Building on Strengths online version

Building on Strengths
A new approach to promoting mental health in New Zealand/Aotearoa

(online version)

Published in December 2002

HP3591

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Contents

3.0 Tackling Inequalities In Mental Health

This section outlines some of the key factors that can positively or negatively determine mental health and wellbeing. It describes how socioeconomic disadvantage can lead to poorer mental health within communities and in individuals. It also defines the scope and priorities of Building on Strengths.

3.1 Determinants of Mental health

a growing understanding of social health issues suggests serious health problems result not only from a lack of clean water, sanitation and basic public services, but also from despair, anger, fear, job and housing insecurity, social alienation and poverty. It is now apparent that too little attention has been paid to the importance of a wider set of determinants, which influence the level of health in any community. Recent work on the issue of inequalities has added significantly to an understanding of what determines good and bad health for individuals, couples, families,
groups, communities and societies.

Research on the subject of health inequalities has identified clear differences in health status between different groups in the community (Marmot 1994; Wilkinson 1996; Christchurch City Council 1997; Stephens 1998; Health Funding authority 2000; Victoria Health Promotion Foundation 2002). Many of these differences have been found to be related to social and economic factors and therefore preventable.

There is a marked difference in health status between people from lower socioeconomic backgrounds, people who live in rural areas, Maori and Pacific peoples, new arrivals, refugees and other New Zealanders. Submissions on Building on Strengths noted that people in lower socioeconomic groups and those people who experience mental problems have the worst access to conditions necessary for positive health. This includes suitable housing, adequate income, access to health services and opportunities for developing individual social coping skills.

Figure 3 (page 15) presents one model of the various determinants of health (Howden-Chapman and Tobias cited in Ministry of Health 2002b). It illustrates how structural conditions ultimately affect mental health and health generally. The structure of society can determine behaviour by encouraging or inhibiting particular lifestyles, and it is with a view to positively influencing the conditions and environment that created these behaviours that Building on Strengths is focused. The intent is on encouraging positive mental health by dealing with inhibiting factors at their origins and at the level of social and economic determinants that affect people’s mental health.

The key determinants of mental health can fall under three categories:

Participation in society
Full participation in society means full access to the conditions necessary for mental health and wellbeing. This includes access to adequate housing, education, and leisure activities. It also means empowering communities to define their own problems and create their own solutions. and wellbeing through mental health promotion

The Ministry of Health will need to work with other government agencies, research agencies and local government authorities to advocate for consideration of mental health in the other service sectors – health, employment, housing, education, environment and social services. The Ministry will also need to work with non-governmental as well as community-based organisations such as health support groups, marae, churches, clubs and other bodies.

each community should determine how it can contribute to the positive mental health of the wider population, taking into account the social, economic and cultural circumstances of its own members. For example, holistic health models (Te whare Tapa wha, Te Pae Mahutonga, see page 43), offer scope for Maori health action aimed at addressing the determinants of mental health, which in turn can be directed at various levels, individual, whanau, hapu and iwi.

It makes sense that the community is best placed to define its own problems and determine how to effect change. Like The ottawa Charter, Building on Strengths emphasises the fundamental importance of community involvement in effecting sustainable change to the mental health and wellbeing of the population. Community development programmes that address the wider factors affecting mental health have been identified as showing the greatest potential (Shiell and Hawe 1996).

Participation also means being able to participate fully in the wider society as well as in particular societies that have a special meaning. For example, Maori participation in society and in Te ao Maori have been identified as equally important dual goals.

Valuing diversity
Socioeconomic status is recognised as a major predictor of health (Howden and Chapman, cited in Ministry of Health 2002b) and low socioeconomic status, in particular and is associated with higher rates of poor health and early death. Indeed, for some groups, it is exclusion from mainstream society that has a detrimental effect on their mental health. Building on Strengths supports action to promote the mental health of disadvantaged people who are affected by their socioeconomic status or who are vulnerable as a result of social isolation, including the unemployed, new arrivals, refugees, gay people, single parents, older people, rural communities, people with disabilities and people with mental illness.

Guided by the ottawa Charter, mental health promotion activity will value the intentions and contributions of an increasingly diverse ethnic population in New Zealand. Strengthening links between ethnic communities and government decision-makers (both local and central) will create an opportunity to build relationships and improve ways of working to address the complex range of mental health and wellbeing needs of communities with distinctive ancestral origins, cultural customs and values, religious beliefs and practices and language characteristics.

By engaging effectively with disadvantaged and excluded communities, decision-makers can have a positive impact on mental health by enabling this diverse range of people to be involved in identifying their own issues and to create their own solutions. This approach challenges sectors, for example, to reorient their processes and establish mechanisms that offer disadvantaged groups greater opportunity to be involved in creating solutions that support positive mental health and which improve these groups’ level of social inclusion. For people who have disabilities or who have experienced mental illness, reforms that counter discrimination and stigma are also key features underpinning mental health promotion activity.

Building on Strengths supports mental health promotion activities that honour the special relationship between Maori and the Crown. However, in undertaking action to reduce socio-economic disadvantage for Maori, it is vital to take account of the intricate web of social determinants that shape the health of Maori, a situation described by Durie (cited National Health Commission 1998) as ‘diverse Maori realities’. In many cases differences in status between Maori is resulting in uneven improvements in health within the Maori population with some Maori lagging further behind others.

Creating safe and cohesive communities
This is about creating safe and cohesive families, and communities as well as community institutions. It is about safe homes and violence free settings for children and other vulnerable members of our community. The Canadian report Population Mental Health in Canada (Stephens 1998) found that a safe, socially supportive environment is the single most powerful influence on wellbeing and lack of distress. unhealthy communities are unable to build or maintain
the physical and social infrastructure their members need to support each other and to realise their individual potential (Baum 1999). Research in New Zealand found that young people who do not mix well socially are between two and three times more likely to experience depressive symptoms, compared with peers who have confiding relationships (Glover et al 1998).

Creating healthy communities (where individuals experience a sense of belonging, trust, participation and social support) raises community cohesiveness and promotes positive mental health (Leeder 1998; Berry and Rickwood 2000). as reported by VicHealth (1999), social support and integration, too, are directly related to an individual or community’s mental health status, illness in general and death.

The ability of community-driven initiatives to attain widespread mental health benefits is well documented (Pransky 1991). Building on Strengths action will focus on empowering community leadership, mental health promotion action, and ensuring access to social and physical activities, as well as access to opportunities to strengthen coping skills.

3.2 What is mental health?

In developing a strategy to promote mental health1, we need to define what mental health is. Mental health and wellbeing means more than the absence of mental illness. It has been described as:

"the capacity of each and all of us to feel, think and act in
ways that enhance our ability to enjoy life and deal with the
challenges we face. It is a positive sense of emotional and
spiritual well-being that respects the importance of equity,
social justice, interconnections and personal dignity."

(International Workshop in Toronto cited in Edwards 1999).

In New Zealand an important feature of any definition of mental health is an acknowledgement of the inter-connectedness between physical, spiritual, environmental and mental health.

This echoes both Maori and Pacific peoples’ holistic approaches to health and wellbeing. Maori and Pacific peoples share broadly similar concepts of health. Maori (whare Tapa wha, Te Wheke) and Samoan (Fonofale) models of wellbeing, for example, acknowledge that the health of the individual and, ultimately, of society mirrors a complex relationship of mental, physical, spiritual, family, community and environmental factors. Mental health is just one of the cornerstones of health, and each element is as important as the next. To address one element, it is essential to
look at the wider picture, which includes all aspects of the holistic approach.

There is increasing recognition that mental health promotion has a key role to play in improving the health of communities. This means not just emphasising disease diagnosis and medical treatment. It also means emphasising services that keep people well and prevent the onset of mental illness. This will require attention to reducing the effects of wider environmental determinants of mental health (such as poverty and geographic isolation) as well as building individual and community resilience within supportive environments (Labonte and Feather, cited in Disley 1997).

3.3 What is Mental Health Promotion?

As outlined above, mental health is more than the absence of mental illness. Building on Strengths acknowledges that mental health is distinguishable but inseparable from general health. Tanahill (2000 cited in Edwards 2001) argues that integrating mental health promotion and general health promotion strategies offers the best prospect of achieving ‘a healthy mind in a healthy body in a healthy society’.

Mental health promotion has been defined as:

"the process of enhancing the capacity of individuals and
communities to take control over their lives and improve their
mental health. Mental health promotion uses strategies that
foster supportive environments and individual resilience,
while showing respect for culture, equity, social justice and
personal dignity."

(Joubert and Raeburn 1998)

Mental health promotion shifts away from an emphasis on disease-based symptoms and deficits to an emphasis on individual resilience and supportive environments. The values of community participation, empowerment, co-operation and trust, are central to mental health promotion.

Submissions on the earlier draft of Building on Strengths emphasised that communities and individuals are in the best position to determine what is in their best interests. empowering communities to do things for themselves can lead to successful results, often because the results are achieved through their own efforts. This supports the view expressed by edwards (1999) that the new approach should allow communities to ‘create their own definitions and
ways of working in a self and community-determined way’.

Mental health promotion involves any action that contributes towards enhancing the mental health and wellbeing of individuals, families, organisations and communities. For example, mental health promotion can:

improve physical health and wellbeing.
improve social relationships at home and with groups.
increase individual, organisational and community awareness of mental health issues.
improve mental health and wellbeing in the workplace.
strengthen the capacity of communities to support social inclusion, tolerance and participation and reduce vulnerability to socioeconomic pressures.
prevent the onset or reduce the risk of some mental health problems; e.g. behavioural disorders, depression and anxiety, substance abuse.
assist recovery from mental health problems.
improve mental health services and the quality of life for people experiencing mental health problems.

There is already a significant amount of work being done in the area of promoting mental health and wellbeing. There are programmes in place throughout the country that have for years supported the re-emergence of individual and community resourcefulness through health and welfare funding (Ministry of Social Development, Child Youth and Family Service, Ministries of education, Youth affairs, Justice and Department of Internal affairs) and through local government, Maori and Pacific provider and other non-government organisation initiatives.

This document attempts to build on the significant contributions of all these organisations by proposing a nationally co-ordinated approach to mental health promotion.

3.4 Scope: Mental Health Promotion on the Mental Health Continuum

Building on Strengths acknowledges the view, expressed in many submissions received, that mental health promotion can be placed on a dynamic continuum that includes promotion, prevention, early intervention, treatment and rehabilitation.

Building on Strengths utilises mental health promotion and prevention activities to increase the capacity of people to participate more actively in decisions that affect their lives. Health promotion does not operate at a different level from prevention. When used together, promotion and prevention can increase individual and community competency to deal with adverse life events, help establish supportive networks and contribute to reduced stress in targeted populations (Swift and Levin 1987). Mental health promotion and prevention activities can be seen as ‘two sides of the same coin and entirely compatible, even mutually reinforcing’ (Stephens et al 1999).

There is a tension created by the inherent differences between prevention (with its emphasis on risk factors) and health promotion (with its emphasis on quality of life and potential for positive mental health). Building on Strengths promotes actions that are focused on developing both individual and community resilience as well as paying attention to mental health protective and risk factors (appendix 3).

This new approach acknowledges that it is ‘sometimes difficult to distinguish the pursuit of prevention from the pursuit of promotion’ (Rowling et al 2002:15) objectives. However, in spite of the difficulties, efforts should continue to support the development of a service integration model that promotes the right mix of promotion and primary prevention interventions.

Numerous submissions on Building on Strengths also indicated the need for a clear alignment between this strategy and the primary care strategy. By focusing on mental health promotion that includes prevention activities, District Health Boards, Primary Health organisations and service providers will be better placed to achieve the key directions of the Primary Health Care Strategy to ‘maintain, restore and improve people’s health’ (Ministry of Health 2001b).

Steps to co-ordinate mental health care across service areas also draws our attention to existing mental health strategic goals (New Zealand, Looking Forward), including those which aim to ‘decrease the prevalence of … mental health problems within the community’ (Ministry of Health 1994). Moreover, the inclusion of prevention activities highlights the growing importance and contribution of early detection toward the effective management of mental health problems and of improved community mental health outcomes, including activity aimed at lessening the
stigma and discrimination often associated with mental illness.

The scope outlined in Building on Strengths ensures an integrated mental health approach that can be directed to whole of population groups, people that are currently well, people who maybe at risk of developing mental health problems and those experiencing early signs of mental illness (Ministry of Health 1997).

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