Post Graduate Diploma in Health Promotion and Public Health GM704F : Analysing HPPH

1. Post Graduate Diploma in Health Promotion and Public Health GM704F : Analysing HPPH 28th November 2008 Session 8 : Mental Health Kate O’Hara CSIP/NIMHE West Midlands

2. Learning Outcomes By the end of this session you should be able to: Understand some of the problems associated with defining mental illness and mental health Hear about emerging evidence, practical frameworks and tools for understanding, delivering and measuring public mental health and well-being Explore the challenges, barriers and enablers to promoting mental health within the current policy context Use one model – the ten elements of mental health

3. What is Mental Health mental health --------------- mental illness Mental health = mental illness

6. Definitions of mental health Mental health consists of the ability to live happily; productively; without being a nuisance. (Preston, 1943) Mental health is the capability of personal growth and development. (Chwedorowicz,1992) Health of the psyche is a matter of maturity. (Winnicott, 1988) Mental health has five senses: a sense of trust, challenge, competency, accomplishment, humour. (Trent, 1994)

7. Definitions of mental health Mental health means harmony between values, interests and attitudes with the scope of action of the individuals and consequently, realistic life planning and purposeful implementation of life concepts. (Neumann et al,1992) Mental health is the capacity to live life to the full in ways that enable us to realise our own potentialities, and that unite us with rather than divide us from all the other human beings that make up our world. (Guntrip, 1964)

8. What does being mentally healthy mean to you?

9. Signs of Mental Health Hedonic Well-Being Emotional well-being 1. Happy with life 2. Interested in life 3. Satisfaction with life

10. Flourishing Mental Health A two continua model The promotion and maintenance of mental health as ‘flourishing’ The treatment and prevention of mental illness Flourishing “Almost every day” or “every day” past month 1 Hedonia 6 or more positive functioning Languishing “Never” or “once or twice” past month 1 Hedonia 6 or more positive functioning Moderately Mentally Healthy “About once a week” or “two or three times a week” 1 Hedonia 6 or more positive functioning Keyes CLM 2007 Promoting and protecting mental health as flourshing: a complementary strategy for improving national mental health. American Psychologist 62 95-108

11. Determinants of mental health Psycho social well-being is strongly related to social structure – notably levels of inequality which influence – social status, social affiliation and childhood experiences. Cultural factors such as materialism and individualism are underestimated determinants of population health and wellbeing in Western societies. Evidence links cultural factors, via psychosocial pathways, to psychological wellbeing, and wellbeing, through behavioural and physiological pathways, to physical health. An important and growing cost of our modern way of life is ‘cultural fraud’: the promotion of images and ideals of ‘the good life’ that serve the economy but do not meet psychological needs or reflect social realities.Psycho social well-being is strongly related to social structure – notably levels of inequality which influence – social status, social affiliation and childhood experiences. Cultural factors such as materialism and individualism are underestimated determinants of population health and wellbeing in Western societies. Evidence links cultural factors, via psychosocial pathways, to psychological wellbeing, and wellbeing, through behavioural and physiological pathways, to physical health. An important and growing cost of our modern way of life is ‘cultural fraud’: the promotion of images and ideals of ‘the good life’ that serve the economy but do not meet psychological needs or reflect social realities.

12. Untangling the determinants Individual skills and attributes Material resources Inequalities in distribution of resources First class travel story At the core of this is the relative importance of: psycho-social factors or attributes (relationships, life satisfaction, positive affect, cognitive style) material factors (income, housing, employment) the influence of inequalities or more precisely, injustice as a mediator between poor socio economic circumstances and poor health Context is crucial in interpreting individual attributes – lack of trust, lack of participation, failure to vote – survival/rational/ Contradictory trend – as inequalities in income and wealth widen, so pursuit of (and influence of) non material explanations for the social gradient in health outcomes increases. Puzzling – very strong relationship between subjective well-being (life satisfaction and happiness) and income – both within countries and between countries - income is a powerful force shaping distribution of happiness Material goods are not just functional but symbolicFirst class travel story At the core of this is the relative importance of: psycho-social factors or attributes (relationships, life satisfaction, positive affect, cognitive style) material factors (income, housing, employment) the influence of inequalities or more precisely, injustice as a mediator between poor socio economic circumstances and poor health Context is crucial in interpreting individual attributes – lack of trust, lack of participation, failure to vote – survival/rational/ Contradictory trend – as inequalities in income and wealth widen, so pursuit of (and influence of) non material explanations for the social gradient in health outcomes increases. Puzzling – very strong relationship between subjective well-being (life satisfaction and happiness) and income – both within countries and between countries - income is a powerful force shaping distribution of happiness Material goods are not just functional but symbolic

13. Contribution of mental health to inequalities Although it is frequently noted that health enables a person to function as an agent and contributes to inequalities in people’s capability to function (Anand 1993), it is mental health that constitutes the key determinant of agency and helps to explain the relationship between low levels of mental well-being and neglect of self, neglect of others and a range of self harming behaviours, including self sedation and self medication e.g. through alcohol, high fat and sugar consumption. Although it is frequently noted that health enables a person to function as an agent and contributes to inequalities in people’s capability to function (Anand 1993), it is mental health that constitutes the key determinant of agency and helps to explain the relationship between low levels of mental well-being and neglect of self, neglect of others and a range of self harming behaviours, including self sedation and self medication e.g. through alcohol, high fat and sugar consumption.

14. (the ecology of) Relationships matter (3) ‘tend to the social and the individual will flourish’ Rutherford 2008 Mental health is produced socially Presence or absence of mental health is above all a social indicator Quality of social relationships is key factor in resilience Social as well as individual solutions Collective efficacy as well as personal efficacy Other regarding agency Attachment style – poverty and disadvantage have indirect influence on attachment style Impact of individual, cultural, environmental and economic factors on relationships: social skills, transport, child friendly spaces, somewhere to meet, financial reciprocity (it’s my round....) More and more aware of status and social recognition – less aware of the disadvantages we share with others and the benefits of collective redress – individual responsibility for failure and adversityCollective efficacy as well as personal efficacy Other regarding agency Attachment style – poverty and disadvantage have indirect influence on attachment style Impact of individual, cultural, environmental and economic factors on relationships: social skills, transport, child friendly spaces, somewhere to meet, financial reciprocity (it’s my round....) More and more aware of status and social recognition – less aware of the disadvantages we share with others and the benefits of collective redress – individual responsibility for failure and adversity

15. Select bibliography

16. Mental Health and Well-being Well-being is about being emotionally healthy, feeling able to cope with normal stresses, and living a fulfilled life. It can be affected by things like worries about money, work, your home, the people around you and the environment you live in. Your well-being is also affected by whether or not you feel in control of your life, feeling involved with people and communities, and feelings of anxiety and isolation. (Coggins & Cooke, 2004) in Mental Well-being Impact Assessment: A Toolkit ‘A Living and Working Document’ (CSIP 2007)

18. The Foresight Project Sponsored by DIUS – Department for Innovation, Universities and Skills Two year project Involved over 400 experts – neuroscience to economics Main Findings: Early Intervention is crucial Small increases in well-being can produce a decrease in mental health problems Substantial scope for improving how to tackle the huge problem of mental ill-health – which costs £77 billion a year

19. Five ways to well-being

20. Three recent reports Measuring Wellbeing in Policy; Sam Thompson, Nic Marks; Foresight & nef; Oct 08 Local Wellbeing – can we measure it? ; Nicola Steuer, Nic Marks; Young Foundation & nef; Sept 08 Five Ways to Wellbeing: the evidence; Jody Aked, Nic Marks; Foresight & nef; Oct 08 Forthcoming: National Accounts of Well-being; January 2009 Happy Planet Index; July 2009

23. The Policy context for public mental health and well-being – the history WHO Helsinki Declaration (Jan 2005) EU Green Paper on Mental Health (October 2005) Choosing Health (2004) Making it Possible: Improving mental health and well-being in England (Nov 2005) National Strategy for Suicide Prevention – Goal 2 MHP NSF for Mental Health St 1 MHP / St 7 SP NSF for Children St’s 1, 2 & 9, NSF for Older people - ST 7 & 8 Mental Health and Social Exclusion – SEU report June 2004 Our Health Our Care Our Say

24. The Policy context for public mental health and well-being - the here, now and future Commissioning Framework for Health and Well-being - World Class Commissioning (December 2007) Working for a Healthier Tomorrow (March 2008) Health Inequalities - Progress and Next Steps (June 2008) Foresight Report: Mental Capital and Wellbeing New Horizons – Creating Flourishing, Connected Communities: A Public Mental Health Framework for developing Well-being

25. Choosing Health – where is mental health? Improving mental health one of 6 over-arching priorities

26. Mental Health Promotion Strategies Requirement since Sept 2002 for each LIT to have a mental health promotion strategy (Autumn Assessment)

27. Settings, target groups and what works Early Years: Children and Families Schools Young People outside School Primary Care Older People People with Mental Health Problems Black and Minority Ethnic Groups Workplace Communities and Neighbourhoods Ref Making It Effective – a guide to evidenced based mental health promotion (mentality See also Making it Possible: Priorities for Action Marketing Mental health, Equality and Inclusion, Violence and Abuse, Early Years, Schools, Employment, Workplace, Communities and Later life

28. Challenges, Barriers and enablers Enablers Mental Health Promotion strategies West Midlands Regional Assembly Health Partnership (PCT’s, LA’s, Acute Trusts, SHA, RDA, LGA, PHO, PHG, Business Council, HEI, FE, LSC, Arts Council) Regional Health and Well-being Strategy Local Area Agreement’s CMO/APHO indications of Public Health in the English Regions 7: Mental Health Regional Lifestyle Survey – Mental health annex NHSWM Delivering Our Clinical Vision for a World Class Health Service Mental Health Clinical Pathway recommendations “Create a seismic change in the services to people who have m h problems and present with physical illnesses”

29. Activity – the ten element map In a small group Choose one pair of opposites on the map Identify one example of a possible intervention for all 6 levels

30. Measures and Practical tools Measures Audit Commission QoL local indicators Sustainable Development Commission indicators for Well-being Warwick Edinburgh Mental Well-being Scale (WEMWEBS) Scottish indicators work European mental well-being indicators - IMPHA individual measures + MINDFUL structural measures CMO regional indicators mental health LAAs + 198 National indicator set Tools Mental Well-being Impact Assessment Tool (MWIA) Social Marketing and Mental Health

31. Warwick Edinburgh Mental Well-being Scale (WEMWbS) New 14 item scale including only positively worded items relating to positive aspects of mental health WEMWbS showed significant improvements over Affectometer 2 being shorter and easier to complete, and less prone to response bias Its exclusively positive content appears to fit better with lay views on what constitutes positive mental health http://www.wellscotland.info/indicators.html

32. Mental Well-being Impact Assessment Tool (MWIA) Provides a practical framework to: Raise awareness and understanding of mental well-being. Enable a range of stakeholders to begin to identify the impact a particular policy, service. programme or project is having on well-being. Encourage stakeholders to explore ways to maximise potential positive impacts and minimise potential negative ones. (This is a prospective tool) Enable stakeholders to explore and develop local indicators to monitor and evaluate progress on promoting mental well-being. http://www.northwest.csip.org.uk/work/mental-health-and-social-wellbeing/mental-health-promotion/mental-wellbeing-impact-assessment-toolkit.html

33. Social Marketing and Mental Health Results of a one day workshop The future development of social marketing approaches to promoting mental health will need to take account of and build on: emerging evidence on behaviour that improves mental well-being e.g. physical activity, diet, learning new skills and the importance of social contact e.g. friends, family relationships, networks the social, material and cultural context for different attitudes to mental health and different strategies for ‘looking after mental well-being’ and coping with life’s challenges NICE guidelines on behaviour change different communities and target groups’ own views on what helps and hinders their mental health and well-being Current project led by Staffordshire university looking at using social marketing approaches to understand/’sell the mental health benefits of physical activity

34. ‘Best Buys’ in mental health promotion Economic analysis – for greater investment on mental health promotion Burden and costs of MI on individuals and society (easier to quantify) Benefits of promoting positive mental health (including for those with a diagnosis) More difficult to quantify but likely to be considerable – no’s Intervention priorities Parenting support, health promoting schools, addressing conditions of employment, lifestyle (diet, exercise, alcohol) and environmental improvements Friedli and Parsonage (2007) Building an economic case for mental health promotion: part 1 journal of public Mental Health Volume 6 issues 3 14-23

35. CSIP WEST MidlandsKate.ohara@csip.org.ukwww.westmidlands.csip.org.uk