Building Up Good Mental Health: Guidelines based on existing knowledge

8/14/2019 Building Up Good Mental Health: Guidelines based on existing knowledge

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Building UpGood Mental Health

VILLE LEHTINEN

Guidelines based on existing knowledge


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Ville Lehtinen

Building Up Good

Mental HealthGuidelines basedon existing knowledge

Monitoring Positive Mental Health Environments Project

STAKES


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Te MMHE Project Partners

J. Agustin Ozamiz (Deusto University, Spain)

Valeria Garcia Landarte (Deusto University, Spain)Jude Stanseld (NIMHE CSIP, UK)Kathy Roberts (Mental Health Matters, UK)Kam Dhillon (Mental Health Foundation, UK)

Jos Carlos Gomes (Escola Nacional de Sade Pblica /Universidade Nova de Lisboa, Portugal)

Wolgang Arnhold (Brcke Rendsburg-Eckernrde e.V, Germany)Igor Krampc (Regional Public Health Institute Maribor, Slovenia)Olivera Stanojevic (Regional Public Health Institute Maribor, Slovenia)Eija Stengrd (WHO CC, SAKES, Finland)

Nina Jutila (WHO CC, SAKES, Finland)

Te MMHE webpage: www.mmhe.eu

Author, SAKES

Tis publication arises rom the MMHE project,which has received unding rom the European Union,in the ramework o the Public Health Programme.

Te sole responsibility lies with the author; the EuropeanCommission and the Public Health Executive Agency arenot responsible or any use that may be made o the

ollowing inormation.

Te inormation contained in this publication does not necessarilyreect the opinion or the position o the European Commission.

ISBN 978-951-33-2248-9

Layout: Minna Komppa/aittotalo PrintOneCover: iina Kuoppala

Gummerus PrintingJyvskyl, Finland 2008


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Contents

Foreword.4

Executive summary. 6

1. Introduction: Environmental changes and mental health. 11

2. How to make things happen?.1421..Enhancing.mental.health.through.comprehensive.mental..

. health.policy.14

22..Building.mentally.healthy.communities.16

23..Developing.the.physical.environment. 1724..Providing.opportunities.for.leisure.activities.18

25..Enhancing.the.mental.health.of.young.children. 19

26..Fostering.the.development.of.mentally.healthy.schools.20

27..Enhancing.mentally.healthy.work.life.21

28..Enhancing.the.mental.health.of.older.people.23

. Basic concepts.2531..Mental.health.25

32..Determinants.of.mental.health.29

33..Promotion.of.mental.health.30

34..Structural.indicators.and.mental.health.policy.34

4. Structural determinants of mental health.3841..Societal.and.environmental.factors..39

. 411.Comprehensive.mental.health.policy.39

. 412.Social.capital:.Mentally.healthy.communities.42

. 413.Factors.related.to.physical.environment.46

. 414.Leisure.activities.48

42. Age-.and.setting-related.factors.50

. 421.Childhood.experiences.before.school.age..50

. 422.Factors.related.to.school.life.55

. 423.Factors.related.to.work.life.57

. 424.Experiences.of.older.people.60

Annex 1. List of the MMHE indicators.63

Annex 2. Some examples of effective interventions.64Annex . Selected literature.71


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4 Building Up Good Mental Health

Foreword

European Union needs a consistent mental health policy

Health is a value shared by all people in both industrial and developing coun-tries. Health is more important to human lie than economic success or apromising uture. From the viewpoint o society, health is a production actorthat ensures a good economic and operational environment.

Health is also a phenomenon with strong social, psychological, spiritualand physical components. A human being is a social creature who is not evenable to develop without a social environment. A amily as understood in the

broad sense provides a human being with a communal culture and at thesame time with the unique environment o ones own amily.Health, however, is a characteristic shared by both individuals and soci-

ety. Maintaining health requires a multisectoral, transdisciplinary approach.Health is generated by all policies, in all sectors. As we approach the inorma-tion society, mental health will become more and more important. Tere isno health without mental health.

Mental health research is multi-disciplinary by denition; it is necessaryto have an understanding o the societal, psychological and physical back-grounds. Te multi-disciplinary approach has maybe been most extensivelyemployed in inant research, whereas research in other areas lags ar behind.Research on mental health determinants is in the early stages.

Te production structure impacts on peoples lives. Industrial societycreated a liecycle o its own: childhood, youth, working age and retirement.Now this cycle is evolving: youth is eroding both childhood and early adult-hood, while at the other end, the crown o lie is extending to a roughlytwo-decade period in retirement.

In the emerging inormation societies, the importance o mental healthis crucial. With no role model to consult in their social development, they

must create a new structure. Te social structures in place in the pioneeringcountries are highly varied. Social capital is needed ever more in the uture.Te inormation society is not a society o machines it is not about

computers, broadband or mobile phones. Rather, it is a purely mental project.Te production methods o the inormation society require people to be ex-ible, creative, innovative, able to learn, make social contacts and network inother words, mental abilities. Consequently, mental health is a prerequisiteor labour productivity and societies competitiveness. While learning andskills become capital, any deprivation o learning will lead to exclusion. With

learning beginning early already at the oetal stage childrens learningopportunities are becoming o utmost importance to the entire world. Tisrequires reconciling work and amily, the development o working lie and


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Building Up Good Mental Health

new leadership but, as yet, prime examples o these remain ew in number.Responsibility or mental health must be adopted everywhere, in com-

merce, community planning, education, culture, national security and com-bating exclusion. Simultaneously, mental health will need to be understood toa much greater extent, in transdisciplinary environments not yet developed.

Mental health policy and its economic dimension mental capital isbecoming a major part o welare policy. Furthermore, mental capital is aprerequisite or any innovation policy. Tis is why projects to explore thephenomena are growing in importance.

Te mental health o people is organically connected with the structureand unction o our societies, as is demonstrated in this manual. I stronglyhope that the manual will give new understanding to the many stakeholders

whose responsibilities lie in the development o mental health policy, espe-cially at the regional level. Te conclusions and recommendations in Chapter2 are especially addressed to the political decision-makers and administratorsin the eld to provide them with evidence-based tools in their importantwork to develop our societies toward mentally more healthy living environ-ments.

Proessor Vappu aipaleFormer Director General o SAKES


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Executive summary

Tis manual is addressed mainly to political decision-makers, administratorsand the many stakeholders who are engaged in the development o our so-cieties, particularly in sectors dealing with health, welare, education, work,communication, culture and the physical environment. Te aim is to help thedierent stakeholders in their task to improve the conditions o mental healthby providing the relevant knowledge base on mental health and its enhance-ment by socio-political actions, especially at the regional level.

Mental health is an essential part o a persons general health. It is organi-cally connected with the structure and unction o our psychosocial and physi-cal environment. Many o these aspects can be seen as important determinantso mental health. Tus, peoples mental health can be aected by tacklingseveral psychosocial and environmental (structural) actors in our societies.

How to make things happen?

Te most important messages o this manual are the conclusions and recom-mendations, which are based on existing research knowledge. Te recom-mendations are grouped into eight domains, corresponding with the proposalby an earlier EU unded project, called MINDFUL.

Enhancing mental health through comprehensive mental health policy,including the ollowing elements: modern mental health legislation; mentalhealth policy analysis; regional or national mental health programmes;co-operation between dierent sectors; active human resource policy;inclusion o users and carers; comprehensive mental health inormationsystem; mental health impact assessment; anti-stigma programme; proper

nancing.

Building mentally healthy communities by: enhancing participation;supporting establishment o sel-help activities; providing support systems;ensuring easy access to mental health services; enhancing equity and socialjustice.

Developing the physical environment by: building mentally healthyhousing environments; building parks and other green spaces; providing

playgrounds or children; reducing noise and crowdedness; securingpublic saety.


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Providing opportunities for leisure activities including: ree-timeeducation; sporting acilities; culture; acilities or civic participation;youth organisations; activity centres or children and amilies.

Enhancing the mental health of young children including: compre-hensive motherhood care; parenting education; paid parenthood leave;comprehensive postnatal care; day care or children; support services orparents at risk.

Fostering the development of mentally healthy schools by: integratingmental health promotion and mental health issues into the school policyand curriculum; providing psychological support or pupils; providing

support or teachers; involving parents; ostering teamwork; implement-ing health promoting school programmes.

Enhancing a mentally healthy work life by: establishing a compre-hensive employment policy; enhancing communication and personnelinvolvement; implementing anti-discrimination provisions; providingmanagement skills training; implementing workplace health promotingprogrammes; adjusting to improve the balance between work and amilylie; supporting those who are unemployed or in precarious work situa-tions; providing supported employment or people with mental disorders;involving the trade unions.

Enhancing the mental health of older peopleby: enhancing social partici-pation; preventing loneliness and social isolation; providing opportunitiesor independent living; providing appropriate health and social services;combating ageism.

Basic concepts

Te most important concepts in this context are: mental health, determinantso mental health, mental health promotion, and mental health policy.Mental health, as an indivisible component o general health, is a broad

concept including psychological well-being (positive mental health) as wellas mental disorders and problems. Mental health is principally a eature othe individual, and it is inuenced by individual biological and psychologi-cal actors, social interactions, societal structures and cultural values. Tismanual is mainly about positive mental health and how it can be enhancedby actions directed at our psychosocial and physical environment. Positive

mental health includes: a positive sense o well-being; individual resources,such as sel-esteem, optimism and a sense o mastery and coherence; ability


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to initiate, develop and sustain mutually satisying personal relationships; andability to cope with adversities (resilience).

Determinants o mental health are actors that are associated with dier-ent aspects o mental health. Determinants o positive mental health can begrouped into enhancing actors, supporting actors and protective actors.

Mental health promotion strives to nd and enhance actors that protectmental health and to reduce actors harmul in terms o mental health. It canwork with whole societies, communities, social groups and individuals, usingdierent kinds o strategies and interventions. According to the WHO theve main strategies in health promotion are:- building healthy public policy;- creation o supportive environments;

- strengthening community action;- development o personal skills; and- a reorientation o health services.

Several mental health promotion programmes have been published andevaluated. An increasing amount o evidence exists that mental health pro-motion is useul and eective.

Mental health policyis a published document in which the goals, strate-gies, necessary actions, and responsible actors are stated. It should outlinethe essential national and/or regional mental health ramework, covering theorganisation o mental health services, prevention and mental health pro-motion, as well as regulations to ensure the human rights o persons suer-ing rom mental disorders. Specic mental health legislation is needed tosupport the implementation o that policy. Development o a national orregional health policy requires a thorough health policy analysis. Te set ostructural mental health indicators, presented by the MMHE Project, couldaid in building incrementally an evidence base that has relevance or a givencountry or region in this task.

Structural determinants of mental health

Here the presentation is based on the earlier EU project MINDFUL, whichproposed 31 structural indicators o positive mental health, grouped intoeight domains. Tese include societal and environmental actors, as well asage- and setting-related actors.

Societal and environmental factors

Components o the comprehensive mental health policy: Te mental health o the

population is in many ways aected by how health policy and societal policyin general is conducted. A comprehensive mental health policy should coverthe ollowing issues: legislation, societal policies, mental health impact assess-


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ment, promotion o mental health, prevention o mental ill-health, delivery oappropriate mental health services, reduction o premature mortality includ-ing suicides, reduction o stigma, protection o human rights, and nancing.

Mentally healthy communitiesare characterised by wide community par-ticipation, broad involvement o all sectors o the community, local govern-ment commitment and creation o healthy public policies. Tese characteris-tics come close to the concept o social capital. Tis concept reers to eatureso social lie such as positive networks, agreement between dierent socialactors and stakeholders, trust and condence in institutions, norms and reci-procity. Empowerment o people and sel-help groups to encounter dierentlie crises are important elements in this context.

Factors related to the physical environment, such as housing conditions,

level o external noise, existence o green spaces, public saety, level o crowd-edness, general cleanliness, and the condition o communication and trans-port systems have been shown to be related to peoples mental health.

Leisure activities may also impact on peoples mental health. Te bestevidence is rom the relationship between physical activity and mental health.Other positive leisure activities may be listening to music, reading, watchinga movie and meeting riends.

Age- and setting-related factors

Childhood experiences beore school ageare o great importance to an individu-als later psychological development and mental health. Tere is also evidencethat promotive and preventive mental health interventions in early childhoodcan be more long-lasting and eective than those introduced later in lie.Crucial actors in this context are home and amily atmosphere, relation-ship between parents, quality o parenting, and attachment style between theinant and the mothering gure.

Factors related to school lie may have great potential in mental healthpromotion. School is the place where the whole age group can rather easily

be reached or several years, and where mental health activities can be wellintegrated into everyday work. Te EC/WHO/Council o Europe initiatedHealth Promoting Schools programme has developed the so-called wholeschool approach to enhance the mental health o all who are involved: thepupils, the school sta and the parents. Te leading principles in this ap-proach are: relationships, participation, autonomy and clarity.

Factors related to work lie: Te relationship between work and mentalhealth is complex: work is o undamental importance to peoples well-beingbut can also be a source o unbearable stress. Adjustment between work and

amily lie is important. Key elements o eective workplace mental healthpromotion include: readdressing eort/reward imbalance; improving com-munication and sta involvement; enhancing social support, especially rom


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managers to subordinates; increasing job control and decision-making lati-tude; and assessing job demands.

Experiences o older people that contribute to psychological well-beinginclude: enhancement o sel-determination, independent living and au-tonomy. Te key actor in mental health promotion in later lie is personal,active participation by the elderly themselves at all levels. Combating ageismis important. Loneliness and physical deterioration are the most importantrisk actors or mental ill-health.


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11Building Up Good Mental Health

1. Introduction: Environmental changesand mental health

Tis manual is about positive mental health or, in other words, psychologicalwell-being which may be a more amiliar term to many o the readers. Temain ocus will be on describing how the state o mental health is aected byactors related to our society, social relationships and physical environmentand how the mental health o the population can be enhanced by actionswhich are targeted at these issues. All the inormation that will be presentedis based on scientic evidence. Te manual is addressed especially to politicaldecision-makers, administrators and the many stakeholders who are engaged

in the development o our societies, particularly in the sectors dealing withhealth, welare, education, work, communication, culture and the physicalenvironment. All decisions made in these matters may have an inuence onpeoples mental health.

As stated by both the World Health Organisation (WHO) and the Com-mission o the European Communities, mental health is an essential part oa persons general health. Tere cannot be any health without good mentalhealth. Furthermore, mental health seems to have become increasingly im-portant in this regard mainly due to the signicant developments and changesthat have taken place in our societies during the post-war period. Our mentalhealth is organically connected with the structure and unction o our psy-chosocial and physical environment. Tus, it is o crucial importance howthe societal policy is organised and conducted by the political leaders andadministrators.

As experienced by all, enormous changes have taken place in our livingsurroundings during the twentieth century. In particular, the psychosocialenvironment in which people grow up and live has changed dramatically.In earlier times the way o lie was in many ways much more stable and lesscomplicated than today. Most things were ruled by the church or the state,

and social control was strict. People generally knew their place in the society,in the community and in the amily. Tis meant, o course, less reedom thannowadays, but on the other hand, more security and predictability o lie.

Te social structure has also become much more complicated than it waseven at the beginning o the last century. Industrialisation brought the rstbig changes. Te major advances, such as electricity, telegraph, telephone,radio and new transportation (trains, steamships, automobiles) had a greatimpact on many aspects o human lie, not least on perceptions o time andspace. Tese issues, or their part, are linked signicantly to a persons sel-

perception, and by association, with aspects o psychological well-being andmental health. Tese developments may have both positive and negativeconsequences. A sense o alienation arising out o an erosion o values and


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standards may be one negative outcome. One o the athers o modern sociol-ogy, mile Durkheim, developed the term anomie to describe this societalphenomenon.

Societal development has continued at an accelerating pace, especially inrecent decades. We are now experiencing the new era o the so-called post-modern society, characterised by ast-travel inrastructures, mass media, theinternet, inormation overload and globalisation. Characteristics o the inor-mation society, such as virtual realities, can again signicantly inuence ourperception o time and space. As a consequence, we have had to change ourways o expressing our existence, our ways o working, loving, reproducing,coping with death and grie and committing to social relationships.

Mental health is built up throughout the whole liecycle o an individual.

All phases have their importance and challenges in this regard: the pre-natalperiod, birth, inancy, childhood, adolescence, adulthood and the period oold age. Old ways o adapting are no longer valid or the most appropriate inacing the new challenges produced by the societal changes described above.O particular importance are the transitions between the developmentalphases: Entering school, puberty, the labour market and retirement bringmore challenges than ever beore, also in terms o mental health. Tereore, itis important that we know how dierent environmental and societal actorsaect our mental health. Tis will help political decision-makers and admin-istrators to make decisions that are benecial and not harmul to peoplesmental health or health in general.

Close human relationships are the cornerstones o our mental health.Proound changes have taken place in amily lie in our modern western soci-eties. Te amily size is much smaller, three-generation amilies have becomeless requent, and single-person households are more common than in earliertimes. Te amily ties have become looser than previously. Even new ormso living together have emerged. All these changes have aected the nature othe most intimate relationships within the amily. Close and mutually satisy-ing connectedness (also called attachment) between a main caregiver and the

child in early inancy is the most important element in building up the goodmental health o the individual.

Other essential prerequisites o good mental health, as part o general health,in our modern society are especially the ollowing:

Possibility or social participation. Tis means participation in civic andcommunity lie, access to mutually satisying relationships and opportuni-ties or social engagement. It can also be considered in the extent to which

social, economic and human capital within a particular group, communityor society, impact on the wider population's health.


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Freedom rom violence and discrimination. Violence may be seen as abroad concept ranging rom psychological and economic abuse to physi-cal and sexual violence. Te WHO divides violence into three categories:sel-directed violence, encompassing suicide and sel-abuse; interpersonalviolence, including amily or partner violence and community violence;and collective violence which includes armed conict, repression and hu-man rights violations. Discrimination, which may take place on the basiso gender, cultural or religious background, sexual identity, political beliesor social position, is oten a predecessor to collective violence.

Access to societal resources and services. Tis includes access to educa-tion, meaningul engagement, work, adequate housing, social and health

services as well as access to sufcient economic resources.

Te purpose o this manual is to help decision-makers in their task by pro-viding the relevant knowledge base on mental health and its enhancementby socio-political actions. o make this manual more readable or the deci-sion-makers the main conclusions and recommendations are presented inthe chapter immediately ollowing this introduction. Reading Chapter 2together with the Executive summary will urnish the reader with the mainmessages in this manual. Te key question is what can health authoritiesand political decision-makers do to improve the conditions o mental healthin their region. Te recommendations are presented as concretely as pos-sible. Tose who are interested in knowing more about the knowledge basebehind the recommendations are invited to read the remaining two chapters.In Chapter 3 the most important key concepts and terms are described anddened, including mental health itsel, the actors (determinants) related tomental health, enhancement (promotion) o mental health, and also struc-tural indicators and mental health policy. Tis will give the needed theoreticalramework or understanding the inormation presented in Chapter 4, whichclaries the most important social and environmental as well as age- and

setting-related actors that are relevant to good mental health, based on theexisting scientic literature and research evidence. Te chapter is divided intosub-chapters, ollowing the grouping o the positive mental health determi-nants into eight domains, as described by the earlier EU-unded developmentproject MINDFUL (Mental health inormation and determinants or theEuropean level). For each domain, some examples o successul mental healthpromotion programmes are given in Annex 2. Finally, a list o recommendedliterature is given in Annex 3.


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2. How to make things happen?

Tis chapter ormulates the policy implications and gives recommendationsespecially or regional level activities, based on the inormation that has beenpresented in the ollowings chapters. Te key question is what can the healthauthorities and political decision-makers do to improve the conditions ormental health in their own region through inuencing positive mental healthdeterminants, as described in Chapter 4. Te recommendations attempt tobe as concrete and useul as possible. All the recommendations are based onsufciently strong research evidence.

2.1. Enhancing mental health through comprehensive mentalhealth policy

Each region should have a comprehensive mental health policy, emphasisingespecially the need to strengthen mental health promotion and preventiono mental ill-health. Tis is especially relevant or countries having ederalgovernance. Many countries have established a national mental health policywhich is ollowed in all regions. Te ollowing elements should be includedin that policy:

Modern mental health legislation: A specic mental health act is needed,covering all aspects o mental health activities. Beside the organisation omental health services and regulations concerning involuntary and orensiccare, the ollowing sections are particularly important to include: 1) broaddenition o mental health and mental health interventions; 2) promotiono mental health; 3) co-operation with other societal sectors; and 4) regu-lations on ensuring patient rights. In addition, mental health aspects maybe incorporated into other legislation, or example, concerning nancingo services, general human rights, and societal impact assessment.

Mental health policy analysisis a means or decision-makers and adminis-trators to ensure that mental health promotion is conducted in the mosteective way. Policy analysis reers to comparisons between countries andregions, and assessment o time trends. Readiness or a policy approachshould exist in each country and region in order to conduct the necessaryactions.

Mental health programmeis a written document which is adopted by the

government. It is a plan or how the mental health policy will be imple-mented in practice. It should cover all relevant aspects o the mental healthpolicy and, especially, the relevant components o the mental health action


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ramework: promotion o mental health, prevention o mental ill-health,combating stigma associated with mental health issues, ensuring the hu-man rights o mental health patients as well as care and rehabilitation opeople with mental disorders.

Co-operation between dierent sectors: Comprehensive mental health policyis not materialised only through health and social welare sectors. Otherimportant societal sectors are education, employment, housing, physicalenvironments and criminal justice. A positive and close co-operation withall these other contributors is an essential prerequisite or an eectivemental health policy implementation. Tis co-operation should take placeat all levels: between the ministries at governmental level, at the regional

administration level and at the local community level.

Active human resource policy: Availability o high quality human resourcesshould be ensured. Tis will in part be ensured by incorporating adequatetraining on mental health issues or all health and social welare proession-als. In addition, the basic training curriculum o many other proessionsshould include courses on mental health promotion and other relevanttopics. Tis concerns especially those working in education, employment,the criminal justice system and environmental planning. It is important topay sufcient attention also to post-graduate training.

Inclusion o users and carers should be a leading principle in all societalplanning as well as in the implementation o activities inuencing peopleswell-being. Tis is especially important in the eld o mental illness ser-vices where the patients have traditionally been excluded rom all decision-making. Similarly the relatives have in earlier times oten been regardedmore as an intererence, than as a partner in the treatment process.

A comprehensive mental health inormation system should be available or

mental health monitoring, planning o services, allocation o resourcesand evaluation o activities. It should be part o the regional health in-ormation system in general. Te ollowing elements should be includedin the mental health inormation system: 1) the set o EU mental healthindicators, covering mental health status (including also positive mentalhealth), determinants o mental health and mental health services (in-cluding promotion and prevention); 2) a structure to routinely collectthe necessary inormation; 3) analysis o the inormation; and 4) eectiveeedback and dissemination o the data.

Anti-stigma programme: Mental disorders and mental health issues in generalbear a strong stigma and are subject to negative attitudes rom the general


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population as well as rom decision-makers. Tis in many ways hampersthe establishment o a comprehensive mental health service ramework insociety. Tereore, it is important to build up and implement an eectiveprogramme to combat stigma related to mental health issues. Te WHOhas a long experience in organising anti-stigma campaigns.

Mental health impact assessmentis needed to evaluate possible mental healthconsequences o dierent societal actions. As has been demonstrated, so-cietal development may either enhance or be harmul to peoples mentalhealth. A Mental Well-being Impact Assessment oolkit has recently beendeveloped and tested by the Care Services Improvement Partnership inBritain.

Research in mental health policy and promotion should be supported byspecic research programmes, developed jointly by mental health proes-sionals, authorities and the research community to provide the necessaryknowledge on specic national and regional circumstances.

Proper fnancing: Te obligation o the regional government is to ensuresufcient nancing o dierent mental health activities. Experience hasshown that the oten undervalued position o mental health in comparisonto other health sectors easily inhibits the development o the mental healthsector. Tereore, it is preerable to have a separate budget or the mentalhealth sector as well as mental health promotion and prevention activities.

2.2. Building mentally healthy communities

Te mental health o the individual is strongly related to the characteristics othe community where he or she is living. Development o communities thatsupport the mental health o the people (i.e. increasing social capital) requiresthe proper implementation o mental health policies and programmes, and

shall include several actions:

Enhancing participation: Active participation o people in dierent activi-ties in the community strongly indicates a well-unctioning living envi-ronment. Tereore, community leaders and key gures should in all wayspossible support the establishment o dierent kinds o joint activities andnetworks that acilitate participation in community development. Em-powerment o people is the key word in these eorts.

Supporting the establishment o sel-help activities: Sel-help groups haveproved to be eective and cost-eective in combating risks connected withdierent kinds o lie crises such as unemployment, divorce, death o the


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spouse, amily members drug or alcohol problems or amily violence. It isimportant, thereore, that regional authorities support by all means pos-sible the establishment o these kinds o activities.

Providing support systems: Family and riends are the natural support sys-tems or most people. Not all people in the community, however, are in aposition to make use o these natural support systems. Tese may includeisolated older people, single-parent amilies, immigrants and people withmental health problems. A healthy community co-ordinates, togetherwith the church and voluntary organisations, the needed social supportor these people through dierent kinds o beriending programmes, com-munity work and easy to access community services. Respect or diversity

and human rights should be key principles in these activities.

Access to mental health services: An essential characteristic o a healthycommunity is the availability o low-threshold community-based mentalhealth services or all who are in need o these services. Te services shouldcomprise a broad spectrum o activities: promotion o mental health,prevention o mental ill-health, early detection, care and rehabilitation omental disorders, as well as prevention o premature mortality.

Enhancing equity and social justice: Equity and social justice need to prevailin the community i they are to promote mental health. No one should bediscriminated against because o his or her social status, religion, educa-tion, ethnic background, age, gender, ability, sexual orientation or politicalopinion. Equal access to education and employment are basic character-istics o just communities. A sufcient livelihood should be ensured oreverybody.

2.3. Developing the physical environment

Characteristics o the physical environment have an impact on peoples men-tal health. Tese can be enhanced or example by the ollowing actions:

Building mentally healthy housing environments: Housing conditions havebeen shown to have a strong impact on peoples mental well-being. Tere-ore, it is important to establish in each region or larger municipality aspecic organisation to ensure that mental health aspects are sufcientlytaken into account in housing planning.

Establishing parks and other green spaces in urban areas is important orpeople to have somewhere to move around and to enjoy the environment,and thus, it has an important meaning or peoples mental health. Having


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the chance to be close to nature has also been shown to provide manypositive inuences.

Providing playgrounds or children: Play is very important or childrenshealthy psychosocial development. ightly built urban environmentsprovide ew opportunities or children to play. Tereore, it is importantto build a network o playgrounds and adventure parks or children odierent age.

Reducing noise and crowdedness: Many o our cities are very noisy and theirstreets over-crowded. Tese are eatures that are known to have a rela-tionship with increased risk o stress symptoms and lowered well-being.

Tereore, all urban areas should have a programme to reduce noise andcrowdedness in streets and other public places. o establish car-ree areasin city centres is one option.

Securing public saety: People should be able to live without ear o violenceor harassment on streets and other public places, in schools and in work-places. Tis can be achieved by applying many available programmes tocombat bullying, sexual harassment and physical violence. Zero-toleranceshould be the leading principle concerning these issues.

2.4. Providing opportunities for leisure activities

Relaxation, recreation and experiences in lie are important elements insupporting the mental well-being o an individual. Such experiences can beachieved by proper leisure activities, such as:

Free-time education: For many adults and older persons studying a topic

that one eels is interesting or useul may be an important leisure activitythat gives pleasure, sel-ullment and new skills. Te topics may comprise

or example oreign languages, handiwork, dierent hobbies or artistic ac-tivities. It is important that the community provides opportunities or thiskind o activity.

Sporting acilities: Physical activity has clearly been shown to have a con-nection with mental health. Tereore, sporting elds, public swimmingpools, cycle paths, jogging trails and tness centres should be availableor every citizen. Te responsibility o the municipality is to support andenhance the building o such acilities.

Culture: Art in its dierent orms provides reviving experiences or aperson. Tese may have a positive inuence on mental health by giving


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opportunities or identication, emotional experience and catharsis. Tus,the municipalities should establish cultural centres, libraries, theatres, artgalleries and concert halls not only to provide artistic experiences or itscitizens, but also because it brings better health.

Facilities or civic participation: Community networks, civic engagementand participation are characteristics o social capital. Te local communitycan support mental health by providing meeting acilities or civic organi-sations engaged in dierent activities. Te needs o dierent age groupsshould be recognised.

Youth organisations: Participation in organisations like the scout movement,

youth theatre groups or other similar activities that enhance co-operationand mutual responsibility have proved to be important to the healthy psy-chological development o adolescents. It is, thereore, important that thesociety supports the establishment and maintenance o such activities andorganisations.

Activity centres or children and amilies: Families with young children needspecial attention. One means o supporting them is through special cen-tres that provide joint activities or both parents and children.

2.5. Enhancing the mental health of young children

Te basis or later mental health is laid down in childhood. Tereore, this ageperiod is the most avourable or eective mental health promoting activities.Given that the home is the natural living environment and parents the mostimportant carers o the child, most o the activities should be directed to thewhole amily. Tese include the ollowing:

Comprehensive motherhood care, available or all pregnant women in the

region, should be organised by the health authorities. Tis should includeregular check-ups during the entire pregnancy, with equal attention topossible physical and psychosocial risk actors.

Parenting education or both parents during the pregnancy should beprovided as part o the public motherhood care. Secure early attachmentbetween the baby and the main caregiver as well as good enough parent-ing are necessary elements in the childs healthy development.

Te paid parenthood leaveater childbirth should be at least two years. Be-cause close relationships with both parents are important or the healthydevelopment o the inant, the ather should be able to use at least six


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months o the parenthood leave. Sufcient economic support or theamily during this period is an essential condition to ensure thepsychological well-being o the amily.

Comprehensive postnatal care: Many countries and regions have establisheda distributed network o so-called well-baby clinics as part o public healthcare. Tey provide regular health check-ups or children under school-age,but also take care o the psychosocial situation o the whole amily. Tus,it is important that the postnatal care does not only look at the physicaldevelopment o the child but also is able to ollow the childs psychologicaldevelopment.

Day care or children: Both parents o young children are nowadays work-ing increasingly outside the home. o support both the amilies and thedevelopment o children it is essential that the society has established a well-distributed and high quality day care system where the child canspend the time when parents are at work. o be mental health promotingthe day care system should oer activities, stimuli and security or thechildren, and inspire a eeling o condence in the parents.

Support services or parents at risk: A special emphasis should be directed toparents and amilies where there is an increased risk or the child o un-desirable development. Tese include single-parent amilies, very youngparents and parents with mental ill-health or abuse problems. Home visitsby proessionals or beriending programmes by voluntary organisationsare examples o eective support services.

2.6. Fostering the development of mentally healthy schools

School is the place where most children and adolescents between 6 and 17years o age can be reached rather easily. Tus it is very natural that most

o the universal mental health promoting activities or these age groups areimplemented in the school setting. Furthermore, these activities may rathereasily be integrated in the normal school lie and general health promotionin schools. Te ollowing activities may be used to enhance positive mentalhealth in the school setting:

Integrating mental health promotion and mental health issues into the school policy and curriculum: A whole school approach to promoting mentalhealth means that the school policy, school environment and school ethos

all promote the mental health o the whole school community. Mentalhealth issues are integrated into the whole school curriculum as a cross-


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cutting principle covering all school subjects. Mental health educationshould continue throughout the school years.

Providing psychological support or pupils: A health promoting school haspsychological support available or pupils whenever necessary. Tis meansthat health nurses, school psychologists and/or school counsellors are parto the school sta, and they participate in the everyday school activitiesso that they become amiliar to the pupils. Pupils condence in theirtrustworthiness is important.

Providing support or teachers: eachers may also need emotional support,especially when working with children in their pubertal turmoil. eam

discussions, individual and group supervision as well as the possibility orconsultation with a mental health expert are some means to overcomeproblems.

Involving parents: An essential element in the healthy school concept isparents participation in discussions and decisions concerning their child.Close parentteacher contact and co-operation is avourable or all part-ners. An active parents council should be established in every school. Tisis a means by which parents can take part in all possible activities o theschool.

Fostering teamwork: Working together strengthens the eeling o solidarityand the social skills o the pupils. Tus, teamwork is one o the key wordsin the everyday lie o a mentally healthy school. Similarly, co-operationand group work is also important or teachers and other school sta. Par-ticipation o pupils at all levels is important.

Implementing health promoting school programmes: Many specic pro-grammes have proved to be eective in enhancing psychological well-be-

ing and security in schools. Tese include or example the Mind Matters-programme and several anti-bullying activities. Each school should chooseprogrammes that are the most appropriate or its needs and purposes.

2.7. Enhancing mentally healthy work life

Te relationship between work and mental health is complex. Depending othe circumstances work can either promote or exploit the mental health oworkers. Building up a mentally healthy workplace is mainly the responsibi-

lity o companies and employers together with the workers and their repre-sentatives. Te role o the politicians is to provide avourable circumstances


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and support rom society or these actions. Te ollowing means can be usedin these eorts:

Comprehensive employment policy: Regular and satisying work is one o the

cornerstones o good mental health o the adult population. Tereore, ullemployment should be the goal o the actual employment policy. Becauseit is not always possible to avoid people becoming unemployed, all avail-able measures to support the unemployed to return to the labour marketas soon as possible should be used. For those whose unemployment showssigns o prolongation actions to avoid social exclusion and marginalisationshould be available.

Enhancing communication and personnel involvement: One importantcharacteristic o a mentally healthy workplace is that the workers have areal and genuine possibility to contribute to the overall decision-makingconcerning the strategy, communication policy and sta management othe workplace as well as the individual work conditions, tasks and goals.

Implementation o anti-discrimination provisions: Discrimination, bully-ing and sexual harassment are very acute risk actors or mental ill-healthin the workplace. Tereore, every workplace should have a commonlyagreed action plan on such negative events. Zero tolerance should be theleading principle in managing and having control over these problems.

Providing management skills training: Managers are in the key position increating a mentally healthy atmosphere in a workplace. Tereore, it isimportant that each workplace has developed a programme or providingmanagement skills training or all senior sta.

Implementing workplace health promoting programmes: Several eectiveprogrammes to promote a healthy workplace and to enhance the mental

health o the personnel have been developed and tested in practice. Goodexamples o workplace mental health promotion practices can be ound inthe report Mental Health at Work: Impact, Issues and Good Practices,published jointly by WHO and ILO. Feasible mental health promotionprogrammes should be implemented in all workplaces.

Adjusting between working and amily lie: In the modern society both par-ents are usually working outside the home, which brings challenges in t-ting together work requirements and amily obligations. Tis is especially

relevant with young children in the amily. Te society should providegood quality day care acilities and sufcient economic support to helpamilies to make their own choices in these issues. Te employers should


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provide opportunities or individual solutions concerning, or example,the work-time exibility.

Supporting the unemployed or those in precarious work situations: Unem-ployment oten means, though not always, a risk situation or the personsmental health. Te same may also be true or precarious work situations,being it undesirable part-time working or a time-limited working relation-ship. Specic programmes to support these people emotionally should beavailable in the community. Sufcient nancial support should also beprovided by society.

Providing supported employment or people with mental disorders: Especially

persons with a long-term mental disorder may oten have difculties inmanaging so-called normal employment because o their illness or themedication they need. Negative attitudes o the employers or work col-leagues are sometimes also a hindrance to normal employment. Tis easilyleads to marginalisation and social exclusion. Tereore, it is important toestablish a system to provide supported employment or these people.

Involving the trade unions: rade unions should have a key role in negotiat-ing working conditions. At the workplace level, the trusted representa-tives should have specic and properly dened positions in the workplaceorganisation.

2.8. Enhancing the mental health of older people

Te number o older people in the community is increasing rather rapidly inall European countries. Older people encounter specic risks to their mentalhealth. Tus, specic means to enhance the mental health o these age groupsshould be available. Tese include the ollowing examples:

Enhancing social participation: Enabling the engagement in the social ac-tivities o the community is one important measure to support the mentalhealth o older people. Providing opportunities or participating in thepolitical, economic and cultural decision-making o the community andlielong learning are a means to ensure social participation.

Preventing loneliness and social isolation: Many older people live alone, andthey may eel lonely, especially i they have difculties in getting out otheir home. Tereore, beriending programmes to help the older person

in his or her everyday living should be organised by the community orthe third sector. Dierent kinds o clubs, recreation centres and socialnetworks can prevent loneliness and isolation.


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Providing opportunities or independent living: Feelings o independenceand autonomy are also important or older people. Tese can be enhancedor example by supporting the establishment o so-called smart-homesolutions, by providing equipment to help communication and movingabout, and in many cases also by providing employment opportunitiesthrough to old age and by encouraging older workers to remain in theworkorce.

Providing appropriate health and social services: Mental health and gen-eral health are strongly interrelated, especially in older age. Poor physicalhealth is a clear risk actor or mental ill-health. Tereore, it is importantto establish a health and social care system to provide all older people with

high quality primary and specialty health services, including easy access topsychiatric services, as well as all the needed social services and benets.

Combating ageism: Negative and depreciating attitudes toward old ageand older people still prevail in our society. Tereore, politicians shouldensure that human rights conventions are implemented with regard toolder persons. Any kind o discrimination should not be tolerated. It isimportant that older people have ull opportunity to participate in thesocial, cultural, economic and political decision-making processes o thesociety.


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3. Basic concepts

Some key concepts have to be claried to ully understand the messages andrecommendations given in this manual. Tus, the goal o this chapter is todescribe and dene the basic concepts and terms in this context, namelymental health, determinants o mental health, promotion o mental healthand the role o structural indicators in mental health policy.

3.1. Mental health

Tere is a lot o misunderstanding and misuse concerning the concept o

mental health. Even many proessionals and experts think that it reers solelyto severe mental disorders. In reality, mental health is a broad concept, and insome way or other concerns everyone in society. Tus, one can say that men-tal health is everybodys business. Another common misunderstanding is thatmental health cannot be promoted and that mental disorders are untreatableand cannot be prevented. Furthermore, issues related to mental health carrya strong stigma, while negative attitudes are still common. One o the maingoals o this manual is to correct some o these misconceptions.

Mental health has been dened in many ways. We can take as the startingpoint the well-known denition o health by the World Health Organization(WHO) rom 1948: Health is a complete state o physical, mental and socialwell-being and not merely the absence o disease or inrmity. Te WHO de-nes mental health similarly as a state o well-being in which the individualrealizes his or her own abilities, can cope with the normal stresses o lie, canwork productively and ruitully, and is able to make a contribution to his orher community.

Te denition, adopted by several EU unded mental health projects, isas presented in the box below.

Mental health, as an indivisible component of general health,reects the equilibrium between the individual and the envi-ronment. It is inuenced by:

a) individual biological and psychological actors;b) social interactions;c) societal structures and resources; andd) cultural values.


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In this context mental health can also be seen as a process thatcomprises predisposing actors (e.g. childhood experiences),actual precipitating actors (e.g. lie events), and supporting orprotecting actors (e.g. social network) as well as various con-sequences and outcomes (e.g. health behaviour). Mental healthhas two dimensions:

1) Positive mental health can be conceptualised as a value in it-sel (eeling well) or as a capacity to perceive, comprehend andinterpret the surroundings, to adapt to them and to change themi necessary; to think and to communicate with each other;

2) Negative mental health (or mental ill-health) is concernedwith mental disorders, symptoms and problems.

The main ocus here will be on positive mental health, andexamples o dierent approaches, denitions and models willbe given.

Tis manual is mainly concerned with positive mental health (psychologicalwell-being), the structural actors related to it and how it can be enhancedby actions directed at our psychosocial and physical environment. Positivemental health is an important resource or individuals, amilies, communitiesand nations. It also enhances a persons capacity to contribute meaningullyto social networks, communities and societies. Mental health problems, incontrast, add signicantly to general health expenditure and contribute todisability, mortality, loss o economic productivity, poverty and low quality olie. Tus, mental health has a conspicuous societal value in itsel, and mental

health problems impose a heavy burden not only on the individuals and theiramilies but on society as a whole.In everyday language the term mental health is used in dierent ways,

and rather oten it has a negative connotation because it is connected withsevere and chronic mental illnesses. However, the positive aspects o mentalhealth have been more and more recognized also by the general public andpolitical decision-makers in recent years, partly due to the activities and re-ports o dierent international organizations, including the WHO and theEuropean Commission.


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Positive mental health includes: a positive sense o well-being individual resources including sel-esteem, optimism,

and a sense o mastery and coherence the ability to initiate, develop and sustain mutually

satisying personal relationships the ability to cope with adversities (resilience).These will enhance the persons capacity to contribute to amilyand other social networks, local community and society.

Mental health is an individual resource that contributes to dierent capacitiesand skills, as described in the box above. Mental health has also been com-pared to natural, renewable resources. In this regard, mental health and itsrenewal must be understood as a continuous process taking place through thelie course. Te liecycle consists o a sequence o phases in which the earlieralways aects those that ollow. In avourable circumstances mental healthcan increase, but mental health resources can also be exploited beyond theirnatural capacity or renewal or even be destroyed by inappropriate actions bysociety.

Basically, mental health is a concept related to the individual, but manyresearchers have widened the term to concern also groups (especially amilies),organisations (e.g. communities or workplaces), and even whole societies. Inthis paper mental health is mainly seen as a concept relating to the individual,which is aected by experiences deriving rom childhood circumstances, re-lationships with signicant others, the characteristics o the living surround-ings, and societal conditions. But it is important to recognise that there isalso an inuence in the opposite direction: Te mental health status o thepopulation aects in many ways how well our communities, organisations,work places and societies unction and are integrated. Tis two-way inu-

ence is demonstrated in Figure 1 by the two-way arrows. Te gure presentsthe so-called unctional model o mental health, originally developed by C.Hosman and later somewhat modied by E. Lahtinen and colleagues. In onesense, this gure can be seen to ollow the unctional process model, includ-ing the input (precipitating) actors, the actual process itsel, and the output(consequences). But on the other hand, the set up is o a systemic equilibriumin which all the actors have an inuence on each other. Finally, the surround-ing society and culture inuence the whole system. We will return to theseissues in the next subchapter.


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SOCIETY & CULTURE

PRECIPITATING

FACTORS

e.g. life events

MENTAL HEALTH

Individual resources

PRESENT SOCIAL

CONTEXT

e.g. social support

CONSEQUENCESPREDISPOSING

FACTORS genetic factors

factors related to

pregnancy and birth

early childhood

experiences

family environment

social circumstances

physical environment

education

employment

work conditions

housing

level of wellbeing

physical health

symptoms

knowledge & skills

quality of relationships

sexual satisfaction

use of services

productivity

public safety

SOCIETY & CULTURE

Figure 1. The functional model of mental health (according to Hosman and Lahtinen et al.)(Source: Hosman C. Oral communication. 1977; Lahtinen E, Lehtinen V, Riikonen E, Ahonen J(eds). Framework for promoting mental health in Europe. Helsinki: STAKES, 1999.)

Te individual characteristics o good mental health are realised as positiveeelings and dierent individual skills and capacities. Feelings o happinessand satisaction are examples o such positive eelings, although these arenot synonymous to positive mental health. Happiness is usually seen as ashort-lasting and transient state whereas the level o mental health is a morepermanent trait o the individual.

Another aspect o mental health is a sense o personal control over theevents o ones lie. J. Rotter launched the concept locus o control to as-sess individuals on a presumed continuum o internality and externality ocontrol. People who believe that they can themselves inuence events in theirlives (internal locus o control) cope better with challenging lie events and

circumstances than those who explain events by such concepts as luck orchance or who attribute events to other people (external locus o control). Another relevant aspect o personal control is the concept o sel-efcacy,which reers to the belie that one can succeed in what one desires to do.It has been shown that people with a strong sense o sel-efcacy show lesspsychological and physiological strain in stressul situations. Some authorsuse the term sense o mastery with the same meaning.

Te concept o sense o coherence, developed by A. Antonovsky, hasbeen associated with mental health by many researchers and authors. An-

tonovskys salutogenic model stresses positive aspects and resources o healthrather than symptoms or disorders. Te three components o the sense ocoherence are comprehensibility (to see the structure, predictability and ex-


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planation o events), manageability (to have the resources available to meetthe challenge o those events) and meaningulness (to see the importance andvalue inherent in those events and ones lie). A person with a strong sense ocoherence is able to choose between various potential resources available. Aweak sense o coherence has repeatedly been associated with mental ill-health,suicidal behaviour and psychosomatic conditions.

One eature o good mental health is resilience which has been denedby M. Rutter to mean resistance towards mental disorders in the ace o liesadversities. Resilience comes close to such characteristics as hardiness andcoping. Resilience may be seen as a dynamic process, inuenced by individualskills and abilities (e.g. problem-solving skills), and existing protective ac-tors. Teir main unction is resistance to stress which can vary across time and

circumstances having both constitutional and environmental determinants.Coping with adversities plays a signicant role in protecting rom unavour-able mental health consequences.

3.2. Determinants of mental health

Tis sub-chapter deals with the concept o determinants. Tese are actors thatare associated with dierent aspects o mental health. Some o them may becauses o the state o mental health, and others its consequences. As explainedbriey in the previous sub-chapter, the determinants o mental health canbe grouped into our domains: the individual actors and experiences, socialinteractions, societal structures and resources, and cultural values (Figure 2).

Figure 2. Determinants of mental health grouped in the four domains.


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Some o the individual actors are not easible targets or mental health pro-motion activities, though they are important determinants o mental health.Tese include especially some demographic actors like age, gender and eth-nicity. Te same is true or genetic actors. Because this manual deals mainlywith the social and environmental actors o positive mental health, that canbe measured and modied by the actions o society, the main ocus will be inthe determinants listed in boxes 2 and 3 in the gure. Many o these determi-nants can also be used as so-called structural indicators o mental health.

In principle, the determinants o mental health can be either those thatenhance positive mental health, or those that reduce it (risk actors). As themain ocus o this paper is on positive mental health we will mainly concen-trate on the ormer. Tey can again be grouped into:

enhancing actors that increase people's positive mental health resources;

supporting actors that help people to strengthen their resilience in theace o adversity;

protective actors that decrease the likelihood that a mental disorder willdevelop by mitigating the eect o negative lie events and other risks.

As can be concluded, there is considerable overlap between these threegroups.

3.3. Promotion of mental health

Promotion o mental health is the third key concept to be dealt with here. Ac-cording to the EU unded Key Concepts Project, promotion o mental healthis a comprehensive strategy and a set o positive activities, aiming to:a) enhance the value and visibility o mental health at the dierent levels osocieties, sections o societies and or individuals; and

b) protect, maintain and improve mental health.

Te second set o activities can also be called mental health promotion proper.Mental health promotion strives to nd and enhance actors and processesthat protect mental health and to reduce actors harmul to mental health.It puts special emphasis on participation and empowerment and on inter-sectoral co-operation. It can work with whole societies, communities, socialgroups, risk groups or individuals, using dierent kinds o strategies. Eectivemental health promotion should result in improved well-being, less human

suering, a lower incidence and prevalence o mental disorders, better use oservices, higher quality o lie, improved social unctioning, enhanced socialintegration, and other related outcomes.


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According to the body ormerly known as the British Health Education Authority, the aims o mental health promotion are concentrated aroundthree main themes that address both the individual, the social and the societalcomponents o mental health:

Issues which relate to each person's ability to deal with their inner world- emotional resilience - thinking and eeling, managing lie and takingrisks;

Issues which relate to each person's ability to deal with their social world- citizenship- belonging, participating, recognising diversity and mutualresponsibility;

Issues which relate to healthy communities - linking the emotional andsocial through a sense oconnectedness and the development of healthystructures. Healthy communities enable the connections to be made. Forexample, the creation o good childcare acilities allows parents to workand care or their children more eectively, and children in turn to eelmore cared or and thereore better able to learn and develop.

Mental health promotion has been dened in many ways by several authorsand organisations. In the box below the denition developed by an expertgroup working or the European Commission in the eld o mental healthpromotion is presented. Tis denition is chosen because it covers mostadequately the broad and complex scope o the concept. Worth noting isthe nal bullet point: prevention o mental disorders can be one outcomeo mental health promotion. Tus, in practice, there is no need to make acategorical distinction between these two activities.

Mental health promotion

is an interdisciplinary and socio-cultural endeavour geared tothe achievement o conditions which enhance the psychologi-cal well-being o individuals, groups and communities;

is a lie-long process rom pregnancy through childbirth,inancy, childhood and adolescence to adulthood and oldage;

is especially ocused on capacities such as eeling secure,autonomy, adaptability, ability to cope with stressors, orm-

ing sustainable intimate relationships, sel-awareness, sel-es-


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cal, cultural and economic environments. Tis action area emphasises theimportance o the interaction between people and their environments andhighlights the importance o mediating structures such as homes, schools,communities, workplaces and community settings as key contexts or cre-ating and promoting positive mental health.

3. Strengthening community action ocuses on the empowerment o com-munities through their active engagement and participation in identiyingtheir needs, setting priorities, and planning and implementing action toachieve better health and to take control o their daily lives. Communitydevelopment approaches strengthen public participation and lead to theempowerment o communities, and increased capacity to improve mental

health at the community level.

4. Developing personal skills involves enabling personal and social devel-opment through providing inormation, education and enhancing lieskills. Improving peoples knowledge and understanding o positive men-tal health as an integral part o overall health orms an important part othis action area, highlighting the need or improved mental health literacy.Developing personal skills such as sel-awareness, improved sel-esteem, asense o control and sel-efcacy, relationship and communication skills,problem-solving and coping skills have all been shown to improve mentalhealth and to acilitate people to exercise more control over their lie andtheir environments.

5. Reorienting health services requires that mental health services embracepromotion and prevention activities as well as treatment and rehabilita-tion services. Tis calls or a health care system that contributes to thepursuit o health as well as the treatment o illness. In terms o mentalhealth, this emphasises the important role o, or example, primary careand mental health services in promoting mental health across dierent

population groups such as children, young mothers, people with chronichealth problems, and mental health service users and their amilies. Reori-enting health services to promote mental health requires greater attentionto the organisation and structure o health services and the training andeducation o health proessionals.

Mental health promotion is an essential element in a comprehensive publicmental health action ramework. Tere also exists an increasing amount oevidence that mental health promotion activities are eective. Several reviews

and directories have been published on eective mental health promotionprogrammes. Te main methods o action in mental health promotion arelisted in the box on the next page.


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Methods in mental health promotion

Health education to the general public, including lessons onmental health issues

Enhancing social support systems, or example school healthcare, counselling services, social work, enhanced co-opera-tion between school and home

Training programmes and courses or key actors, such ascommunity leaders, teachers, workers in employment ser-vices

Skills training (coping skills, problems solving skills, social

skills) Social advocacy: dialogue with experts, community repre-

sentatives, key authorities and decision-makers Work with mass media, providing relevant material and infu-

encing the way they write about mental health issues Encouraging sel-help activities on dierent mental health is-

sues Specic measures o support, or example, peer support in

schools and workplace mental health promotion Individual and amily counselling Creation o low-threshold services Expert consultation or dierent settings such as day care,

schools, primary care, social welare and employment ser-vices.

3.4. Structural indicators and mental health policy

Te ultimate responsibility or organising services and other activities withinthe mental health eld belongs to the government o the country or the cor-responding region, depending on the administrative system o the countryin question. Each country and region should have a comprehensive mentalhealth policy in which the goals, strategies, necessary actions and responsibleactors are stated. Specic mental health legislation is needed to outline theessential national and/or regional mental health ramework, covering theorganisation o mental health services, prevention and mental health promo-tion, as well as regulations to ensure the human rights o people experiencing

mental disorders. Published documents that describe the mental health policyand strategy should be available, and specic mental health programmesshould provide guidelines on how the policy should be operationalised.


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Te report by WHO Regional Ofce or Europe, Policies and practices ormental health in Europe (in press), shows that 38 o the 42 countries inthe European region that took part in the baseline project have a nationalmental health policy available. All participating countries reported havingmental health legislation in place. However, only 29 countries stated to havededicated mental health legislation, the rest covering mental health issues inthe general health legislation.

It is essential that the implementation and success o the mental healthpolicy are regularly ollowed and monitored by relevant means. Tis requiresa comprehensive mental health inormation system, including indicators o allrelevant aspects o the mental health o the population, and o the mental healthactivities provided by the society, including promotion, prevention and care.

A development project, co-unded by the European Commission, calledMINDFUL (Mental health inormation and determinants or the Europeanlevel), has recently published a proposal or a comprehensive mental health in-ormation system. Tis proposal includes a set o relevant mental health indica-tors to be included in the European Community Health Monitoring System.

A health indicator can be conceptualised as a bridge between health policyand scientic inormation (or example epidemiology). Proper guidelinesshould be provided to interpret the trends revealed by these indicators. Further-more, one needs a conceptual model o health to acilitate that interpretation.Health care indicators reect aspects o both individual health and health carein the community. Tus, mental health indicators reveal problems or prioritiesin relation to mental health in a particular population. Tey may derive romroutinely collected data or items in health surveys, and are most useul i theprocedure is regularly repeated. Interpretation needs a broad understanding ohealth, health care and communities, and several indicators may need to beconsidered together, as many things may aect any one indicator.

Health indicators may be described as characteristics or aspects o indi-viduals, amilies, and health services or other actions to enhance health, aswell as being described as dierent kinds o social and environmental aspects

o the community that are related to peoples health. Tese last-mentionedmeasures may be called structural indicators. A set o structural indicatorso positive mental health was primarily developed by one o MINDFULssub-projects, which provided the ollowing denition: Structural indicatorso positive mental health are directly observed phenomena which can be usedas quantitative measures o any o the dimensions that are included in theconcept o positive mental health. Tey can be related to stages o the liecycle, dierent settings, environments, ecological actors, objective circum-stances, as well as statistics about observable human behaviour. One goal

o the MMHE project is to rene these structural indicators and propose amethod or their use in mental health policy analysis.Development o a national or regional health policy requires a thorough


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analysis. Health policy analysis has been dened as a process o assessing andchoosing among spending and resource alternatives that aect the health caresystem, public health system or the health o the general public. Health policyanalysis involves several steps: identiying or raming a problem; identiyingwho is aected; identiying and comparing the potential impact o dierentoptions or dealing with the problem; choosing among the options; imple-menting the chosen option(s); and evaluating the impact. Te stakeholderscan include government, private healthcare providers, proessional associa-tions, industry and trade associations, advocacy groups and consumers. Sys-tematic mental health policy analysis, using some structural methodology,has so ar been rather scarcely developed and utilised.

Comparing outcomes o mental health promotion policies between di-

erent European countries having partly common social rameworks, butdierent cultures, histories and economic situations, could be a very useulmethod to provide valid reerences to decision-makers. Tis requires cleargoal-setting and use o evidence-based actions, taking into consideration,however, what kind o evidence is relevant to programmes addressing wholecommunities and populations. Te set o structural mental health indicators,presented by the MMHE Project, could aid in building incrementally anevidence base that has relevance or a given country or region in this task.

A useul method or comparing policies is the building o typologies. Teunderlying hypothesis in typology building is that there exists a natural con-vergence in health policies when there are similarities in the environmentalactors and a shared knowledge. Within the EU, common eatures are, orexample, the ageing o the population, advances in communication technolo-gies, and the growing expectations and demands o the public. Identicationo typologies could be a useul tool in bringing clarity and order to the com-plex eorts to compare countries and regions in dierent time periods.

Figure . Matrix for mental health policy analysis.(Source: Ozamiz A. Oral communication. 2008.)


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Figure 3 presents a matrix o two axes to build a possible typology or mentalhealth promotion policies. An increase in the welare model, shown by thestructural indicators, would ollow the development presented by the twoaxes, namely the context and the process o policies. Te context covers suchactors as the economic situation, peoples expectations, the history o mentalhealth promotion and level o decentralisation. Te axis o process includesactors and values, interest groups, policy makers, plans, research, and train-ing.

Asking which is the most relevant sector or developing mental healthpolicies the health sector or social welare sector already narrows too arthe areas o responsibility. It is evident that almost all sectors o society haveconnections with or inuence the mental health o the population. Tus,

the mental health o the population is in many ways aected by how societalpolicy in general is organised and conducted. In addition to health and socialwelare, the ollowing sectors are o special importance: education, employ-ment, housing, environment, culture and sport, the justice and prison system,communication, and the economy. In a comprehensive mental health policythe tasks and responsibilities o all these sectors must be considered.


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4. Structural determinants of mental health

Te EU project MINDFUL proposed as one o its outcomes a set o 31 struc-tural indicators or positive mental health. Tese indicators mainly reer tosocietal, social, economic and environmental as well as some age- and setting-related determinants o mental health. Te indicators were selected originallyrom more than 100 determinants, by an expert panel o 100 persons, app-lying the so-called Delphi method. In order to be practical and useul therewas a need to reduce the number o indicators. Te most relevant, as assessedby the members o the panel, were selected. Te nal indicators were groupedinto eight domains as presented in the box below.

The eight domains of the structural indicators of mentalhealth

National mental health ramework Pre-school experiences and amily support/childcare Promotion o mental health through schools and education Employment and workplace mental health Social capital: mentally healthy communities Physical environment Leisure activities Mental health and older adults.

Tis manual is the rst deliverable o a new EU unded project called Moni-toring Positive Mental Health Environments (MMHE). Tis project is adirect continuation o the MINDFUL project. Te 31 indicators have beenurther rened and dened, and a tailored questionnaire has been developed

to collect relevant inormation about these indicators on a regional level.Te chapter uses this same grouping into eight domains in its subchap-ters, although they are not quite in the same order, and they are dividedinto two categories: societal and environmental actors, and age- and set-ting-related actors. For each domain the available scientic knowledge aboutthe relationship between mental health and the determinants as well as theindicators proposed by the MMHE project are presented. Some illustrativeexamples o eective mental health promotion actions towards some o thedeterminants are given in Annex 2 o this manual.


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4.1. Societal and environmental factors

4.1.1. Comprehensive mental health policyAs stated earlier in this manual, mental health can be compared to renewablenatural resources. Tis metaphor helps when trying to understand the rela-tion o mental health to societal phenomena and structures. Te individualis strongly bound with many ties to the community where he or she is living.Tus, the community can in many ways exploit the mental health resourceso the individuals over their natural capacity or renewal, or example byunavourable circumstances, inappropriate requirements or discrimination.On the other hand, the community may give support, security, stimuli and

opportunities to the individual and in this way enhance the development andrenewal o mental health resources. Tus, the mental health o the populationis in many ways aected by how health policy and societal policy in generalis conducted. Te political decision-makers at national and/or regional levelare key here.

A comprehensive mental health policy should cover several issues. Tebox below highlights the essential components o a national or regional men-tal health ramework.

Components of a national or regional mental health frame-work(according to Lavikainen et al.):

Mental health legislation, covering the overall strategies omental health work, provision o relevant services, and pro-tection o human rights o the patients;

Development o general societal policies so that they are a-vourable to peoples mental health;

Establishment o systematic mental health impact assessment

beore every major societal policy decision, as part o generalhealth impact assessment, in societal planning and decision-making;

Promotion o mental health in all relevant settings, coveringall phases o the liecycle;

Prevention o mental health problems by reduction o risk ac-tors;

Improvement o the health and social unctioning o peoplewith mental disorders;

Delivery o appropriate mental health services or early de-tection, care treatment, and rehabilitation;


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Reduction o premature mortality o people with mental disor-ders, including prevention o suicides;

Reduction o stigma and negative attitudes toward mentaldisorders;

Protection o human rights and dignity o all citizens, andespecially people with a mental health problem;

Financing o the necessary actions.

Source: Lavikainen J, Lahtinen E, Lehtinen V (eds). Public health approach

on mental health in Europe. Helsinki: STAKES, 2000.

One important means in supporting the mental health strategy is to assess themental health impact o dierent societal policies and actions beore the naldecision-making and implementation. As has been stated, public policy playsa vital role in shaping the social and physical environment in ways that areconducive to better health. Te mental health o people is strongly determinedby their living and working conditions, the quality o their physical and socio-economic environment and the quality and accessibility o services. Tus, men-tal health impact assessment, as part o the general health impact assessment,should be an integral component o the national and/or regional mental healthstrategy. Its task is to predict and assess the eects on mental health o variousproposed policies, programmes and projects and to support policy-makers inimproving the decision-making process. Te box below presents how healthimpact assessment supports decision-makers in several ways.

How health impact assessment supports decision-makers(according to WHO-Europe)

It inorms decision-makers on how they can make optimaldecisions between a range o policy options, and it improvesthe investment o public unds.

It oers an opportunity to prevent potential negative healtheects and to maximize the positive health eects o propo-sals.

It oers inormation about a proposals eects on the distribu-tion o health in the population, thus providing an opportunityto reduce inequality in health between groups.

It makes p

Building Up Good Mental Health: Guidelines based on existing knowledge

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