Mental health promotion
mental illness prevention
Dr Kwame McKenzie MD
12th George Brown Mental Health
Conference
What caused Bill Clinton’s heart problem?

Chest pain in 2004
Coronary artery disease
Bypass surgery
Heart attack prevented

Possible causes:

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• Family history of heart
problems
• Fast food eater
• High cholesterol
• Smoker - cigars
• High blood pressure
• Stress - President from 19932000, difficult end
2
What caused Clinton’s heart problem


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No one cause
Lots of factors acted together to increase his risk
They “decreased his hearts resilience to stress”
3
Why do some people have a heart attack

Whether you have a heart problems depends on
balance between
• Risk factors / physical insults to your heart
• Protective factors / interventions to protect your heart


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Some factors genetic / some upbringing
But these are risk factors not destiny
Without childhood or genetic influences what
happens to us and how we live can still cause a heart
attack.
4
What caused Clinton’s heart problem?
Exercise
Good diet
Treat medical problems
Treat cardiac symptoms
Smoking
Poor diet
Stress
Medical problems
5
Think of this model when
you think of mental health
What is mental health

“a state of wellbeing in which an individual realizes
his or her own abilities, can cope with the normal
stresses of life, can work productively and is able to
make a contribution to his or her community”

World Health Organization.
7
Poor mental health may lead to…

Risky behaviors
•
•
•
•

substance misuse
anger
violence
time discounting
Lack of energy for social roles
• family roles
• community participation
• absenteeism
8
So…

mental health is the foundation for individual
wellbeing and the effective functioning of a
community

there is no health without mental health

there is no wealth without mental health
9
Mental illness

“clinically significant patterns of behavior or emotions,
associated with some level of distress, suffering, or
impairment in one or more areas such as school,
work, social and family interactions, or the ability to
live independently. “
10
Mental illness facts


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more than 450 million people
four of the top ten leading causes of disability
30% of disability claims and 70% of the total costs
life expectancy of people with a diagnosis of
schizophrenia is 10-15 years lower
Estimated cost of mental illness to the Canadian
economy is $51 billion
11
Linking mental health and mental illness

you can have a mental illness and have mental
health

but

poor mental health increases your chance of mental
illness
12
Preventing mental illness &
promoting mental health
Health promotion




International work on health promotion started in
Canada..
Ottawa Charter for Health Promotion - 80s
Jakarta Declaration - 90s
Bangkok Charter - 00s
14
Health promotion =




building healthy public policy;
developing supportive environments;
increasing community efficacy and human capital;
a re-orientation of health services.
15
Specific approaches



developing partnerships between different sectors
human rights that facilitate self-efficacy.
the agreements challenge governments to:
• regulate and legislate to ensure a high level of protection
from harm and to enable equal opportunity to health and
wellbeing.
16

Both mental health and mental illness are determined
by a number of different social, psychological, and
biological factors
17
Mental health mental illness and care
18
Associations with poorer mental health:

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persistent socio-economic pressures
low educational attainment
rapid social change,
stressful work conditions,
gender discrimination,
social exclusion,
unhealthy lifestyles,
violence
physical ill-health
human rights violations
19


Mental health promotion strategies
actions to create living conditions and environments
that support psychological health and allow people to
adopt and maintain healthy lifestyles
20
mental illness prevention

prevention of the occurrence of illnesses,
• (eg decreasing risk factors)

prevention of chronicity,
• (eg through early detection and treatment),

and prevention of secondary consequences
• (eg through intersectoral collaboration are part of the
spectrum of action ).
21
Effective mental health promotion

Evidenced based, costeffective strategies for
mental health promotion
and mental illness
prevention have been
documented.
22
Mental Health Strategy Framework


The MHCC framework for
a transformed mental
health service
A major issue will be a
move towards an
increased focus on the
prevention of mental
illness and the promotion
of mental health
23
This may cause problems
because of globalisation
Globalisation leads to diversity
20 cities with over a million foreign born
25
Immigration

Main driver of population growth
• Responsible for more than two-thirds of growth between
2001 and 2006

Nearly 20% of Canadian population foreign-born
26
Number of Permanent Residents, by
Category, Canada, 1984-2008
Source: Citizenship and Immigration Canada. Facts and Figures 2008: Immigration Overview--Permanent and Temporary Residents. 2009, p. 6.10
27
Immigrant population



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Diverse groups with different realities and needs
Diversity between and within provinces and
communities
All provinces have changing demographics
64% belong to three Statistics Canada groupings:
“South Asian”, “Chinese”, and “Black”
28
Percentage change in visible
minorities 2001 to 2006
19.6
46.9
100.0
48.6
20.6
37.7
25.2
22.9
27.5
31.4
55.1
Canadian Average
Increase 27.2%
41.6
9.1
29
Region of birth of people who have
immigrated to Canada in last 5 years
30
Where are people coming to?
Figure 3: Destination of Permanent Residents and Temporary Foreign Workers, 2008
Notes: Percentages are rounded for clarity of presentation.
Provinces at 1% or below (NS, NB, PEI, NL and the Territories) are not shown.
Source: Citizenship and Immigration Canada. Facts and Figures 2008: Immigration Overview--Permanent and Temporary Residents. 2009, p. 26, 62.10
31
We have little information
on evidence based
prevention and promotion
We know there is a problem
Canadian literature tagcloud
34
Clusters of research

Rates
Social determinants

Barriers and facilitators of care

35
Diverse cultural groups
Different rates of mental illness

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Low rates of mental illness in immigrant groups when
they arrive in Canada but may increase over time
Local studies in Canada report high rates of mental
health problems and illnesses in some IRER groups
Rates vary in IRER groups in Canada
Little information on racialised groups or Caribbean
origin groups
36
Emotional problems in new comers
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Female immigrants more emotional problems (33% F 25% M).
Immigrants from USA & Western Europe lowest levels of
emotional problems (17%), and stress
Immigrants from Central or South America, and Africa and the
Middle East reported the highest levels of stress (33%)
Refugees highest levels of emotional problems (36%)
Family class immigrants the lowest levels (25%).
Skilled workers
• principal applicants highest levels of stress (17%
• family class immigrants the lowest (10%).
37
Canadian-Born Population and Immigrants
Reporting "Fair" or "Poor" Health,
Source: Newbold KB. Self-rated health within the Canadian immigrant population: Risk and the healthy immigrant effect. Social Science and Medicine, 2005.16
38
Effect size 0.41 – refugees worse mental
health
Porter and Haslam - JAMA
39
Migrants risk of schizophrenia
Selten & Cantor Graae Am J Psychiatry. 2005 Jan;162(1):12-24
Migrant group
Relative risk
95% CI
first generation
2.7
2.3-3.2
second generation
4.7
1.5-13.1
“black” migrants
4.8
3.7-6.2
“white” migrants
2.3
1.7-2.9
.
40
Why the problem?
Canadian literature
Social determinants important

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Social factors linked to mental health problems for all
More detrimental usual social determinants
Cultural groups also exposed to novel social
determinants
• migration, discrimination and language difficulties.

less availability of social forces that decrease risk
42
Ratio of earnings of recent immigrants to
Canadian people is decreasing over time
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
1980
Males w Univ. Deg
1990
Females w Univ. Deg
2000
Males w/o Univ. Deg
2005
Females w/o Univ. Deg
43
Households currently in housing that is
inadequate, unsuitable or unaffordable.
*
44
Recent Immigrants Reporting Emotional
Problems, by Income Quartile
Figure 1:
Source: Statistics Canada. Longitudinal Survey of Immigrants to Canada, 2005.
45
* Significantly different from estimate for Canadian-born (p <0.01).
Note: All explanatory variables are based on the situation in 1994/95. Because of rounding, some confidence intervals with 1.0 as upper/lower limit are significant.
Data source: 1994/95 to 2002/03 National Population Health Survey, longitudinal file.
46
Poorly researched factors,
migration, language, racism
Example causes of psychological problems in
refugees
48
Recorded racially aggravated crime
England and Wales (data Home Office)
25000
20000
15000
10000
5000
0
1999/00
2000/1
Property crime
2001/2
2002/3
2003/4
2004/5
Assault and wounding
Harrassment
49
Hate crimes in Canada in 2006

50
Models of pathways to
health impact of racism
Pathways to racism’s health impact

Socially inflicted trauma
• mental, physical, or sexual

Economic and social inequality
• Decreased mobility due to racism (education,
employment)

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Inadequate, inappropriate or degrading
medical care
Targeted marketing of commodities and
lifestyles that can harm health: alcohol,
tobacco, drugs
52
US Surgeon general report mental
health pathways
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Internalization of racial stereotypes & negative images
which denigrate individuals’ self-worth and adversely
affecting their social and psychological functioning;
Institutional racism resulting in stressors that can affect
mental health due to living conditions, crime, violence,
poverty …
53
Racism effects –
getting under the skin
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Acute stressor (life events)
Chronic stressor (micro-aggression)
Body:
•
•
•
•
•
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adreno-corticoids
t-cell change
early aging
weathering
foetal growth
Cognitive development
• Long term change in cognitive focus eg / increased vigilance

Personality/ identity
• (resilience/ vulnerability)
54
Racism stress is different
3 stage model:
1) Stress because of life event
2) Stress because life event
considered unfair
3) Stress because of inability to do
anything about it
55
Pascoe and Richman
56
Pascoe and Richman
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Links between racism and health occur through the
mechanisms of stress responses and health
behaviors.
These relationships remained even when important
covariates were included in the analyses.
Our synthesis of existing literature also suggests that
social support, active coping styles, and group
identification were most likely to serve a protective
function in these pathways.
57
conclusion

We have strategies to improve mental health
We have strategies to improve mental illness
We know that people are unhealthy
We have an increased understanding of why

There are things we can fix…
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58
Thank you
Diverse populations: Barriers to care
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Less likely to get care and poorer care received
Numerous barriers eg:
•
•
•
•
•
•
Awareness and stigma
Pathways unclear
Models of care and personnel not acceptable
Lack of cultural competence and sensitivity
Financial barriers
Language
60
% immigrant population by electoral ward
In Toronto and Vancouver moving from city centre to
suburbs
61
Diverse populations:
facilitators of care
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length of stay in Canada / acculturation
knowledge and education
ethno-specific health promotion
trust in the system
cultural competency
co-operation between service providers
diversity of services including alternative approaches
62
What do we do?
63
Focus groups
Kwame McKenzie
5 questions
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Current service satisfaction
Most important issues for prevention
Who most risk / should be targeted
Would more racially diverse workforce change use
mental health services?
Are there other important issues?
65
How do you feel about the
mental health services you are
receiving now?

“I live the life of a single person even though I have family around me
(client breaks down and cries), I appreciate the fact that my worker is
available to me 24/7, she is there for me in terms of alternating her
schedule and she calls to ask me if I am doing okay and she treats
me like a daughter. She always calls me on Monday morning to ask
me how I am doing and I appreciate that so much. I do not know if I
could go on without her assistance. Speaking of assistance I find
housing problems a significant barrier in my ability to live my
life. I hope this issue is brought to light”
67
What do you think the most
important issues are for
preventing mental health
problems in your community?

“While using the mental health services such going to
a psychiatrist, participating in a mental health
awareness workshop or attending a group, usually
we are labelled as mad or crazy”.
69
Are there particular people in
your community who you think
are most at risk of mental health
problems and should be the first
targeted for help?
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“If youth are not targeted, there is a big risk of addiction to
drugs and joining the gangs …”
“…if our children are healthy and fine, we are happy and
relieved, but if they are suffering from mental health problems
then the whole family are affected and our symptoms are
worsened.”
“Youths are suffering from the cultural conflict, from one side
they are forced by parents to stick to their culture and traditions
while from the other side, they are exposed to different cultural
norms, therefore it is important focus on youth and adolescents
groups.”
71
Would a more racially diverse
workforce, or someone who
speaks your language in
mainstream services make any
difference to whether or how
you use mental health services?

“I have the ability to speak with an individual in Tamil and
English, which is nice. I definitely think the language barrier is a
key component in many people in our community not being
able to take advantage of the services that are offered. I had
switched from having a doctor at (Hospital A) to (a Tamil doctor
at Hospital B) because I felt there was a spiritual/cultural
component/link to understanding my health problems.
I did not receive this respect for culture in using the services at
(Hospital A).”
73

“…language and culture play an important role in
mental health service delivery. For example if I go to
a service provider who doesn’t know my language
and is not familiar with my culture, first of all I will not
be able to explain my problem to him/her as I want to
say it, secondly, even if he/she gets me, will still not
be able to provide me with a culturally appropriate
treatment which is very important.”
74
Are there other issues that you
think are important for improving
the health service response to
ethno-racial groups?
More can be done

Afghan
• Employment, support groups, English language and computer
classes

Somali
• Services at places of worship, Imams taught, decrease stigma,
choice to use ethno-specific or culturally competent mainstream

Tamil
• Housing, befriending, education, programming, day care, work
76
Task group SSAC MHCC produced report
tried to get multiple voices
census
literature
Policy makers
synthesis
Task group
Focus groups
website
forums
Issues and options
roundtable
77
Options based on theory of health equity
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Different groups may have different needs.
The issue not just different needs but service
response.
Health inequities = differences in access, use or
outcome because of an interaction between
community need and service response
78
Multi-level needs - multi-level solutions
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Need to promote strong and healthy communities
and build resiliency
Need to improve services
So...
 Need
•
•
•
•
Traditional health services
Government
Public organisations
Private and voluntary sectors
79
Model of services
80
Thanks
http://www.african-caribbeanhealth.ca/