MHP: 1997 - 2001
by Monica Briggs, Manager, Auckland Regional Public Health Service
Monica
Briggs came to New Zealand from the UK 10 years ago in 1997.
In the UK she had trained in hospitality management with a focus
on people in organisations and the psychology of organisations.
Her exposure to public health came when she got accepted on a
bursary at Huddersfield University (UK). Her interest grew as
she listened to her colleagues talk about the challenges of the
work they did and she absorbed their information.
Her next roles were with health promotion teams at Enfield Local Authority and Enfield and Harringay Health Authorities in London. She worked on cancer prevention programmes and managed various different teams.
When she arrived in New Zealand she was with the then Southern Regional Health Authority as a contract manager for public health and 'always had mental health promotion in her portfolio.' She continued working in the field of mental health as the organisation became the Health Funding Authority and then merged into the Ministry of Health. In 2001, she resigned and moved from Dunedin to Auckland to start work with the Auckland District Health Board as Manager, Auckland Regional Public Health Service.
Her legacy to mental health promotion is her contributions to the Like Minds, Like Mine programme, her health promotion Master's thesis (University of East London) called "Building on Strengths": An innovative approach to developing a mental health promotion strategy for New Zealand (June 2001) and it's (and her) contribution to Building on Strengths: a new approach to promoting mental health in New Zealand/Aotearoa (December 2002).
My time working in mental health promotion in New Zealand was brief, but intense. In a very short space of time I found myself involved at many different levels on a variety of regional and national projects.
What stands out for me most are the people I worked with over that time. They were passionate about what they were doing and determined to make a difference and change the way mental health promotion was seen and how it worked in New Zealand.
1997 - Like Minds, Like Mine
My first big project was to help set up the regional Canterbury Like Minds, Like Mine providers in Christchurch - Te Awa O Te Ora (Maori provider), the Mental Health Foundation's Christchurch based Like Minds team and Pacific Trust Canterbury. There was also support from the Public Health Unit staff in Christchurch.
Then, later in 1997, I started working with Janet Peters (the first national manager of Like Minds, Like Mine) at the national level of the programme.
Our first national meeting in Rotorua was like no other meeting that I had experienced before. There was an explosion of groups and people trying to work out how the new Like Minds, Like Mine programme was going to work. We took all their feedback and ideas and went to Canberra to see how the Australian's ran their campaign.
We learnt a lot from the Australian experience about the challenges of running a national programme to counter stigma and discrimination against people with experience of mental illness.
Rather than following the Canberra example, we chose to tread a slightly different path and do some things that had not been done before.
We reversed their process of national promotion followed by regional promotion - by working closely with tangata whaiora and setting up the grassroots, community process and regional providers before we started running the TV and radio ads.
It has been fascinating seeing the evolution of the campaign since my involvement ended. I think that what made it work so well were:
- The framework we put in place
- Working with tangata whaiora and the clear Maori and Pacific Island strategies
- Understanding the evidence informed programmes from a broad world view (the synthesis of mental health and public health)
- And the great relationships that developed and the goodwill that was generated through cooperation, listening and ongoing communication.
When Janet left the program, I stepped into her role on a temporary contract to establish the national tendering process for the national Like Minds, Like Mine advertising campaign. Just after we had contracted (Draft) FCB advertising agency, Warren Lindberg was recruited as national manager and I stepped back into my regional role.
1999 - Building on Strengths
My next challenge was being invited to participate in developing the national mental health promotion strategy, which later became Building on Strengths.
I used the experience of leading the process around the mental health promotion strategy to write a thesis for a master's degree (see below).
An initial step in the process of developing the strategy involved organising the Open Space Technology Day for mental health promoters where we gathered ideas that jump-started the project.
We had many people involved in strategic development: an internal group, an external group as well as Maori and Pacific groups. Organisations were extremely receptive to and supportive of the idea of the strategy, particularly as it focused on wellness. We took what had been drafted on a national road show to engage tangata whaiora and others in further development of the work.
Hearing people's stories was humbling and kept you grounded. What I found particularly revealing was my entrée into the Maori viewpoint, courtesy of Marty Rogers. The Maori process of visualising and strategising around wellness and holistic approaches is truly unique.
From there Heather Allan and myself finalised the draft for peer review. There were so many ideas, politics and ideologies incorporated into the document that I was pleased that we got it to a place where everyone was happy and positive about it.
Then, in 2001, I handed over the reins of the draft strategy to others who put their hallmark to the work.
After 2001
What I have enjoyed seeing since my role in mental health promotion finished has been how Like Minds, Like Mine has gone from strength to strength. It is slowly growing a national body of research that is recognised internationally as 'trailblazing'. It has resources and providers available locally, regionally and nationally. Following the development of mental health promotion over the past seven year has also been interesting. We've moved from Building on Strengths to somewhere new and it's all thanks to the extraordinary people who work hard to raise awareness of mental health every day.
The outstanding challenge is to recognise mental health as a public health issue. When you see the World Health Organisation predictions that depression is going to be top health issue worldwide by 2020, you know that more attention, more focus and more resources need to be allocated to mental health promotion - it really is important for our well being.
Building on Strengths: an innovative
approach to developing a mental health promotion strategy for New
Zealand
By Monica Jacqueline Briggs
A thesis submitted in partial fulfilment of the requirements for the degree of MSc Health Promotion, The University of East London, June 2001
The following is a retrospective look at parts of Monica's thesis. As mentioned above, Monica undertook it during her employment with the Health Funding Authority in 1999, whilst participating in the development of a draft national mental health promotion strategy.
In the 'Findings' chapters of her thesis she talks about reference groups, stakeholders, hui, fono and project sponsors - these all relate to the groups of people participating in the initial strategic development of the draft national mental health promotion strategy.
Monica left the Health Funding Authority in 2001. However her research provided the groundwork and established a case for the development of the 'first ever' national mental health promotion strategy that was picked up by the Ministry of Health Executive. It shares the same name as the final mental health promotion strategy published by the Ministry of Health in December 2002.
1. Introduction
Monica's research was based on notions of inclusion, openness, active engagement and joint decision-making. It was designed to have real practical application to a national strategic framework for New Zealand in the area of mental health promotion and primary prevention.
It resulted in a national strategy entitled Building on Strengths being developed which signalled a new direction of policy focusing on wellness for New Zealand. It specified priority areas and processes to be adopted to achieve a long-term vision of "good mental health and wellbeing for all New Zealanders". Read on to find out more about the research findings in Monica's thesis.
2. An environment of change
At the time Monica's research was being conducted, public health approaches were being looked to for implementation in what was traditionally the province of the mental health (illness) sector in New Zealand. This involved the application of public health processes, ideology and values to an area that had been bio-medically determined and which used 'health' terminology but in fact related to 'illness'. It therefore crossed the mental health/public health interface and confronted inherent terminology and ideological paradigms such as interventions targeting individuals within systems or interventions aimed at changing the heart of systems.
3. Methodology
The project engaged with 132 people formally and over 90 more informally. Specific research questions centred on:
- What constitutes the delineation of mental health promotion and primary prevention?
- What strategy framework would be appropriate to adopt for the New Zealand context?
- What was an appropriate response for indigenous issues in this area?
- Could an interactive and consultative method be adapted successfully to policy development?
- What dynamics would be apparent when applying a public health approach to the arena of mental health?
4. Findings: Building theory
(from Chapter 5 of Monica's thesis, published in 2001)
The last decade has seen the area of mental health promotion being recognised as a domain of health promotion work. As it is a comparatively new field within mental health promotion the body of knowledge around it is still in its relative infancy. It was therefore essential to systematically collect data and ensure a process that would advance the debate within New Zealand around central issues.
The major themes that emerged were as follows:
- Debate around the delineation of promotion and prevention
- Models to be adopted for practical application
- Mental health promotion and culture
- Structural issues versus non-structural approaches
- Priorities for mental health promotion and primary prevention
- Effective interventions for the priority areas
Many of these themes were inter-related. The debate around the delineation of promotion and prevention was an over arching theme that crossed all population groups and set the framework for this strategy.
There is no common agreement in relation to the delineation between promotion and prevention. Many authors, with a few exceptions (eg, Orley and Weisen, 1998) believe in the value of a dual/complementary promotion and prevention approach (eg Breton, 1999; Commonwealth Department of Health and Aged Care, 1999). Many others see prevention as part of a promotion and propose that mental health promotion activities can contribute to prevention of mental health problems (eg Whiteford, 1992, Lahtinen et al 1999).
However, Orley and Weisen (1998, p41) propose that to develop mental health promotion strategies, promotion needs to be recognised as a distinct domain and not merely part of prevention. They propose this for three reasons:
- Mental health promotion is a desirable activity in itself
- Mental health promotion is effective in the prevention of a range of behaviour related disease and not just in the prevention of mental disorders
- Focusing mental health promotion on mental disorders prevention may define a great many health problems from a psychiatric slant.
What has contributed to the confusion is that mental health promotion programmes often include the prevention of mental problems among their objectives (Breton, 1999); and that mental illness is often referred to as mental health.
Keith Tudor (1996) argues that mental health prevention and promotion are very different entities. He puts forward three possible scenarios:
- Merge mental health promotion with mental illness prevention
- Separate the two concepts
- Abandon one or the other
Having consulted the literature and presented the controversy around delineation of promotion and prevention at various consultative meetings it was agreed by the reference group and Monica that mental health prevention would be run parallel to mental health promotion, with the promotion aspect receiving more attention. Promotion was to be given dominance, as it was the more under-developed of the two areas, one that holds great potential, is a new direction within the policy framework for New Zealand and is an umbrella concept that covers a wide range of approaches. A framework and greater conceptual clarity was required to develop the strategy. Monica therefore investigated different models of promotion and prevention that could work in a complementary and parallel fashion.
There is debate in the literature as to how to conceptualise mental health promotion and mental health prevention. Having reviewed the literature it is concluded that mental health prevention is ideologically within the domain of health promotion.
Having reached this conclusion it followed that there needed to be a framework for both promotion and prevention. No agreement was reached following the stakeholder forum, hui and fono as to single model or framework that could be ascribed to by all. The United States Institute of Medicine (IOM) framework for prevention was implicitly used, as this was what the key audiences understood and were familiar with.
However, there is no common representation of a mental health promotion model. This left a void for promotion. When reviewing the literature around these areas, although no explicit models of mental health promotion appeared to exist, both Maori and Pacific health writers have published and disseminated holistic models of health, which are easily transferable to mental health promotion. This is recognised and has support amongst the mental health sector in New Zealand as evidenced by the stakeholder workshop feedback and key informant interviews.
It therefore becomes critical to understand the goal of a programme, whether it is geared to risk reduction and is therefore of a preventative nature, or a goal of wellbeing and therefore health promotion. However, it needs to be borne in mind that promotion can prevent and prevention initiatives can promote (Barry, 2001; Mrazek and Haggerty, 1994).
5. Findings: building capacity
(from Chapter 5 of Monica's thesis, published in 2001)
Hodgson et al (1996) concluded that there are identifiable components of effective programmes and that the following factors determine a programme's success:
- The programme aims to influence a combination of several risk or protective factors
- It involves the social network of the target groups such as parents, teachers or family
- It intervenes at a range of times rather than once only
- Combinations of intervention methods are used (eg: social support and coping skills). These can be seen to relate to prevention interventions with terminology around 'target groups', 'risk' and 'protective factors'.
Working with the different groups participating in the research around building a mental health promotion strategy, Monica gathered their feedback and built it into a grid that was based on the Health Education Framework (HEA 1997). The grid applied the strategies of community development, inter and intra sectoral work, workforce development, reorientating policy, promoting a life stages approach and encouraging research and innovation to the identified priority areas of child and youth mental health and reducing disparities for Maori, Pacific people and other lower socio-economic groups.
Following feedback from key stakeholders, the reference group and project sponsors, the framework for the draft mental health promotion strategy was modified.
The revised draft strategy comprised of:
- A Vision: Good, positive mental health and well-being for all New Zealanders
- Eight Underlying principles: such as 'people have a right to be involved in determining their future', and 'It is important to work with other agencies'.
- Nine Goals: such as 'encourage services that promote strong individuals and cohesive families', and 'have a society where people who experience a mental illness are valued'.
- A Guide for Action: that was split into Action on factors that affect mental health (determinants) such as 'improve the skills of the workforce, leadership through policy, encourage research, innovation and development'; and Population groups - like 'mental health service users/ tangata whaiora, Maori, Pacific people and children and youth'.
- Eight Outcomes: such as 'Strong research base supporting mental health promotion' and 'discrimination against people with mental illness is reduced'.
6. Where to from here?
(from Chapter 6 of Monica's thesis, published in 2001)
Monica's research resulted in the development of a draft strategy, providing a framework from which to move forward.
Her research acknowledges the long-term time scale required to really make a difference, however, there are short-term initiatives and interventions that could be implemented immediately which would make a difference in the right direction. They include:
- Further exploration of Maori and Pacific models - such as the Te Pae Mahutonga model - and their possible application to all New Zealanders
- An evaluation of the research process as applied to policy development and tracking of the level of success in strategy implementation
- Research around indicators and data for wellness
- More work around building the evidence/research base for health promotion and mental health promotion initiatives
- Accepted criteria for what constitutes evidence/research in this area
- Develop action plans to implement strategic directions set in Building on Strengths
- Engage with inter-agency forums
- Consult with the New Zealand public on the strategy Building on Strengths
7. Concluding remarks
(from Chapter 6 of Monica's thesis, published in 2001)
A Maori saying that is often quoted and summarises what is at the heart of this research, is:
He aha tem ea nunui kit e ao
He tangata, He tangata, He tangata
(What is the most important thing in the world?
It is people, it is people, it is people)
References
(a selection of references from Monica's thesis, published in 2001)
Barry, M.M., (2001) Promoting Positive Mental Health: Theoretical Frameworks for Practice. The International Journal of Mental Health Promotion, 3(1), 25 - 34.
Breton, J.J., (1999) Complementary development of prevention and mental health promotion programs for Canadian children based on contemporary scientific paradigms. Canadian Journal of Psychiatry, 44(3), 227 - 34.
Commonwealth Department of Health and Aged Care (1999) Mental Health Promotion and Prevention National Action Plan, Under the Second National Mental Health Plan: 1998 - 2003. Canberra: Commonwealth Department of Health and Aged Care.
Health Education Authority (1997) Mental Health Promotion: A Quality Framework. Pilot Copy. London: Health Education Authority.
Hodgson, R., Abbasi, T. and Clarkson, J., (1996) Effective mental health promotion: A literature review. Health Education Journal, 55(1), 55 - 74.
Lahtinen, E., Lehtinen, V., Riikonen, E. and Ahonen, J. (Eds.) (1999) Framework For Promoting Mental Health in Europe. Helsinki: STAKES, National Research and Development Centre for Welfare and Health.
Mrazek, P.J. and Haggerty, R.J., (Eds.) (1994) Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington DC: National Academy Press, for Institute of Medicine (IOM).
Orley, J. and Weisen, R.B. (1998) Mental health promotion: What it is, what it is not. International Journal of Mental Health Promotion, 1, 41 - 44.
Tudor, K. (1996) Mental Health Promotion: Paradigms and Practice. London: Routledge.
Whiteford, H. (1992) Future directions for mental health services in Australia. Australian Journal of Public Health, 16(4), 350 - 353.
