, is that people from different professions, not to mention the potential recipients
of the programmes, may have difficulty in articulating what they mean by mental health or even
widely disagree in what they conceive of as good mental health. This also refers to ways in which
they conceive of circumstances that lead to good mental health. The possibility of widely differing
ideas has increased as international partnerships are formed to address mental health promotion.
The recognition of this diversity has led to the emphasis on community involvement in the deve-
lopment of programmes with the aim of developing respectful partnerships between communi-
ties and mental health professionals.
Mental health professionals have to reframe what they see as mental health issues in ways that
engage those from other cultures or disciplines in useful dialogue. Similarly, it might be helpful
to assist others to conceptualize certain actions or behaviours in mental health terms. Working
towards this improved communication in itself constitutes a form of mental health promotion.
An understanding of people’s conceptions is useful for those designing and implementing pro-
grammes to promote mental health so that programmes that are introduced are as far as possible
compatible with the existing views of the people. In this way, you can build on what is already
there, as well as understand what is happening that may not be optimal for the development and
maintenance of good mental health.
Approach of this chapter
This chapter has attempted to address these issues by posing these challenges to practitioners
working with different groups in different parts of the world and asking for their comment, rather
than entering the debate on culture and mental health or attempting to provide a glossary of
“interesting” cultural phenomena collected from around the world.
The latter would have constituted an emic approach to examining culture, in which the focus is
on studying each cultural group as a separate entity. Although such a culture-specific approach
may increase cultural sensitivity, it is unhelpful in that it assumes homogeneity within cultures
and ignores individual differences. It also tends to feed into prejudice and stereotyping. With
the impact of globalization there are few homogeneous cultures anywhere in the world and an
approach that allows for cultural diversity and overlapping cultures within communities is possi-
bly more helpful (Lee, 1996).
The practitioners selected include people working with different developmental stages in the life-
cycle, such as infancy, the school context and the elderly, and practitioners working with groups
that pose particular challenges, such as under-age soldiers, people with HIV/AIDS and the termi-
nally ill. This was not intended to be an exhaustive or representative list, but was helpful in broa-
dening the debate into seeing what is actually happening in the field. By selecting such diverse
groups in terms of age and issues, the intention was to afford an opportunity for differences and
similarities in relation to perspectives of mental health to emerge, whether or not originating
from cultural beliefs.
The exercise has been both enlightening and frustrating to the authors and the contributors,
which perhaps reflects the challenges encountered in working in this field. Contributors generally
commented on how important it was to understand the concept of mental health held by the
individuals they worked with. Such understanding, however, seems to be usually inferred by the
professional from the behaviour of the group they are working with rather than from any attempt
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to directly address this with the people concerned. The point was made several times of the dan-
ger of generalizing and stereotyping. It is also clear how difficult it is to address “mental health”,
and to recognize what is identified and valued by people in relation to their own mental health
and to build on these strengths. It seems much easier to identify problems or “illness” and inter-
vene accordingly.
Concepts of mental health in infancy and early childhood
The promotion of mental health in infancy and childhood understandably has received great
attention and today much is known about what constitutes good childrearing practices. Studying
the differences in childrearing beliefs and practices in diverse cultures has always been of great
interest to practitioners. It is suggested that understanding the function of these practices in their
context is essential before any intervention is planned within a particular community, even if ulti-
mately the goal of the practitioner might be to encourage change.
In his paper examining cultural diversity and infant care, Tomlinson (2001, p. 4) strongly criticizes
reports that encourage the “drawing of false dichotomies between methods of childcare in the
developed world and the rest”. He makes the point that when attempting to understand the
conceptualizations of infancy and childhood in a particular culture it is essential to analyse them
within their political, economic and social context in terms of their functional meaning and at a
particular point in time. To illustrate this he describes how a Xhosa mother in the apartheid era in
South Africa explained in an interview with him that she did not comfort her son when he cried,
not for any cultural reasons, but because she felt he had to grow up strong enough to leave the
country and join the armed struggle. However, it could be argued that to understand the political
or social function of a behaviour does not necessarily mean to condone it.
Pedro Mendes (2003b) also makes the distinction between behaviours motivated by “external life
conditions” as opposed to “culture”. He illustrates how the political, economic and social condi-
tions faced by those living in war-torn countries impact hugely on the population. He describes
the situation in Angola, where 4 million (40%) of the population have been displaced as a result
of the war and have moved from small towns or rural areas into slums on the outskirts of towns or
into camps. He portrays the last decade as being violent and destructive in terms of people, the
social fabric and means of production. He considers that these conditions have damaged cultures
and their transmission processes. The inability to cope with urban life, loss of loved ones and
property and current lack of work opportunity leads to an ingrained sense of hopelessness,
dependency on external aid and resignation to an unpredictable future.
The resulting attitudes of apathy and passivity impact on all human relationships, but particularly
on relationships with children. Although mothers try to feed and care for the basic needs of their
children, even this is often not possible, and the mothers themselves are underfed and unable to
breastfeed. It would seem that often they lack the impulse for bonding or interacting with their
children. Mendes (2003b) describes how mothers can be seen sitting on the ground in front of
their huts, gazing away and not responding to the crying of their babies.
Another reason given by Mendes for the restricted bonds of affection and interaction of mothers
with their children relates to the high infant mortality rate in the camps and suburbs. He suggests
that the pain of losing a child is the “ultimate blow in a meaningless life” and the function of this
restriction of affection is to make the loss of the child more bearable, particularly during the first
two years of life and until the child becomes more autonomous. This behaviour becomes entren-
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ched culturally as new mothers brought up in this way repeat and perpetuate this pattern of
childrearing.
Likewise, in a Brazilian community with a high infant mortality rate the tendency for new mothers
to avoid bonding with their children may derive not from cultural beliefs but from a functional
sense of keeping some emotional distance until the child is older and less likely to die (Scheper-
Hughes, 1992). This same behaviour is being recorded in HIV-positive mothers in South Africa, but
here the mothers state they are also trying to protect their children from the pain associated with
the mother’s potential death (Landman, 2002). Emotional distance, it would seem, is elected for as
a way of dealing with a hostile environment and attempts to change this behaviour would need
to take cognizance of its functional purpose.
Cultural beliefs may also play a part, however. Mendes (2003b) suggests that in many cultures
children are not considered “people” with their own feelings, thoughts and wishes until they can
communicate and engage in domestic tasks. He also describes how, despite the harsh conditions,
mothers in Angola are more active towards their babies if they are the first-born. The first child in
most Angolan cultures is both a personal and a social symbol. On a personal level it confirms to
the mother that she is a healthy and complete woman; on a social level it proves that she is capa-
ble of “generational continuity”. It establishes her place with her husband, his family and the com-
munity. First-born children are thus particularly meaningful and so receive more attention, ten-
derness and expressive care than children born later. Although loved and welcomed, subsequent
children lack the symbolic meaning of the first-born, detrimental though this may be for them.
Tomlinson (2001, p. 3) cautions against producing cultural stereotypes which leave no room for
changing beliefs and individual differences. He describes one of his interviews on the Thula Sana
Mother Infant Project as follows:
A commonly stated belief amongst many Xhosa people has to do with how parents are
to understand the crying of their infant. Providing that the infant has been fed and does
not need to be changed, then the crying is understood as a signal reassuring the parents
that the infant is still alive. Furthermore it is seen as a device to ward off evil spirits.
Tomlinson (2003, p. 2) also reports that in one Xhosa community there is “an often repeated belief
that infants cannot hear until they are a year or so old”, although he has no independent data on
this. He suggests, “the reality on the ground is however, that for every mother that believes infants
cannot hear until they are one, there are two or three who believe that to be a ridiculous idea
(even if they are not always immediately willing to share that belief)”. While it is good to know
that this deafness belief is not strongly held, there do seem to be mothers who have this idea and
it is unlikely to be confined to the Xhosa. Certainly in the United Kingdom, as well as elsewhere,
most mothers can be surprised at the extent to which their newborn baby has the capacity to be
involved in quite complex social interactions. Once they come to understand that their (cultural)
preconception of their baby’s passivity is wrong they feel encouraged to make greater efforts at
interaction, which is surely beneficial for their child’s development.
On another issue, Tomlinson reports (2001, p. 3):
In one of my interviews I asked an older mother (both her children were now adults)
about whether the belief about why infants cried was in fact something that she subs-
cribed to and had followed. She said yes and that in the case of both her children this
was in fact the way that she had dealt with their crying. I asked her whether her children
believed the same thing. She said no. She stated that she had informed them of these
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beliefs but had also told them that infants might cry for a number of other reasons – ill-
ness, or the need for contact and comfort being just two of these alternative reasons.
I then asked her how she had come to these alternative beliefs. She said that she had
always believed that infants cry for various reasons. Why she had left her infants to cry
was that she was living in the house of her mother-in-law. Her status within the house
required her to respect the child care views of her mother-in-law – even if they contra-
dicted her own.
Similar examples could be drawn from many countries which have a wide diversity of cultures
undergoing rapid social change and where cultural groups themselves are not homogeneous.
The point has been made how important it is to recognize the complexity of all the factors that
impact on childrearing behaviour. One wonders how often people are asked to speak for them-
selves and how often their beliefs are inferred by others from their behaviour, often interpreted
from another cultural background. Asking parents what goals they strive for in relation to their
children, in other words their concept of good mental health, and the role, if any, they believe
they can play in reaching this, would provide answers that would be very helpful when designing
promotion programmes.
Concepts of mental health and the school context
The teaching profession would assume that it has a positive role to play in the promotion of
mental health. While teachers may agree that they are particularly concerned with “mastery and
coherence” (Lavikainen, Lahtinen & Lehtinen, 2000), there are differences in opinion within and
between countries as to how this should be attained and how the learner, and ultimately the
adult, should demonstrate this mastery. For example, in the South African context some black
school headmasters consider being “obedient and docile” as highly admirable qualities in appli-
cants for tertiary education, an opinion not shared by a university selection board. In some parts
of the world it is considered acceptable for learners to challenge their teachers, while elsewhere
this is punished severely. These different perceptions of this aspect of mental health must be reco-
gnized, as there are reports of how school life skills programmes that teach assertive behaviour
can create confusion in learners if such behaviour is not condoned by other teachers or by their
parents and community.
Teachers are in a very powerful position. Their behaviour as a model and their opinions as to what
constitutes good mental health impact very directly on the concepts of mental health adopted by
their pupils. Sexual abuse of girls by male teachers, for example, is common in some countries and
sends an unfortunate message about power and gender relationships to the pupils.
Teachers are also concerned, in varying degrees in different parts of the world, in promoting other
aspects of mental health, such as improving the self-esteem of their learners, teaching accepta-
ble ways of relating to others and managing stress and adversity. As such, their interpretation of
what constitutes good mental health is significant. In deprived communities, and in communities
undergoing rapid social change, teachers often have particular responsibilities as they are faced
with youth needing guidance with many life skills, such as conflict resolution and problem-sol-
ving. For many of these young people little parental guidance is available at home.
Van der Merwe (2003) describes conditions in South Africa where many teachers feel the need
to help pupils but feel helpless as they do not have these skills themselves. Others are anxious,
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stressed and worried, and feel that caring for the mental well-being of learners should not be part
of their job description. Some consider it their responsibility to talk to the learners and assist them
with their problems but, with the diversity of cultures and rapid social change, feel unsure what
constitutes acceptable behaviour. Discipline in schools is becoming increasingly problematic and
norms of behaviour are changing. The HIV/AIDS pandemic has forced many other changes, par-
ticularly in relation to dealing with sexuality and sexual relationships. Economic conditions have
also sometimes split rural families, with fathers having to obtain work in urban areas. This leads to
boys receiving little guidance from their fathers and it is not considered appropriate for mothers
to do so.
It is also essential to understand and respect the spiritual aspect of mental health as defined by
both individuals and cultures. Mental well-being for many people is linked to their relationship
with their concept of God. Problems are considered to be caused by a breakdown in this rela-
tionship or an oversight in the respect that should have been shown. Consequently, problem-sol-
ving requires some action that repairs this relationship. Undertaking this spiritual action may not
necessarily preclude other, more secular, problem-solving activities. In traditional African cultures
the relationship breakdown may be concerned with ancestors and healing this relationship may
require a concrete atonement of some kind, while in other belief systems the breakdown may be
couched in other terms and require other actions.
Concepts of mental health and under-age soldiers
The phenomenon of children and youths being forced into the role of soldiers is all too common
today throughout the developing world. When hostilities cease they have to reintegrate into a
society that, for them, appears alien. It is important to understand what they consider, or value,
as good mental health in order to identify the circumstances that would help them attain it. The
example related below refers to the situation in Angola, but the interruption of normal develop-
mental experiences is common in any situation when children are forced into adult roles.
Mendes (2003a), working with men who had been under-aged soldiers involved in conflict for at
least 10 years, found soldiers from opposing parties to share similarities in their past experiences
and future aspirations; in other words, the aspects of mental health they most valued for the
future. Regarding the past, they felt expendable or used, although some were more aware of this
feeling than others. They felt they had lost their youth and the experience and richness of family
life and the socialization experience that this would have provided. They felt clumsy in dealing
with social situations and unsure of social norms. They felt “different” and had difficulties adapting
to and finding a place in their families, although they had formed an “inner circle“ of comradeship
with each other. They tended to be aggressive and have difficulty controlling their aggression and
instituted strict discipline in their homes. They had difficulties relating to children, including their
own, and some reported that children were afraid of them.
Regarding the future, the aspect of mental health that seemed of particular importance to them
was the “sense of coherence (life experienced as meaningful and manageable)” (Lavikainen,
Lahtinen & Lehtinen, 2000, p. 56). Having spent a considerable part of their lives fighting for
something, they were now “striving for a place in a society they had supposedly served” and they
“wanted to build a new world of meaning and purpose, and this meant reframing and retouching
what had happened” (Mendes, 2003a, p. 1). Helping them to re-experience their childhood was a
very meaningful and emotional experience for them and important in helping them to relate to
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their own children. Such interventions are essential, not only to facilitate the adjustment of these
people back into a peacetime society but also to enable them to provide an environment condu-
cive to the promotion of mental health in their children.
Young people in unstable societies, or societies characterized by political, racial or religious discri-
mination, sometimes are forced, or elect to join, activist movements that remove them from nor-
mal developmental life experiences, including education. Their concerns and aspirations are not
unlike those of under-aged soldiers as they struggle to find a place in the society that they had
hoped to change. Returning exiles also struggle with this task.
Concepts of mental health and HIV/AIDS
The HIV/AIDS pandemic impacts on all aspects of those societies in which the prevalence rates
are high and there is limited access to drugs. Freeman (2003, p. 1) describes the complexity of the
pandemic as follows:
With HIV prevalence rates round 30% in some countries and dramatic increases in severe
illness and deaths in communities, mental health problems are inevitably on a dramatic
rise. While not universally true, and perhaps not yet evident in some situations where
the epidemic is in its early stages, whole societies are and will increasingly experience
the mental health impacts of the virus. Starting with the infected person him/herself
the effects ripple in widening circles to the direct family and caregivers of the infected
person, to other family and friends, to communities confronted with multiple deaths and
large numbers of children orphaned by the disease.
He goes on to state that mental health problems peak at the time of hearing of the diagnosis,
when the person becomes symptomatic and in the last stages of AIDS. People close to the infec-
ted person also experience depression and anxiety when they die.
The stigma associated with HIV/AIDS impacts hugely on all concerned:
Given the stigma attached to HIV and the discrimination against infected people and
their families, the psychological reactions often become more complex and difficult to
deal with compared to other illness. For example, a family member may themselves hold
stigmatized attitudes and values and be angry with the infected person for behaving
“irresponsibly” and for bringing shame on the family, while at the same time feeling love
and compassion and fear for the person dying. The situation is often exacerbated by the
“clustering” of AIDS. Thus both partners in a relationship may be affected at the same
time, a parent may find more than one (or all) their children infected. Children orphaned
by AIDS have also been shown to experience depression, suicidal ideation and other psy-
chological difficulties (Freeman 2003, p. 1).
The scale of the pandemic is such that the impact on the community as a whole must also be
recognized:
Moving on to a more community level some countries are reaching a situation where
young people are being buried each week as a result of AIDS deaths. Two scenarios may
develop, either communities may become overwhelmed by the deaths and the grieving
and suffer deep ongoing emotional turmoil or they may deny their emotional reactions
and cut off from them in order to protect themselves from their continual grief. Neither
of these options is good for mental health. Orphaned children may find themselves out
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on the streets and having to fend for themselves. Lack of early bonding and emotional
abandonment may well lead to personality disorders and other mental health problems.
This in turn will have negative impacts of crime, violence and social stability.
All the above points then need to be added together. In doing this it appears most pro-
bable that the whole impact will be far greater than the sum of the parts. In other words,
the interactive effects are more than likely to result in mental health problems, the like of
which may perhaps not have been previously seen … if mental health professionals wish
to mitigate the mental health impacts of HIV/AIDS it is important to fully understand
what is happening in each of the “layers” mentioned and design promotion programs to
deal with or minimize the effects (Freeman, 2003, p. 1).
HIV/AIDS impacts on every aspect of a person’s quality of life. The unique nature of the condition
is the stigma associated with HIV infection that results in much of the distress and disability asso-
ciated with the illness. Disclosure and failing health may lead to HIV-positive people losing their
jobs. Families sometimes reject them. Communities struggle to accommodate them. The fear of
disclosure prevents the infected person accessing help and programmes aimed specifically at HIV-
positive people are often avoided. The “meaning” of HIV/AIDS in itself causes huge problems for
the HIV-positive person and their social network.
It would be helpful to understand the aspects of quality of life of most concern to HIV-positive
people as they may live with the illness for many years. Certainly, if the stigma were removed
their personal relationships and social support systems would improve, enabling them to live
more satisfying lives and possibly better able to take care of themselves financially. Likewise, if the
stigma were removed the distress experienced by others in their social network would be lesse-
ned. However, the sheer enormity of the pandemic in some communities can lead to the whole
community lacking the resources to respond helpfully.
Efforts to combat the spread of HIV/AIDS have continuously been frustrated by people continuing
to engage in behaviour that places them at risk of contracting the virus, despite knowledge about
its transmission. It seems that the behaviour change required conflicts with more strongly felt
beliefs, personal or cultural, about acceptable or desired behaviour. In other words, the change in
behaviour required may threaten the person’s self-esteem, their sense of mastery or their personal
relationships. For example, an adolescent equates risk behaviour or sexual conquest with a sense
of mastery. In a patriarchal society, a woman places her relationships in jeopardy if she refuses sex
or insists on condom use. In contrast, it seems that behaviour change has occurred in societies
where norms of acceptable behaviour have been targeted. It would seem that it would be helpful
to focus on the concepts of mental health held in order for intervention programmes to be perti-
nent to a particular community.
Concepts of mental health and palliative care
Dying is a normal part of life and the same qualities of positive mental health are important to the
dying person as at any other time of their life. Advances in medicine have tended to over-focus on
the person’s illness to the detriment of these other qualities.
Palliative care aims to rectify this, and can be understood as:
… an approach that improves the quality of life of patients and their families facing the
problems associated with life-threatening illness, through the prevention and relief of suf-
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fering by means of early identification and impeccable assessment and treatment of pain
and other problems, physical, psychosocial and spiritual (Sepulveda et al., 2002, p. 91).
As such, the approach is grounded in promoting mental health rather than focusing on illness.
The philosophy of palliative care is simply that the individual’s own concept of what is good men-
tal health for them should direct all interventions of the palliative care team. Helping the person
to identify these wishes and make these decisions is one of the tasks of the team:
Palliative care encourages open communication and truth-telling and empowers the
patient to take an active role in the management of his/her illness. This gives the patient
a sense of control, which has often been lost in the turmoil of the diagnosis and treat-
ment of the illness. Palliative care emphasises that one should not give the patient false
hope (by colluding in denial of the seriousness of the illness) but that hope is still an
important part of quality of life. Thus palliative care personnel foster hope in realistic
terms e.g. to gain a full night’s sleep by control of pain, to realise a life-long goal, to
reconcile estranged family members and at the end for a dignified and peaceful death
(Gwyther, 2003, p. 1).
This philosophy of aiming to understand what is important to the person underpins palliative
care anywhere in the world. What people consider important will differ, and the philosophy allows
for this. Similarly, the form that grief takes will vary. For example, the HIV/AIDS pandemic means
that patients will be younger, with young children who will be bereaved. They may have suffered
from stigma, have suffered multiple losses and come from deprived backgrounds. The course of
the condition may be very uneven, with their health varying greatly as opportunistic infections
occur and are treated. How these individuals wish these issues to be addressed should direct the
intervention.
Concepts of mental health and older people
Throughout the world the proportion of old and very old people is growing, while at the same
time the attitudes of families towards their care is changing. What were previously considered the
normal results of ageing are being increasingly recognized as the result of illnesses, deprivation
or externally or internally inflicted abuse, and therefore avoidable. Developed, unlike developing,
countries have shown some success in reducing the level of incapacity in the elderly, with the
exception of dementia, by improving their health when younger. Depression and dementia
remain the two major mental illnesses affecting old people (Copeland, 2003).
What is becoming increasingly understood is that the concepts of mental health or ideas regar-
ding quality of life held by older people do not differ substantially from those of younger people.
Most differences in behaviour are the result of physical or mental disease or social disadvantage
rather than the ageing process itself. For example, elderly people have to contend with real issues
of lack of financial and social support, isolation or increased responsibilities in caring for grand-
children in the case of HIV/AIDS.
Other misconceptions include that the elderly choose to “disengage” socially, that depression is
natural, that intellectual decline is a normal feature of ageing and that older people are not dis-
tressed by the death of contemporaries or their own disabilities. These attitudes, in fact, are either
in response to disability or are simply not valid assumptions. Dementia has also been confused
with the ageing process (Copeland, 2003).
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As with the other stages of the life-cycle, the older person’s values regarding their mental health
should be respected and they should be encouraged to make their own decisions regarding their
lifestyle rather than having others decide for them. There will be individual and cultural differen-
ces across the world but the principle remains the same. Efforts to maximize their options through
improved physical health, supportive social conditions and opportunities for personal growth
would promote their improved mental health (Copeland, 2003).
Conclusion
This chapter has attempted to examine concepts of mental health in selected, diverse groups in
various countries through a process of engaging mental health practitioners currently concerned
with different population groups and inviting them to comment.
A strong theme that has emerged is the centrality of mental health in enabling individuals to
function constructively in their particular roles and therefore to contribute positively to their com-
munity. Communities in which individuals struggle to experience a positive sense of well-being
and connectedness to others, to experience life as having meaning and being manageable, are
largely dysfunctional. Far from mental health being a “luxury” as some might argue, it is recogni-
zed as fundamental to a healthy society.
The practitioners consulted for this chapter clearly articulate that beliefs and actions need to
be understood within their political, economic and social contexts and that cultural beliefs are
only one element to be considered. Today there are very few homogeneous cultural groups, and
socioeconomic class and urban-rural differences impact greatly on lifestyle and beliefs. Many
societies are also undergoing rapid social change.
There is also an appreciation that while the components of positive mental health are universal,
their expression and interpretation will differ individually, culturally and in relation to the current
context. Similarly, different aspects of mental health will take on particular importance and prio-
rity depending on the situation and context. However, while the mental health perspectives held
by groups should always be acknowledged, it is clear that they are not always helpful.
A constructivist approach, which “recognizes the presence of diversity as normative” (Lee, 1996,
p. 189) is advocated as a useful way forward. In this approach, no assumptions are made by the
practitioner as to how individuals or groups might perceive a situation, its etiology and meaning,
or how it might be addressed. Rather, the practitioner is charged with hearing the group’s cons-
truction of their own reality, thus avoiding simplistic, often incorrect, “cultural” explanations.
This approach also allows for the process of “co-construction” between the practitioner and the
target group or community in which, through a “recursive and educational process” (Lee, 1996, p.
199), the practitioner can assist the target group to consider new, more appropriate behaviours.
This approach provides a framework for respecting people’s conceptions of mental health while
allowing for change.
The challenge posed to those involved in mental health promotion is to take cognizance of these
differences in order that programmes are experienced by participants as meaningful and relevant.
This is particularly important when attempting to introduce programmes that may run counter to
locally held beliefs and perceptions. While the general goals of programmes may be similar across
groups and cultures, the focus, form and intervention strategy will vary as they respond to the
norms and priorities of the particular community.
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References
Copeland J (2003). Some thoughts on older people and
Mendes P (2003a). A chapter missing? Aspects of the
mental health. Unpublished paper/communication.
inner life of ex-under-aged soldiers. Unpublished
Freeman M (2003). Mental health impact of HIV/AIDS.
paper/communication.
Unpublished paper/communication.
Mendes P (2003b). Mother-child affectionate bonds in a
Gwyther L (2003). Palliative care and mental health pro-
war-torn country. Unpublished paper/communication.
motion. Unpublished paper/communication.
Scheper-Hughes N (1992). Death without weeping: the
Lavikainen J, Lahtinen E, Lehtinen V (2000). Public health
violence of everyday life in Brazil. Berkeley, University of
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help-seeking process of clients: A response to cultural
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paper/communication.
Chapter 6
Social Capital and Mental Health1
Harvey Whiteford, Michelle Cullen, Florence Baingana
Introduction
Research over the last two decades has demonstrated that social capital is linked with economic
development, the effectiveness of human service systems and community development. Social
capital has also been shown to decrease transaction costs in the production and delivery of goods
and services, thereby improving productivity and efficiency. Political scientists have studied
the contribution of social capital to the functioning of democracy, more efficient government,
decreased corruption and the reduction of inequality within a society. Social scientists have inves-
tigated how higher social capital may protect individuals from social isolation, create social safety,
lower crime levels, improve schooling and education, enhance community life and improve work
outcomes (Woolcock, 1998).
This research has also demonstrated a downside of social capital. The same strong ties that are
needed for people to act together can also exclude non-members, such as the poor or minority
groups. Strong ties within the group may lead to less trust and reciprocity to those outside the
group. For example, drug cartels and terrorist groups may have high levels of social capital among
group members, with obvious detrimental effects for those outside the group. Social interactions
can have negative as well as positive effects – as good behaviour spreads, so does bad (as shown
by studies on education and crime). Networks can just as easily influence and reinforce bad choi-
ces as they can good.
Understanding the positive and negative effects on health of what is now called social capital has
been an increasing focus of research in the last decade. At the same time authors have begun to
speculate about and attempt to unravel possible relationships between social capital and mental
health (Kawachi & Berkman, 2001; McKenzie, Whitley & Weich, 2002; Sartorius, 2003). This chapter
explores the concept of social capital, outlines the understanding at present on the relationship
between social capital and health and mental health and discusses the potential for mental health
promotion to enhance social capital.
Conceptualizing social capital
There are four views of social capital. The narrowest conceptualization focuses on local, horizontal
community associations and the underlying norms (trust, reciprocity) that facilitate coordination
and cooperation for mutual benefit (Uphoff, 2000). This view primarily focuses on the positive
aspects of social capital and does not necessarily include the detriments (such as exclusion and
excessive demand on members).
A broader conceptualization of social capital, such as that employed by Coleman (1988), incor-
porates a wider spectrum of social dynamics. A definition based on function, this view includes
vertical associations, characterized by both hierarchy and an unequal power distribution among
members within a society.
1 This chapter draws heavily on a Discussion Paper by Michelle Cullen and Harvey Whiteford entitled The
Interrelationships of Social Capital with Health and Mental Health released by the Australian Department of Health
and Ageing in 2001.
CHAPTER 6 • SOCIAL CAPITAL AND MENTAL HEALTH • 71
A more macro view of social capital (Grootaert, 1998) focuses on the social and political environ-
ment that shapes social structures and enables norms to develop. This social and political environ-
ment includes formalized institutional relationships and structures within government and related
agencies, the political regime and the legal and regulatory systems.
An integrative view of social capital recognizes that micro, meso and macro institutions co-exist
and interact with each other:
This view not only accounts for the virtues and vices of social capital, and the impor-
tance of forging ties within and across communities, but recognizes that the capacity
of various social groups to act in their interest depends crucially on the support (or lack
thereof) that they receive from the state as well as the private sector. Similarly, the state
depends on social stability and widespread popular support (World Bank, 2004).
Given these varying conceptualizations of social capital, it is not surprising that it also has elas-
tic definitions. In this chapter, social capital means “the features of social organization, such as
civic participation, norms of reciprocity, and trust in others, that facilitate cooperation for mutual
benefit” (Kawachi et al., 1997, p. 1491). Despite contention over definitional parameters, there is a
growing consensus that social capital captures a concept that facilitates collective action and can
promote social and economic growth and development by complementing other forms of capital
(Grootaert, 1998).
Although the consensus is that social capital is “social” and collective, debate continues around
whether it is a form of “capital”. Capital is conceived of in two fundamentally different ways
(Eatwell, Milgate & Newman, 1987). It may be thought of as a fund of resources that can be swit-
ched from one use to another. This has been called the “financial” concept of capital. It may also
be conceived of as a set of productive factors that are embodied in the production process, the
so-called “technical” concept of capital.
Using the technical concept, traditional capital theory arbitrarily divided productive factors
(inputs) into three groups: natural resources, human labour and man-made goods (financial and
physical capital). This last was called capital goods (or often just “capital”) and was defined as
produced goods that could be used as inputs for further production (Samuelson & Scott, 1975,
p. 50; Dow & Hendon, 1991). Over time, the other inputs, natural resources and human labour,
began to be referred to as capital as well. In the early 1960s economists such as Schultz and
Becker reintroduced Adam Smith’s term human capital to refer to how educated and healthy
workers productively utilized other capital inputs (Schultz, 1963; Becker, 1962). Thus the literature
now routinely recognizes natural capital (soil, atmosphere, forests and water), human capital
(human productivity) and physical or financial capital (man-made goods, e.g. buildings, roads and
technology). The concept of social capital, referred to as the missing link in economic develop-
ment (Grootaert, 1998), has grown out of the belief that cohesive and productive groups of indivi-
duals are more than just the sum of their human capital.
Social capital emerges from interactions that are social and external to the individual, not lodged
within individuals as human capital is. It is inherent in the structure of social relationships and the-
refore is an ecological characteristic (Henderson & Whiteford, 2003). Using the term to mean the
assets of individuals or families (Portes, 1998; Walkup, 2003) introduces confusion.
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Deconstructing social capital
To understand the relationships between social capital and mental health we need to understand
its cognitive and structural components. Cognitive social capital is derived from “mental processes
and resulting ideas, reinforced by culture and ideology, specifically norms, values, attitudes, and
beliefs that contribute to cooperative behaviour” (Uphoff, 2000, p. 218). Cognitive social capital
influences behaviour, including control of risk-taking behaviour, mutual support and informal
means of information exchange.
Structural components of social capital are the “roles, rules, precedents and procedures as well as
a wide variety of networks that contribute to cooperation” (Uphoff, 2000, p. 218). Structural social
capital has two dimensions – horizontal, reflecting ties that exist among individuals or groups of
equals or near-equals, and vertical, stemming from hierarchical or unequal relations due to diffe-
rences in power or resource bases. Structural social capital is shaped by government policies and
the formal service networks that result from their implementation.
Social capital, health and mental health
Considerable investments are made, nationally and internationally, to improve the health of peo-
ple. However, as Lomas (1998, p. 1181) has noted:
On the one hand, millions of dollars are committed to alleviating ill-health through indi-
vidual intervention. Meanwhile we ignore what our everyday experience tells us, i.e. the
way we organize our society, the extent to which we encourage interaction among the
citizenry and the degree to which we trust and associate with each other in caring com-
munities is probably the most important determinant of our health.
There is an extensive literature on health and social factors that is sometimes seen to come under
the rubric of social capital. Indeed some commentators feel that the notion of introducing social
capital to health is merely putting old wine into new bottles (Labonte, 1999, in Campbell, 2000).
While the socioeconomic determinants of health have been well studied and there is good eviden-
ce that more socially isolated individuals have poorer health (House, Landis & Umberson, 1988),
the notion of social capital is addressed in studies showing that more socially cohesive societies
are healthier with lower mortality (Kawachi & Kennedy, 1997). Studies have shown that there is a
correlation between poor health and lower levels of social capital, as evidenced by levels of inter-
personal trust and norms of reciprocity.
Population health measures, whether morbidity or risk factors, are usually considered as the
aggregate of the individual characteristics in the population. When considering the environmental
contribution to, or protection against, disease, the conceptualization again is usually one of binary
associations between one (or more) environmental factors and individual health (Marmot, 1998).
The power of the concept of social capital lies in its potential to understand the environment in
another way: the interaction between environmental (including social) factors and connected
groups of individuals. The smallest of these groups is usually the family, with the size increasing up
to entire nations. This perspective of networks of individuals interacting with environments has the
power to explain an array of collective outcomes beyond that explained by aggregated individual
health outcomes. Many studies have shown the powerful health effects of social connectedness
(Putnam, 2001). The mechanisms by which this social capital is beneficial to health are not clearly
delineated, but social networks are believed to promote better health education, improve access
to health services and informal caring, and enforce or change societal norms that impact on
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public health (e.g. smoking, sanitation and sexual practices) (Baum, 1999; Kawachi, Kennedy &
Glass, 1999). Much work remains to be done in accounting for the mechanisms underlying the
alleged health–community link (Gillies, 1997; Henderson & Whiteford, 2003) and the interrelations
of social capital with mental health. It is also unclear if the relations between these two variables
are multidirectional and of causality or correlation (Lochner, Kawachi & Kennedy, 1999). While
quantitative data is lacking, the four areas discussed below – socialization, protection during crisis,
income disparities and suicide and antisocial behaviour – suggest a theoretical basis for important
relationships between health, mental health and social capital.
Socialization
The norms that govern interpersonal behaviour are transmitted through socialization within what
can be considered social capital networks (e.g. the family and community). With this process comes
the transmission of cultural norms and acceptable behaviour within society. Individual functioning,
well-being (self-esteem, individual identity) and vulnerability are affected by diverse social expe-
riences and conditions, which include an individual’s social capital environment (OECD, 2001).
It is necessary to examine this social capital environment to understand the health of a population.
Durkheim (1897) was among the first to note that a lack of social cohesion within a society had
negative consequences on health and mental health. The benchmark Whitehall study demons-
trated the link between social exclusion and ill-health (Marmot, Shipley & Rose, 1984) and social
isolation has been linked to unhappiness, illness and shortened life (OECD, 2001). Veenstra (2000)
specifically included what we now call social capital and demonstrated that socializing with col-
leagues from work, attending religious services and participating in clubs are related to positive
health status. In fact, frequency of socializing with workmates and attendance at religious services
had the strongest (most positive) relationships with health in his social engagement questions,
even after controlling for human capital (K McKenzie, personal communication, 2000).
Kawachi et al. (1997) studied the relationship between health and social capital using the indi-
cators of interpersonal trust, reciprocity norms and density of associational membership (a wide
array of voluntary associations such as church groups, fraternal organizations and labour unions).
The results suggested a breakdown in social trust is linked to higher mortality rates. They found
that “per capita group membership was strongly inversely correlated with all-cause mortality …
level of group membership was also a predictor of coronary heart disease, malignant neoplasms,
and infant mortality” (Kawachi et al., 1997, p. 1494). Associational membership and civic trust were
highly correlated. Conversely, levels of distrust were significantly correlated with age-adjusted
mortality rates. In regression models, variations in the level of trust explained 58% of the variance
in total mortality across states. Lower levels of social trust were associated with higher rates of
most major causes of death (Berkman & Kawachi, 2000). Veenstra (2000), however, suggests that
trust may not be significant once effects from human capital (socioeconomic status measured by
income and education) are controlled.
The classic studies of Faris and Dunham (1939), Hollingshead and Redlick (1958), Leighton (1959)
and Brown and Harris (1978) demonstrated relationships between mental illness and social struc-
ture, social isolation, poverty, life events and psychological stress. One explanation for the rela-
tionship is that at the individual level mental disorder impairs psychological and social functioning
and this leads to downward “social drift” (Goldberg & Morris, 1963). There is some support for this
as mental disorders such as schizophrenia interfere with the person’s capacity to cope with the
usual demands of interpersonal interaction and the decoding of social communication (Murphy,
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1972). As a result, individuals lose social connectedness and end up more socially isolated. Adverse
effects on socialization can also arise from the more common mental disorders, such as depression
and anxiety. These mental disorders have adverse consequences that include breakdown in marital
stability (Kessler, Walters & Forthofer, 1998), increased teenage parenthood (Kessler et al., 1997),
more distant social relationships (Mickelson, Kessler & Shaver, 1997) and other factors associated
with social deterioration. For individuals, early identification of, and intervention to remove, target
symptoms associated with the social and vocational decline is possible (Hafner et al., 1999). The
outcomes of these interventions have traditionally been measured in terms of clinical outcomes
and/or “social reintegration”. However, the implications of such outcomes include the enhancement
of cognitive social capital with benefits accruing to the wider social group as well as the individual.
At a population level, the challenge is to identify risk reduction (e.g. teaching cognitive-beha-
vioural or parenting skills) and protective (e.g. increasing social connection) strategies that can be
widely implemented (Rose, 1992).
Protection during crisis
A second explanation for the association between mental disorders and poor social circumstan-
ces (which would be considered environments with depleted social capital) is that individuals in
these circumstances are exposed to more psychosocial stressors (adverse life events) than those in
more advantaged environments. The impact of these stressors is modulated by the psychological,
social and physical resources available in a person’s environment (see figure 6.1). Interventions
which augment these resources can protect against the adverse effects of psychosocial stressors
(Marsella, 1995; Muntaner & Eaton, 1998). For example, vulnerability for depression includes a lack
of confiding relationships, unemployment and low social status (Perry, 1996), all of which can deri-
ve from a breakdown in social cohesion. This relationship has been reported even in conditions
where psychosocial factors are generally not considered to be pathological. For example, socially
isolated elderly people have a relatively greater risk of developing Alzheimer disease, controlling
for other risk factors (Fratiglioni et al., 2000).
Figure 6.1
Social capital and psychosocial processes
Decreased
social capital
Individual anxiety/
Community anxiety/
behavioural change
behavioural change
Decreased buffers/
social support
Hostile environment, increased vulnerability
factors, precipitants of mental illness
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During crisis, assistance and support rely on the availability of social capital networks. These
networks include nuclear and extended families (basic social units) as well as local religious ins-
titutions, political organizations and economic systems. During extreme strife, families first help
themselves, then relatives, and then neighbours. During recovery, it is these basic social units that
are most looked to for emotional recovery and thus influence mental health status (Cuny, 1994).
Rose (2000), in his survey of how social capital networks in Russia contributed to basic welfare
such as income security, health and food consumption, concluded that measures of social integra-
tion explained almost 10% of the variance in “emotional health“.
Social capital adds another dimension to our understanding of mental health and mental disor-
der. It broadens the biopsychosocial determinants of mental disorder (genetics, neurobiology,
psychological factors, social environment, etc.) and brings an understanding of population men-
tal health beyond the aggregation of individual health characteristics or risk factors. One might
postulate that the best ways to address mental health with social capital interventions would be
to target those aspects closest to the psychosocial determinants of health, i.e. those closest to
the cognitive aspects of social capital (T Harpham, personal communication, 2000). For example,
following Durkheim, a lack of social norms (cognitive social capital) produces social disintegration
which results in anomie, suicide and antisocial behaviour. A social capital intervention which
addressed social norms could therefore have positive mental health outcomes.
Income disparities
According to Putnam (1993), a thriving civic community is typically characterized by strong hori-
zontal, rather than vertical, relationships. This has ramifications for the relationship between social
capital and inequality. According to Putnam (1993, p. 105), “equality is an essential feature of the
civic community”. Putnam’s more recent work continues to reinforce findings that “economic ine-
quality and civic inequality are less in states with higher “social capital” (Putnam, 2001, p. 50).
As Murray, Gakidou and Frenk (1999, p. 540) have noted:
Both health inequalities and social group health differences are important aspects of
measuring population health. In the face of enormous variation in health within popula-
tions, we cannot simply focus on average levels of health. There are convincing reasons
to measure social group health differences: they are normatively important; they provide
insights into causal pathways linking distal socioeconomic determinants and health; and
they are relatively easy to measure.
While income disparity is associated with a decline in health status (e.g. Kaplan et al., 1990), social
capital is also relevant. According to Kawachi and colleagues (1994), income inequality may be
linked to ill-health through the frustration that results from increasing inequality, which may be
catalyzed or perpetuated by underinvestment in human capital. This underinvestment can occur
in areas with low social capital, which concurrently may be those more prone to allow large dispa-
rities to emerge (RG Wilkinson, personal communication, 2000). Putnam (2001) also found that in
states with low social capital and high levels of perceived inequality, self-assessments of well-being
and happiness were low.
Wilkinson (1996), when discussing the relationship between income inequality and a less cohesive
social environment, suggested that there is a “culture of inequality” that is more aggressive and
violent and less cohesive. By examining the relationships between income inequality, social capital
and health, Wilkinson has emphasized the importance of psychosocial pathways in physical health.
His work has shown that the social environment is more cohesive in more egalitarian places (less
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violence, less homicide, less hostility and more trust). This has obvious ramifications for public
health. From Wilkinson’s work, and the findings of others such as Putnam and Kawachi, a likely way
to build social capital would be through improving income equality.
Suicide and antisocial behaviour
Variations in antisocial and suicidal behaviour have been traced to strengths or absences of social
cohesion (OECD, 2001). Weak social controls and the disruption of local community organization
have long been hypothesized to be factors producing increased rates of suicide (Durkheim, 1897)
and crime (Shaw & McKay, 1942). Social disorganization, defined as the “inability of a community
structure to realize the common values of its residents and maintain effective social controls”,
correlates with rates of suicide and crime (Sampson & Groves, 1989). The social organizational
approach views local communities and neighbourhoods as complex systems of friendship, kinship
and acquaintanceship networks and formal and informal associational ties rooted in family life
and ongoing socialization processes (Sampson, 1996). From the perspective of crime control, a
major dimension of social disorganization is the inability of a community to supervise and control
teenage peer groups, especially gangs. Shaw and McKay argue that residents of cohesive com-
munities are better able to control the youth behaviours that set the context for gang violence
(Berkman & Kawachi, 2000).
Social disorganization has been linked to social capital by Sampson, Raudenbush and Earls (1997),
who surveyed neighbourhood residents on their perceptions of social cohesion and trust. They
found a high rating of collective efficacy was significantly inversely related to neighborhood vio-
lence, violent victimization and homicide rates. The link between social capital and violent crime/
homicide has been replicated at the state level (Kawachi, Kennedy & Glass, 1999). In an analysis
of ecological factors, societies with low trust levels exhibited higher rates of violent and property
crime, such as homicide, assault, robbery and burglary (Berkman & Kawachi, 2000).
Mental health promotion and social capital
Social capital can enhance mental health and reduce the impact of mental illness. Further, men-
tal health promotion can potentially build social capital in various ways, with outcomes at both
the societal and community levels. At the community level, mental health promotion can build
pathways between health and social capital that can affect behaviour and service provision
by promoting the psychological attributes of individuals and strengthening the relationships
between individuals. While many mechanisms can be postulated, three are briefly discussed here:
health-related behaviours, access to services and amenities, and psychosocial processes.
Health-related behaviours
Social capital can influence population health behaviours by promoting a more rapid diffusion
of health information (mental health literacy), increasing the likelihood that healthy behaviour
norms are adopted and by exerting social control over deviant health-related behaviour. The
theory of diffusion of innovations (see Chapter 19) suggests that innovative behaviours (e.g. use
of preventive services) diffuse much more rapidly in communities that are cohesive and that have
higher levels of trust (Rogers, 1983). Some studies have suggested that the higher the degree
of “collective efficacy” the more likely the community is to prevent antisocial behaviour (e.g.
Sampson, Raudenbush & Earls, 1997). This process may be applied similarly to prevent deviant
behaviour, such as adolescent drug abuse (Berkman & Kawachi, 2000).
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Access to services and amenities
Community social capital can affect access to services and amenities. Cohesive communities are
more able to unite to form appropriate social organizations which ensure access to services that
are directly related to health, such as community health clinics. Decreased access to services and
amenities is often a result of poverty, crisis or chronic illness. Social capital links in these situations
become even more important; they can serve as a mechanism that helps improve social support,
integration, rehabilitation and recovery. Long-term solutions to the problems of inadequate
resources and social exclusion require connecting marginalized groups to mainstream resources
and services through mechanisms of bridging social capital, which unites these excluded groups
with the majority (Putnam, 1995; see also Chapter 10).
Psychosocial processes
High levels of social capital are conducive for the development of an individual’s psychosocial
processes that are needed to cope with life’s stressors and protective against ill-health. These
psychosocial processes in part arise from social interaction within an individual’s community.
Interaction with others is enhanced if it is based on trust and reciprocity, which provide protective
factors against the initiation of any psychosocial processes that are known to be determinants of
ill-health.
The developmental processes by which the moral values of trust and reciprocity become instilled
in children occur more quickly in communities with higher social capital. Members of such com-
munities have some sense of public responsibility for each other, even if they have no related ties.
These norms of reciprocity or mutual respect can translate into easier childrearing, improved self-
government and the maintenance of public life civility (Berkman & Kawachi, 2000).
Variations in the availability of psychosocial resources at the community level may help to explain
the anomalous finding that socially isolated individuals residing in more cohesive communities do
not appear to suffer the same ill-health consequences as those living in less cohesive communi-
ties (Berkman & Kawachi, 2000, p. 105).
Building social capital
Studies examining and projects incorporating social capital have revealed more about what
destroys this phenomenon than what builds it. For instance, merely creating civil society groups
does not automatically lead to the concurrent creation of social capital within and among these
new groups. Instead, efforts to build social capital must consider the various sources of social
capital that stem from these: “family, schools, local communities, firms, civil society, public sector,
gender and ethnicity”. From this, social capital can be built “at the ‘level’ of families, communities,
firms, and national or sub-national administrative units and other institutions” (OECD, 2001, p.
45). Regardless of the level of intervention, the process of developing social capital takes a long
time. Consequently, investing in social capital should be seen from a life-course approach, for
investments now may not only benefit this generation but also the next. Similarly, current disin-
vestment may have parallel long-term effects. It has been posited that interventions that target
various dimensions of social capital simultaneously may be more effective. This would entail inter-
vening across multiple levels, including macro social policy reform while also increasing commu-
nity access to external resources and power (Grant, 2000; also see figure 6.2).
78 • PROMOT
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It is accepted that improved health status enhances human capital (Bhargava et al., 2001; World
Bank, 1993). Can the argument be made that improvements in health and mental health can
build social capital? For those with mental illness, action to remove psychosocial stressors, pro-
vide social and psychological support and provide clinical treatments to reduce symptoms and
disability can all lead to an enhancement of the individual attributes necessary for constructive
social interaction and assuming a productive social role. Mental health promotion activities targe-
ting “well” populations have aims of enhancing resilience and social competencies. These actions
should have a pay-off in terms of building social capital as good mental health enhances the
competencies necessary for more constructive participation in civil society. In this context, mental
health may have specific importance in contributing to the cognitive and psychological attribu-
tes necessary for the interactions that underpin social capital. There is some evidence to support
these hypotheses. Studies carried out by the World Bank in Rwanda and Cambodia demonstrated
that individual attributes such as resilience contributed to the rebuilding of social capital in the
post-conflict periods in both countries (Colletta & Cullen, 2000).
Conclusion
The level of social capital in a country or neighbourhood is an attribute of the social environment.
Research to identify the relationships between social capital and mental health has relied largely
on cross-sectional data, and has produced mixed results (McCulloch 2001; McKenzie 2000; Rose
2000; Rosencheck et al., 2001; Weitzman & Kawachi, 2000). Much of the work so far relates to men-
tal ill-health, and the trend is towards an inverse relationship between social capital and mental
illnesses of various kinds in a population. Overcoming the methodological challenges (Henderson
& Whiteford, 2003) is necessary before social capital can become a tool to explain the epidemio-
logy and outcomes of mental disorders. More work beyond that is required to understand the
demonstrated links between social capital and positive mental health, and their relationships to
economic development, the effectiveness of human service systems and community develop-
ment. The links between social capital, population health and mental health, and the potential of
mental health promotion to enhance social capital are current topics of research and debate with
important implications for improving population mental health.
Figure 6.2
Interventions to build social capital at the community level
■ Strengthen social networks
e.g. Employ a community health worker to mobilize resources within social networks
and bring resources into communities
■ Build social organizations
e.g. Facilitate the development of nongovernment organizations (NGOs)
■ Strengthen community ties
e.g. Bring together groups normally divided along class, caste, race/ethnicity or religious
grounds
■ Strengthen civil society
e.g. Inform decision-makers about the social consequences of macroeconomic policies
CHAPTER 6
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Chapter 7
Mental Health and Human Rights
Natalie Drew, Michelle Funk, Soumitra Pathare, Leslie Swartz
Introduction
The international human rights system offers a useful framework for the promotion of mental
health. The international human rights discourse today widely recognizes mental health as a basic
human right. The right to physical and mental health was first enunciated in the Constitution of
the World Health Organization in 1946, which states that “the enjoyment of the highest attainable
standard of health is one of the fundamental rights of every human being”. The United Nations
International Covenant on Economic, Social and Cultural Rights (1966) also articulates this in
Article 12, when it recognizes “the right of everyone to the enjoyment of the highest attainable
standard of physical and mental health”.
Beyond merely acknowledging the right to mental health, the international human rights dis-
course recognizes that certain sociopolitical and economic conditions need to exist in order to
promote the mental well-being of the population. Indeed, the right to mental health extends to
the underlying determinants of mental health and is dependent upon the realization and enjoy-
ment of a range of civil, political, economic, social and cultural rights.
Certain people and groups within society are particularly vulnerable to human rights violations.
Factors such as discrimination and marginalization increase their propensity for developing men-
tal health problems as well as acting as a barrier to accessing appropriate health care services. The
human rights discourse recognizes the need for countries to pay particular attention to the needs
and interests of such people, as well as the necessity to adopt specific measures in order to safe-
guard and realize their rights, including their right to mental health.
The international human rights framework thus offers useful guidance to governments in unders-
tanding the requirements for creating the necessary social, economic and political conditions to
promote the mental health of the population.
The link between mental health and human rights
A fundamental link exists between mental health and human rights. Human rights violations
within a country can have damaging and harmful repercussions on the mental health of the
population. Conversely, people’s mental health is dependent upon their ability to enjoy and exer-
cise a range of human rights (Gostin, 2001).
It has long been acknowledged that extreme forms of abuse, human rights violations and crimes
against humanity such as genocide and ethnic cleansing impact negatively on people’s mental
health. The loss of loved ones, the exposure to extreme forms of violence and the general disrup-
tion to people’s lives not only result in dramatic increases in post-traumatic stress disorders but
also in other more long-term and chronic mental health problems related to trauma, such as
depression and anxiety (Rwema, 2003; Sotheara, 2003).
One of the fundamental purposes of torture and other forms of inhuman and degrading treat-
ments and punishments is to inflict psychological as well as physical harm. This leads to poor
mental health in victims as well as their families and the community. Similarly, rape, domestic vio-
lence and other physical and psychological abuses directed against women result in poor mental
health outcomes (Gostin, 2001).
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It is not only extreme forms of human rights violations that have a negative impact on the mental
health of the population, however. Indeed, the link between poverty and increased risk of mental
disorders has become increasingly apparent over the last decade (WHO, 2001). Unemployment,
low levels of education and lack of food, shelter and access to health care (including health insu-
rance coverage) limit people’s ability to be active and productive members of society, to realize
their potential and ultimately to be mentally as well as physically healthy. These negative social
and economic factors associated with poverty furthermore act as a barrier to health and mental
health care services.
Similarly, restrictions in civil liberties such as the right to vote; to take part in public affairs; to
express one’s opinion; to seek, receive and impart information; and to have freedom of associa-
tion, assembly and movement can also adversely affect the mental health of a population. These
limitations impede one’s ability to participate fully and actively in the community, be part of the
decision-making process on issues affecting one’s life and have the opportunity to improve one’s
social and economic situation and status.
Discrimination can also impact negatively on mental health. Victims of discrimination are particu-
larly vulnerable to limitations in civil, political, economic, social and cultural rights that make it dif-
ficult for them to integrate into society and lead well-balanced and productive lives. The negative
repercussions of discrimination, along with the sense of alienation and discrimination itself, can
deeply affect a person’s dignity and self-esteem, which is detrimental to mental health and well-
being (Gostin, 2001).
The international human rights framework
International human rights instruments provide a useful and comprehensive framework for men-
tal health promotion. Key instruments within the UN system are known as the International Bill of
Rights. These comprise the Universal Declaration of Human Rights (UDHR) adopted in 1948 and
the International Covenant on Economic, Social and Cultural Rights (ICESCR) and International
Covenant on Civil and Political Rights (ICCPR), both adopted in 1966.
The latter two Covenants impose legally binding obligations upon Member States to respect, pro-
tect and fulfill the human rights contained within them. Importantly, these instruments have been
ratified by the vast majority of UN Member States. The UDHR, while not legally binding, represents
a consensus among the international community as to the basic human rights that must be pro-
tected. The provisions within it are widely accepted as representing international customary law.
The focus of discussion in this chapter is on the UN human rights system, though it is important
to note that there are also a number of other regional mechanisms and instruments protecting
human rights. Key examples include the European Convention for Protection of Human Rights
and Fundamental Freedoms (1950), the American Convention on Human Rights (1978) and the
African Charter on Human and Peoples’ Rights (1982; also known as the Banjul Charter).
As previously stated, the right to physical and mental health is recognized as a fundamental
human right to be afforded to all people. The Committee on Economic, Social and Cultural Rights,
which monitors the ICESCR, adopted a General Comment on the right to health at its twenty-
second session in 2000 (General Comment 14) in order to provide guidance to countries on the
meaning and requirements of implementing this right. In recognition that many people expe-
rience barriers to health and mental health services and care, the Committee states that health
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care services require adequate funding to ensure that health facilities, goods, services and pro-
grammes as well as health care professionals and essential medication are available in sufficient
quantity.
The Committee also underscores the importance of making health care services accessible. This
means that facilities, goods and services must be physically accessible (that is, within safe physical
reach for all sections of the population, including rural populations and vulnerable or margina-
lized groups), economically accessible (affordable to all based on the principle of equity) and
accessible to everyone without discrimination. Information on health matters must also be acces-
sible (that is, people have the right to seek, receive and impart information and ideas concerning
health issues).
Finally, the Committee stresses that health facilities must be acceptable and of good quality. In
other words, health facilities should be sanitary, respect medical ethics and the right to confiden-
tiality, be culturally, medically and scientifically appropriate and have medical personnel that are
adequately skilled.
These guiding principles are particularly pertinent to the mental health field if one considers
the numerous barriers to mental health care. The low priority of mental health on the agenda
of governments means that there is a paucity of mental health care services and essential medi-
cation in some countries. Mental health care facilities in many countries have poor standards of
treatment and care and inadequate living conditions. In certain countries health insurance com-
panies fail to provide people with adequate coverage for mental health treatment. The stigma
and discrimination associated with mental health also means that many people fail to seek the
treatment they require. These principles therefore represent important means for overcoming the
different barriers to care and thus for promoting the mental health of the population.
The international human rights framework also provides an effective tool to identify, analyse and
respond directly to the underlying determinants of mental health. Importantly, there is wides-
pread recognition that all human rights are interrelated, indivisible and interdependent (Vienna
Declaration and Programme of Action, 1993) and that the realization of the right to physical and
mental health is therefore reliant upon the realization of a range of other basic human rights. This
is reflected in Article 25 of the UDHR which states:
Everyone has the right to a standard of living for the health and well-being of himself
and his family, including food, clothing, housing and medical care and necessary social
services and the right to security in the event of unemployment, sickness, disability,
widowhood, old age or other lack of livelihood in circumstances beyond his control.
The Committee on Economic, Social and Cultural Rights reiterates the need for countries to con-
sider the underlying determinants of health and to adopt measures to promote a range of civil,
political, economic, social and cultural rights as contained in the International Bill of Rights. These
include the right to life, food, housing, work, education, participation, the enjoyment of the bene-
fits of scientific progress and its applications, non-discrimination, equality, prohibition against
torture, privacy, access to information, and freedom of association, assembly and movement.
Additionally, the Committee strongly emphasizes that the participation of the population in all
health-related decision-making processes, both at community and national level, is an essential
aspect of health and mental health promotion.
Freedom from discrimination is one of the fundamental principles of the international human
rights discourse. In relation to the right to health, it proscribes:
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… any discrimination in access to health care and underlying determinants of health, as
well as to means and entitlements for their procurement, on the grounds of race, colour,
sex, language, religion, political or other opinion, national or social origin, property,
birth, physical or mental disability, health status (including HIV/AIDS), sexual orientation
and civil, political, social or other status, which has the intention or effect of nullifying or
impairing the equal enjoyment or exercise of the right to health (General Comment 14).
Vulnerable groups
Certain groups within society, such as women, children and refugees, are at particularly high risk
of suffering from mental disorders and having their human rights overlooked or violated due to
marginalization and discrimination. The United Nations Special Rapporteur on the Right to Health
notes that discrimination is a social determinant of health:
Social inequalities fueled by discrimination and marginalization of particular groups,
shape both the distribution of diseases and the course of health outcomes amongst
those afflicted. As a result, the burden of ill-health is borne by vulnerable and margi-
nalized groups in society. At the same time, discrimination and stigma associated with
particular health conditions, such as mental disabilities and diseases like HIV/AIDS, tend
to reinforce existing social divisions and inequalities (Hunt, 2003).
Although the ICCPR and the ICESCR are designed to protect the basic human rights of all people
without exception, the international human rights discourse recognizes that particular attention,
and in certain instances particular measures, need to be adopted in order to address the deep-
rooted inequalities within society and to ensure that the rights of vulnerable groups are promo-
ted and protected. Therefore, in addition to the International Bill of Rights, the UN human rights
mechanism has a number of other legally binding instruments concerned with these groups, such
as the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW),
the Convention on the Rights of the Child (CRC) and the Convention Relating to the Status of
Refugees (CRSR).
Women around the world bear a disproportionate burden of poverty and human rights violations.
The unequal position they hold within society means that they often experience discrimination
in the fields of employment and education and in the exercise of their civil liberties. The unequal
power relationship between men and women also means that women are exposed to domestic
and sexual violence. These factors have been linked to a higher prevalence of certain mental
disorders such as depression and anxiety among women. The 2001 World Health Report notes
that “the traditional role of women in societies exposes them to greater stresses, as well as making
them less able to change their stressful environment” (WHO, 2001, p. 42).
In recognition of the particular vulnerability of women within society, CEDAW requires that coun-
tries adopt appropriate legislative and other measures, including special measures if necessary,
to eliminate discrimination and ensure the full participation of women in the political, social,
economic and cultural life of their community on equal terms with men. The Convention also
requires the enactment and effective enforcement of laws and the formulation of policies to
address domestic and sexual violence against women. Article 12 of CEDAW focuses specifically on
the right to health of women. General Recommendation 24 (adopted by the Committee on the
Elimination of Violence Against Women at its twentieth session in 1999), which aims to provide
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guidance to countries on the meaning and implementation of this article, emphasizes the need
to address the barriers that women face in accessing health services. It also acknowledges the
disproportionate susceptibility of women to mental health problems as a result of gender discri-
mination, violence, poverty, armed conflict, dislocation and other forms of social deprivation, and
indicates that countries need to take measures to ensure that health services are sensitive to the
particular needs and human rights of these women.
Minors also represent a vulnerable group and often lack the cognitive abilities and legal status to
make independent decisions concerning their own interests. Their emotional, social and econo-
mic environment can greatly influence their emotional and physical development. Minors in many
parts of the world live in impoverished conditions and have to work in poor and often hazardous
conditions in order to contribute to the income of the family, which may result in their being
denied educational opportunities. Also, minors are often denied the opportunity to express their
opinions on issues concerning them, including health-related matters. Contrary to popular belief,
mental and behavioural problems are common among children (WHO, 2001) and result in signi-
ficant harm and suffering to both children and families. Because many of the disorders are not
detected, these problems remain and are often further exacerbated in adulthood.
The UN Convention on the Rights of the Child specifically acknowledges that an adequate stan-
dard of living is fundamental to promoting children’s physical, mental, spiritual, moral and social
development (Article 27), and sets out a range of rights that require particular attention and pro-
tection. These include the protection from all forms of physical and mental abuse; non-discrimi-
nation; the right to life, survival and development; consideration of the best interests of the child;
and respect for the views of the child. The Convention stresses the need for children to be protec-
ted from any work that is likely to be hazardous or interfere with their education, in recognition
of the particularly detrimental effects that this can have on their physical and mental health, well-
being and development (Article 32). Finally, it makes specific reference to the right of children
with mental disabilities to enjoy a full and decent life in conditions that ensure dignity, promote
self-reliance and facilitate the child’s active participation in the community (Article 23).
People who have been exposed to genocide, ethnic cleansing, war-related violence, persecution,
repression and other life-threatening situations, such as refugees, forced migrants or displaced
people, represent a particularly vulnerable group. In addition to the trauma that they may have
suffered in the past, other risk factors exacerbate or contribute to poor mental health among
these people including chronic unemployment, poverty, starvation, racial discrimination, lack of
access to medical care, poor physical health, lack of safe and affordable housing, marginalization,
social isolation and absence of family and community networks and social support structures
(Jablensky et al., 1994; Jaranson, Forbes Martin & Ekblad, 2000).
The UN Convention Relating to the Status of Refugees represents one of the key instruments pro-
tecting the rights of refugees and other stateless people. These people are not in their country of
origin and are often not afforded the same rights as the nationals of the country they are in. The
Convention therefore sets out a range of civil, political, economic, social and cultural entitlements.
These include the rights to freedom from discrimination; freedom of religion, association and
movement; and access to courts, gainful employment, housing and education as well as property
rights. Refugees and other stateless people are also offered protection under humanitarian law
(namely, the 1949 Geneva Conventions). Though humanitarian law has different origins and uses
different mechanisms of implementation, it shares a fundamental common objective to that of
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human rights law, that is, the respect for human dignity without any discrimination whatsoever as
to race, colour, religion, sex, birth, wealth or any similar criteria (WHO, 2002).
Finally, people with mental disorders are also particularly vulnerable to human rights violations.
Violations can often occur in psychiatric institutions through inadequate, degrading and harmful
care and treatment practices as well as unhygienic and inhuman living conditions. Violations can
also occur outside the institutional context. The stigma, myths and misconceptions associated
with mental disorders negatively affect the day-to-day lives of people with mental disorders
leading to discrimination and the denial of even the most basic rights. People all over the world
experience limitation in the fields of employment, education and housing due to their mental
disorder (WHO, in press). As we have seen, this stigma and discrimination can in turn impact on a
person’s ability to gain access to appropriate care, integrate into society and recover from illness.
Any effort towards the promotion of the mental health of the population as a whole necessarily
entails the promotion and protection of the needs and interests of people with mental disorders.
To date, however, the UN human rights framework does not comprise a legally binding interna-
tional instrument dealing specifically with the rights of people with mental disorders. However,
people with mental disorders are commonly considered as part of the larger group of people
who are disabled for any reason, including physical, intellectual, sensory and psychiatric disability.
The UN has a Global Programme on Disability. This stems from the World Programme of Action
Concerning Disabled Persons, adopted by the UN in 1982, and the Standard Rules on Equalization
of Opportunities for Persons with Disabilities, adopted in 1993. In 2001, a process was begun
towards the development of a UN convention on the rights and dignity of people with disabilities;
this process is ongoing at the time of writing. Key to the process is the emphasis on full participa-
tion by people with disabilities in all aspects of society.
It is important, though, not to consider people with mental disorders only under special catego-
ries. Indeed, by virtue of their humanity, people with mental disorders are entitled to all the same
basic rights and protections found within the articles of different binding instruments such as
the ICESCR and ICCPR as people without mental disorders. The adoption of the UN Principles for
the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care (the
MI Principles) in 1991 reflected a growing consensus that there are a number of issues and con-
cerns in relation to the rights of people with mental disorders that require special consideration
by governments, however. Important ethical standards underpinning the provisions of the MI
Principles include the promotion of individual independence and social integration, the right to
treatment that enhances individual autonomy, rights related to standards of care and treatment
including involuntary admission and consent to treatment, the right to be treated in the least
restrictive environment and with the least restrictive or intrusive treatment, the right to protection
of confidentiality, the right to live and work in the community and the right to community care.
The question of how to implement the rights required to promote mental health remains an
enormous challenge in the light of political instability and severe financial and human resource
constraints faced by many countries. Undeniably, governments are often faced with hard choices
in terms of prioritizing different health and development issues, and historically mental health has
been a poor contender in such decisions. In addition, many countries use the lack of resources as
an excuse to avoid taking responsibility for implementing human rights.
In recognition that the realization of the right to health is likely to require reform, restructuring,
investment and planning on the part of governments, and consequently cannot be achieved
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overnight, the Committee on Economic, Social and Cultural Rights provides for the progressive
realization of the right to health (General Comment 14, adopted at the twenty-second session in
2000). This requires countries to take expeditious, deliberate, concrete and targeted steps towards
the realization of this right, and to ensure that all available resources are used equitably and judi-
ciously (General Comment 3, adopted at the fifth session in 1990). The Committee emphasizes
that even in times of severe resource constraints vulnerable members of society must be protec-
ted by the adoption of relatively low-cost targeted programmes. The Committee also states that
countries must adopt all appropriate means to put human rights into effect. This may include for-
mulation and implementation of health and other relevant social policies and programmes, and
in particular “the adoption of legislative measures”.
As an example, a number of countries have used the UN Principles for the Protection of People
with Mental Illness as a guide to promoting the rights of people with mental disorders. Mexico,
Hungary, Costa Rica, Portugal and Australia, for example, have incorporated the Principles in
whole or in part into their own domestic laws. Other countries, such as Nicaragua and Costa Rica,
have used the Principles as a guide for the development of their mental health policies (WHO,
2003). The fact remains, however, that countries still need encouragement and assistance to adopt
international standards that will lead to the promotion of mental health.
Conclusion
A climate that respects and protects basic civil, political, economic, social and cultural rights is
fundamental to the promotion of the mental health of the population. Without the security and
freedom provided by these rights it is very difficult to maintain a high level of mental health
(Gostin, 2001).
A human rights framework offers a useful tool for identifying and addressing the underlying
determinants of mental health. The instruments which make up the UN human rights mechanism
represent a set of universally accepted values and principles which can serve to guide countries in
the design, implementation, monitoring and evaluation of mental health policies, laws and pro-
grammes. As legal norms and standards ratified by governments, they generate accountability for
mental health and thus also offer a useful standard against which government performance in the
promotion of mental health can be assessed.
Human rights empower individuals and communities by granting them entitlements that give rise
to legal obligations on governments. They can help to equalize the distribution and exercise of
power within society, thus mitigating the powerlessness of the poor (WHO, 2002). The principles of
equality and freedom from discrimination, which are integral elements of the international human
rights framework, demand that particular attention be given to vulnerable groups. Furthermore,
the right of all people to participate in decision-making processes, which is reflected in the
International Bill of Rights and other UN instruments, can help to ensure that marginalized groups
are able to influence health-related matters and strategies that affect them and ensure that their
interests are considered and addressed.
Mental health promotion is not solely the domain of ministries of health. It requires the action
and involvement of a wide range of sectors, actors and stakeholders. Human rights encompass
civil, cultural, economic, political and social dimensions and thus provide an intersectoral fra-
mework to consider mental health across the wide range of mental health determinants.
88 • PROMOTING MENTAL HEALTH
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Chapter 8 • Responding to the Social and Economic Determinants
of Mental Health: A Conceptual Framework for Action
Lyn Walker, Irene Verins, Rob Moodie, Kim Webster
Introduction
Global attention is now focused on the development of strategies to reduce mental ill-health and
promote mental health and well-being. As indicated in Chapter 1, this phenomenon has occurred
for a number of reasons. We now know that the global burden of mental ill-health is increasing, is
well beyond the treatment capabilities of all countries and is linked to adverse social and econo-
mic changes that are enduring and unacceptable (VicHealth, 1999).
We also know that mental ill-health is more common among people with relative social disadvan-
tage (Desjarlais & Kleinman, 1997). A focus on social and economic determinants of mental health
in our health promotion efforts should not only result in lower rates of some mental disorders and
improved mental health but also improved physical health, educational and work performance,
relationships and community safety. Thus, as indicated in Chapter 2 in terms of health promotion
overall, the promotion of mental health and well-being is as much an emerging political project
as a health project (Mittelmark, 2003).
Conceptual and practice frameworks to progress work in the promotion of mental health and
well-being have been developed over the last decade in a number of countries, including Finland,
the United Kingdom and New Zealand. In this chapter we present a framework that has been
developed by the Victorian Health Promotion Foundation (VicHealth) in Australia to address the
key socioeconomic determinants of mental health. Through examining three of these determi-
nants, we present concepts, emerging evidence and examples of practice which indicate the role
that varying sectors can play and the partnerships that can be created to promote mental health.
The process of developing and using the framework is similar to that found in other fields of
public health and health promotion as outlined in Chapter 2.
The VicHealth framework to promote mental health and well-being
At the International Primary Health Care Conference held in Alma-Ata in 1978 a declaration was
made in which health was reaffirmed as a human right, the role of social and economic sectors
in promoting health was illuminated and health inequalities were termed politically, socially and
economically unacceptable. The ensuing Alma-Ata Declaration and Ottawa Charter for Health
Promotion introduced a social model of health promotion that is now a common feature of health
promotion practice (see Chapters 1 and 2).
Robertson and Minkler (1994) suggest that some two decades since the development of the
influential Ottawa Charter, prominent features of contemporary health promotion include:
■ broadening the definition of health and its determinants to include the social and economic
context in which health or ill-health is produced;
■ going beyond the earlier emphasis on individual lifestyle strategies to achieve health to broa-
der social and political strategies;
■ embracing the concept of empowerment, individual and collective, as a key health promo-
tion strategy; and advocating for the participation of the community in identifying health
problems and strategies for addressing those problems.
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Figure 8.1
VicHealth’s framework for the promotion of mental health and well-being
Key Determinants of Mental Health & Themes For Action
Social inclusion
Freedom from
Economic participation
discrimination & violence
■ Supportive relationships
■ Valuing of diversity
■ Work
■ Involvement in group
■ Physical security
■ Education
activities
■ Self-determination and
■ Housing
■ Civic engagement
control of one’s life
■ Money
Í
Population Groups & Action Areas
Population groups
Health promotion action
■ Children
■ Research, monitoring & evaluation
■ Young people
■ Individual skill development
■ Women and men
■ Organisational development
■ Older people
■ Community strengthening
■ Indigenous communities
■ Communication & marketing
■ Culturally diverse communities
■ Advocacy of legislative & policy reform
■ People who live in rural communities
Í
Sectors & Settings for Action
HOUSING
COMMUNITY
EDUCATION
WORKPLACE
SPORT, ARTS &
HEALTH
RECREATION
TRANSPORT
CORPORATE
PUBLIC
ACADEMIC
LOCAL GOVT
JUSTICE
Í
Intermediate Outcomes
Individual
Organisational & Community
Societal
Increased sense of:
■ Accessible and responsive
■ Integrated & supportive
organisations
public policy & programmes
■ belonging
■ Safe, supportive & inclusive
■ Strong legislative platform
■ self-esteem
environments
■ Resource allocation
■ self-determination
& control
Í
Improved Mental Health
Í
Long-term Benefits
Less anxiety & depression
Improved productivity at work,
Reduced health inequalities
Less substance misuse
home & school
Improved quality of life & life
Improved physical health
Less violence & crime
expectancy
Source: VicHealth 1999.
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It was in this context that VicHealth developed its framework for the promotion of mental health
and well-being (VicHealth, 1999).
As shown in figure 8.1, the framework begins with acknowledgement of three key determinants
of mental health: social inclusion, freedom from discrimination and violence, and access to eco-
nomic resources. Health promotion actions that address these determinants can be carried out
with different populations, through involvement with different sectors and in varying settings.
Health promotion methodologies are used to secure intermediate outcomes (increased sense of
belonging; safe, supportive and inclusive environments; accessible and responsive organizations;
supportive and integrated public policy; and a strong legislative platform). These are expected to
result in improved mental health as well as less substance misuse, improved physical health and
productivity and other longer-term outcomes.
Key aspects of the framework
An intersectoral approach
A central challenge for moving public mental health forward will be to shift the debate
about mental health away from a singular focus on the health sector to a focus on areas
such as employment, education, transport, housing, criminal justice, welfare and the built
environment (Friedli, 2002, p. 1).
The contribution that health promotion can make in the area of mental health is currently misun-
derstood and sometimes contested. This is not a new phenomenon if we recall that some 30 years
ago a medical model of health informed management of heart disease with little acknowledge-
ment of the role that those working in areas such as physical activity, tobacco control and nutri-
tion could play in promoting heart health and preventing heart problems. Some three decades
later the contribution of these sectors in the promotion of heart health and the prevention of
heart disease is well evidenced and acknowledged (see Chapter 2).
In the area of mental health we stand at a crossroad where medical concepts of health are the
prevailing paradigm but emerging evidence is now indicating that, as in the case of heart heath, a
major contribution to the promotion of mental health and the prevention of mental ill-health will
be made by those working outside the health system.
Thus, given the relationship between social and economic factors and mental health, success in
promoting mental health and well-being can only be achieved and sustained by the involvement
and support of the whole community and the development of collaborative partnerships with a
range of agencies throughout the public, private and nongovernment sectors. Mental health pro-
motion needs to occur within the health sector and in all other sectors that influence the way in
which people live, love, are educated and work (Walker & Rowling, 2002).
Use of multiple and mutually reinforcing health promotion methodologies
Health promotion has a strong history in the use of multiple and complementary methods. If we
apply health promotion theory to mental health these methods are likely to include:
■ research and evaluation to build the evidence for mental health promotion and assess the
effectiveness of strategies;
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■ developing the capacity of communities and organizations to implement strategies that
increase participation in a range of social, educational and economic activities and create safe
and supportive environments;
■ supporting community development approaches which increase levels of civic engagement
and assist communities to articulate priority areas for action;
■ developing education and training programmes to strengthen understanding of mental
health promotion theory and practice across sectors and to ensure there is a trained and
skilled workforce to promote mental health and well-being;
■ communicating about mental health promotion issues through local, regional and national
media and avenues such as community meetings, conferences and forums; and
■ advocating for policy and programme development, resource allocation and legislative and
regulatory reform.
A focus on social and economic determinants
It is predicted that the continuing decline of social cohesion over the next two decades will be
reflected in high levels of structural unemployment, an increase in part-time, insecure and low
paid employment, a widening gap between rich and poor, demographic shifts, technological
progress, open trade and greater competition in less constrained market places (Murray, 2001;
Zubrick et al., 2000). This rapid economic and social change could translate into relationship and
family breakdown, child abuse, early school failure, depression, suicide, alcohol and drug misuse,
teenage pregnancy and violence, with serious negative effects on the development of mental
health and well-being of children and young people (Zubrick et al., 2000).
As many of the chapters in this book indicate, our knowledge of the determinants of mental
health is growing. There is also consensus among authors that some of the major determinants of
mental health are located within social and economic domains and include:
■ social inclusion and access to supportive social networks;
■ stable and supportive family, social and community environments;
■ access to a variety of activities;
■ having a valued social position;
■ physical and psychological security;
■ opportunity for self-determination and control of one's life; and
■ access to meaningful employment, education, income and housing.
The evidence suggests that these determinants are also common to alcohol and drug use
(Resnick et al., 1997), crime (Homel, 2001), dropout from school and reduced academic achieve-
ment (Zubrick et al., 2000). It is therefore reasonable to assume that the development of strategies
designed to address the socioeconomic determinants of mental health could also have a positive
impact in other domains.
The three major determinants of mental health that inform the VicHealth framework – social
inclusion, freedom from discrimination and violence and economic participation – are discussed
further below.
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Increasing social inclusion
Concepts
A socially inclusive society is defined as one where “all people feel valued, their differences
are respected, and their basic needs are met so they can live in dignity”. Social exclusion is
the process of being shut out from the social, economic, political and cultural systems which
contribute to the integration of a person into the community (Cappo, 2002).
Social inclusion for an individual means access to supportive relationships, involvement in group
activities and civic engagement. Social networks can provide social support, social influence and
opportunities for social engagement and thus create meaningful roles, resources and opportuni-
ties for intimate one-on-one contact. The impact on mental health can occur through two mecha-
nisms: either as a main effect influence in which social networks have a beneficial effect on mental
health regardless of whether or not the individuals are under stress, or as a stress buffer, in which
social networks improve the well-being of those under stress by acting as a buffer or moderator of
that stress (Kawachi & Berkman, 2001).
Evidence
There is strong epidemiological evidence of significant and persistent correlations between poor
social networks and mortality and ill-health from almost every cause of death (Berkman & Glass,
2000; Seeman, 2000). Social isolation and lack of social support are linked with increased likeli-
hood of heart disease, complications in pregnancy and delivery and suicide (Syme, 1996).
In relation to heart health, an expert working group of the National Heart Foundation of Australia
reviewed evidence relating to major psychological risk factors to assess whether there are inde-
pendent associations between these and the development of coronary heart disease. They
concluded that there is strong and consistent evidence of an independent causal association
between depression, social isolation and lack of quality social support and the causes and pro-
gnosis of this disease (Bunker et al. 2003). The links between physical health and mental health
are discussed further in Chapter 11.
A lack of social connections and networks is also associated with poor mental health. In a study
conducted by the Centre For Adolescent Health in Australia, young people who reported having
poor social connectedness (defined in this case as not having someone to talk to, someone to
trust, someone to depend on and someone who knows you well) were two to three times more
likely to experience depressive symptoms than peers who reported the availability of confiding
relationships (Glover et al., 1998). Similarly, a meta-analysis of routinely collected data about USA
college students from 1952 to 1993 found correlations between a rise in anxiety and reduced
social connections (Twenge, 2000).
As indicated elsewhere in this volume, greater levels of community participation, social support
and trust in others have been associated with lower crime figures, higher educational achievement,
better economic growth and reduced experience of psychological distress (Berry & Rickwood,
2000; see also Chapter 10). Positive mental and physical health benefits of social interaction are
also well-documented for specific population groups, such as older adults (Seeman, 2000).
Practice
While information about these global associations and impacts can be overwhelming and leave
many of us wondering what can be done in our own sphere of influence, it is clear that we can
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facilitate social inclusion at the local level. Evaluation of local interventions then leads to greater
understanding about what works as well as growth of the evidence base for causal associations.
The overall aim of this practice is to build the capacity of organizations and communities to cons-
ciously and systematically increase opportunities for participation and belonging: to build a cons-
ciousness of health into planning, programmes and policy. This can involve, for example, working
at the community level to ensure that the built environment does not isolate people from one
another or conversely cause overcrowding. It can also involve strategies at the organizational level
that increase access to participation in groups, associations and networks.
Because vulnerability to ill-health is not equally distributed in the population but rather modera-
ted by gender, socioeconomic position and stage in life (Kawachi & Berkman, 2001), few reviews
thus far have identified population-wide interventions that seek to promote mental health or pre-
vent depression and anxiety by building social networks or enhancing existing social networks.
Most social support interventions have rather focused on “at risk” populations (Rychetnik & Todd,
2004). A large body of work focuses on such targeted social inclusion activity which involves spe-
cific individuals, groups or neighbourhoods likely to be affected by multiple forms of economic,
social or environmental deprivation; deals with the causes of deprivation rather than (or as well
as) its symptoms; and works in partnership with local people or communities of interest. Examples
of such evidence can be found at the website of the Centre for Economic and Social Inclusion
(www.cesi.org.uk/_newsite2002).
The following are two examples of this approach.
Urban design in San Francisco – The tale of three streets
Three streets in San Francisco were studied, looking at the traffic passing and the level of
connectedness and safety as perceived by the residents. One (heavy street) had approxi-
mately 16 000 cars per day, one 8000 per day and one (light street) 2000 per day. Those
living on light street had three times as many friends among their neighbours as those on
heavy street. The light street was perceived to be friendly and safe for kids, whereas the
heavy street residents kept to themselves and there was little sense of community (Dora &
Phillips, 2000).
This study shows how local government planning can create environments that increase
access to social relationships.
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The Walking School Bus
A study of more than 1000 children in Australia found that almost three out of every
four children were driven to school, although a significant proportion preferred to walk
(VicHealth, 2003b). Most children who did walk to school identified the social aspect of
the activity as the most important, describing it as a fun activity which gave them a sense
of freedom and independence and feelings of better health.
The Walking School Bus concept is a simple one: a group of children walk to and from
school under the supervision of adult volunteers.
Through this process:
■ children engage in regular physical activity;
■ traffic congestion and pollution outside and around schools is reduced;
■ children become more familiar with their community and are provided with the oppor-
tunity to develop and improve road safety and pedestrian skills; and
■ cooperative relationships between local government, primary schools, families and the
community are established that facilitate a positive sense of community and increase
the opportunities for the children and project supporters to access social networks.
Reducing discrimination and violence
Concepts
Discrimination and violence perpetrated on the basis of gender, cultural or religious background,
sexual identity, political beliefs, health status or level of ability is one of the most enduring cha-
racteristics of humanity. The health effects of discrimination resulting in extreme violence were
obvious in Nazi Germany, in Aboriginal lands in Australia, in the killing fields of Cambodia and in
the lives of women from across the globe (Walker, Moodie & Herrman, 2004).
Racial discrimination is present if there is:
■ under-representation of minority group members in the media;
■ reinforcement of negative stereotypes in the reporting of conflicts involving minority groups;
■ continuing restrictive immigration policies;
■ limitations in access to education and employment for minority group members; and
■ limitations in access to adequate standards of health, housing and basic infrastructure
(Sanson et al., 1998).
Violence is defined as “the intentional use of physical force or power, threatened or actual, against
oneself, another person or against a group or community, that either results in or has a high like-
lihood of resulting in injury, death, psychological harm, maldevelopment or deprivation” (WHO,
1996). The World Report on Violence and Health divides violence into three broad categories,
according to who commits the violent act:
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■ self-directed violence, which encompasses suicide and self abuse;
■ interpersonal violence, which is divided into two main categories: family or intimate partner
violence and community violence which takes place in settings such as schools and workpla-
ces, including sexual assault by strangers; and
■ collective violence, which takes a variety of forms including armed conflict, repression and
human rights abuses (WHO, 2002).
The report comprehensively maps the etiology of violence across all population groups and notes
the dimension of the problem, referring to surveys from around the world indicating that 10–60%
of women report being physically assaulted by an intimate partner at some point in their lives.
In some countries, one in four women report sexual violence by an intimate partner and up to
one third of girls report forced sexual initiation. Hundreds and thousands more are forced into
prostitution or subjected to violence in other settings such as schools, workplaces and health care
institutions (WHO, 2002).
Evidence
Community and population level studies focused on racial discrimination have consistently
shown an association between higher rates of self-reported discrimination and poorer mental
health (Krieger, 2000). For example, there are proven associations between racial discrimination
and diminished sense of well-being, low self-esteem, lack of control or mastery, psychological dis-
tress, and depression, anxiety and other mental illnesses (Brown et al., 2000; Kessler, Mickelson &
Williams, 1999; Williams & Williams-Morris, 2000; Williams, Neighbours & Jackson, 2003).
Evidence indicating a relationship between the experience of interpersonal victimization and
adverse mental health outcomes is strong. For example, women who have experienced interper-
sonal violence have high rates of depression, anxiety, stress, pain syndromes, phobias and chemi-
cal dependency as well as poor subjective health (WHO, 2002).
A study into the burden of disease associated with violence perpetrated against women in intima-
te relationships found that intimate partner violence constituted the highest risk factor for poor
health in Australian women aged between 15 and 45 years. Mental illnesses such as anxiety and
depression were the most significant resulting health burden (VicHealth, 2004).
Research has also linked poor mental health with interpersonal victimization in the form of bul-
lying. Trauma from bullying has been associated with depression, low self-esteem, poor self-con-
cept, loneliness and anxiety (Hawker & Boulton, 2000). A Victorian study of 14–15 year olds found
that students with a history of victimization were two to three times more likely to be depressed
than other students (Bond et al., 2001).
Practice
Interventions at the societal level are the most effective mechanisms for reducing discriminating
attitudes and behaviours (Rychetnik & Todd, 2004). Examples of this include racial vilification
legislation designed to combat discrimination on the basis of race or ethnicity, sexual harassment
complaint procedures designed to combat discrimination on the basis of gender and codes of
conduct. While legislative reform alone will not make substantial changes where discrimination
is rife, combined with widespread communication strategies its effects can be significant. The fol-
lowing practice example illustrates this point.
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If racism wins, sport loses
To combat racism on sporting fields in Australia, government authorities have worked
with peak sporting organizations to develop codes of conduct to indicate behaviours that
are deemed unacceptable and the penalties that will be applied if these behaviours exist
and resource material to assist sporting organizations to manage racism within their clubs.
A widespread communication and marketing campaign designed to increase awareness
of the damage caused by racism within the sporting environment was also developed.
Due to the very visible and public nature of sport in Australia, in the longer-term it is likely
that these developments will enhance notions of fair play and teamwork within sporting
clubs and help to build positive attitudes and behaviours at the broader community level.
Such combined approaches to legislative reform and widespread communication can be
implemented to address key determinants of mental health and well-being at the orga-
nizational and broader community level. (Further information is available at http://www.
voma.vic.gov.au.)
While legislative reform and large-scale communication strategies are among the most powerful
mechanisms for changing discriminatory attitudes and behaviours at a societal level, they are
also the most costly. Consequently, in recent years other common approaches to discrimination
reduction have targeted individuals and groups and have been based on the “contact hypothesis”
(Oskamp, 2000). This hypothesis centres on the premise that prejudice is largely derived from
ignorance and that one of the major means of reducing inter-group prejudice is through contact
between groups under optimal conditions.
Pettigrew and Tropp (2000) conducted a review of prejudice reduction programmes based on
inter-group contact. A meta-analysis was performed of 203 individual studies combining 90 000
subjects from 25 nations. An inverse relationship between contact and prejudice was found in
94% of these studies. They concluded that inter-group contact should be a critical component
of any successful effort to reduce discrimination. They identified six issues relevant to achieving
optimal contact. First, programmes to reduce prejudice should incorporate four elements: equal
status between the groups in the situation; cooperative activity towards common goals; persona-
lized acquaintance, that is, perception of common interests and common humanity; and support
for the contact by authorities. Second, the perspectives of both in-group and out-group members
must be considered. Third, the contact should be designed to improve several components of pre-
judice, such as beliefs, social distance and stereotypes. Fourth, contact in work and organizational
settings has stronger effects than those typical of travel and tourism settings. Fifth, it is important
to actively create situations that counter prevailing negative stereotypes. Finally, social-structural
changes in institutional settings are necessary to provide opportunities for optimal inter-group
contact on a scale sweeping enough to make a societal difference; although such changes are
typically resisted by powerful minorities. The following intervention is an example of the contact
hypothesis in practice.
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Addressing discrimination through the Arts
The Torch Project is a community building initiative designed to address racial discrimina-
tion in rural and regional areas of Victoria. Artists working alongside young people from
Indigenous and mainstream communities develop theatre pieces that explore issues of
discrimination, violence and widespread oppression. The young people work together
in development of the work which culminates in a performance attended by community
members. Individual assessments indicate that through the contact facilitated by the
Torch project understandings between participants are forged and friendships made.
Issues around discrimination and violence are also communicated to the audience, which
has prompted community dialogue at a broader level. (More information on the Torch
project is available at http://thetorch.asn.au/.)
A vast literature also indicates the systematic changes – cultural, political and social – that are nee-
ded to alter well-entrenched patterns of violence, especially violence against women (Rychetnik
& Todd, 2004). While prejudice is often closely tied to ignorance, evidence indicates that violence
linked to discrimination has its roots in social-structural relationships with a power imbalance
between groups being the dominant feature. This is often the case in relation to racial and gende-
red violence. Thus, a range of strategies designed to address institutionalized violence is required.
An example of a community development approach to this issue is the Comprehensive Rural
Health Project (CRHP) in India which is discussed in detail in Chapter 18 and outlined below.
Comprehensive Rural Health Project (CRHP), Jamkhed, Maharashta, India
In order to respond to the primary health care needs of rural Indian communities, local
women were provided education, training and support to assist them to develop skills
to respond to presenting health issues. The women were then able to make a significant
contribution to the health of their families, neighbours and friends. Over time, the women
developed the confidence to step outside the traditional confines of their roles as wives
and mothers to explore economic development activities that would also benefit their
communities. Their value at the community level increased and with this came a marked
decrease in the level of domestic violence perpetrated against them.
Through such community development approaches power imbalances can be addressed
with a resulting reduction in discrimination and consequent levels of violence.
Increasing economic participation
Concepts
Economic participation is not simply a question of full employment. It includes a continuum
ranging from adequate employment (e.g. secure, appropriately paid, good job satisfaction) to
inadequate employment, through to unemployment (Dooley, Prause & Ham-Rowbottom, 2000) as
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well as access to the money and education necessary to feed, clothe and house one’s self and to
participate in community life.
Evidence
Research consistently finds that mental health is relatively poor among those with low education
levels, low-status occupations and low incomes (Astbury, 2001, cited in VicHealth, 2004; Schwabe
& Kodras, 2000; WHO, 2000) and among unemployed people and those with job insecurity (Creed,
Machin & Hicks, 1999; Power et al., 2000).
Occupying a low social rank also limits access to material and psychosocial resources and affects
individuals’ autonomy and decision-making over severe life events. Both of these factors have
consistently been associated with an increased risk of depression (WHO, 2000). These factors can
also have a flow-on effect from one generation to another. For example, recent work by Zubrick
and colleagues indicates that children of unemployed parents have higher incidences of mental
health problems and lower academic competence than children with working parents (Zubrick et
al., 2000 in Walker & Rowling, 2002; see also Chapter 12).
Children living in low socioeconomic status households and disadvantaged neighbourhoods
suffer more anxiety, depression, substance abuse, delinquent behaviour and poor adaptive
functioning. Children living in low socioeconomic status circumstances are also more likely to
be exposed to multiple adverse events and experiences (acute and chronic) which can have a
cumulative effect on their long-term mental health (Bradley & Corwyn, 2002; McMunn et al., 2001;
Power et al, 2000).
The link between low socioeconomic status, unemployment, income insecurity and mental ill-health
is well established. In an era characterized by downsizing, reductions in benefits, globalization, use
of temporary workers and welfare reform there is a need to continue to document and understand
the impact of economic and social policies on the mental health of populations and subpopulations
(Kaplan & Lynch, 1997).
We need to ensure that fewer people fall and that they fall less far. Societies that enable all their citi-
zens to play a full and useful role in the social, economic and cultural life of their society will be heal-
thier than those where people face insecurity, exclusion and deprivation (Wilkinson & Marmot, 1998).
Practice
A comprehensive approach to promoting mental health would ideally address the socioeconomic
conditions that exacerbate poor mental health such as low income, low literacy, limited educa-
tion, insecure employment, stressful work conditions or unemployment, poor quality housing,
violent and run-down neighbourhoods, and social and political disenfranchisement.
While stabilizing global economies and increasing national rates of employment is not within the
scope of localized mental health promotion activity, it is possible to undertake research into the
mental health impacts of government policies and programmes across jurisdictions. It is also possi-
ble to develop the skills required for employment and to create enterprise opportunities for people
and communities at the local level. This can be achieved through a range of health promotion stra-
tegies including legislative control, advocacy and organizational and community capacity building.
The following examples show the role that intersectoral collaboration can play in this area.
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Whitelion project
In this project, partnerships have been developed between juvenile youth correction faci-
lities and private industry to secure supportive employment experiences for young people
being released back into the community from detention. Through this process workplaces
are provided with guidance to ensure optimal support for the young people employed,
the skills of the young people are enhanced, contact with mainstream society is initiated,
self-confidence develops and the likelihood of re-offending is lessened. (More information
is available at http://www.whitelion.asn.au.)
This project shows how partnerships developed between public organizations and private
industry can create opportunities where mental health and well-being can flourish.
Urban renewal programme
A 5.5 million pound, five-year housing renewal programme (1992–1998) in Newcastle
upon Tyne in the UK was used as an opportunity to research the health effects of poor
housing and to evaluate the effectiveness of housing improvement. The intervention
comprised environmental improvements, external repairs, refurbishment, demolition of
void dwellings, renovation grants for individual dwellings and improvements to security
and road safety. Psychological distress showed significant decline (a fall of 10% in adults
with one or more mental health problems in cross-sectional data and a 50% reduction in
adults having “trouble with nerves” in longitudinal data). The prevalence of smoking was
halved on both cross-sectional and longitudinal samples (Blackman et al., 2001).
The framework in action: mental health promotion in refugee communities
Over the past four years, the VicHealth framework has been applied to guide development of
mental health promotion programmes at population and subpopulation levels. These program-
mes have been designed to respond to the socioeconomic determinants of mental health, use the
full range of contemporary health promotion methods and be implemented by people working
across sectors and disciplines. The following description of VicHealth’s approach to mental health
promotion in refugee communities shows how the framework operates in practice.
Reasons for focusing on refugee communities
There are currently over 17 mil ion refugees and displaced persons global y, with forced human move-
ment becoming a major issue for many countries, both developed and developing (UNHCR, 2004).
As indicated in Chapter 7, fundamental solutions to this problem lie in efforts to address the
root causes of conflict, violence and human rights abuses. However, for the foreseeable future
there will be a large number of people for whom repatriation is not a viable option and who will
face the challenge of integration in their countries of asylum or resettlement in a third country
(UNHCR, 2002).
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While the countries receiving refugees and asylum seekers are diverse, a large body of evidence
indicates that there are a number of common negative social and economic influences on men-
tal health in the asylum and resettlement environments (Chung et al., 2001; Dyregrov, Gjesta &
Raundelen, 2002; Gorst-Unsworth & Goldenberg, 1998; Hyman, Beiser & Vu, 2000; Silove et al.,
1997). These include hostility and racism in the receiving community as well as limited access to
basic economic resources such as housing and income, key cultural, legal and economic institu-
tions, and family and community support (VicHealth, 2003a). These exposures can compound the
existing vulnerability resulting from the exposure to deprivation, conflict and social and economic
exclusion commonly preceding forced movement (Silove et al., 1997; Thomas & Lau, 2002).
As a signatory to the UN Convention, Australia, alongside many developed and developing coun-
tries, is a destination for asylum seekers and offers a formal resettlement programme in coope-
ration with the United Nations High Commissioner for Refugees (UNHCR). A large proportion of
these entrants come to Victoria, where VicHealth has worked with government and nongovern-
ment organizations and mainstream and refugee communities to promote mental health and
well-being in the new arrival population.
Programmes developed under the framework
A number of programmes have been developed under the framework to promote the mental
health and well-being of refugee communities in Victoria. A selection of these is described in the
box below.
Research: involving the academic sector
The Centre For Refugee Health is conducting a longitudinal study into the settlement
experience of young refugees. This research will investigate the settlement experiences
that have positive and negative mental health impacts on young people and their fami-
lies, and the policy, legislative and organizational reforms required to promote mental
health and well-being among this population group.
Policy and programme reform: involving local government and communities
Australia has seen an increasing trend towards migrant and refugee settlement in rural
areas where there are better employment opportunities, a trend supported by govern-
ment. Keen to ensure that policy development in this area not only takes account of
employment issues but also the need for an inclusive and supportive environment,
VicHealth has commissioned research to assess the mental health impact of this emerging
policy and to evaluate two rural refugee relocation programmes being conducted by local
government authorities. The evaluation will identify good practices that can be used to
inform future government policy development and implementation.
Community development: involving refugee communities and education and business
sectors
Melbourne’s African communities were supported by an adult migrant education service
to develop a community newspaper. In addition to providing participants with tangible
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skills to enhance their future employment prospects, the newspaper has strengthened the
communities by improving access to information vital to positive resettlement and promoting
communication both within the communities and between them and the mainstream
community and business networks. It has also helped to build a positive African-Australian
community identity. The newspaper is developed in six languages and is currently working
towards sustainability through attracting advertising fees from small businesses.
Community enterprise: involving refugee and mainstream communities, education and
business
Through onsite education and support, older African men opened their own carpentry
business, the United Wood Cooperative. This has led to the development of supportive rela-
tionships and acquisition of English language, carpentry, marketing and business manage-
ment skills. This has facilitated increased levels of self-esteem, mutual reliance, productivity
and family and community pride in their achievement. Those providing mentoring assistance
have also experienced a sense of purpose through their contribution. The cooperative now
provides traineeships to young men and partnerships are being formed with the business sec-
tor. Thus, community and organizational capacity building is being achieved
Organizational development: involving the education sector
As well as an important context for the building of social connections, progress in the edu-
cation system influences refugee young people’s access to current and future economic
resources. Partnerships have been developed with Victorian schools and technical colleges to
enhance their responsiveness to the needs of refugee children and young people. Activities
have included policy and curriculum development, group programmes and piloting of alter-
native approaches to education and training. The resulting changes to educational settings
have been embedded in their ongoing practice.
Workforce development: involving the sports sector
Sports settings are important for the development of social connections between young peo-
ple and between them and significant adults. They may also be sites for discrimination and
exclusion. The Centre for Multicultural Youth Issues has been supported to undertake work with
sporting organizations to build their capacity to engage refugee young people and address
discrimination in sporting environments. Through this process, access to mainstream activity is
created and enduring relationships between young people across cultures are formed.
Advocacy and legislative reform: involving faith organizations
The Justice for Asylum Seekers Project, a network of refugee, human rights and faith-based
groups, was supported to develop an accessible publication, The Better Way: Refugees,
Detention and Australia. As well as seeking to influence changes in government asylum policy,
the resource provided information to counter common myths about asylum seekers, many
of which underlie discriminatory practices toward this group. Through such advocacy, the
Australian policy in relation to the detention of asylum seekers, particularly children, is in the
process of reform.
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Communication: working with the media
As a means of raising community awareness about the socioeconomic influences on mental
health and well-being, the Together We Do Better campaign focused on the importance of
creating opportunities for people to connect with each other and to build bridges within and
across age and cultural groups. Print and radio advertisements described why connection and
active social participation in community life are important and suggested ways in which this
can be achieved.
Communication and marketing: involving artists, communities and community leaders
Work is currently taking place on the development of a publication designed to promote
mental health and well-being through portrayal of the positive individual, family and commu-
nity impacts of multiculturalism. The publication, A Day in the Life of Multicultural Melbourne:
Together We Do Better, will be produced by over 300 community members working with pho-
tographic artists to capture images which celebrate and honour diversity. The publication will
be supported by key political, community and faith leaders and will be produced and marke-
ted through a mainstream publishing house. Images developed will then be used for ongoing
communication activity by participating organizations.
Future challenges
Cross-sector engagement
In order to engage all sectors in mental health promotion activity, synergies across sectors must
be identified and a common language which focuses on health as opposed to illness developed.
Given the scarcity of resources and the global effort required for managing and reducing the
mental health burden, it is also critical that any perceived or actual competition for resources with
the health treatment sector is avoided.
Integrated long-term approaches
Government policy, research and practice often take place in systems or organizations that have
little involvement with each other (“silos”). In order to develop effective mental health promotion
activity at a population level, long-term and integrated planning, implementation and investment
across these silos is essential. Evaluation needs to occur and progress will be slow. Long-term
gains are not always the drivers attractive to governments in the short-term, so effective ways of
managing political discourse must be developed for the promotion of mental health to be seen as
a non-party-political public good.
Focusing upstream
Health promotion is an emerging field of activity with mental health promotion being one of the
most recent areas of focus. While the rhetoric of health promotion includes multi-methodological
approaches to combating structural determinants of health, as indicated in Chapter 15, practice in
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this area has not moved far beyond the rhetoric. Challenges lie in the development of strategies
to address health issues at their source.
To assist this process, it is critical that interdisciplinary collaborations are forged between those
working in health and sociopolitical domains. This will require a melding of varying ideological
perspectives as well as a cultural shift in the competitive academic and practice environments.
Skilling multisector workforces
In order to develop and implement evidence-based mental health promotion practice, a skilled
intersectoral workforce is required. To facilitate this process, practitioners require training and
tools to assist the conceptual development and planning, implementation and evaluation of pro-
ject and programme activity. Efforts in this regard are emerging in a number of countries; howe-
ver, a challenge lies in ensuring that these efforts are coordinated and that the training and tools
developed have relevance for workers in both developed and developing countries.
Working in partnership
Finally, competition across sectors, disciplines, states and nations will keep us divided and obs-
truct our progress. The development of international collaborative arrangements is fundamental
to ensuring that mental health promotion activity takes place in developed and developing coun-
tries and is informed by the shared wisdom and expertise of all.
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Part II
The Emerging Evidence
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Chapter 9
The Nature of Evidence and its Use in Mental Health Promotion
Margaret M Barry, David V McQueen
Introduction
There have been important advances in establishing a sound evidence base for mental health
promotion in recent years. There is consensus that there are clusters of known risk and protec-
tive factors for mental health and there is evidence that interventions can reduce identified
risk factors and enhance known protective factors (Mrazek & Haggerty, 1994). An International
Union for Health Promotion and Education (IUHPE) report for the European Commission in 2000
clearly endorsed that mental health promotion programmes work and that there are a number
of evidence-based programmes that inform mental health promotion practice (IUHPE, 2000). This
accumulating evidence demonstrates the feasibility of implementing effective mental health pro-
motion programmes across a range of diverse population groups and settings.
An important challenge is strengthening the evidence base in order to inform best practice and
policy globally. There is a need to identify gaps in, and expand, existing knowledge in order that
the complexities and creativity of contemporary practice can be captured and disseminated
widely. While researchers are more likely to be concerned with the quality of the evidence, its
methodological rigour and contribution to the knowledge base, different stakeholders in the
area may have different perspectives on the types of evidence needed. As described by Nutbeam
(2000), policy-makers are likely to be concerned with the need to justify the allocation of resour-
ces and demonstrate added-value, practitioners need to be able to have confidence in the likely
success of implementing interventions, and the potential users or the people who are to benefit
need to see that both the programme and the process of implementation are participatory and
relevant to their needs. Another major task is to promote the application of existing evidence
to good practice on the ground, particularly in disadvantaged and low income countries and
settings. This entails identifying programmes that are effective, feasible and sustainable across
diverse cultural contexts and settings. The challenge is therefore twofold: translating research
evidence into effective practice and translating effective practice into research so that currently
undocumented evidence can make its way into the published literature and thus build on and
expand the existing evidence base (see figure 9.1). This calls for critical consideration of how best
to assemble and apply evidence which is congruent with the principles of mental health promo-
tion practice and which is inclusive of the realities of programme implementation across diverse
cultural settings.
Evaluating the promotion of positive mental health
As discussed in earlier chapters, mental health promotion reconceptualizes mental health in
positive rather than negative terms and is concerned with the delivery of effective programmes
designed to reduce health inequalities in an empowering, collaborative and participatory man-
ner. This shift in focus from negative to positive indicators of well-being calls for methodological
refinement in establishing sound measures of protective factors and positive indicators of mental
health outcomes. Chapter 12 of this volume provides a useful discussion of this issue and outli-
nes a socioecological framework for developing indicators of positive mental health. A focus on
positive mental health also calls for more attention to the process and principles of programme
delivery. Evaluation methods are needed that focus on documenting the process, as well as the
CHAPTER 9 • THE NATURE OF EVIDENCE • 109
Figure 9.1
Bridging the gap between evidence and practice
Generating the evidence
Assess needs and determinants
Document process and outcome
Employ a broad range of research methods
Engage key stakeholders in the process
Evidence
Practice
Base
and Policy
Enhancing policy and practice
Identify effective initiatives
Devise active dissemination strategies
Develop guidelines for practitioners and policy-makers
Ensure relevance across cultural contexts and settings
outcomes, of enabling positive mental health and identifying the intervening or mediating varia-
bles which act as key predictors of change. This leads to a focus on evaluation methods aimed at
capturing the dynamics of programmes in action and identifying the critical ingredients for suc-
cessful programme development, planning and implementation.
The available evidence supports the view that competence-enhancing programmes carried out
in collaboration with families, schools and wider communities have the potential to produce mul-
tiple positive outcomes across social and personal health domains (Barry, 2001; Durlak & Wells,
1997; Friedli, 2003; Hosman & Jané-Llopis, 2000; Tilford, Delaney & Vogels, 1997). Most interven-
tions have been found to have the dual effect of reducing problems and increasing competencies.
However, much of the existing evidence has focused on individual-level interventions and, as
highlighted in Chapter 15, there is a paucity of evidence on the effectiveness of upstream policy
interventions such as improved housing, welfare, education and employment in improving men-
tal health. There is a need to generate evidence of the effectiveness of interventions operating at
different levels – individual, community and macro-level policy – in promoting positive mental
health.
The evidence-based practice of health promotion is a relatively recent phenomenon, therefore
strengthening the evidence base in order to inform best practice and policy is an important
challenge. There is considerable debate, however, as to how this is best approached. This chapter
takes a critical look at some of the key issues, challenges and opportunities in strengthening the
mental health promotion evidence base.
110 • PROMOT
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Adopting an evidence-based approach: issues and challenges
There has been much discussion about what constitutes legitimate evidence in health promotion
evaluation and how best to assemble the evidence in ways which are relevant to the complexities
of contemporary practice (McQueen, 2001; Nutbeam, 1999; Tones, 1997; see also Chapter 2). As
health promotion is an interdisciplinary area of practice, the challenge is to use evaluation methods
and approaches that are congruent with the principles of health promotion practice (Labonté &
Robertson, 1996), that cross methodological boundaries and that seek to evaluate initiatives in
terms of their process as well as their outcomes. The WHO European Working Group on Health
Promotion Evaluation (1998) set forth recommendations for policy-makers concerning the appro-
priate methods for evaluation in health promotion (see table 9.1). They point out that the use of
randomized control trials (RCTs) to evaluate health promotion initiatives “is, in most cases, inappro-
priate, misleading and unnecessarily expensive”. While RCTs and systematic reviews are regarded as
the “gold standard” in the traditional hierarchy of research designs (WHO, 2002), their application to
The Cochrane Collaboration
Jodie Doyle
The Cochrane Collaboration, an international organization of health professionals, aims to
promote the preparation and use of high quality, regularly updated, systematic reviews on
the effectiveness of health interventions. Cochrane reviews begin life as a registered title
of a Collaborative Review Group. A protocol (a blueprint for the review) is developed, peer
reviewed and published electronically on the Cochrane Library. The review is then carried
out, peer reviewed and published. The authors make a commitment to update the review
at least every two years and Cochrane protocols and reviews are open throughout their
lifespan to comments and criticism by readers. The Health Promotion and Public Health
Field (the Field) of the Collaboration is aiming to improve the quality and quantity of sys-
tematic reviews in order to develop a solid foundation of evidence relevant to core public
health questions, including reviews of mental health promotion interventions and inter-
ventions with mental health outcomes. The emergence of the Campbell Collaboration,
which focuses on social, education and justice interventions, also has relevance for identi-
fying interventions that have an impact on mental health.
In October 2003, the Field completed a collaborative initiative to develop a list of priority
topics for future health promotion and public health Cochrane reviews. A global taskforce
including representatives from the IUHPE, WHO, Global Health Council, Global Forum
for Health Research, Centers for Disease Control and Prevention and MacFarlane Burnet
Institute for Medical Research and Public Health identified a list of the top 15 topics for
review. Six of these 15 are directly relevant to mental health promotion and are highligh-
ted in bold below.
Further information can be found at:
Cochrane Collaboration: www.cochrane.org
Cochrane Health Promotion and Public Health Field: www.vichealth.vic.gov.au/cochrane/
Campbell Collaboration: www.campbellcollaboration.org
CHAPTER 9
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Health promotion and public health field topics for review
1. Community-building interventions (designed to build a sense of community,
connectedness, cultural revival, social capital) to improve social and mental health
2. Healthy cities, municipalities or spaces projects in reducing cardiovascular disease risk
factors [Could include mental health outcomes]
3. Interventions to build capacity among health care professionals to promote health
and/or
Interventions to build organizational capacity to promote health
4. Physical exercise to improve mental health outcomes for adults [specified to
adults to avoid overlap with existing reviews focusing on children and young people]
5. Interventions utilizing marketing strategies to promote healthy behaviours in young
people [focusing on tobacco, alcohol and food]
6. Prenatal and early infancy interventions for prevention of mental disorder
7. Interventions using the WHO Health Promoting School framework in improving
health and academic achievements among students in schools
8. Interventions that employ a combination of environmental, social and educational
strategies to prevent infectious diseases such as malaria, dengue and diarrhoea
9. Interventions addressing gender disparities in family food distribution to improve
child nutrition
10. Interventions to decrease/minimize adverse health effects of urban sprawl
and/or Interventions to increase the supply of sidewalks and walking trails for the
public
11. Interventions for healthier food choices
• Sales promotion strategies of supermarkets to increase healthier food purchases
• Pricing policies to increase healthy food choices
12. Transport schemes to increase use of maternal and newborn health services (with a
skilled attendant), increase community support and action for maternal and newborn
health populations
13. Interventions to improve nutrition of refugee populations and displaced populations
14. Interventions that aim to reduce health risk behaviours through enhancing
protective environments for adolescents
15. Interventions focusing on adolescent girls in order to improve nutritional status of
women of child-bearing age prior to first pregnancy
112 • PROMOT
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the field of health promotion has generated considerable debate. Such approaches restrict the cur-
rent body of evidence to published research carried out mainly in high income countries.
McQueen and Anderson (2001) discuss the complexity of the debate and call for a broadening
of the base of appropriate research methods in keeping with the diversity of practice in the area.
They point out that researchers and practitioners in health promotion have not reached consen-
sus on any hierarchy of evidence and that international groups have asserted that it is premature
to prioritize types of evidence in a linear hierarchy. They argue for the establishment of rules
of evidence that take into account the diverse, multidisciplinary and contextualized nature of
health promotion practice. Different methodological approaches are required to encompass the
different elements of process, impact and outcome evaluation. While outcome-focused studies
may lend themselves to more quantitative approaches, process-focused research requires more
qualitative and naturalistic methods. Standards of rigour and quality can equally be applied to
evidence derived from different methodological perspectives. The quality of the different types of
evidence should be judged on criteria derived from their respective paradigms and ultimately on
their appropriateness to the research questions being addressed. A useful generic framework for
guiding the evaluation of health promotion initiatives has been proposed by Goodstadt and col-
leagues (2001). This model has its conceptual and operational roots in the Ottawa Charter (WHO,
1986) and describes a structure and logical sequence of steps that can be followed.
Flexible and creative approaches are required for mental health promotion evaluation ranging
from RCTs to more qualitative process-oriented methods. This calls for an expansion of the current
range of evaluation methodologies and analytical frameworks applied in mental health promo-
tion and a widening of the evidence base to be more inclusive of the realities of practical appli-
cations from a more global perspective (Barry, 2002; Friedli, 2001; Jenkins, Lehtinen & Lahtinen,
2001). This includes the use of case studies, narrative analyses, correlational studies, quasi-experi-
mental and experimental studies, interviews and surveys, epidemiological studies, ethnographic
studies and others (McQueen & Anderson, 2001). Approaches covering action research and parti-
cipatory research methods also have an important role to play in developing more collaborative
forms of research inquiry. These approaches seek to actively engage those most involved in and
affected by the research with the researcher and the process of evidence gathering.
There is also a need to agree on quality standards and rules of evidence at each stage of the
evidence building process. In this manner, research methods can be tailored to the evaluation of
programmes at different stages of development and levels of implementation. As mental health
promotion draws on a diverse range of disciplines, different theoretical and methodological pers-
pectives may also be brought to bear in establishing a sound evidence base. As McQueen (2001)
suggests, we need to identify the rules of different disciplines and where they fit into the process
of building the evidence base in order to capitalize on the multidisciplinary nature of the field.
This broad approach is the one endorsed and taken up by the IUHPE Global Programme on Health
Promotion Effectiveness (Jané-Llopis, in press).
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Table 9.1
Conclusions and recommendations from WHO European Working Group on Health Promotion
Evaluation
Conclusions
Recommendations to policy-makers
Those who have a direct inte-
Encourage the adoption of participatory approa-
rest in a health promotion
ches to evaluation that provide meaningful oppor-
initiative should have the
tunities for involvement by all of those with a direct
opportunity to participate in
interest in health promotion initiatives.
all stages of its planning and
evaluation.
Adequate resources should be
Require that a minimum of 10% of the total finan-
devoted to the evaluation of
cial resources for a health promotion initiative be
health promotion initiatives.
allocated to evaluation.
Health promotion initiatives
Ensure that a mixture of process and outcome
should be evaluated in terms
information is used to evaluate all health promo-
of their processes as well as
tion initiatives.
their outcomes.
The use of RCTs to evaluate
Support the use of multiple methods to evaluate
health promotion initiatives is,
health promotion initiatives.
in most cases, inappropriate,
Support further research into the development of
misleading and unnecessarily
appropriate approaches to evaluating health pro-
expensive.
motion initiatives.
Expertise in the evaluation of
Support the establishment of a training and edu-
health promotion initiatives
cation infrastructure to develop expertise in the
needs to be developed and
evaluation of health promotion initiatives.
sustained.
Create and support opportunities for sharing infor-
mation on evaluation methods used in health pro-
motion through conferences, workshops, networks
and other means.
Adapted from: WHO European Working Group on Health Promotion Evaluation, 1998
Evaluating the process of programme implementation
As already discussed, there is a need for an approach that embraces the process of programme
development and implementation as well as programme outcomes and how the two areas are
linked. This is essential if the area is to move to a new level of understanding and sophistication
beyond the question of whether programmes work to consider what makes them work, with
whom and under what circumstances. The published research studies are largely restricted to
research outcomes and typically little information is provided on the process and extent of pro-
gramme delivery that must occur in order for those outcomes to be produced.
114 • PROMOT
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Programme implementation refers to the actuality of putting a programme or intervention into
practice: what the programme consists of and how it is delivered (Durlak, 1998). Details of pro-
gramme implementation are typically under-reported in the published literature. As a result, there
is a dearth of published information to guide practitioners and decision-makers regarding the
practical aspects of programme adoption and replication. In contrast to the absence of formal
measurement there is, however, a wealth of information based on practitioner experience. This is
what Domitrovich and Greenberg (2000) refer to as the “wisdom literature”, a body of knowledge
based on practical experience of programme delivery. There is a need for greater attention to
documenting and accessing this body of knowledge in order to become better informed about
the circumstances and practices that enhance programme implementation. Process evaluation
techniques based on careful project description, documentation and monitoring are required to
assess both the quantity and quality of programme implementation.
Although the majority of evaluation studies provide little or no data on implementation (Dane &
Schneider, 1998; Durlak, 1998), it is clear from those studies that have monitored it that it is often
variable and imperfect in field settings and that the level of implementation influences outcomes
(Durlak, 1998; Domitrovich & Greenberg, 2000; Mihalic et al., 2002). Monitoring and documenting
the process of programme implementation is critical to highlighting programme strengths and
weaknesses, determining how and why programmes work, enhancing the validity of outcome
evaluation and providing feedback for continuous quality improvement in programme delivery
(Domitrovich & Greenberg, 2000). If programme implementation is not monitored and assessed,
an outcome evaluation may be assessing a programme that differs greatly from that originally
designed and planned. The collection of systematic data on programme implementation plays an
essential role in advancing knowledge on best practice for replication in real world settings.
Evaluating implementation is a complex process as it entails capturing the dynamics of program-
mes in action and monitoring the gaps between plans and delivery. Information is needed about
the specific programme components, how they are delivered and the characteristics of the con-
texts or settings in which they are conducted (Dane & Schneider, 1998). In addition to identifying
the core components of the intervention, information is also needed on what Chen (1995) refers
to as “the implementation system”. This includes the process and structure of the planning, imple-
mentation and training; the characteristics of programme implementers and participants and the
nature of their relationships; and facilitating and inhibitory factors in the local context, including
readiness, mobilization of support, ecological fit of the programme, cultural sensitivity and the
extent of participation and collaboration with key stakeholders. Chen (1995) argues that although
the intervention itself is the major change agent, the implementation system is likely to make an
important contribution to programme outcomes as it provides the means and the context for the
intervention. Comprehensive documentation of programme delivery provides data on the prac-
tical realities of implementation including programme modification and adaptation for the local
setting.
Barry (2002) highlighted the need for a more explicit understanding of programme theory and
a more systematic study of programme implementation in mental health promotion practice.
Of interest is the growing emphasis on theory-driven evaluation (Chen, 1995; Goodstadt et al.,
2001) and the use of evaluation logic models (Scheirer, Shediac & Cassady, 1995) in clarifying the
connections between a programme’s operations and its effects. While outcome-focused evaluation
provides summary information on the total effects of a programme, it does not of necessity evaluate
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the intervening mechanisms responsible for the intervention’s success or failure. The usefulness
of the theory-driven perspective is its focus on examining the causal mechanisms underlying the
change process and the relationship between the programme’s conceptual theory and action
theory, i.e. its translation into practice. Evaluation logic models have been used to make explicit
the logic of the change processes linking programme implementation with intermediate and
early outcomes. Scheirer, Shediac & Cassady (1995) illustrate the use of a chain of events research
paradigm to examine the detail of actual programme delivery by tracking prospectively the
sequence of programme actions influencing intended outcomes. The detailing of the programme
in action permits an accurate record to be kept as it unfolds and plays a crucial role in informing
the detection of intermediate-level changes which lead to ultimate programme outcomes. This
form of evaluation research gives equal emphasis to process and outcome data and attempts to
link the two in a logical and systematic fashion, relating variability in programme implementation
with variability in outcomes. This type of logic model approach has been adopted, developed fur-
ther and consistently and effectively applied in the systematic reviews of evidence carried out by
the USA Community Preventive Services Task Force over the past several years (Briss et al., 2000).
The systematic study of programme implementation calls for the use of a wide range of research
methods and the collection of rigorous data drawn from multiple sources. The generation of prac-
tice-based evidence and theory is an important challenge in this area and will require researchers
and practitioners to work in partnership to document and analyse the implementation of mental
health promotion programmes. Through the development of more collaborative and participa-
tory evaluation methods there will be an opportunity to include the knowledge of programme
implementers and participants into the evaluation process, thereby incorporating the wisdom
literature into the evidence base. There is a need for analytic frameworks that integrate process
and outcome data in a meaningful way so that clear statements can be made about how and
why programme changes have come about. Contrasting and complementary perspectives and
methods are needed to fill out the larger picture and to tap previously undocumented areas of
knowledge and practice.
Widening the evidence base: applying the evidence to low income
countries
While good progress is being made on building the research base of mental health promotion,
there is a need to extend the evidence debate beyond an academic elite concerned with the qua-
lity of research design to focus more directly on the quality of the intervention programmes and
their wider practice and policy implications. As advocated by Mittelmark (2003), it is time to draw
clear messages from the existing evidence and establish guidelines based on that evidence in
order to inform best practice and policy on the ground. While addressing the complex methodo-
logical issues and specifics of the evidence debate, it is critical not to lose sight of the bigger pic-
ture, which is to apply what we do know in order to inform decision-making and bring about las-
ting change in the broader policy context. Speller, Learmonth & Harrison (1997) highlighted that
there is a tendency for researchers reviewing the evidence to focus their energies on the research
and methodological issues rather than on the quality of the actual programmes being evaluated.
While continuing to build on systematic reviews of specific topic areas, it is important to identify
crosscutting themes and generic processes that underpin the successful implementation of men-
tal health promotion programmes. There is a need for practice and policy guidelines based on the
116 • PROMOT
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existing evidence to inform practitioners and decision-makers concerning effective programme
planning, delivery and evaluation and the critical factors that are needed to ensure the implemen-
tation of successful programmes. This information is beginning to emerge, and there are some
useful practitioner-oriented publications, such as Price et al. (1988), the Blueprints series by Elliott
(1997) and Making it Happen (Department of Health, 2001), all concerned with providing practical
guidance on programme implementation.
There is a particularly urgent need to expand the evidence base to be more relevant to the reali-
ties of those working and living in low income countries. McQueen (2001) points out the strong
cultural and geographic bias in the manner in which evidence is currently articulated and repre-
sented in the health promotion literature. The evidence debate has been mainly conducted in the
English language within a European-American context and is largely the preserve of an academic
elite. As McQueen points out, much of the relevant material that could broaden the discussion
on evidence is unpublished. Voices from developing countries are absent as indeed are the voi-
ces of practitioners and programme users/recipients. This view is echoed in a WHO 2002 report
on prevention and promotion in mental health which highlights that evidence is “least available
from areas that have the maximum need, i.e. developing countries and areas affected by conflicts”
(WHO, 2002, p. 27).
In many countries implementing programmes usually entails working with minimal resources,
few of which can be allocated to large research programmes. Because there may not be “evi-
dence” as represented by sophisticated outcome measures, this doesn’t mean that there is not
good practice. There may indeed be many worthwhile and effective interventions taking place
in developing countries; however, the documented evidence may lag behind the practice. In the
absence of large grants, a key challenge is how to uncover and document good practice which is
not yet disseminated in the literature. Traditional documentation is often lacking and even such
rudimentary publications as newsletters and brochures may not exist. Nonetheless, intervention
programmes may be known through word of mouth and other traditional ways of spreading
the word about good practice in the field. The problem for those trying to assess these practices
is how to bring them into view of the so-called scholarly world. That is a challenge that calls for
innovative methods of discovery such as Delphi techniques among recognized health promoters
who are in the field. Such a type of data gathering and the methodological rigour that it should
pursue remain developmental and a task for programmes such as that of the IUHPE. In the mental
health field the challenges may be even greater.
Much energy and many resources have been devoted to establishing efficacy and effectiveness
trials in middle to high income countries; it is now timely to invest in dissemination research to
examine how the existing evidence can be used effectively across diverse cultural settings. As
discussed in Chapter 13, the development of user-friendly information systems and databases
is required in order to make the evidence base accessible to practitioners and policy-makers. In
particular, there is an urgent need to identify effective programmes that are transferable and
sustainable in low income country settings such as schools and communities. In this respect it
may be useful to explore the application of programmes based on community development and
empowerment methods, such as the community mothers programme (Johnson, Howell & Molloy,
1993; Johnson et al., 2000) and the widow-to-widow peer support programme (Silverman, 1988)
to name but two. These programmes, among others, have been shown to be highly effective, low-
cost replicable programmes based on empowerment principles and successfully implemented
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and sustained by non-professional community members in disadvantaged community settings.
The implementation of school-based programmes for young people would also appear to be a
key area for development in low income countries.
Mental health promotion needs to be incorporated into the wider health development agenda
in order that the broader determinants of poor mental health such as poverty, social exclusion,
exploitation and discrimination can be successfully addressed. The innovative Voices of the Poor
study, carried out under the auspices of the Poverty Reduction Group of the World Bank (Narayan
& Petesch, 2002), underscored the need to invest in poor people’s assets and capabilities and to
work in partnership with people living in poverty in order to develop strategies and solutions that
can be locally owned and adapted.
In establishing a credible evidence base from low income countries there is a need for interna-
tionally supported dissemination research that will examine the documentation, replication and
adaptation of effective programmes across diverse low income country settings. More active stra-
tegies are required for disseminating the evidence and providing technical assistance and capa-
city building resources for mental health promotion in low income countries. As Backer (2000)
points out, dissemination entails not only distributing information about successful programmes
and practices but also the provision of technical assistance and capacity building resources to
enable practitioners to actually implement the programmes and the complex processes involved.
This involves funding not only a particular programme but also the overall ability and resources
of the organization or group needed to implement and sustain the programme in complex and
challenging local contexts. Capacity building also entails increasing the organizations’ ability to
share new programmes and practices with others, including documenting innovative practice at
the local level. Learning will then be a two-way process in terms of innovation, adaptation and
dissemination of promising programmes and creative practice.
Conclusion
A key challenge in establishing the mental health promotion evidence base is how this evidence
can be used to create change and bring about improved mental health for individuals, families
and communities in most need. The evidence base should serve the needs of practitioners and
policy-makers concerned with the practicality of implementing successful programmes that are
relevant to the needs of the populations they serve. This calls for the active dissemination of
validated programmes and guidelines on best practices based on efficacy, effectiveness and dis-
semination studies. There is a need for international cooperation in assisting low income countries
with technical support and other capacity building resources, designing dissemination strategies,
publishing guidelines for effective implementation of low-cost sustainable programmes and pro-
viding training in programme planning and evaluation. The ultimate test will be how the evidence
base can be effectively used to inform practice and policy that reduces inequalities and brings
about improved mental health, especially where it is needed most.
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Chapter 10
Social Determinants of Mental Health and Mental Disorders
James C (Jim) Anthony
Introduction
The famous astronomer Carl Sagan often used the crisply enunciated phrase “billions and billions”
to convey our universe’s vast macroscopic scale and the numerous celestial objects of study in
astronomy. Over the course of the 20th century we have learned that this same phrase applies
just as well to the vast microscopic scale of the human brain and central nervous system. With
respect to mental health and mental disorders, the numbers of controlling neurons, synaptic con-
nections and elements in pre-synaptic and post-synaptic signaling pathways readily match the
numbers of the celestial objects Sagan had in mind.
Concurrent with advances in the brain sciences and neuroscience, there has been an evolution of
ideas about the social determinants of mental health and mental disorders. For example, at the
start of the 20th century, there was great enthusiasm for eugenics and accompanying ideas about
the use of social institutions to breed humans selectively in order to cull defective germ lines and
to enhance the successful adaptation of the most fit (see box 10.1). Eugenics lost favour, however,
particularly after World War II. Towards the end of the 20th century we returned to a position of
widespread enthusiasm about our genetic endowment and social shaping of its expression. At
present, the predominant motif is not from “eugenics” as practiced at the population level via the
now-rejected modes of ethnic cleansing and selective sterilization, but that gene expression can
be shaped by exogenous agents and may be affected by social experience. Some of the newest
transdisciplinary bridges between genetics, neuroscience, the social sciences, psychiatry and the
other mental health disciplines involve elaborations of ideas about the use of social institutions
to control exposure to exogenous agents and to influence social experience in order to promote
mental health and prevent and control the occurrence of mental disorders.
It will be important for the lay public and for societal leaders to grasp these ideas as they emerge
and are developed during the new decades of the 21st century. Perhaps the most important
reason for science education on these topics is that social mobilization of resources depends
more upon shared consensus about values than on the quality of scientific evidence. The man-
date for mobilization of resources in order to prevent or control occurrence of mental disorders or
other health problems depends upon our capacity to predict the occurrence of harm and upon
Box 10.1
The discredited eugenics approach
In 1916–17, psychiatrist Aaron J Rosanoff designed and conducted a detailed house-to-
house survey of the inhabitants of Nassau County, New York, in the USA. One of the focal
points of inquiry was the intergenerational transmission of mental disorders. The survey
aimed to identify households and families that were breeding mental disorders and
associated socially maladaptive behaviour, including criminal acts. A prominent motif in
Rosanoff’s introduction and description of the study is eugenics (Rosanoff, 1917).
CHAPTER 10 • SOCIAL DETERMINANTS OF MENTAL HEALTH AND MENTAL DISORDERS • 121
Box 10.2
Making decisions to mobilize resources
The mandate for societal response and action is a function of two values: the accuracy
of our scientific predictions of whether serious harm will occur, and an evaluation of the
benefit-to-risk ratio of acting versus not acting to prevent or control the occurrence of the
serious harm.
For example, psychiatric epidemiologists now are improving the accuracy of our predic-
tion of who will make repeat suicide attempts and who will complete suicide after one or
more suicide attempts (e.g., Chitsabesan et al., 2003). Via RCTs, investigators are refining
interventions that have clear benefit in reducing risk of completed suicide among suicide
attempters. Some of these interventions have considerable costs (e.g. civil commitment
and involuntary hospitalization after the suicide attempt). Other apparently effective
interventions are less intrusive and cost very little to deploy once we identify individuals
who have made a suicide attempt but who show no immediate threat of self-harm to
complete the suicidal act (e.g. Motto & Bostrom, 2001). As our prediction of serious harm
increases, and as the evaluation of the benefit–risk ratio becomes more favourable, there
is an increasing mandate for societal response and action to prevent and control the
occurrence of the harm.
our benefit–risk analysis with respect to deployment of individual or societal resources (box 10.2).
Although the accuracy of our predictions is disclosed in the evidence and is more or less objec-
tive, the benefit–risk evaluation and the choice of interventions depend upon an expression of
shared consensus about values.
During occasions of social response to prevent or control the occurrence of serious harm, we see
manifestations of social interconnectedness between members of society and the expression of
this shared consensus about values. Consider the tragic instance of a mother and father returning
home from work to find their house on fire and progressively burning to the ground, surrounded
by a fire brigade that is struggling to bring the fire under control. Under most circumstances, the
fire brigade will restrain the parents and not allow them to enter the household – even if there is
a chance that children, grandparents or other household members still are alive inside and might
be rescued. Social interconnectedness between members of the society is manifest not only in
the appearance of an organized fire brigade in response to the fire, but also in the fire brigade’s
actions to inhibit the parent’s expression of an intent to act individually in order to control the
harm to children or others still in the burning household.
For more than 150 years, social and behavioural scientists have speculated about this type of social
interconnectedness, as well as other aspects of the importance of society and social institutions in
the promotion of mental health and the prevention and control of mental disorders. For over a
century there have been empirical investigations on these topics. A central theme in this research
has been a belief that societies have an impact on human life over and above the sum of the
impact of their individual members. From sociologist Emile Durkheim’s work between 1893
and 1912 we have the idea that humans together direct their own fortunes through a spirit of
122 • PROMOT
O ING MENTA
T L HEALT
L H
social collectivity and solidarity and must be studied at a level above the level of the individual
(Durkheim 1895, 1897).
Durkheim described social structures and functions in organic terms, using concepts such as the
“cerebrospinal system of the social organism” and the “social brain”. He discouraged the idea that
suicide and suicidal acts should be understood as the behaviour of disturbed individuals and was
an especially strong advocate of a social interpretation for increasing suicide rates during the 19th
century. According to this interpretation, the increasing numbers and rates of suicide should be
understood as a manifestation of the weakening of social solidarity and the institutions that bind
the individual within the social collective: family, religion and political states.
Consistent with his belief that the social sciences should offer remedies to promote health,
Durkheim pointed towards the possibility that social solidarity might be found and cultivated
within the occupational groups or corporations of society that were gaining increased prominen-
ce relative to family, church and state. A century later, one of the most promising recent suicide
prevention programmes has been implemented within the US Air Force. Within this programme,
which is intended to reverse an upward trend in suicide rates of pilots, mental health promotion
and the prevention of suicide have been made an explicit social role expectation at multiple levels
within the organization – from top-rank generals down to individual pilots and peers. The suicide
prevention programme not only calls for individualized intervention services for individual pilots
as needed, but also calls for interventions at the level of collectives within the Air Force (e.g. at the
level of divisions and battalions). The upward trend in suicide rates for Air Force pilots has been
reversed in the years since first implementation of this programme (Knox et al., 2003) and the
