Peter's Mental Notes
Monday, January 30, 2006
Meeting the Challenges in Implementing Evidence-Based Practices and Treatments
Jane Tallim and I have the opportunity to deliver a series of workshops across Ontario, on implementing evidence-based practice.
These workshops are organized and hosted by Safeguards: Children's Services Training.
The description of the workshops is below:
The Provincial Centre of Excellence for Child and Youth Mental Health at CHEO is committed to facilitating your use of evidence-based practices and treatments. In this workshop, Peter Levesque and Jane Tallim explore evidence-based practice and treatment and how it relates to child and youth mental health. They also discuss the challenges encountered by service providers in implementing these in their daily practice and provide strategies for overcoming these challenges.
Learning Outcomes:
In this practical interactive workshop, participants will learn to enhance their current work by better understanding the tools, methods, and supports available for implementing evidence-based and evidence-informed practices and treatments. Some of the issues to be addressed include: What is evidence? Why is it important to meeting the mental health care needs of children, youth and families? How do I find out about evidence-based practices and treatments? How do I judge their quality? How do I select the most appropriate ones to introduce in my work? What does my organization need to do to increase the chances of successfully introducing new practices and treatments? Finally, the workshop will also ask what the Centre can do to further facilitate your use of evidence-based practices and treatments. ¶ 9:42 a.m. 0 comments
These workshops are organized and hosted by Safeguards: Children's Services Training.
The description of the workshops is below:
The Provincial Centre of Excellence for Child and Youth Mental Health at CHEO is committed to facilitating your use of evidence-based practices and treatments. In this workshop, Peter Levesque and Jane Tallim explore evidence-based practice and treatment and how it relates to child and youth mental health. They also discuss the challenges encountered by service providers in implementing these in their daily practice and provide strategies for overcoming these challenges.
Learning Outcomes:
In this practical interactive workshop, participants will learn to enhance their current work by better understanding the tools, methods, and supports available for implementing evidence-based and evidence-informed practices and treatments. Some of the issues to be addressed include: What is evidence? Why is it important to meeting the mental health care needs of children, youth and families? How do I find out about evidence-based practices and treatments? How do I judge their quality? How do I select the most appropriate ones to introduce in my work? What does my organization need to do to increase the chances of successfully introducing new practices and treatments? Finally, the workshop will also ask what the Centre can do to further facilitate your use of evidence-based practices and treatments. ¶ 9:42 a.m. 0 comments
Wednesday, January 18, 2006
Preliminary Research Questions
In the Methodology seminar (POP8920), we have been assigned three linked projects that will lead to a fully formed dissertation proposal. The first part is a one page preliminary draft that outlines the issue of interest and some questions associated to this issue.
Here is my draft:
To: Dr. Lise Dubois, Dr. Maurice Lévesque
From: Peter Levesque, 424540
Date: 2005-01-17
Re: POP8920 Preliminary version of research question
----------------------------------------------------------
Mental health problems and illnesses (MHPI) affect approximately one in five children and youth in Canada . Yet only about one in six of these individuals receive any service from a mental health professional.(1) Many MHPI can be prevented and all can be treated. (2)
In the context of schools, mental health problems contribute significantly to class disruption and dropping out. When in school, students cannot optimize their learning if their mental health needs are not met. This leads to other behaviors that are manifested in other areas such as physical health, youth justice, and child welfare. More troubling is not just removal from school but from life, by committing suicide. Statistics Canada reports suicide as the second leading cause of youth death, after fatal motor vehicle accidents. (3)
Given that children and youth have an almost universal access to school in Canada, what does child and youth mental health mean for school principals, administrators, and teachers? They are often in an excellent position to promote mental health and to assist in the detection of mental illnesses. They receive almost no training or support in this area.
School is identified by youth as both the most positive aspect of their life and the most stressful. The 1992 Canadian Psychiatric Association’s Canadian Youth and Mental Health & Illness Survey demonstrated that for youth, school was seen as the most positive aspect of their life. The same survey also identified school as the most stressful aspect of their life. When it comes to discussing mental health concerns however, teachers, principals, school health workers appear to be left out of the loop. When youth are ready to seek help, they go to their family doctor first, family and friends next, almost never to a school worker. Why not?
• What is the prevalence of mental health problems and illnesses (MHPI) in Canada compared to other countries?
• What is the relationship between MHPI and socioeconomic status?
• What is the relationship of access to treatment and SES?
• What are the current barriers, gaps, and resource needs for schools to be a “first line” of detection and treatment of MHPI?
• How can school professionals be effectively developed to support CYMH?
• What issues are preventing the development of an integrated system for CYMH?
• How can mental health be viewed as a component in the holistic health of a population?
• What is the cost of non-treatment of MHPI versus the potential gains in productivity from early and adequate treatment?
1) Davidson, S. & Manion, I.G. (1996). Facing the challenge: mental health and illness in Canadian youth. Psychology, Health & Medicine 1, (1), 41-56.
2) World Health Organization. Fact sheet No. 265, Mental and neurological disorders. December 2001. Available from: http://www.who.int/mediacentre/factsheets/fs265/en/print.html
3) Statistics Canada (2005). Major Causes of Death. Available online at: http://142.206.72.67/02/02b/02b_003_e.htm ¶ 9:33 a.m. 0 comments
Here is my draft:
To: Dr. Lise Dubois, Dr. Maurice Lévesque
From: Peter Levesque, 424540
Date: 2005-01-17
Re: POP8920 Preliminary version of research question
----------------------------------------------------------
Mental health problems and illnesses (MHPI) affect approximately one in five children and youth in Canada . Yet only about one in six of these individuals receive any service from a mental health professional.(1) Many MHPI can be prevented and all can be treated. (2)
In the context of schools, mental health problems contribute significantly to class disruption and dropping out. When in school, students cannot optimize their learning if their mental health needs are not met. This leads to other behaviors that are manifested in other areas such as physical health, youth justice, and child welfare. More troubling is not just removal from school but from life, by committing suicide. Statistics Canada reports suicide as the second leading cause of youth death, after fatal motor vehicle accidents. (3)
Given that children and youth have an almost universal access to school in Canada, what does child and youth mental health mean for school principals, administrators, and teachers? They are often in an excellent position to promote mental health and to assist in the detection of mental illnesses. They receive almost no training or support in this area.
School is identified by youth as both the most positive aspect of their life and the most stressful. The 1992 Canadian Psychiatric Association’s Canadian Youth and Mental Health & Illness Survey demonstrated that for youth, school was seen as the most positive aspect of their life. The same survey also identified school as the most stressful aspect of their life. When it comes to discussing mental health concerns however, teachers, principals, school health workers appear to be left out of the loop. When youth are ready to seek help, they go to their family doctor first, family and friends next, almost never to a school worker. Why not?
• What is the prevalence of mental health problems and illnesses (MHPI) in Canada compared to other countries?
• What is the relationship between MHPI and socioeconomic status?
• What is the relationship of access to treatment and SES?
• What are the current barriers, gaps, and resource needs for schools to be a “first line” of detection and treatment of MHPI?
• How can school professionals be effectively developed to support CYMH?
• What issues are preventing the development of an integrated system for CYMH?
• How can mental health be viewed as a component in the holistic health of a population?
• What is the cost of non-treatment of MHPI versus the potential gains in productivity from early and adequate treatment?
1) Davidson, S. & Manion, I.G. (1996). Facing the challenge: mental health and illness in Canadian youth. Psychology, Health & Medicine 1, (1), 41-56.
2) World Health Organization. Fact sheet No. 265, Mental and neurological disorders. December 2001. Available from: http://www.who.int/mediacentre/factsheets/fs265/en/print.html
3) Statistics Canada (2005). Major Causes of Death. Available online at: http://142.206.72.67/02/02b/02b_003_e.htm ¶ 9:33 a.m. 0 comments
Thursday, January 12, 2006
Computer Supported Cooperative Work
Dr. Melanie Barwick, at SickKids Hospital in Toronto, a Canadian leader in knowledge exchange and translation for children and youth mental health, sent me this very interesting conference link:
Computer Supported Cooperative Work 2006, Banff, AL, Nov 4-8 2006
CSCW 2006, the ACM Conference on Computer Supported Cooperative Work, is the premier venue for presenting research and development achievements in the design, introduction, and use of technology that affect groups, organizations, communities and societies. Although work is an important area of focus for the conference, technology is increasingly supporting a wide range of recreational and social activities. As more and more people in all regions of the globe are able to interact online we are rapidly moving toward a Computer Supported Collaborative World.
Appropriate topic areas for CSCW 2006 include all contexts in which technology is used to mediate human activities such as communication, coordination, cooperation, competition, entertainment, education, medicine, art, and music. The technology may include: email, instant
messaging, blogs, shared workspaces, teleconferencing, games, co-located systems, robotics, haptics, and much more.
I think I will submit something based on my current systematic review work.
(Thanks Melanie) ¶ 4:06 p.m. 0 comments
Computer Supported Cooperative Work 2006, Banff, AL, Nov 4-8 2006
CSCW 2006, the ACM Conference on Computer Supported Cooperative Work, is the premier venue for presenting research and development achievements in the design, introduction, and use of technology that affect groups, organizations, communities and societies. Although work is an important area of focus for the conference, technology is increasingly supporting a wide range of recreational and social activities. As more and more people in all regions of the globe are able to interact online we are rapidly moving toward a Computer Supported Collaborative World.
Appropriate topic areas for CSCW 2006 include all contexts in which technology is used to mediate human activities such as communication, coordination, cooperation, competition, entertainment, education, medicine, art, and music. The technology may include: email, instant
messaging, blogs, shared workspaces, teleconferencing, games, co-located systems, robotics, haptics, and much more.
I think I will submit something based on my current systematic review work.
(Thanks Melanie) ¶ 4:06 p.m. 0 comments
Wednesday, January 11, 2006
Rewarding Work
Last semester, I worked on a student consulting project with Dr. Yolande Chan at the Queen's University School of Business. The students in her knowledge management class produced three excellent consulting projects that will soon be posted on the COE of CYMH website.
Yesterday, I received a nice thank you email from one of the students - Miriam. Besides the pleasure of receiving a thank you, I know that she will soon be graduating and I want to let anyone who reads this that her work is first-class and she is a joy to work with. I don't she will mind if employers - in business, government, or public agencies - contact her with enquiries.
_______________________
Hi Mr. Levesque,
Just wanted to sincerely thank you for the acknowledgment letter and your offer of acting as a reference in the future. Your time and efforts in supporting us throughout the project is very much appreciated. Many thanks!
Regards,
Mariam
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Mariam Ghiacy
Co-Chair,
Queen's Management Consulting Association (QMCA)
School of Business,
Queen's University ¶ 9:30 a.m. 0 comments
Yesterday, I received a nice thank you email from one of the students - Miriam. Besides the pleasure of receiving a thank you, I know that she will soon be graduating and I want to let anyone who reads this that her work is first-class and she is a joy to work with. I don't she will mind if employers - in business, government, or public agencies - contact her with enquiries.
_______________________
Hi Mr. Levesque,
Just wanted to sincerely thank you for the acknowledgment letter and your offer of acting as a reference in the future. Your time and efforts in supporting us throughout the project is very much appreciated. Many thanks!
Regards,
Mariam
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Mariam Ghiacy
Co-Chair,
Queen's Management Consulting Association (QMCA)
School of Business,
Queen's University ¶ 9:30 a.m. 0 comments
Sunday, January 08, 2006
60 hours a week?
After a 2005 that almost did me in, I am trying hard to limit my work week this year to 60 hours a week. It is a difficult balance given the needs at the Centre, the 4 seminars that I am taking this semester, the speaking engagements that are already planned, and the inevitable issues that come out of the blue.
This week looks like the following:
POP 8930 - seminar, readings, and assignment - 15 hours
POP 8920 - seminar and readings - 8 hours
EPI 6188 - seminar and readings - 8 hours
Population Health Strategic Area Conference and readings - 9 hours
Implementation Research seminar - 2 hours
KT workshop preparation - 3 hours
CU Case studies - 4 hours
KE Journal editing - 4 hours
Email and correspondence - 4 hours
That looks like all that I can get done this week. Hopefully, I can keep to this agenda and not get too many unexpected issues popping up. ¶ 7:17 p.m. 0 comments
This week looks like the following:
POP 8930 - seminar, readings, and assignment - 15 hours
POP 8920 - seminar and readings - 8 hours
EPI 6188 - seminar and readings - 8 hours
Population Health Strategic Area Conference and readings - 9 hours
Implementation Research seminar - 2 hours
KT workshop preparation - 3 hours
CU Case studies - 4 hours
KE Journal editing - 4 hours
Email and correspondence - 4 hours
That looks like all that I can get done this week. Hopefully, I can keep to this agenda and not get too many unexpected issues popping up. ¶ 7:17 p.m. 0 comments
Population Health Interventions
Tomorrow, I start POP 8930, Population Health Interventions.
"This course examines approaches to influence population health. Contextual influences on and interactions between individual and population health approaches for health promotion, disease prevention and risk management. Process for establishing transdisciplinary teams and intersectoral partnerships. Sustainable systems change, including health care reform and policy development."
"Overall course objectives are described in this section. Additional objectives are defined for each of the three blocks in the course.
1. To analyze the theoretical foundations for and underlying assumptions of population health interventions.
2. To examine the evidence base supporting population health interventions.
3. To review and critique alternative strategies for identifying population health needs.
4. To consider population health interventions that may reduce inequity gaps.
5. To identify pertinent multi-jurisdictional and intersectoral influences on population health interventions.
6. To debate the relative contributions (immediate and sustained) of alternative population health interventions to achieve improvements in health."
Faculty: Nancy Edwards, Michelle Giroux, and invited guests
This appears to be a very structured seminar with a "killer" amount of readings. The readings that had to be done before Monday's seminar included the following:
Baba A, Cook DM, McGarity TO, Bero LA. Legislating “sound science”: The role of the tobacco industry. Am J Public Health. 2005;Suppl 1: 95;S1: S20-S27.
Bal DG, Lloyd JC, Roeseler A, Shimizu R. California as a model. J Clin Oncology. 2001;19;18s:69s-73s.
Bauer JE, Hyland A, Li Q, Steger C, Cummings M. A longitudinal assessment of the impact of smoke-free worksite policies on tobacco use. Am J Public Health. 2005;95(6):1024-9.
Berryman, J. Canadian reflections on the tobacco wars: some unintended consequences of mass tort litigation. International & Comparative Law Quarterly. 2004; (53 ICLQ 579)
Callard C, Thompson D, Collishaw N. Transforming the tobacco market: Why the supply of cigarettes should be transferred from for-profit corporations to non-profit enterprises with a public health mandate. Tob Control. 2005;14:278-83.
Friedman LC, Daynard RA, Banthin CN. Learning from the tobacco industry about science and regulation. How tobacco-friendly science escapes scrutiny in the courtroom. Am J Public Health. 2005;95;S1: S16-S20.
Gostin LO. “ ¶ 7:05 p.m. 0 comments
"This course examines approaches to influence population health. Contextual influences on and interactions between individual and population health approaches for health promotion, disease prevention and risk management. Process for establishing transdisciplinary teams and intersectoral partnerships. Sustainable systems change, including health care reform and policy development."
"Overall course objectives are described in this section. Additional objectives are defined for each of the three blocks in the course.
1. To analyze the theoretical foundations for and underlying assumptions of population health interventions.
2. To examine the evidence base supporting population health interventions.
3. To review and critique alternative strategies for identifying population health needs.
4. To consider population health interventions that may reduce inequity gaps.
5. To identify pertinent multi-jurisdictional and intersectoral influences on population health interventions.
6. To debate the relative contributions (immediate and sustained) of alternative population health interventions to achieve improvements in health."
Faculty: Nancy Edwards, Michelle Giroux, and invited guests
This appears to be a very structured seminar with a "killer" amount of readings. The readings that had to be done before Monday's seminar included the following:
Baba A, Cook DM, McGarity TO, Bero LA. Legislating “sound science”: The role of the tobacco industry. Am J Public Health. 2005;Suppl 1: 95;S1: S20-S27.
Bal DG, Lloyd JC, Roeseler A, Shimizu R. California as a model. J Clin Oncology. 2001;19;18s:69s-73s.
Bauer JE, Hyland A, Li Q, Steger C, Cummings M. A longitudinal assessment of the impact of smoke-free worksite policies on tobacco use. Am J Public Health. 2005;95(6):1024-9.
Berryman, J. Canadian reflections on the tobacco wars: some unintended consequences of mass tort litigation. International & Comparative Law Quarterly. 2004; (53 ICLQ 579)
Callard C, Thompson D, Collishaw N. Transforming the tobacco market: Why the supply of cigarettes should be transferred from for-profit corporations to non-profit enterprises with a public health mandate. Tob Control. 2005;14:278-83.
Friedman LC, Daynard RA, Banthin CN. Learning from the tobacco industry about science and regulation. How tobacco-friendly science escapes scrutiny in the courtroom. Am J Public Health. 2005;95;S1: S16-S20.
Gostin LO. “ ¶ 7:05 p.m. 0 comments
Thursday, January 05, 2006
Workshop on Strategic Directions for Population Health
STRATEGIC DIRECTIONS FOR POPULATION HEALTH
AT THE UNIVERSITY OF OTTAWA
Workshop 10 January 2006
Your participation in our workshop is greatly valued. This document has been designed to initiate reflections and prompt informal exchange and discussion.
In 2006, the University of Ottawa finds itself in an environment that differs significantly from that in which it created IPH/IRSP in 2000. First, the University has ratified Vision 2010, in which it has reaffirmed its commitment to research excellence, high-quality learning, passion for knowledge and innovation, leadership on language issues, and openness to diversity. Second, there is even greater recognition of the significant opportunities arising from our unique geographic location to partner with government departments and national and provincial agencies. Third, findings of the IPH/IRSP review conducted in 2004 provide an informed critique of strengths and weaknesses of current structures in Population Health. Fourth, development of administrative and governance structures to better promote interdisciplinarity at the University of Ottawa is underway. Fifth, organisational expansion continues to create designated positions for research chairs and Faculty appointments pertinent to Population Health. Sixth, a smooth change of leadership in IPH/IRSP itself was achieved in 2005. Seventh, other Canadian universities now are creating innovative enterprises in Population Health with similar if not identical mandates as originally afforded IPH/IRSP to promote research and training.
By reaffirming Population Health within HEALTH as a Strategic Area of Development, the University of Ottawa is inviting its renewal and seeking a clear statement of strategic direction. At its meeting on 12 September 2005, the College of Principal Scientists of IPH/IRSP recognised this opportunity and many other challenges requiring thoughtful, timely and incisive analysis and response. Dialogue instigated during the 2005 summer reinforced the breadth of unrealised potential at the University of Ottawa beyond IPH/IRSP in Population Health research and training. Subsequent investigations revealed a positive readiness to broaden the scope of consultation and dialogue to engage a wider community in the development of the future for Population Health in Ottawa.
Hence, the first proposed objective towards which our workshop represents a key step is to articulate the vision, scope, performance and future impact of Population Health.
It then is intended that a framework document will be produced that will convey a contemporary vision, mission, values, objectives, strategies (ie actions for the next five years) and performance indicators for Population Health. This planning framework will enable subsequent decisions about issues such as governance, structures, priorities, resources, capital development and recruitment foci at the University of Ottawa to be informed, timely, enabling and reflective of a shared understanding of Population Health. Through the College of Principal Scientists at IPH/IRSP, it has been proposed that this framework be entitled Opportunities and outcomes: Possibilités et résultantes 2010.
Opportunities and outcomes: Possibilités et résultantes 2010
The following questions that have been generated to provide prompts for reflection ahead of the workshop. Key developments since 2000 also are summarised in a series of ten brief appendices to update all participants.
FOCUS QUESTIONS
POPULATION HEALTH RESEARCH AGENDA
What is it that we have in common? What unites us as Population Health researchers
What is the Population Health research agenda that IPH/IRSP should commit to deliver? How might it differ from other health research agendas?
How should its research be characterised in terms of quality, direction, underpinning values?
What are the advantages of creating designated clusters of research and what should these be?
What expertise is currently missing for IPH/IRSP to be a credible and comprehensive Population Health research enterprise?
How well do the current classifications of association and conditions of employment enable researchers to excel?
What new research agenda emerge from the Health Goals for Canada?
What is our obligation to provide postdoctoral training in Population Health research? How well do we do this now?
What happens once postdoctoral experience is obtained? How should we nurture the careers of junior researchers to ensure that each becomes an outstanding and effective contributor in Population Health?
SIGNIFICANCE AND OPPORTUNITIES AS A STRATEGIC AREA OF DEVELOPMENT
What are the implications of being a designated focus within HEALTH as a Strategic Area of Development (SAD) for the University of Ottawa?
What are our deliverables?
Who is nurturing our development? Who can measure our performance? How are they doing this? How can performance management help us?
How should IPH/IRSP better avail itself of appointment mechanisms, new initiatives and time-limited opportunities such as CRCs, ORCs, etc?
What might be done that is new, bold and builds upon our first five years?
TRAINING AND TEACHING
What is the Population Health training agenda that IPH/IRSP should deliver? Should it be research-only training at PhD level?
What is the role for IPH/IRSP with respect to the Faculty of Graduate and Postdoctoral Studies?
What have we learned from the development of alternative graduate opportunities such as graduate certificates? What is our future with respect to Masters courses that are vocationally oriented (eg Masters in Health Services Management, Masters in Public Health)
What markets are we trying to reach? How well do we equip our graduates for the positions they seek?
How should our training be characterised in terms of quality, direction, underpinning values?
What expertise is currently missing for IPH/IRSP to be a credible and comprehensive Population Health training enterprise?
What additional resources are needed to deliver this Population Health research training agenda?
How well do the current classifications of association and conditions of employment enable our students to acquire the best learning experience possible?
FUNDING THE FUTURE
What might a more strategic approach to CFI and other funding opportunities look like to ensure longterm stability and infrastructure for Population Health?
How should IPH/IRSP position itself in relation to philanthropic donations, foundations and long-term institutional funding arrangements?
Is there anything we shouldn’t do or any partnerships we ought never progress?
VALUES, ORGANISATIONAL CULTURE and INTERPERSONAL BEHAVIOUR
What are the values that underpin our enterprise?
What behaviour is condoned? What behaviour is unacceptable?
What standards and behaviours will distinguish those who work in IPH/IRSP and what will be unacceptable standards and behaviours?
To what extent do those contributing to Population Health embrace the stated values of the University of Ottawa? What values could be added to these based on our unique perspective, contributing disciplines and vision? What would be distinct about the values we embrace in Population Health?
IDENTITY
What is the ‘essence’ of IPH/IRSP that should distinguish its image, its external communications and its identity within the University of Ottawa?
How should IPH/IRSP market itself in an increasingly ‘noisy’ and competitive environment?
CROSS-CUTTING QUESTIONS
How ‘current’ is the original vision, mission and objectives as envisaged for IPH/IRSP?
How well has this vision been realised?
What might any new vision for the University of Ottawa include?
What are obvious gaps between current capacity and performance and those envisaged?
What are the University’s existing strengths (recognised areas of excellence) and weaknesses? Not only in IPH/IRSP but across the campus in Population Health?What are the greatest opportunities for Population Health? How ready are we? ¶ 7:12 p.m. 0 comments
AT THE UNIVERSITY OF OTTAWA
Workshop 10 January 2006
Your participation in our workshop is greatly valued. This document has been designed to initiate reflections and prompt informal exchange and discussion.
In 2006, the University of Ottawa finds itself in an environment that differs significantly from that in which it created IPH/IRSP in 2000. First, the University has ratified Vision 2010, in which it has reaffirmed its commitment to research excellence, high-quality learning, passion for knowledge and innovation, leadership on language issues, and openness to diversity. Second, there is even greater recognition of the significant opportunities arising from our unique geographic location to partner with government departments and national and provincial agencies. Third, findings of the IPH/IRSP review conducted in 2004 provide an informed critique of strengths and weaknesses of current structures in Population Health. Fourth, development of administrative and governance structures to better promote interdisciplinarity at the University of Ottawa is underway. Fifth, organisational expansion continues to create designated positions for research chairs and Faculty appointments pertinent to Population Health. Sixth, a smooth change of leadership in IPH/IRSP itself was achieved in 2005. Seventh, other Canadian universities now are creating innovative enterprises in Population Health with similar if not identical mandates as originally afforded IPH/IRSP to promote research and training.
By reaffirming Population Health within HEALTH as a Strategic Area of Development, the University of Ottawa is inviting its renewal and seeking a clear statement of strategic direction. At its meeting on 12 September 2005, the College of Principal Scientists of IPH/IRSP recognised this opportunity and many other challenges requiring thoughtful, timely and incisive analysis and response. Dialogue instigated during the 2005 summer reinforced the breadth of unrealised potential at the University of Ottawa beyond IPH/IRSP in Population Health research and training. Subsequent investigations revealed a positive readiness to broaden the scope of consultation and dialogue to engage a wider community in the development of the future for Population Health in Ottawa.
Hence, the first proposed objective towards which our workshop represents a key step is to articulate the vision, scope, performance and future impact of Population Health.
It then is intended that a framework document will be produced that will convey a contemporary vision, mission, values, objectives, strategies (ie actions for the next five years) and performance indicators for Population Health. This planning framework will enable subsequent decisions about issues such as governance, structures, priorities, resources, capital development and recruitment foci at the University of Ottawa to be informed, timely, enabling and reflective of a shared understanding of Population Health. Through the College of Principal Scientists at IPH/IRSP, it has been proposed that this framework be entitled Opportunities and outcomes: Possibilités et résultantes 2010.
Opportunities and outcomes: Possibilités et résultantes 2010
The following questions that have been generated to provide prompts for reflection ahead of the workshop. Key developments since 2000 also are summarised in a series of ten brief appendices to update all participants.
FOCUS QUESTIONS
POPULATION HEALTH RESEARCH AGENDA
What is it that we have in common? What unites us as Population Health researchers
What is the Population Health research agenda that IPH/IRSP should commit to deliver? How might it differ from other health research agendas?
How should its research be characterised in terms of quality, direction, underpinning values?
What are the advantages of creating designated clusters of research and what should these be?
What expertise is currently missing for IPH/IRSP to be a credible and comprehensive Population Health research enterprise?
How well do the current classifications of association and conditions of employment enable researchers to excel?
What new research agenda emerge from the Health Goals for Canada?
What is our obligation to provide postdoctoral training in Population Health research? How well do we do this now?
What happens once postdoctoral experience is obtained? How should we nurture the careers of junior researchers to ensure that each becomes an outstanding and effective contributor in Population Health?
SIGNIFICANCE AND OPPORTUNITIES AS A STRATEGIC AREA OF DEVELOPMENT
What are the implications of being a designated focus within HEALTH as a Strategic Area of Development (SAD) for the University of Ottawa?
What are our deliverables?
Who is nurturing our development? Who can measure our performance? How are they doing this? How can performance management help us?
How should IPH/IRSP better avail itself of appointment mechanisms, new initiatives and time-limited opportunities such as CRCs, ORCs, etc?
What might be done that is new, bold and builds upon our first five years?
TRAINING AND TEACHING
What is the Population Health training agenda that IPH/IRSP should deliver? Should it be research-only training at PhD level?
What is the role for IPH/IRSP with respect to the Faculty of Graduate and Postdoctoral Studies?
What have we learned from the development of alternative graduate opportunities such as graduate certificates? What is our future with respect to Masters courses that are vocationally oriented (eg Masters in Health Services Management, Masters in Public Health)
What markets are we trying to reach? How well do we equip our graduates for the positions they seek?
How should our training be characterised in terms of quality, direction, underpinning values?
What expertise is currently missing for IPH/IRSP to be a credible and comprehensive Population Health training enterprise?
What additional resources are needed to deliver this Population Health research training agenda?
How well do the current classifications of association and conditions of employment enable our students to acquire the best learning experience possible?
FUNDING THE FUTURE
What might a more strategic approach to CFI and other funding opportunities look like to ensure longterm stability and infrastructure for Population Health?
How should IPH/IRSP position itself in relation to philanthropic donations, foundations and long-term institutional funding arrangements?
Is there anything we shouldn’t do or any partnerships we ought never progress?
VALUES, ORGANISATIONAL CULTURE and INTERPERSONAL BEHAVIOUR
What are the values that underpin our enterprise?
What behaviour is condoned? What behaviour is unacceptable?
What standards and behaviours will distinguish those who work in IPH/IRSP and what will be unacceptable standards and behaviours?
To what extent do those contributing to Population Health embrace the stated values of the University of Ottawa? What values could be added to these based on our unique perspective, contributing disciplines and vision? What would be distinct about the values we embrace in Population Health?
IDENTITY
What is the ‘essence’ of IPH/IRSP that should distinguish its image, its external communications and its identity within the University of Ottawa?
How should IPH/IRSP market itself in an increasingly ‘noisy’ and competitive environment?
CROSS-CUTTING QUESTIONS
How ‘current’ is the original vision, mission and objectives as envisaged for IPH/IRSP?
How well has this vision been realised?
What might any new vision for the University of Ottawa include?
What are obvious gaps between current capacity and performance and those envisaged?
What are the University’s existing strengths (recognised areas of excellence) and weaknesses? Not only in IPH/IRSP but across the campus in Population Health?What are the greatest opportunities for Population Health? How ready are we? ¶ 7:12 p.m. 0 comments
Wednesday, January 04, 2006
Systematic reviews and meta-analysis
Tomorrow I start the "Systematic reviews and meta-analysis" seminar series with David Moher and Dean Fergusson.
The course outline is very interesting as were the first set of readings.
The evaluation is along 3 lines:
Protocol 30% - Must be handed in by 27th February
Final report 50% - Must be handed in by 21st April
Class participation 20%
Compulsory Text
· “Systematic reviews to support evidence-based medicine: how to review and apply findings of healthcare research” by Khan, Kunz, Kleijnen and Antes.
Optional Text
· “The Cochrane Handbook”, freely downloadable http://cochrane.mcmaster.ca/manuals.asp
· “Undertaking systematic reviews of researh on effectiveness. CRD’s guidance for carrying out or commissioning reviews”. CRD Report.
After reading the texts I went poking around the Cochrane Library again. There is not enough work in producing systematic reviews and meta-analyses for mental health issues, especially for children and youth. The work that Howard Schacter is doing with the COE is helping to close the gap but there is still so much that need to be done.
Here is the outline and first week's readings:
For the first session please review the following readings:
· Bhandari M, Devereaix PJ, Montori V, Cinà C, Tandan V, Guyatt GH, for the Evidence-Based Surgery Working Group. Users’ guide to the surgical literature: how to use a systematic review and meta-analysis. Canadian Journal of Surgery. 2004; 47:60-67.
· Pai M, McCulloch, Gorman JD, Pai N, Enanoria W, Kennedy G, Tharyan P, Colford JM. Systematic reviews and meta-analyses: an illustrated, step-by-step guide. National Medical Journal of India. 2004; 17:86-95.
Atkins D, Fink K, Slutsky J. Better information for better health care: the evidence-based practice center program and the Agency for Healthcare Research and Quality. 2005;142:1035-1041.
· Bero L, Rennie D. The Cochrane Collaboration. Preparing, maintaining, and disseminating systematic reviews of the effects of health care. JAMA 1995; 274: 1935-8.
· Moher D, Cook DJ, Eastwood S. Olkin I, Rennie D, Stroup D, for the QUOROM group. Improving the quality of reporting of meta-analysis of randomized controlled trials: the QUOROM statement. The Lancet 1999;354:1896-1900
Session 1(5th January):
Overview of systematic reviews
What is a systematic review; types of systematic reviews; systematic review programs; where do systematic reviews fit in the EBM framework; decision maker and policy maker needs; and how good are we conducting systematic reviews.
Session 2 (12th January):
Question and Protocol development
Any research project, including a systematic review, requires a road map to answer a specific question. In this session we will work on developing and refining the research question; developing a template for a protocol and beginning to populate it. We will also discuss time management for completing a systematic review. We will also consider issues surrounding development data collection forms, extraction and discuss qualitative data synthesis.
Session 3 (19th January):
Refining the research question and Searching the literature I
An early and essential part of conducting a systematic review involves identifying and retrieving the individual studies. This combines both electronic and manual methods: the students will have the opportunity to develop various search strategies tailored to their protocols during this session.
Session 4 (26th January)
Searching the literature II
Computer Lab, using Reference Manager and RevMan
This lab will be devoted to helping students become familiar with the various bibliographical and statistical programs available to complete quantitative data synthesis. This software includes ‘Revman’ produced by the Cochrane Collaboration. Revman can be downloaded from “http://hiru.mcmaster.ca/cochrane/default.htm”. The lab will take place in the Children’s Hospital of Eastern Ontario
Session 5 (2nd February):
Refining the protocol and conducting systematic reviews – process issues I
Computer lab, using RevMan
Specification of the question(s) to be addressed by a systematic review often arise(s) through debate and exploration of issues surrounding a general health problem. Precise and detailed formulation of the question is important to ensure that the review will produce answers that are meaningful to health care professionals and others. The lab will take place in the Children’s Hospital of Eastern Ontario
Session 6 (9th February):
Conducting systematic reviews – process issues II
Computer Lab, Mastering RevMan
To be systematic criteria outlining the characteristics of studies eligible for inclusion in the review should be developed and stated a priori. This session will consider the form and scope of these criteria, how they relate to the research question, and how they are best operationalized. The session will also discuss issues in the development of data abstraction forms. The lab will take place in the Children’s Hospital of Eastern Ontario
Session 7 (16th February):
Methodological issues in systematic reviews I
This session will concentrate on quality assessment, including approaches that have been developed to assess quality. Students will participate in a informal debate.
Session 8 (2nd March):
Methodological issues in systematic reviews II
The validity of a systematic review depends, in part, on several characteristics beyond simply ‘quality’. This session will concentrate on other characteristics, such as language publication, publication status, duplicate publications, and sponsorship.
Session 9 (9th March):
Statistical issues in systematic reviews I
This session will focus on the analytical issues required to synthesis data from a single primary study and will include examples for dichotomous and continuous outcomes.
Session 10 (16th March)
Statistical issues in systematic reviews II
This session will focus on the analytical issues required to synthesis data from multiple studies together and will include examples for dichotomous and continuous outcomes. The session will also discuss issues involved in detecting, describing and explaining both the clinical and statistical heterogeneity found in systematic reviews.
Session 11 (23rd March):
Statistical issues in systematic reviews III
This session will focus on publication bias: prevention, detention and adjustment.
Session 12(30th March):
Hot topics in systematic reviews
This session will include the following topics: what is evidence; use of non-randomized evidence in systematic review; updating systematic reviews; incorporating qualitative information into systematic reviews; patient safety/quality improvement and registering systematic reviews.
Session 13 (6th March):
Limitations of systematic reviews
The session will review themes concerning the limitations of systematic reviews, such as responding to policy makers needs; the labor-intensive methods of conducting a systematic review. This session will also review limitations in light of emerging methodology literature.
Session 14 (13th April):
Reporting systematic reviews
Reporting EMB, including systematic reviews, is currently undergoing ‘standardization’. These developments will be discussed and student reports will be discussed in light of these developments. We will also discuss how to prepare your manuscript of publication submission. ¶ 10:40 p.m. 0 comments
The course outline is very interesting as were the first set of readings.
The evaluation is along 3 lines:
Protocol 30% - Must be handed in by 27th February
Final report 50% - Must be handed in by 21st April
Class participation 20%
Compulsory Text
· “Systematic reviews to support evidence-based medicine: how to review and apply findings of healthcare research” by Khan, Kunz, Kleijnen and Antes.
Optional Text
· “The Cochrane Handbook”, freely downloadable http://cochrane.mcmaster.ca/manuals.asp
· “Undertaking systematic reviews of researh on effectiveness. CRD’s guidance for carrying out or commissioning reviews”. CRD Report.
After reading the texts I went poking around the Cochrane Library again. There is not enough work in producing systematic reviews and meta-analyses for mental health issues, especially for children and youth. The work that Howard Schacter is doing with the COE is helping to close the gap but there is still so much that need to be done.
Here is the outline and first week's readings:
For the first session please review the following readings:
· Bhandari M, Devereaix PJ, Montori V, Cinà C, Tandan V, Guyatt GH, for the Evidence-Based Surgery Working Group. Users’ guide to the surgical literature: how to use a systematic review and meta-analysis. Canadian Journal of Surgery. 2004; 47:60-67.
· Pai M, McCulloch, Gorman JD, Pai N, Enanoria W, Kennedy G, Tharyan P, Colford JM. Systematic reviews and meta-analyses: an illustrated, step-by-step guide. National Medical Journal of India. 2004; 17:86-95.
Atkins D, Fink K, Slutsky J. Better information for better health care: the evidence-based practice center program and the Agency for Healthcare Research and Quality. 2005;142:1035-1041.
· Bero L, Rennie D. The Cochrane Collaboration. Preparing, maintaining, and disseminating systematic reviews of the effects of health care. JAMA 1995; 274: 1935-8.
· Moher D, Cook DJ, Eastwood S. Olkin I, Rennie D, Stroup D, for the QUOROM group. Improving the quality of reporting of meta-analysis of randomized controlled trials: the QUOROM statement. The Lancet 1999;354:1896-1900
Session 1(5th January):
Overview of systematic reviews
What is a systematic review; types of systematic reviews; systematic review programs; where do systematic reviews fit in the EBM framework; decision maker and policy maker needs; and how good are we conducting systematic reviews.
Session 2 (12th January):
Question and Protocol development
Any research project, including a systematic review, requires a road map to answer a specific question. In this session we will work on developing and refining the research question; developing a template for a protocol and beginning to populate it. We will also discuss time management for completing a systematic review. We will also consider issues surrounding development data collection forms, extraction and discuss qualitative data synthesis.
Session 3 (19th January):
Refining the research question and Searching the literature I
An early and essential part of conducting a systematic review involves identifying and retrieving the individual studies. This combines both electronic and manual methods: the students will have the opportunity to develop various search strategies tailored to their protocols during this session.
Session 4 (26th January)
Searching the literature II
Computer Lab, using Reference Manager and RevMan
This lab will be devoted to helping students become familiar with the various bibliographical and statistical programs available to complete quantitative data synthesis. This software includes ‘Revman’ produced by the Cochrane Collaboration. Revman can be downloaded from “http://hiru.mcmaster.ca/cochrane/default.htm”. The lab will take place in the Children’s Hospital of Eastern Ontario
Session 5 (2nd February):
Refining the protocol and conducting systematic reviews – process issues I
Computer lab, using RevMan
Specification of the question(s) to be addressed by a systematic review often arise(s) through debate and exploration of issues surrounding a general health problem. Precise and detailed formulation of the question is important to ensure that the review will produce answers that are meaningful to health care professionals and others. The lab will take place in the Children’s Hospital of Eastern Ontario
Session 6 (9th February):
Conducting systematic reviews – process issues II
Computer Lab, Mastering RevMan
To be systematic criteria outlining the characteristics of studies eligible for inclusion in the review should be developed and stated a priori. This session will consider the form and scope of these criteria, how they relate to the research question, and how they are best operationalized. The session will also discuss issues in the development of data abstraction forms. The lab will take place in the Children’s Hospital of Eastern Ontario
Session 7 (16th February):
Methodological issues in systematic reviews I
This session will concentrate on quality assessment, including approaches that have been developed to assess quality. Students will participate in a informal debate.
Session 8 (2nd March):
Methodological issues in systematic reviews II
The validity of a systematic review depends, in part, on several characteristics beyond simply ‘quality’. This session will concentrate on other characteristics, such as language publication, publication status, duplicate publications, and sponsorship.
Session 9 (9th March):
Statistical issues in systematic reviews I
This session will focus on the analytical issues required to synthesis data from a single primary study and will include examples for dichotomous and continuous outcomes.
Session 10 (16th March)
Statistical issues in systematic reviews II
This session will focus on the analytical issues required to synthesis data from multiple studies together and will include examples for dichotomous and continuous outcomes. The session will also discuss issues involved in detecting, describing and explaining both the clinical and statistical heterogeneity found in systematic reviews.
Session 11 (23rd March):
Statistical issues in systematic reviews III
This session will focus on publication bias: prevention, detention and adjustment.
Session 12(30th March):
Hot topics in systematic reviews
This session will include the following topics: what is evidence; use of non-randomized evidence in systematic review; updating systematic reviews; incorporating qualitative information into systematic reviews; patient safety/quality improvement and registering systematic reviews.
Session 13 (6th March):
Limitations of systematic reviews
The session will review themes concerning the limitations of systematic reviews, such as responding to policy makers needs; the labor-intensive methods of conducting a systematic review. This session will also review limitations in light of emerging methodology literature.
Session 14 (13th April):
Reporting systematic reviews
Reporting EMB, including systematic reviews, is currently undergoing ‘standardization’. These developments will be discussed and student reports will be discussed in light of these developments. We will also discuss how to prepare your manuscript of publication submission. ¶ 10:40 p.m. 0 comments
Implementation Research Methods
My supervisor, Dr. Jeremy Grimshaw has offered to teach his students the basics of Implementation Research Methods through a series of workshops this semester. I am looking forward to it.
_____________________________________________________
Hello Everyone,
Please note the dates of the Implementation Research Methods Sessions:
Session #1 January 11th, 2006 5:00 - 6:30 C4 Conf. Room
Session #2 Feb 2nd, 2006 5:00 -6:30 C4 Conf. Room
Session #3 Feb 13th, 2006 5:00 -6:30 C4 Conf. Room
Session #4 March 9th, 2006 5:00 -6:30 C4 Conf. Room
Session #5 March 23rd, 2006 5:00 -6:30 C4 Conf. Room
Please let me know if you have any further questions.
Regards,
Karen McPherson
Research Administrative Assistant to
Dr. Jeremy M. Grimshaw
Director, Clinical Epidemiology Program
Ottawa Health Research Institute ¶ 7:32 p.m. 0 comments
_____________________________________________________
Hello Everyone,
Please note the dates of the Implementation Research Methods Sessions:
Session #1 January 11th, 2006 5:00 - 6:30 C4 Conf. Room
Session #2 Feb 2nd, 2006 5:00 -6:30 C4 Conf. Room
Session #3 Feb 13th, 2006 5:00 -6:30 C4 Conf. Room
Session #4 March 9th, 2006 5:00 -6:30 C4 Conf. Room
Session #5 March 23rd, 2006 5:00 -6:30 C4 Conf. Room
Please let me know if you have any further questions.
Regards,
Karen McPherson
Research Administrative Assistant to
Dr. Jeremy M. Grimshaw
Director, Clinical Epidemiology Program
Ottawa Health Research Institute ¶ 7:32 p.m. 0 comments
Tuesday, January 03, 2006
What is Population Health
The question of what is population health was only partly answered by the two required readings.
Contandriopoulos, C. How Canada's health care system compares with that of other countries: an overview. In: Forum national de la santé. Le secteur de la santé au Canada et ailleurs. Sainte-Foy, Qc: Editions MultiMondes; 1998.
Evans RG (2000). Canada. Journal of Health Politics, Policy and Law, 25 (5): 890-897.
This appears to be normal due to the emerging nature of this area of study and the complex nature of the questions addressed. The historical shift from medicine to public health and health promotion, to population health is interesting and led me to further readings. These include David Mechanic’s ”Who Shall Lead: Is There a Future for Population Health?”, the Charter of Transdisciplinarity, the Ottawa Charter, Higginbotham et al.’s “Health Social Science”, and the Lalonde Report.
Reflecting on how these readings apply to the area of children and youth mental health, it is clear to me that although mental health is sometimes mentioned, it is a under-developed (or under-used) perspective. A search on PUBMED using the terms: population health, mental health, children, youth, adolescent, produced only six papers, the most useful being McLennan et. al.’s, “Canada’s programs to prevent mental health problems in children: the research-practice gap. This theme of addressing the research-practice gap was picked up in the Kickbusch paper under knowledge transfer. The relationship between knowledge transfer/exchange and population health appears strong but insufficiently researched and implemented. This would be an interesting paper.
What surprised me most from the readings from week two was the Evans paper. His demonstration that the Canadian health system is, for the most part, private but that insurance coverage is mainly public caused me to revisit my own preconceptions about what the Canadian health system is. The focus in my knowledge exchange work has been on incentives and infrastructure to support behavior from these incentives leading to more and more effective knowledge exchange. If, as Evans presents, most of the actors are private then my assumptions about their interactions within institutions and with the policies of various governments will have to be reworked.
The social determinants reading was a useful reference point for thinking about the complexity of factors which need to be addressed however; I need more information about how they interact with each other and what are the relative weights of each factor in differing circumstances. Again, mental health is mentioned in several places, with manifestations such as stress, suicide, and work satisfaction pointed to directly however, I do not have a clear sense of how to apply each of these determinants to an examination of the child and youth mental health system/context in Ontario. This is another interesting possibility for a paper.
The Contandriopoulos paper (NTS: met both father and son during the J.L Denis CHSRF evaluation in 2005-01, Montreal) provided a very useful view of where Canada places within the OECD. The cross-border competition for personnel and resources caused by the USA was clear. The outrageous costs incurred by the USA is a possibility of what costs could have been in Canada without the stabilizing effect that Medicare introduced in the late 1960’s.
It would have been interesting if the author had also analyzed the unit cost of service per person and looked at the distribution across the population. I presume that the USA and Mexico would start to look even more similar, with enormous differences in access across the population. I found the social determinant evidence linking relative population wealth to better health and longer life is very interesting and supported by what Contandriopoulos presented.
From the perspective of child and youth mental health, it could be an interesting study to look at what the expenditure comparisons are. I will have to look for more details of how the numbers presented can be broken down by treatment area. ¶ 10:08 p.m. 0 comments
Contandriopoulos, C. How Canada's health care system compares with that of other countries: an overview. In: Forum national de la santé. Le secteur de la santé au Canada et ailleurs. Sainte-Foy, Qc: Editions MultiMondes; 1998.
Evans RG (2000). Canada. Journal of Health Politics, Policy and Law, 25 (5): 890-897.
This appears to be normal due to the emerging nature of this area of study and the complex nature of the questions addressed. The historical shift from medicine to public health and health promotion, to population health is interesting and led me to further readings. These include David Mechanic’s ”Who Shall Lead: Is There a Future for Population Health?”, the Charter of Transdisciplinarity, the Ottawa Charter, Higginbotham et al.’s “Health Social Science”, and the Lalonde Report.
Reflecting on how these readings apply to the area of children and youth mental health, it is clear to me that although mental health is sometimes mentioned, it is a under-developed (or under-used) perspective. A search on PUBMED using the terms: population health, mental health, children, youth, adolescent, produced only six papers, the most useful being McLennan et. al.’s, “Canada’s programs to prevent mental health problems in children: the research-practice gap. This theme of addressing the research-practice gap was picked up in the Kickbusch paper under knowledge transfer. The relationship between knowledge transfer/exchange and population health appears strong but insufficiently researched and implemented. This would be an interesting paper.
What surprised me most from the readings from week two was the Evans paper. His demonstration that the Canadian health system is, for the most part, private but that insurance coverage is mainly public caused me to revisit my own preconceptions about what the Canadian health system is. The focus in my knowledge exchange work has been on incentives and infrastructure to support behavior from these incentives leading to more and more effective knowledge exchange. If, as Evans presents, most of the actors are private then my assumptions about their interactions within institutions and with the policies of various governments will have to be reworked.
The social determinants reading was a useful reference point for thinking about the complexity of factors which need to be addressed however; I need more information about how they interact with each other and what are the relative weights of each factor in differing circumstances. Again, mental health is mentioned in several places, with manifestations such as stress, suicide, and work satisfaction pointed to directly however, I do not have a clear sense of how to apply each of these determinants to an examination of the child and youth mental health system/context in Ontario. This is another interesting possibility for a paper.
The Contandriopoulos paper (NTS: met both father and son during the J.L Denis CHSRF evaluation in 2005-01, Montreal) provided a very useful view of where Canada places within the OECD. The cross-border competition for personnel and resources caused by the USA was clear. The outrageous costs incurred by the USA is a possibility of what costs could have been in Canada without the stabilizing effect that Medicare introduced in the late 1960’s.
It would have been interesting if the author had also analyzed the unit cost of service per person and looked at the distribution across the population. I presume that the USA and Mexico would start to look even more similar, with enormous differences in access across the population. I found the social determinant evidence linking relative population wealth to better health and longer life is very interesting and supported by what Contandriopoulos presented.
From the perspective of child and youth mental health, it could be an interesting study to look at what the expenditure comparisons are. I will have to look for more details of how the numbers presented can be broken down by treatment area. ¶ 10:08 p.m. 0 comments
Science of Population Health
The discussion of how to approach a science of population health seems to be not unlike the science of making a stew or a casserole. Each of the ingredients are of their own particular nature and “flavour”, yet when they are added together, spiced, and simmered, the result is something quite different from what one started with. Preference for one method or another appears to be one of taste. I could not distinguish a clear method to determine how to best judge what is most effective approach, yet I could see value in most views presented in the readings.
This also brings to mind the difference between complicated and complex. It appears impossible to pull apart the interconnected elements of population health without destroying the powerful framework in which to study the health of populations. Not that population health is the “Holy Grail” of a unified theory. It seems to approach however, the necessary level of completeness to arrive at a more effective; perhaps more efficient, understanding of how to reduce harm to individuals within populations as well as improving the macroscopic conditions which “manufactures” health.
The pulling apart of Evans & Stoddart and to a lesser extent Frank & Mustard by Labonte, Robertson, Poland and colleagues is “normal” behavior found in most fields of research. The setting of boundaries and the dismantling of other frameworks are regular exercises of influence and power. With tongue in cheek, whenever I read any article, I am looking for actionable alternatives that are applicable, feasible, sustainable, and transferable to other contexts. Most of the critiques did not provide this and thus I find them in some respects, to be of limited utility.
Each of the articles however, provided interesting points to consider, the following being what I consider highlights:
Friedman:
A good introduction to models of population health “…it is important to acknowledge that no single widely accepted definition of population health exists.”
Evans & Stoddart:
“There are always unmet needs.”
“…most of the public and political debate over health policy continues to be carried on in the rhetoric of “unmet needs” for health care.”
“Once we recognize the importance and potential controllability of factors other than health care in both the limitation of disease and the promotion of health, we simultaneously open for explicit consideration the possibility that the direct positive effects of health care on health resources may be outweighed by its negative effects through competition for resources with other health-enhancing activities.”
(This is of particular interest to my thinking on examining the models of mental health service delivery and looking for alternatives outside the current framework which has been subject to gross under-funding for decades.)
Frank & Mustard:
“It is not lack of access to health care that is setting this gradient but the underlying social economic factors (unemployment, income, and education) as in Marmot’s study…”
Dunn and colleagues:
“A population health framework situates the importance of social relations centre-stage…Many dimensions of social relations are simultaneously involve in shaping our health experience – global capitalism, gender, ethnicity, religion, identity, power, housing, telecommunications, etc.”
Frank:
“The major determinants of human health status…are not medical care inputs and utilization, but cultural, social and economic factors – at both the population and individual level.”
Labonte:
“Population health arguments are largely silent on ecological issues.”
Poland and colleagues:
“the rhetoric of community-based care…the burden of health care is not being removed from society, but simply shifted from the public domain to the private (domestic) sphere.”
Robertson:
“…what counts as data depends on what we judge to be important to notice in the first place, and them to measure.”
Mechanic:
“If the field of population health is to have sustained policy influence, it requires a persistent constituency, a strong organizational base both within and outside of government, and academic respectability.”
“Population health is most basically about aggregates and not about individuals.”
“Population health policy is different from medical care policy…”
Wilkinson and Marmot:
“…the common causes of ill health that affects populations are environmental: they come and go far more quickly than the slow pace of genetic change because they reflect the changes in the way we live.”
“People further down the social ladder usually run at least twice the risk of serious illness and premature death as those near the top.”
“People who have more control over their work have better health.”
As I move towards an idea for a paper, what is emerging is an examination of child and youth mental health service delivery in Ontario rated against a population health perspective rather than a health care perspective.
Most of these readings address mental and psychological issues but almost exclusively from an adult perspective. I would appreciate suggestions for readings that may show population health from a child and youth perspective – beyond what I can infer from what I have currently read. ¶ 10:05 p.m. 0 comments
This also brings to mind the difference between complicated and complex. It appears impossible to pull apart the interconnected elements of population health without destroying the powerful framework in which to study the health of populations. Not that population health is the “Holy Grail” of a unified theory. It seems to approach however, the necessary level of completeness to arrive at a more effective; perhaps more efficient, understanding of how to reduce harm to individuals within populations as well as improving the macroscopic conditions which “manufactures” health.
The pulling apart of Evans & Stoddart and to a lesser extent Frank & Mustard by Labonte, Robertson, Poland and colleagues is “normal” behavior found in most fields of research. The setting of boundaries and the dismantling of other frameworks are regular exercises of influence and power. With tongue in cheek, whenever I read any article, I am looking for actionable alternatives that are applicable, feasible, sustainable, and transferable to other contexts. Most of the critiques did not provide this and thus I find them in some respects, to be of limited utility.
Each of the articles however, provided interesting points to consider, the following being what I consider highlights:
Friedman:
A good introduction to models of population health “…it is important to acknowledge that no single widely accepted definition of population health exists.”
Evans & Stoddart:
“There are always unmet needs.”
“…most of the public and political debate over health policy continues to be carried on in the rhetoric of “unmet needs” for health care.”
“Once we recognize the importance and potential controllability of factors other than health care in both the limitation of disease and the promotion of health, we simultaneously open for explicit consideration the possibility that the direct positive effects of health care on health resources may be outweighed by its negative effects through competition for resources with other health-enhancing activities.”
(This is of particular interest to my thinking on examining the models of mental health service delivery and looking for alternatives outside the current framework which has been subject to gross under-funding for decades.)
Frank & Mustard:
“It is not lack of access to health care that is setting this gradient but the underlying social economic factors (unemployment, income, and education) as in Marmot’s study…”
Dunn and colleagues:
“A population health framework situates the importance of social relations centre-stage…Many dimensions of social relations are simultaneously involve in shaping our health experience – global capitalism, gender, ethnicity, religion, identity, power, housing, telecommunications, etc.”
Frank:
“The major determinants of human health status…are not medical care inputs and utilization, but cultural, social and economic factors – at both the population and individual level.”
Labonte:
“Population health arguments are largely silent on ecological issues.”
Poland and colleagues:
“the rhetoric of community-based care…the burden of health care is not being removed from society, but simply shifted from the public domain to the private (domestic) sphere.”
Robertson:
“…what counts as data depends on what we judge to be important to notice in the first place, and them to measure.”
Mechanic:
“If the field of population health is to have sustained policy influence, it requires a persistent constituency, a strong organizational base both within and outside of government, and academic respectability.”
“Population health is most basically about aggregates and not about individuals.”
“Population health policy is different from medical care policy…”
Wilkinson and Marmot:
“…the common causes of ill health that affects populations are environmental: they come and go far more quickly than the slow pace of genetic change because they reflect the changes in the way we live.”
“People further down the social ladder usually run at least twice the risk of serious illness and premature death as those near the top.”
“People who have more control over their work have better health.”
As I move towards an idea for a paper, what is emerging is an examination of child and youth mental health service delivery in Ontario rated against a population health perspective rather than a health care perspective.
Most of these readings address mental and psychological issues but almost exclusively from an adult perspective. I would appreciate suggestions for readings that may show population health from a child and youth perspective – beyond what I can infer from what I have currently read. ¶ 10:05 p.m. 0 comments
Accepted Submission to the Society for Applied Anthropology Annual Meeting, Vancouver
Dear Peter Levesque:
Congratulations! Your abstract submission has been accepted for the SfAA 2006 Annual Meeting at the Hyatt Regency Hotel in Vancouver, British Columbia, March 28-April 2.
Information on the date and time of your presentation is below. If you have more then one presentation scheduled, all will be listed below.
Within the next few weeks, we will have an electronic version of the preliminary program posted on the SfAA annual meeting web site. You will receive another e-mail notice when the preliminary program is ready for review. Please review the posted preliminary program carefully, as presentation dates and times may change.
You may visit the annual meeting web site at: http://www.sfaa.net/sfaa2006.html
You will also find information about the annual meeting hotel, travel, and Vancouver attractions. Make your hotel and travel arrangements soon! We have added an entire day (March 28) to the meetings. This day will be devoted to sessions, tours, and other activities that highlight the region we are visiting.
We look forward to seeing you in Vancouver!
Sincerely,
Orit Tamir and Bruce Miller
SfAA 2006 Program Co-Chairs
_______________________
Presentation Day, Date, and Time:Fri, March 31
_______________________
Submission:
Sessions Abstract
Multi-Level Community-Based Culturally Situated Intervention Science (Sessions I and II)
Jean J. Schensul
Change efforts in health have argued for multilevel approaches that can include advocacy for policy change, campaigns, community mobilization models, norms change through peer influence, dyads and small group interventions combined with targeted individual change efforts. Multilevel intervention studies are substantial, and multisectoral. They are simultaneously theoretically driven and locally situated. They utilize unconventional research design and evaluation strategies and though costly in the short run, may offer the best hope for sustainability. This two-part session will consider strategic, methodological and political implications of multilevel community based interventions with illustrated examples of work conducted by anthropologist-led interdisciplinary teams. Session I: Theory, Method, and
Political Infrastructure
Introduction: Jean Schensul
Paper I: Community intervention theory: a shift from ‘program’ thinking to ‘system’ thinking
Penny Hawes, Ph.D., University of Calgary
Overly technological ways of viewing interventions dominate in population health, affecting how intervention integrity is defined and implementation measured. Non compromising rules on adaptation may affect sustainability. A newly funded International Collaboration on Complex Interventions links an interdisciplinary group of investigators in Canada, USA, UK and Australia in a six year program to explore these issues. The collaboration addresses key program areas - ethics and community engagement; intervention theory; intervention x context interaction; and the economic valuation of social benefits that accrue at levels higher than the individual. Thinking of interventions as “events” in systems helps to recast methodological assumptions.
Paper II: Multi-Level Community Interventions: Ecological Considerations of Design and Implementation
Edison J. Trickett and Susan Ryerson Espino, University of Illinois at Chicago
Multilevel community-based interventions pose conceptual and pragmatic questions related to design and implementation. This paper applies an ecological framework to such interventions. It highlights (a) the development of local knowledge as prelude to intervention; (b) the value of collaborative relationship building; and (c) community development or enhancing local social capital as a prime intervention objective. Embedded is the importance of creating alternative designs to randomized controlled trial and new intervention roles to document the ripple effects of such interventions. We include an analysis of existing multi-level interventions to assess the degree to which they fulfill these ecological criteria.
Paper III: Do multilevel interventions increase sustainability of effects?
Jean J. Schensul, ICR
This presentation addresses the critical interface between multilevel collaborative or participatory interventions and sustainability. Multilevel interventions are designed to bring about changes in health status, health access and health disparities at the individual, social and societal levels. A major challenge in prevention or intervention research is sustainability of intervention results over time. Sustainability involves both immediate and long term outcomes, and the ability to adapt interventions to changing conditions. We explore the question of whether and under what conditions multilevel interventions can improve intervention sustainability and whether embedding an intervention in local culture can achieve sustainability without broader structural changes.
Political Will: Promoting Multilevel Intervention Community Based Partnership Research at the National Level
Levesque, Peter (Institute for Population Health, University of Ottawa)
The conditions that sustain international efforts at CBR include active adjusting of incentives and infrastructure within university, government, and civic organizations. As Deputy Director (Knowledge Mobilization) and program officer (CURA) at SSHRC, I engaged in knowledge brokering, incentive and infrastructure adjustment, and policy entrepreneurship to support the conditions that allowed for the development and growth of CBR in Canada and Europe. An active discursive process between disciplines such as Anthropology, Economics, and Sociology, with leaders in policy, community, and business, is necessary for successful on-going political support of multilevel CBR efforts.
Discussant: Anthony Davis
Session II: Theory driven illustrations
V.I.P. Vaccinate for Influenza Prevention, a multilevel empowerment intervention to increase flu vaccination uptake in older minority adults.
McElhaney, Janet, Radda, Kim, and Schensul, J.
Vaccine acceptance is promoted via changes in national and international policies, campaigns and targeted vaccination through primary health care and community situated clinics. Factors affecting vaccination decisions and rates include availability (production, supply and distribution), acceptability (belief in efficacy versus risk), and affordability (whether cost is bearable). In the United States, a country without a coordinated national health care system, disparities in these areas are notable among poor and ethnic minority populations. This paper describes a theory-driven comprehensive multilevel model to reach and empower older low-income adults in senior housing to activate and sustain efforts to obtain influenza vaccine annually.
Changing Drug-users’ Risk Environments: Peer Health Advocates as Multi-level Community Change Agents
Margaret Weeks, Julia Dickson-Gomez, Maria Martinez, Mark Convey
Peer driven, social oriented HIV prevention and other interventions conducted with networks of high-risk groups are increasingly popular for addressing broader contexts of health risk beyond individual factors. To the degree that these models take on multiple levels of risk and change, they become more effective mechanisms to support sustained health improvement. The Risk Avoidance Partnership, conducted with drug users in Hartford, CT, builds on individual identity of trained Peer Health Advocates as social change agents, group processes of norm modification for harm reduction, and community engagement in advocacy for broad health enhancement.
A Site-Based Social Marketing Intervention to Prevent Party Drug Use
Diamond, Sarah and Bermudez, Rey, ICR
This presentation provides an overview of a theoretically-driven, multi-level substance use intervention model that combines social marketing, entertainment-education and cognitive behavior change methodologies. We have developed an innovative site-based drug prevention program to address environmental and social influences of party culture in promoting drug use. Through organizing and promoting drug-free parties, which incorporate drug prevention messages into the entertainment, this intervention aims to create new social contexts, networks, and motivations to support non-drug use among hard-to-reach urban youth. Some of the challenges in evaluation design will also be addressed.
Cultural, Community, And Health System Approaches To The Prevention Of Hiv/Sti In Mumbai, India.
Schensul, Stephen L. and Mekki-Berrada, Abdelwahed (U of Connecticut Hlth. Ctr.)
This paper reports on the results of formative research and intervention conducted through a five-year, NIMH-funded, Indo-US project in economically marginal, migrant communities in Mumbai. The project utilizes a multilevel intervention focusing on culturally-based sexual health concerns centered on performance dysfunctions (gupt rog) as a means of engaging men in health services. The intervention involves the training and support of non-allopathic providers in one community and an allopathic male health clinic in a governmental primary care facility in another community. The study utilizes a quasi-experimental design to test the efficacy of the intervention at the community, provider and patient levels.
Discussant: Edison Trickett ¶ 2:09 p.m. 0 comments
Congratulations! Your abstract submission has been accepted for the SfAA 2006 Annual Meeting at the Hyatt Regency Hotel in Vancouver, British Columbia, March 28-April 2.
Information on the date and time of your presentation is below. If you have more then one presentation scheduled, all will be listed below.
Within the next few weeks, we will have an electronic version of the preliminary program posted on the SfAA annual meeting web site. You will receive another e-mail notice when the preliminary program is ready for review. Please review the posted preliminary program carefully, as presentation dates and times may change.
You may visit the annual meeting web site at: http://www.sfaa.net/sfaa2006.html
You will also find information about the annual meeting hotel, travel, and Vancouver attractions. Make your hotel and travel arrangements soon! We have added an entire day (March 28) to the meetings. This day will be devoted to sessions, tours, and other activities that highlight the region we are visiting.
We look forward to seeing you in Vancouver!
Sincerely,
Orit Tamir and Bruce Miller
SfAA 2006 Program Co-Chairs
_______________________
Presentation Day, Date, and Time:Fri, March 31
_______________________
Submission:
Sessions Abstract
Multi-Level Community-Based Culturally Situated Intervention Science (Sessions I and II)
Jean J. Schensul
Change efforts in health have argued for multilevel approaches that can include advocacy for policy change, campaigns, community mobilization models, norms change through peer influence, dyads and small group interventions combined with targeted individual change efforts. Multilevel intervention studies are substantial, and multisectoral. They are simultaneously theoretically driven and locally situated. They utilize unconventional research design and evaluation strategies and though costly in the short run, may offer the best hope for sustainability. This two-part session will consider strategic, methodological and political implications of multilevel community based interventions with illustrated examples of work conducted by anthropologist-led interdisciplinary teams. Session I: Theory, Method, and
Political Infrastructure
Introduction: Jean Schensul
Paper I: Community intervention theory: a shift from ‘program’ thinking to ‘system’ thinking
Penny Hawes, Ph.D., University of Calgary
Overly technological ways of viewing interventions dominate in population health, affecting how intervention integrity is defined and implementation measured. Non compromising rules on adaptation may affect sustainability. A newly funded International Collaboration on Complex Interventions links an interdisciplinary group of investigators in Canada, USA, UK and Australia in a six year program to explore these issues. The collaboration addresses key program areas - ethics and community engagement; intervention theory; intervention x context interaction; and the economic valuation of social benefits that accrue at levels higher than the individual. Thinking of interventions as “events” in systems helps to recast methodological assumptions.
Paper II: Multi-Level Community Interventions: Ecological Considerations of Design and Implementation
Edison J. Trickett and Susan Ryerson Espino, University of Illinois at Chicago
Multilevel community-based interventions pose conceptual and pragmatic questions related to design and implementation. This paper applies an ecological framework to such interventions. It highlights (a) the development of local knowledge as prelude to intervention; (b) the value of collaborative relationship building; and (c) community development or enhancing local social capital as a prime intervention objective. Embedded is the importance of creating alternative designs to randomized controlled trial and new intervention roles to document the ripple effects of such interventions. We include an analysis of existing multi-level interventions to assess the degree to which they fulfill these ecological criteria.
Paper III: Do multilevel interventions increase sustainability of effects?
Jean J. Schensul, ICR
This presentation addresses the critical interface between multilevel collaborative or participatory interventions and sustainability. Multilevel interventions are designed to bring about changes in health status, health access and health disparities at the individual, social and societal levels. A major challenge in prevention or intervention research is sustainability of intervention results over time. Sustainability involves both immediate and long term outcomes, and the ability to adapt interventions to changing conditions. We explore the question of whether and under what conditions multilevel interventions can improve intervention sustainability and whether embedding an intervention in local culture can achieve sustainability without broader structural changes.
Political Will: Promoting Multilevel Intervention Community Based Partnership Research at the National Level
Levesque, Peter (Institute for Population Health, University of Ottawa)
The conditions that sustain international efforts at CBR include active adjusting of incentives and infrastructure within university, government, and civic organizations. As Deputy Director (Knowledge Mobilization) and program officer (CURA) at SSHRC, I engaged in knowledge brokering, incentive and infrastructure adjustment, and policy entrepreneurship to support the conditions that allowed for the development and growth of CBR in Canada and Europe. An active discursive process between disciplines such as Anthropology, Economics, and Sociology, with leaders in policy, community, and business, is necessary for successful on-going political support of multilevel CBR efforts.
Discussant: Anthony Davis
Session II: Theory driven illustrations
V.I.P. Vaccinate for Influenza Prevention, a multilevel empowerment intervention to increase flu vaccination uptake in older minority adults.
McElhaney, Janet, Radda, Kim, and Schensul, J.
Vaccine acceptance is promoted via changes in national and international policies, campaigns and targeted vaccination through primary health care and community situated clinics. Factors affecting vaccination decisions and rates include availability (production, supply and distribution), acceptability (belief in efficacy versus risk), and affordability (whether cost is bearable). In the United States, a country without a coordinated national health care system, disparities in these areas are notable among poor and ethnic minority populations. This paper describes a theory-driven comprehensive multilevel model to reach and empower older low-income adults in senior housing to activate and sustain efforts to obtain influenza vaccine annually.
Changing Drug-users’ Risk Environments: Peer Health Advocates as Multi-level Community Change Agents
Margaret Weeks, Julia Dickson-Gomez, Maria Martinez, Mark Convey
Peer driven, social oriented HIV prevention and other interventions conducted with networks of high-risk groups are increasingly popular for addressing broader contexts of health risk beyond individual factors. To the degree that these models take on multiple levels of risk and change, they become more effective mechanisms to support sustained health improvement. The Risk Avoidance Partnership, conducted with drug users in Hartford, CT, builds on individual identity of trained Peer Health Advocates as social change agents, group processes of norm modification for harm reduction, and community engagement in advocacy for broad health enhancement.
A Site-Based Social Marketing Intervention to Prevent Party Drug Use
Diamond, Sarah and Bermudez, Rey, ICR
This presentation provides an overview of a theoretically-driven, multi-level substance use intervention model that combines social marketing, entertainment-education and cognitive behavior change methodologies. We have developed an innovative site-based drug prevention program to address environmental and social influences of party culture in promoting drug use. Through organizing and promoting drug-free parties, which incorporate drug prevention messages into the entertainment, this intervention aims to create new social contexts, networks, and motivations to support non-drug use among hard-to-reach urban youth. Some of the challenges in evaluation design will also be addressed.
Cultural, Community, And Health System Approaches To The Prevention Of Hiv/Sti In Mumbai, India.
Schensul, Stephen L. and Mekki-Berrada, Abdelwahed (U of Connecticut Hlth. Ctr.)
This paper reports on the results of formative research and intervention conducted through a five-year, NIMH-funded, Indo-US project in economically marginal, migrant communities in Mumbai. The project utilizes a multilevel intervention focusing on culturally-based sexual health concerns centered on performance dysfunctions (gupt rog) as a means of engaging men in health services. The intervention involves the training and support of non-allopathic providers in one community and an allopathic male health clinic in a governmental primary care facility in another community. The study utilizes a quasi-experimental design to test the efficacy of the intervention at the community, provider and patient levels.
Discussant: Edison Trickett ¶ 2:09 p.m. 0 comments
Monday, January 02, 2006
Population Health 8910 Term Paper
The Mental Health Frontier: opportunities for Population Health in addressing the mental health concerns of children and youth.
Peter Levesque, BSocSc, MA, PhD (student)
Institute of Population Health, University of Ottawa
Mailing Address
1961 Caprihani Way
Ottawa, Ontario, Canada
K4A 4R6
Contact
T: (613) 841-0858
E: peterlevesque@yahoo.ca
Citation
Levesque, P. The Mental Health Frontier: opportunities for Population Health in addressing the mental health concerns of children and youth. Ottawa: PhD Working Paper 1, 2005.
Introduction
Mental health is an underdeveloped area of health care in Canada - a frontier. For children and youth mental health, the frontier is especially wide open. As such, there are significant opportunities, for researchers, practitioners, advocates, and policymakers, to increase their involvement in addressing the complex nature of mental health and the problems associated with mental functioning, whether in children and youth or adults. The utilization in population health of complex, holistic models that include the social determinants of health, multiple disciplinary perspectives, and multiple sources and forms of data, is well suited to addressing mental health problems that often create economic and social burdens, not only for individuals directly affected, but also for their families, communities and countries.1
One of the groundbreaking documents in the creation of the health field concept, "A new perspective on the health of Canadians"2, otherwise known as the Lalonde Report, includes a chapter on mental health. This chapter consists of 2 pages. The information provided in this chapter, the shortest of the report, is almost as relevant today as when it was written in 1974. Few still "want to admit to the parenthood of a child with an emotional disorder"3. The statement, "much needs to be done in providing the mentally ill with adequate protection, care and readaptation opportunities and in informing the public and modifying attitudes towards mental illness"4 could have been written in 2005 rather than over three decades ago.
Yet, mental health continues to be the "orphan child" of health5 and one of the least integrated aspects of health care6. The new reality of mental health care, post deinstitutionalization, is that most care is home based, with many mental health patients discharged with insufficient resources and networks to support their ability to live at home.7
The situation for children and youth with mental health issues is even more difficult than that of adults. Senator Michael Kirby said, "If mental health services generally are the orphan of the health care system, then children's services are the "orphan of the orphan."8
The purpose of this paper is to describe the situations of both the "orphan" and the "orphan of the orphan" and to suggest how they may find a home within a population health perspective. Definitions of mental health and mental illness are provided as well as an introduction to some of the conditions that may be prevented or treated. The prevalence of these conditions is presented from global and Canadian perspectives. Several examples of mental health initiatives that have adopted complex, multidisciplinary approaches are presented. These are followed by a discussion of how the mental health of children and youth is better served by adopting a population health perspective. The conclusion is a series of research questions that may help provide direction for new or modified program development at the three levels presented.
For the purpose of this paper, a child refers to a young person between the ages of 1 and 12. A youth (commonly referred to as an adolescent in the United States) generally refers to someone between the ages of 13 and 18 or 19. Age subgroups are often created as a function of interaction with important social institutions such as daycare and school, thus common groupings are found for children under the age of one, ages 1 to 4, ages 5 to 12, for early teens (13 to 15) and late teens (16 to 19). The term youth sometimes extends to young adults under the age of 25. As such, some sources will provide data for age groups such as 15-24. In general, children are more dependent on a parent or caregiver than a youth, however both children and youth have some level of dependence on a parent or caregiver, and all ages fall along a continuum of social, neurological and physiological development.
Mental health and mental illness
Mental health is one aspect of the holistic health of a human being. One way to think of mental health is that humans are "mental beings" as much as they are "physical beings".9 The World Health Organization's definition of health, endorsed by 191 member states, includes mental health: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."10 The WHO further defines mental health "as a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community."11
The Surgeon General of the United States has adopted a lifespan approach to mental health and mental illness: "Mental health and mental illness are dynamic, ever-changing phenomena. At any given moment, a person's mental status reflects the sum total of that individual's genetic inheritance and life experiences. The brain interacts with and responds-both in its function and in its very structure-to multiple influences continuously, across every stage of life. At different stages, variability in expression of mental health and mental illness can be very subtle or very pronounced." 12
As per the Surgeon General's report, health should be viewed as a continuum over a life span, with greater or lesser health necessitating health care of an appropriate nature. The relationship of the physical and mental components of health cannot be separated. As an example, a physically healthy person may suffer from depression, which if left untreated, may lead to suicide. The disorder in this case is mental rather than physical but may lead to the end of a life in a manner that is no less significant than cancer, heart disease, or infection.
Mental illness is illness. Although manifested differently, the effects of mental illness on overall health, are no less dramatic. There is considerable confusion about the difference between mental health and mental illness. This confusion is similar to that shown in understanding the difference between health and medicine, or the production of health and the consumption of health care services.
Given that mental health is broader than mental illness, one may argue that the production of mental health is not the primary function of most mental health practitioners - psychologists, psychiatrists, social workers, and speech language pathologists, among other professional groupings. While they are an important part of a complex system that builds mental health, they most often deal with the downstream effects of upstream opportunities to prevent or treat, which were missed or ignored. Despite a growing anti-psychiatry movement, mental health workers are neither the cause of nor the final cure for mental illness. Many mental health professionals follow the Western medical model that relies primarily upon the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), produced by the American Psychiatric Association, to diagnose and treat the symptoms associated with mental illnesses and disorders, in a manner similar to how a general practitioner, medical specialist, nurse, or physiotherapist may use guidelines, trials and experience from clinical practice, or various compendia to assist in the creation of health by treating the symptoms, illnesses, and disorders which affect physical health. As with all of these practices, there are things that are working quite well and there is much room for improvement. It is important to recognize that health, health care, medicine, mental health, are all connected parts of a larger enterprise of human activity which happens over time and space.
The above is not a criticism of mental health professionals. Rather, by stating the limits of the current professionals, the door is open to serious conversation of how to best approach mental health from a broad population health perspective that includes social determinants, cultural factors, historical biases, and other factors not part of the "normal" mental illness treatment system. In reality, the exisitng system is suffering and there are too few professionals available to provide treatment when needed. The Canadian Academy of Child and Adolescent Psychiatry estimates the need for child and adolescent psychiatrists at 1 per 4000 youth. That means there should be nearly 2000 psychiatrists to serve the 7.8 million Canadians age 19 and under. In reality, there are about 480. In Ontario in 2002, the latest year for which the Academy has figures, there was 1 psychiatrist for every 32 000 youth. Quebec has 1 for every 11 000.13
Mental illness generally include disorders of the brain that disrupt a person's thinking, feeling, moods, and ability to relate to others, to work, and in the case of children, to play. The WHO states that mental illnesses "affect the functioning and thinking processes of the individual, greatly diminishing his or her social role and productivity in the community. In addition, because mental illnesses are disabling and last for many years they take a tremendous toll on the emotional and socio-economic capabilities of relatives who care for the patient."14
These disorders include, but are not limited to the following:
Alcoholism and Alcohol Abuse,
Alzheimer's Disease,
Anankastic Personality Disorder,
Anorexia Nervosa,
Anti Social Personality Disorder,
Anxiety,
Anxious Personality Disorder,
Attention Deficit Hyperactivity Disorder (ADHD),
Autism,
Avoidant Personality Disorder,
Bipolar Affective Disorder,
Body Dysmorphic Disorder,
Borderline Personality Disorder,
Bulimia Nervosa,
Dementia,
Dependent Personality Disorder,
Depression,
Dissocial Personality Disorder,
Eating Disorders,
Gender,
Grief,
Hearing voices,
Histrionic Personality Disorder,
Hyperactivity,
Impulsive Personality Disorder,
Insomnia,
Mania,
Manic Depression,
Munchausen Syndrome,
Narcissistic Personality Disorder,
Narcolepsy,
Neurosis,
Obsessive-compulsive disorder (OCD), Panic Attacks,
Paranoia,
Paranoid Personality Disorder,
Personality Disorders,
Phobias,
Post Natal Depression,
Posttraumatic stress disorder,
Psychopathy,
Psychosis,
Schizoaffective Disorder,
Schizoid Personality Disorder, Schizophrenia,
Schizotypal Personality Disorder, Seasonal Affective Disorder (SAD),
Self harm,
Sleep Disorders,
Stress,
Substance Abuse,
Suicide,
Tourette's Syndrome
According to the WHO, 25% of individuals develop one or more mental or behavioral disorder at some stage in life. This applies for both developed and developing countries. Some disorders can be prevented; all can be successfully managed and treated.15 The UK's Mental Health Foundation states that on average one in four individuals will experience a mental health problem in the course of a year.16 The Canadian context is similar according to the Canadian Mental Health Association.17
Mental health of children and youth
The "orphan of the orphan" statement by Senator Kirby emerged from the cross-Canada hearings by the Standing Senate Committee on Social Affairs. His observation was that children's mental health services are the "most neglected piece" of the Canadian health care system.18 The stigma accurately noted by Lalonde continues to present day.
The Canadian Psychiatric Research Foundation, in the 1992 Canadian Youth and Mental Health & Illness Survey found that one in five (20%) children and youth have a mental health problem and that this number may be higher due to under-reporting.19, 20. Yet only about one in six of these children and youth receive any service from a mental health professional, whether this is a child and youth worker, psychologist, psychiatrist, nurse, or social worker.
Given the dependence of children and youth on their parents and caregivers, it may not be surprising to some that even childhood accidents can be related to the psychosocial states of parents and to their socio-economic context. Wilkinson points to the Brown study that demonstrated that "psychiatric difficulties in the mother appear to account for much of the class differences in childhood accidents"21 Rates of depression were four times as high among the working-class as middle-class mothers. Because the study followed mothers over a period, it was able to show that accident rates were only higher while the mothers were depressed.22
The definitions of mental health provided above relate to active involvement in society, community, family, while maintaining a sense of individual identity - in other words, a balancing of individual and collective life. The Mental Health Foundation states that individuals with good mental health: should develop emotionally, creatively, intellectually and spiritually; initiate, develop and sustain mutually satisfying personal relationships; face problems, resolve them and learn from them; are confident and assertive; are aware of others and empathize with them; use and enjoy solitude; play and have fun, and; laugh, both at themselves and at the world. 23
With regards to children and youth, much of what constitutes good mental health is found in a balance between actual and potential, between existing conditions and development for future use. The good mental health of children and youth is largely dependent on contexts wider than an individual's genetics or their family situation. As early as 1897, Emile Durkheim wrote about social integration and how it was related to patterns of mortality, especially suicide.24
It is from the perspective of a broader societal view of health that the "orphan of the orphan" statement clearly takes on meaning. Given that mental health is a complex, dynamic process, if the conditions that lead to good mental health in adults are not supported (access to professional support when needed, good living conditions, good working conditions, adequate social networks, etc.) then it follows that the children and youth in families under stress, are more at risk of developing mental health problems. The relationship between unemployment, mental health and well-being has been demonstrated in longitudinal studies.25 Adults with mental health problems are often orphans in the health care system and their offspring are often even further removed from adequate supports. Children and youth appear to be in a state of double jeopardy - affected by their own individual genetic make-up and experience, as well as being directly impacted by the mental state of those upon whom they depend the most. This is despite, in at least developed countries, almost universal access to a health care system and an early-education/school system, which has consistently been identified as important locales of early identification of mental health issues.26 27
The cost of not adequately treating mental illness and mental health problems in children and youth is hard to measure, however some indicators point us to a massive sum. In 1992, Lafleur 28 calculated, using actuarial methods, the cost to Canadians of all children dropping out of school in 1989 would, over their lifetimes, total $4 billion. This is the total from one year's dropouts. Think of the total over a decade or a generation. The costs and loss to Canadian society are extraordinary, yet this has become the norm. While not all cases of dropping out of school are due to mental health problems, there is a strong relationship between the effects of mental health problems and the ability to stay in school.29 30
Mental health problems, such as stress, anxiety, and depression, contribute significantly to youth dropping out of school every year. The effects are not limited only to dropouts however, since students cannot optimize their learning if their mental health needs are not met. This often leads to other behaviors that are then manifested in other areas such as physical health, youth justice, and child welfare.31 More troubling still is when youth take this to another level, not just removing themselves from school but from life, by committing suicide. Statistics Canada 32 reports suicide as the second leading cause of youth death, after fatal motor vehicle accidents.
Continuing with the example of school, school has been identified by youth as both the most positive aspect of their life as well as the most stressful. The 1992 Canadian Psychiatric Association's survey, noted above, demonstrated that for youth, school was seen as the most positive aspect of their life (28.1%), followed by friends/relationships (23.5%), family (15.1%), sports, music, and culture (11.1%), other (12.1%), or none (10.1%). The same survey also identified school as the most stressful aspect of their life (64.6%), followed by home and parents (10.6%), friends and relationships (7.9%), money and work (4.3%), with other or no opinion responses comprising 12.6% of responses.
When it comes to discussing mental health concerns however, teachers, principals, school health workers, appear to be left out of the loop. The first line of discussion is with a friend (43%), followed by a parent or family member (23.9%) or other (1.3%). What is troubling however is that over a third of youth are discussing their mental health concerns with no one (31.8%). 33
When youth are ready to seek help, they go to their family doctor first (32 %). The next most common choices are a mental health professional in a quarter of cases (child and youth worker, psychologist, psychiatrist, social worker) or a counselor (21%). Friends and family (4%), hot lines or teen-health clinic (8%), or other (3%), is how the minority seek help. Seven percent seek help from no one.
Given the central role that school plays in the lives of children and youth, and the prevalence of mental health problems faced by children and youth, it is significant that schools do not generally play a more active role in promoting good mental health, of reducing stigma, of developing help-seeking behaviors, and of providing good data and information into the streams where youth seek advice and help. As indicated above, the challenge of child & youth mental health is not being met. Alternative approaches must be found which build on what works, to eliminate what does not work, and to implement activities that are based on evidence.34
Global context on mental health
There is considerable debate as to whether mental health problems and mental illnesses can accurately be described as epidemics.35 36 Measurement and evaluation is often inadequate and the longitudinal data is often flawed due to changing diagnoses. Despite the debates and the ongoing disagreements, the World Health Organization provides some global estimates on the prevalence of mental health problems that are useful to outlining the scope of the number of individuals affected: 37
* 450 million people worldwide are affected by mental, neurological or behavioral problems at any time.
* About 873,000 people die by suicide every year.
* Mental illnesses are common to all countries and cause immense suffering. People with these disorders are often subjected to social isolation, poor quality of life and increased mortality. These disorders are the cause of staggering economic and social costs.
* One in four patients visiting a health service has at least one mental, neurological or behavioral disorder but most of these disorders are neither diagnosed nor treated.
* Mental illnesses affect and are affected by chronic conditions such as cancer, heart and cardiovascular diseases, diabetes and HIV/AIDS. Untreated, they bring about unhealthy behavior, non-compliance with prescribed medical regimens, diminished immune functioning, and poor prognosis.
* Cost-effective treatments exist for most disorders and, if correctly applied, could enable most of those affected to become functioning members of society.
* Barriers to effective treatment of mental illness include lack of recognition of the seriousness of mental illness and lack of understanding about the benefits of services. Policy makers, insurance companies, health and labor policies, and the public at large - all discriminate between physical and mental problems.
* Most middle and low-income countries devote less than 1% of their health expenditure to mental health. Consequently mental health policies, legislation, community care facilities, and treatments for people with mental illness are not given the priority they deserve.
With specific regard to children and youth mental health globally, the World Health Organization's, Atlas: child and adolescent mental health resources: global concerns, implications for the future, outlines the need for services 38:
* Worldwide prevalence of child and adolescent mental disorders of approximately 20%. Of this 20% it is recognized that from 4 to 6% of children and adolescents are in need of a clinical intervention for an observed significant mental disorder.39
* Half of all lifetime cases of mental disorders start by age 14.40
* Nowhere in the world is the documented need for child and adolescent mental health services fully met.
* In high-income countries child and adolescent mental health service need is identified for between 5 and 20% of the population. This is comparable to the range of estimated service need in the lowest income countries.
* In a European survey of 36 countries (70.5% of all European countries) showed that the degree of coverage and quality of services for the young were generally worse in comparison with adults.41
* In high-income countries the service gap, while substantially less than in low-income countries is still very high.
* European countries, particularly in the Scandinavian region and certain countries, such as Israel with highly developed mental health services approach 80% provision, but others among the high income countries report as low as 20% provision of services.
* The Mental Health Atlas - 2005 showed that 23% of countries in Europe lacked specific programs for child mental health.
* While a services gap exists in all countries in the Americas, 26% of countries lacked basic clinical mental health services for children and adolescents.42
* The Child and Adolescent Mental Health ATLAS documents that countries with the higher proportion of children in the world are the ones that lack both mental health policy addressing the needs of children and adolescents and services for the population.
* In Africa and other countries with a high rate of HIV/AIDS deaths the population of young people will increase disproportionately in the coming years. (UNICEF, 2005) The number of AIDS orphans is currently estimated to be 14 million, and anticipated to rise to 20 million by 2010 (UNICEF).
The WHO, as mentioned earlier, has identified mental health as carrying both an undefined burden of economic and social hardship for families, communities and countries as well as a hidden burden of stigma and violations of human rights and freedoms. These burdens are not effectively or efficiently measured and there are significant difficulties in measuring and evaluating the state of mental health and access to needed services.43
Even in one of the wealthiest nations of the world, the United States of America, the Surgeon General states that: "Tragic and devastating disorders such as schizophrenia, depression and bipolar disorder, Alzheimer's disease, the mental and behavioral disorders suffered by children, and a range of other mental disorders affect nearly one in five Americans in any year, yet continue too frequently to be spoken of in whispers and shame."44
Canadian context on mental health
The Canadian context is similar to that described in the United States and European countries. The Health Canada Report on Mental Illnesses in Canada45 provides an overview of mental health in Canada:
* Mental illnesses indirectly affect all Canadians through illness in a family member, friend or colleague.
* Twenty percent of Canadians will personally experience a mental illness during their lifetime.
* Mental illnesses affect people of all ages, educational and income levels, and cultures.
* The onset of most mental illnesses occurs during adolescence and young adulthood.
* A complex interplay of genetic, biological, personality and environmental factors causes mental illnesses.
* Mental illnesses can be treated effectively.
* Mental illnesses are costly to the individual, the family, the health care system and the community.
* The economic cost of mental illnesses in Canada was estimated to be at least $7.331 billion in 1993.
* Eight-six percent of hospitalizations for mental illness in Canada occur in general hospitals.
* In 1999, 3.8% of all admissions in general hospitals (1.5 million hospital days) were due to anxiety disorders, bipolar disorders, schizophrenia, major depression, personality disorders, eating disorders and suicidal behavior.
* The stigma attached to mental illnesses presents a serious barrier not only to diagnosis and treatment but also to acceptance in the community.
The Canada section of the World Health Organization's Mental Health Atlas provides a synthesis of mental health services.46 Canada has no national mental health program. There is no national therapeutic drug policy or essential list of drugs. Given the context of federal, provincial, and territorial government relations on health, each province frames mental health legislation independently. There are no federal budgets for mental health. Each province has its own health and mental health budgets. The Medicare system pays basic medical and hospital bills however the direct and indirect costs related to mental health problems are estimated be among the costliest of all conditions and represent nearly one-sixth of the national corporate net operating profits.47 Provincial health insurance plans fund general practitioners but do not usually cover services provided by other mental health professionals. There are thirteen interlocking health insurance plans and thirteen separate delivery systems. Mental health services are provided through an often confusing mix of sources: primary care, general hospital care, community service, specialized treatment facilities, psychiatric hospitals, community providers, non-governmental organizations, and consumer-run organizations.48
On a positive note, Canada has disability benefits (although limited, even General Romeo Dallaire, post Rwanda, had difficulty receiving benefits49) for persons with mental disorders, if they can receive proper diagnosis and ongoing treatment. There are specific programs for mental health for minorities, refugees, disaster-affected populations, indigenous populations, elderly and children, and there are services available for mentally disordered offenders. With regards to offenders, one of the few coherent national policy documents, is the 1991 "Report on the Task Force on Mental Health" published by Correctional Services of Canada.
Given the complexity of the legislative, financing, and service-delivery systems for mental health, Dickinson has argued that there is an on-going tension between the medical-scientific model of practice and the multidisciplinary, community-based model of mental health promotion and mental illness prevention originating in the mental hygiene movement.50 This tension is perhaps one reason why mental health services tend to be under-developed.
In the Romanow Report, there is the repeated recommendation that the quality of care and support available to people with mental illnesses be improved by including home mental health case management and intervention services as part of the Canada Health Act.51
Complex, multidisciplinary approaches
Given the prevalence of mental health problems and mental illnesses globally, as well as the gaps in services, access to professionals, competing systems, inconsistent policies, and inadequate financial resources, it is not surprising that a significant number of initiatives have been created in an attempt to leverage existing scarce resources. It is also not surprising that given these scarce resources, there have been few successes in bringing these initiatives together into a comprehensive framework.
The Ontario provincial government has recently begun putting more resources into mental health care, and into child and youth mental health in particular. According to ICES, an under-funding of mental health is consistent with historical perceptions of the mental illness. "Mental illnesses are often perceived as rare conditions and have been characterized historically as afflicting primarily people who are weak or lack moral fibre. These illnesses do not have clear-cut causal agents (such as bacteria or viruses) that are easily identifiable and treatable. Furthermore they are seen as less debilitating..."52
The creation in June 2004, of the Provincial Centre of Excellence for Mental Health53, located at the Children's Hospital of Eastern Ontario, is an example of the adoption of a multidisciplinary approach. With a budget of approximately $6 million per year, this Centre has adopted a four-prong approach to assisting the process of building an integrated mental health system for children and youth in Ontario. The stated strategic directions include:
* Networks and Partnerships
o Create and maintain partnerships and networks among and between mental health stakeholders
o Identify potential partners including parents, children, youth and their families
o Facilitate partnership building as well as provincial and province-wide activities
o Advocate for capacity building
* Research and Development
o Scan mental health research to consolidate and identify gaps
o Undertake leading edge research to fill the gaps
o Support researchers through consultation
o Fund new research
* Intervention
o Champion a fully integrated and collaborative system across the full continuum of needs in child and youth mental health
o Provide interventional consultation
o Ensure cultural and linguistic diversity
o Develop best practices guidelines
* Education and Training
o Scan education and training activities
o Provide mentorship and educational consultation
o Develop web-based training
o Target community awareness of the importance of child and youth mental health
While it is too early to determine whether the activities of the Centre will have the desired effect, there is already clear indication of a shift away from the more traditional hiring patterns of those involved with mental health care. Employees of the Centre come from a range of disciplines: psychology, education, psychiatry, sociology, epidemiology, communications, administration, knowledge exchange, and computer science, among others. The introduction of diverse professional perspectives, as well as the utilization of multiple sector advisory committees (service providers, researchers, consumers and caregivers, etc.), is a strong indicator of the recognition that if one involves only those involved in treating the symptoms of mental illness, it will be difficult to build a system that supports overall mental health.
The co-director of the Centre of Excellence, Drs. Ian Manion and Simon Davidson, were founders, over ten years ago, of a successful program supporting youth mental health. "Youth Net", was started at the Children's Hospital of Eastern Ontario and is now operating in the Ontario communities of Hamilton, Halton, Peel, and Grey Bruce, in the Quebec communities of Montréal, Montéregie, and Montmagny, in Delta, British Columbia and in Newcastle, United Kingdom. This bilingual program is run by youth for youth with an aim to: 1) increase communication and promote awareness among youth regarding mental health and illness issues, 2) identify those youth who are at risk for mental illness and bridge them to appropriate, youth friendly mental health services, 3) reduce the stigma surrounding mental health and illness through education and communication, and 4) attend to what youth are saying in order to make current mental health services more youth appropriate. The program is supported by a safety net of mental health professionals. 54
Another youth oriented program, HealthNet, based in Halifax, "is comprised of a range of programs, workshops, and health materials for young people, parents and teachers. Materials for youth are distributed online through (an) interactive health magazine for youth. Materials for parents and teachers are located and maintained through separate websites." These websites provide "both content and infrastructure that allow young people, teachers and parents to enhance health literacy using novel and interactive technologies as well as to track health needs, outcomes and risk behaviors as required." 55 Combining psychology, computer science, education, sociology, and psychiatry; the stated goal of the websites is "to promote health literacy in youth. Health literacy is a key component of making good choices for health and well-being." 56
As discussed above, schools can play a leadership role in the development of better parenting of children and youth. Programs such as COPE (Community Parent Education Program)57 developed at McMaster University and now operating in cities across Canada (Calgary, Regina, Toronto, Hamilton, and various places in Nova Scotia), the United States (Buffalo and ten sites in Orange County, California), in five cities in Sweden, and Istanbul, Turkey, uses active learning models to develop better parenting skills that have a direct effect on the mental health of families and children. This allows for better school performance as a result of better mental health.
A related program, from Australia, Triple P - Positive Parenting Program58 is an evidence-based parenting program based on over 25 years of clinical and empirical research. The program provides parenting and family support strategies that aim to prevent severe behavioral, emotional and developmental problems in children by enhancing the knowledge, skills and confidence of parents. This program has led to the development of a hit television show in the United Kingdom, "Driving Mum and Dad Mad"59.
Also from Australia, the Australian Broadcasting Corporation's youth radio station, "Triple J" 60, is using podcasts as a method to enable youth to listen to information pieces in a format they want (on their portable devices) and at a time they choose. Recent episodes include a pharmacist's investigation of Australia's depression epidemic. She wonders why over a million Australians now take antidepressant drugs? Other podcasts available include why it's not easy getting off anything that you are addicted to. This podcast includes stories of people who have kicked their drug habits and how they managed it. It was part of a promotion of "Positive Stories" by the Australian National Council on Drugs.
While the relative effectiveness and efficiency of any of the above examples is the subject for another paper, there does seem to be an international trend in dealing with mental health problems that recognizes their complex nature and the need to include a diverse set of perspectives and expertise. The challenge faced by mental health is similar to that faced by many areas of study and treatment: knowledge exchange - how do we know what we know and how do we move this knowledge into policy, practice, and perspectives.
The Centre of Excellence for Child and Youth Mental Health, provided as an example above, has recognized the challenge of knowledge exchange and has created a dedicated Knowledge Exchange Centre to help build the processes and tools to essentially "Do more with what we know."61 The emphasis on knowledge exchange within health care has also been emphasized by many organizations internationally, including in Canada by the Canadian Health Services Research Foundation62 and the Canadian Institutes of Health Research63, among others.
Population health perspective on child and youth mental health
"When people talk about health and health care, they usually think in terms of physical illness and medical treatments. Mental health is usually ignored or added only as an after thought."64 For a population health perspective to be truly adopted in Canada, mental health should be an integrated component of a complex, emergent process that looks at health over the lifespan. Given where we are, how do we do this?
The World Health Organization suggests that the federal government in Canada plays an important role in consensus building and setting priorities for policies, such as health care, including mental health care.65 With regards to mental health, the Public Health Agency of Canada's, Mental Health Promotion Unit appears to have been given the mandate to manage this role of "consensus builder".
The MHPU was created in 1995, as a unit of Health Canada. Their website states that the: "MHPU addresses mental health promotion from a population health perspective that takes into account the broad range of determinants of mental health... the mandate of the unit is to promote and support mental health and reduce the burden of mental health problems and disorders, by contributing to the development, synthesis, dissemination and application of knowledge; the development, implementation and evaluation of policies, programs and activities designed to promote mental health and address the needs of people with mental health problems or disorders."66
While the MHPU's mandate may state that they have adopted a population health perspective, a reading of their research documents and website pages, clearly identifies their activities as health promotion. While an important part of population health, health promotion has a focus on individual behavior: "mental health promotion is the process of enhancing the capacity of individuals and communities to take control over their lives and improve their mental health...our unit emphasizes the following elements: By working to increase self-esteem, coping skills, social support and well-being in all individuals and communities, mental health promotion empowers people and communities to interact with their environments in ways that enhance emotional and spiritual strength. It is an approach that fosters individual resilience and promotes socially supportive environments. Mental health promotion also works to challenge discrimination against those with mental health problems. Respect for culture, equity, social justice, interconnections and personal dignity is essential for promoting mental health for everyone."67
The MHPU clearly has an important role to play in developing a population health perspective for Canadian but it cannot be successful if it is the only section charged with doing this. This "modern" form of organization is often where the intention to action falls apart - how can one manage something that is complex?
Kindig and Stoddart state that a hallmark of the field of population health "is significant attention to the multiple determinants of health outcomes, however measured. These determinants include medical care, public health interventions, aspects of the social environment (income, education, employment, social support, culture) and the physical environment (urban design, clean air and water), genetics, and individual behavior."68 They further state "no one in the public or private sectors currently has responsibility for overall health...the importance of population health ...is that it forces review of health outcomes across determinants."
The Ottawa Charter for Health Promotion outlined the prerequisites for health as: peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity.69
Looking to Graham70, it appear that certain prerequisites need to be met before we can truly have an integrated population health system - one that includes mental health, including the mental health of children and youth. She suggests that the complexity of looking at macro determinants of health inequalities requires new methods and theories. The linking of epidemiology with social policy research may be helpful if one takes into account cumulative exposure over the life course and the effect of state policies to help or hinder health. This is keeping with the perspective that the US Surgeon General has recommended.
New health strategies recognize that the roots of health inequalities "run deep" and there are movements in many jurisdictions from a focus on disease and individuals to the wider determinants of health but clearly building science into policy is not straightforward. Marmot71 states that we cannot ignore how people got where they are and we always need to look upstream. In times of rapid social change, the dynamics of inequality also change. Tax and social security are only two of the measure by which governments can reduce inequalities in living standards - the third is the broad set made of things like education, health care, housing, personal social services, and public transport. This is one reason for the emphasis on the school system as an integral part of the health system that supports good mental health for children and youth. It also supports the emphasis on helping parents become better parents.
The tax system, the social security system, and the welfare system combine in ways that temper the life course effects of social and economic change. Social capital may not be the underlying determinant of the relationship between income inequality and health, although it may be a marker and outcome of the level of investment in systems that redistribute wealth. This is one of the reasons Graham argues for the need for an interdisciplinary science - one capable of capturing both the dynamics and the health consequences of social inequality.
This interdisciplinary perspective is partially captured by the Public Health Agency of Canada.72 They list the key social determinants of health as: income and social status, social support networks, education and literacy, employment/working conditions, social environments, physical environments, personal health practices and coping skills, healthy child development, biology and genetic endowment, health services, gender, and culture. However, they miss many of the connections of these determinants to mental health.
Mental health is linked explicitly to employment/working conditions by stating, "Employment has a significant effect on a person's physical, mental and social health... (a) major review done for the World Health Organization found that high levels of unemployment and economic instability in a society cause significant mental health problems and adverse effects on the physical health of unemployed individuals, their families and their communities." 73
It is also linked to healthy child development: "New evidence on the effects of early experiences on brain development, school readiness and health in later life has sparked a growing consensus about early child development as a powerful determinant of health in its own right. At the same time, we have been learning more about how all of the other determinants of health affect the physical, social, mental, emotional and spiritual development of children and youth."74
The link to health services shows that access to mental health services is inadequate: "Access to universally insured care remains largely unrelated to income; however, many low- and moderate-income Canadians have limited or no access to health services such as eye care, dentistry, mental health counseling and prescription drugs."75 The obvious link to income and social status is not explicitly made in the PHAC materials.
No direct links are made to: income and social status, social support networks, education and literacy, social environments, physical environments, personal health practices and coping skills, biology and genetic endowment, gender, and culture.
All of these have an effect on mental health. The mental health of individuals has an effect on each of the environments encompassed by the social determinants - 20 to 25% percent of people suffering some sort of mental health problem is going to have an impact on social environments, on culture, on gender relationships, on education and the ability to develop literacy.
While the PHAC appears to be moving in the direction of adopting a population health framework, it is too slow given what "we", as a society "know" about the effects of mental health problems, and more importantly, on what we know about the positive impact of early prevention and treatments on children and youth.
Another example, "The Population Health Template: Key Elements and Actions that define a Population Health Approach" from Health Canada76 has no reference to mental health. Two competing assumptions can be made. Either it is included as part of their concept of health or is it completely ignored, as described by Goel and colleagues, either way, it is not clear.
Two examples that demonstrate a movement to adopt a population health perspective for mental health come from the provinces of British Columbia and Quebec.
The Province of British Columbia's, Child and Youth Mental Health Plan77 adopts a long-term view, in which the Ministry of Children & Family Development has applied a population health framework that includes mental health: "Children are British Columbia's most important investment in the future. Families and communities share the responsibility to ensure that children in British Columbia have access to the resources that promote health, well-being and optimal human development. It is our common goal - and in our common interest - to see that children thrive...Mental illnesses now constitute the most important group of health problems that children suffer - superceding all other health problems in terms of the number of children affected and the degree of impairment caused. Currently, one in seven (more than 140,000) children in British Columbia are estimated to have a mental illness serious enough to cause significant distress and impair their development and functioning at home, at school, and in the community. The majority of these children (and their families) do not receive the services they need, with the result that impairments often continue, causing increased suffering and affecting productivity and functioning in adulthood."
In Quebec, recognizing that mental health is an issue of growing importance: "La santé mentale, la violence et le suicide sont devenus des préoccupations de première importance dans notre société. En 1998, 20 % de la population québécoise de 15 ans et plus se situait au niveau de détresse le plus élevé selon l'Enquête Santé Québec. De 1976 à 1999, on a observé une augmentation du taux de suicide de 62 % dans la population en général, plus particulièrement de 25 % chez les femmes et de 78 % chez les hommes. Avec ses 1 500 décès par année, le Québec se retrouve dans le peloton de tête des pays industrialisés pour son taux de suicide." the Institut national de santé publique78, has partnered with the Observatoire pour la promotion de la sécurité et la prévention des traumatismes, to provide expertise, research, and capacity building for a range of stakeholders involved in addressing mental health problems from a population health perspective.
Both of these examples include broad partnerships between diverse actors. Again, they are both too newly implemented to determine whether their approaches will be successful.
Research questions
Population health and mental health are both complex emergent concepts that are not fully defined. As such, there appears to be no silver "implementation strategy" bullet. This however, provides many opportunities to build on what is already known and to venture into the frontier.
The main questions that emerge from the above discussion are the following:
* How to change the culture of stigma against mental health problems and mental illness? What can be learned from other campaigns to reduce stigma? Why is mental health such a difficult issue around which to mobilize?
* How to bridge what is known with what is practiced? What does knowledge exchange and knowledge mobilization look like for mental health presented from a population health perspective? Can the diverse federal, provincial, territorial infrastructures be brought together into a mutually beneficial community of practice? Can organizations such as the WHO improve on their international efforts and what are the responsibilities of member nations to each other and non-member nations, with regards to the mental health of children and youth? What is the role of multinational corporations in developing the conditions for good mental health, both in their workers and the communities where they live?
* Which models are more effective than others? Given that no society appears to be completely addressing mental health issues - is there a fundamental flaw in current endeavors? Do we have the methods and theories to properly address the upstream issues that affect mental health in children and youth?
* The artist and child advocate, Raffi, once asked at a conference79: "Do we have the courage to be a healthy society?" Given that existing incentives in schools and workplaces often run counter to the conditions for good mental health, what is needed to shift the focus from profits and efficiencies, to people and long-term effectiveness? Is this shift possible and if so, what are the timeframes and infrastructure adjustments needed to support such a movement?
* Given the complexity of interactions of the social determinants of health, is it possible for a society to become healthier, both physically and mentally, without first dealing with the power and structural issues of social class and economic inequities?
* What is the role of "community" in causing mental health problems or in creating the conditions for good mental health?
Final Remarks
Health, including mental health, is a continuum over the life course. The ideal of perfect health, physically and mentally, is just that, an ideal: something desired yet almost impossible to attain. This seeming impossibility however, is the very reason to venture forward with the development of further understanding, better tools, creative theories, and resilient practices. Population health is a study of how to live better, with what we have, where we are, and with whom we interact. Health is never complete: it changes as people change, as they move, grow, breathe, interact, and become, whatever they are becoming. This "reality" is a source of frustration in a world where "ends" are rewarded and the "means" or processes are of a secondary importance.
The mental health of children and youth, worldwide, says much about the societies we have built. The rising rate of depression, suicide, anxiety, eating disorders, self-harm, among our children and youth, may simply be a result of better measurement and diagnosis. It may also be that we are creating the conditions that cause more children and youth, to consider suicide and self-harm, as reasonable options to the life that is offered to them.
These questions are only of importance if one considers life, important.
____________________________________________________
Endnotes
1 World Health Organization. Fact sheet No. 218, Mental health problems: the undefined and hidden burden. November 2001. Available from: http://www.who.int/mediacentre/factsheets/fs218/en/print.html
2 Lalonde M. A new perspective on the health of Canadians: a working document (1974). Ottawa: Ministry of Supply and Services Canada; 1981. Cat. No. H31-1374.
3 Lalonde M. A new perspective on the health of Canadians: a working document (1974). Ottawa: Ministry of Supply and Services Canada; 1981. Cat. No. H31-1374. p.61.
4 Lalonde M. A new perspective on the health of Canadians: a working document (1974). Ottawa: Ministry of Supply and Services Canada; 1981. Cat. No. H31-1374. p. 62.
5 Romanow, R. Building on Values: The Future of Health Care in Canada - Final Report. Ottawa: Commission on the Future of Health Care in Canada; 2002. p. 32.
6 Romanow, R. Building on Values: The Future of Health Care in Canada - Final Report. Ottawa: Commission on the Future of Health Care in Canada; 2002. p. 213.
7 Romanow, R. Building on Values: The Future of Health Care in Canada - Final Report. Ottawa: Commission on the Future of Health Care in Canada; 2002. p. 214.
8 Eggertson, L. Children's mental health services neglected: Kirby. Ottawa: CMAJ, Aug. 30, 2005; 173 (5). p. 471
9 Mental Health Foundation [homepage on the Internet]. London: Mental Health Foundation; [updated 5005-10-07; cited 2005-12-28]. Available from: http://www.mentalhealth.org.uk/page.cfm?pagecode=PMWM
10 World Health Organization. Fact sheet No. 220, Mental Health: strengthening mental health promotion. November 2001. Available from: http://www.who.int/mediacentre/factsheets/fs220/en/print.html
11 World Health Organization. Fact sheet No. 220, Mental health: strengthening mental health promotion. November 2001. Available from: http://www.who.int/mediacentre/factsheets/fs220/en/print.html
12 U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General-Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999. Available from: http://www.mentalhealth.samhsa.gov/features/surgeongeneralreport/chapter2/conc2.asp
13 Eggertson, L. Children's mental health services neglected: Kirby. Ottawa: CMAJ, Aug. 30, 2005; 173 (5). p. 471
14 World Health Organization. Fact sheet No. 218, Mental health problems: the undefined and hidden burden. November 2001. Available from: http://www.who.int/mediacentre/factsheets/fs218/en/print.html
15 World Health Organization. Fact sheet No. 265, Mental and neurological disorders. December 2001. Available from: http://www.who.int/mediacentre/factsheets/fs265/en/print.html
16 Mental Health Foundation [homepage on the Internet]. London: Mental Health Foundation; [updated 5005-10-07; cited 2005-12-28]. Available from: http://www.mentalhealth.org.uk/page.cfm?pagecode=PMWM
17 Canadian Mental Health Association. [homepage on the internet]. Toronto: Canadian Mental Health Foundation [cited 2005-12-28]. Available from: http://www.cmha.ca/bins/index.asp?lang=1
18 Eggertson, L. Children's mental health services neglected: Kirby. Ottawa: CMAJ, Aug. 30, 2005; 173 (5). p. 471
19 Canadian Psychiatric Research Foundation. When Something's Wrong: Ideas for Families. Toronto: Canadian Psychiatric Research Foundation, 2004.
20 Davidson, S. & Manion, I.G. (1996). Facing the challenge: mental health and illness in Canadian youth. Psychology, Health & Medicine 1, (1), 41-56.
21 Brown. G.W. Social class, psychiatric disorder of the mother, and accidents to children. Lancet 1:378. 1978
22 Wilkinson, R.G. Unhealthy Societies. London: Routledge. p. 180.
23 Mental Health Foundation [homepage on the Internet]. London: Mental Health Foundation; [updated 5005-10-07; cited 2005-12-28]. Available from: http://www.mentalhealth.org.uk/page.cfm?pagecode=PMWM
24 Berkman, L.F. and I. Kawachi. A historical framework for social epidemiology. In: Berkman, L.F. and I. Kawachi, editors, Social Epidemiology. New York: Oxford University Press, 2000. p. 7.
25 Kasl, S.V. and B.A. Jones. The impact of job loss and retirement on health. In: Berkman, L.F. and I. Kawachi, editors, Social Epidemiology. New York: Oxford University Press, 2000. p. 127.
26 Owens, JS, Richerson, L, Beilstein, EA., Crane, A, Murphy, CE., Vancouver, JB. School-Based Mental Health Programming for Children With Inattentive and Disruptive Behavior Problems: First-Year Treatment Outcome. J Atten Disord, 2005 9: 261-274
27 Weist, MD. Fulfilling the Promise of School-Based Mental Health: Moving Toward a Public Mental Health Promotion Approach, Journal of Abnormal Child Psychology, Volume 33, Issue 6, Dec 2005, Pages 735 - 741
28 Lafleur, B. (1992). Dropping out: the cost to Canada. Conference Board of Canada Report, 83-92-E.
29 Acosta, Olga M., Weist, Mark D., Lopez, Fernando A., Shafer, Micheal E., Pizarro, L. Josefina
Assessing the Psychosocial and Academic Needs of Latino Youth to Inform the Development of School-Based Programs, Behav Modif, 2004 28: 579-595
30 Fremont, WP. School refusal in children and adolescents. Am Fam Physician. 2003 Oct 15;68(8):1555-60.
31 Levesque, P and I. Manion. Better Together: Child and Youth Mental Health. Journal of the Canadian Association of Principals. January 2006. p. 14.
32 Statistics Canada (2005). Major Causes of Death. Available online at: http://142.206.72.67/02/02b/02b_003_e.htm
33 Davidson, S. & Manion, I.G. (1996). Facing the challenge: mental health and illness in Canadian youth. Psychology, Health & Medicine 1, (1), 41-56.
34 Levesque, P and I. Manion. Better Together: Child and Youth Mental Health. Journal of the Canadian Association of Principals. January 2006. p. 15.
35 Weir, E and Wallington, T. Suicide: The Hidden Epidemic, CMAJ; 2001: 165(5):634-6.
36 Sudak, HS. The Invisible Plague: The Rise of Mental Illness From 1750 to the Present. Am J Psychiatry 2003 160: 1017-1018
37 World Health Organization. [homepage on the Internet]. Mental Health: The bare facts. New York: World Health Organization; [cited 2005-12-29] Available from: http://www.who.int/mental_health/en/
38 World Health Organization. Atlas: child and adolescent mental health resources: global concerns, implications for the future. Geneva: World Health Organization, 2005. p. 16.
39 World Health Organization. The world health report 2001- Mental Health: new understanding, new hope. Geneva: World Health Organization, 2001.
40 Kessler RC, Berglund PMBA, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Study Replication. Arch GenPsychiatry, 2005, 62(6):593-602.
41 Levav I, Jacobsson L, Tsiantis J, et al. Psychiatric services and training for children and adolescents in Europe: Results of a country survey. Eur Child Adolesc Psychiatry, 2004, 13:395-401.
42 Rohde LA, Celia S, Berganza C. Systems of care in South America. In: Remschmidt H, Belfer ML, Goodyer I, Eds. Facilitating pathways: Care, treatment and prevention in child and adolescent mental health. Berlin, Springer, Berlin, 2004, pp. 42 - 51.
43 World Health Organization. Fact sheet No. 218, Mental health problems: the undefined and hidden burden. November 2001. Available from: http://www.who.int/mediacentre/factsheets/fs218/en/print.html
44 U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General-Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999. Available from: http://www.mentalhealth.samhsa.gov/features/surgeongeneralreport/home.asp - forward
45 Health Canada. A Report on Mental Illnesses in Canada. Ottawa: Health Canada, 2002. p. 7.
46 World Health Organization. Mental Health Atlas. Geneva: World Health Organization, 2005. p. 120-122.
47 World Health Organization. Mental Health Atlas. Geneva: World Health Organization, 2005. p. 121.
48 World Health Organization. Mental Health Atlas. Geneva: World Health Organization, 2005. p. 120.
49 Royal Bank of Canada. Mental Health Today and Tomorrow. Toronto: RBC Letter, August 2002. Available from: http://www.rbc.com/community/letter/august2002.html
50 Dickenson, H. A sociological perspective on the transfer and utilization of social scientific knowledge for policy-making. In: Lemieux-Charles, L. and F. Champagne, Eds., Using Knowledge and Evidence in Health Care. Toronto: University of Toronto Press, 2004.
51 Romanow, R. Building on Values: The Future of Health Care in Canada - Final Report. Ottawa: Commission on the Future of Health Care in Canada; 2002. p. 171.
52 Goel V, Williams J, Anderson G, Blackstien-Hirsch P, Fooks C, Naylor D. Patterns of health care in Ontario, 2nd edition. Toronto: Institute for Clinical Evaluative Sciences, May 1996. p. 265-286.
53 Provincial Centre of Excellence for Child and Youth Mental Health. [homepage on the Internet] Ottawa: Provincial Centre of Excellence for Child and Youth Mental Health. [cited 2005-12-30]. Available from: http://www.cymh.ca/index_e.htm
54 Youth Net. [homepage on the Internet]. Ottawa: Youth Net [cited 2005-12-30] Available from: http://www.youthnet.on.ca/
55 Yoomagazine. [homepage on the Internet] Halifax: Yoomagazine [cited 2005-12-30] Available from: http://www.yoomagazine.net/page.php?id=12
56 Yoomagazine. [homepage on the Internet] Halifax: Yoomagazine [cited 2005-12-30] Available from: http://www.yoomagazine.net/page.php?id=12
57 Community Education Service. [homepage on the Internet] Hamilton: McMaster University. [cited 2005-12-30]. Available from: http://www.communityed.ca/
58 Triple P International. [homepage on the Internet] Brisbane: Triple P International. [cited 2005-12-30]. Available from: http://www9.triplep.net/
59 Driving Mum and Dad Mad, ITV. [homepage on the Internet] London: ITV. [cited 2005-12-30]. Available from: http://www.itv.com/page.asp?partid=2978
60 Triple J. [homepage on the Internet] Brisbane: Australian Broadcast Corporation. [cited 2005-12-30]. Available from: http://www.abc.net.au/triplej/default.htm
61 Provincial Centre of Excellence for Child and Youth Mental Health. [homepage on the Internet] Ottawa: Provincial Centre of Excellence for Child and Youth Mental Health. [cited 2005-12-30]. Available from: http://www.cymh.ca/index_e.htm
62 Canadian Health Services Research Foundation. [homepage on the Internet] Ottawa: Canadian Health Services Research Foundation. [cited 2005-12-30]. Available from: http://www.chsrf.ca/home_e.php
63 Canadian Institutes of Health Research. [homepage on the Internet] Ottawa: Canadian Institutes of Health Research. [cited 2005-12-30]. Available from: http://www.cihr-irsc.gc.ca/e/193.html
64 Goel V, Williams J, Anderson G, Blackstien-Hirsch P, Fooks C, Naylor D. Patterns of health care in Ontario, 2nd edition. Toronto: Institute for Clinical Evaluative Sciences, May 1996. p. 265.
65 World Health Organization. Mental Health Atlas. Geneva: World Health Organization, 2005. p. 120-122.
66 Mental Health Promotion Unit. [homepage on the Internet]. Ottawa: Public Health Agency of Canada. [updated 2003-01-15, cited 2005-12-30] Available from: http://www.phac-aspc.gc.ca/mh-sm/mentalhealth/mhp/index.html
67 Mental Health Promotion Unit. [homepage on the Internet]. Ottawa: Public Health Agency of Canada. [updated 2003-01-15, cited 2005-12-30] Available from: http://www.phac-aspc.gc.ca/mh-sm/mentalhealth/mhp/faq.html
68 Kindig, D and G. Stoddart. What is Population Health? American Journal of Public Health. March 2003, Vol., 93, No. 3. p. 381.
69 World Health Organization. Ottawa Charter for Health Promotion. Geneva: World Health Organization, 1986. p. 1.
70 Graham, H. Building an inter-disciplinary science of health inequalities: the example of lifecourse. Social Science & Medicine. 55 (2002) 2006-2016.
71 Marmot, M, Shipley, M, Brunner, E, & Hemingway, H. Relative contribution of early life and adult socioeconomic factors to adult morbidity in the Whitehall II study. Journal of Epidemiology and Community Health, 55 (2001), 301-307.
72 Public Health Agency of Canada. [homepage on the Internet] Ottawa: Public Health Agency of Canada. [cited 2005-12-30]. Available from: http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/
73 Public Health Agency of Canada. [homepage on the Internet] Ottawa: Public Health Agency of Canada. [cited 2005-12-30]. Available from: http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/determinants.html#unhealthy
74 Public Health Agency of Canada. [homepage on the Internet] Ottawa: Public Health Agency of Canada. [cited 2005-12-30]. Available from: http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/determinants.html#unhealthy
75 Public Health Agency of Canada. [homepage on the Internet] Ottawa: Public Health Agency of Canada. [cited 2005-12-30]. Available from: http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/determinants.html#unhealthy
76 Strategic Policy Directorate of the Population and Public Health Branch, Health Canada. The Population Health Template: Key Elements and Actions that define a Population Health Approach. Ottawa: Health Canada, July 2001 Draft. Available from: http://www.phac-aspc.gc.ca/ph-sp/phdd/pdf/discussion_paper.pdf
77 Ministry of Children & Family Development. [homepage on the Internet] Victoria: Province of British Columbia. [cited 2005-12-30]. Available from: http://www.mcf.gov.bc.ca/mental_health/mh_publications/cymh_plan.htm
78 Institut national de santé publique. [homepage on the Internet] Quebec: Institut national de santé publique. [cited 2005-12-30] Available from: http://www.inspq.qc.ca/domaines/IndividusCommunautes/SanteMentaleViolenceSuicide.asp?D=8&D8=1
79 Levesque, P. Private notes from attendance at the Canadian Council on Learning, Health and Learning Knowledge Network planning conference, June 2005, Vancouver. ¶ 9:00 p.m. 0 comments
Peter Levesque, BSocSc, MA, PhD (student)
Institute of Population Health, University of Ottawa
Mailing Address
1961 Caprihani Way
Ottawa, Ontario, Canada
K4A 4R6
Contact
T: (613) 841-0858
E: peterlevesque@yahoo.ca
Citation
Levesque, P. The Mental Health Frontier: opportunities for Population Health in addressing the mental health concerns of children and youth. Ottawa: PhD Working Paper 1, 2005.
Introduction
Mental health is an underdeveloped area of health care in Canada - a frontier. For children and youth mental health, the frontier is especially wide open. As such, there are significant opportunities, for researchers, practitioners, advocates, and policymakers, to increase their involvement in addressing the complex nature of mental health and the problems associated with mental functioning, whether in children and youth or adults. The utilization in population health of complex, holistic models that include the social determinants of health, multiple disciplinary perspectives, and multiple sources and forms of data, is well suited to addressing mental health problems that often create economic and social burdens, not only for individuals directly affected, but also for their families, communities and countries.1
One of the groundbreaking documents in the creation of the health field concept, "A new perspective on the health of Canadians"2, otherwise known as the Lalonde Report, includes a chapter on mental health. This chapter consists of 2 pages. The information provided in this chapter, the shortest of the report, is almost as relevant today as when it was written in 1974. Few still "want to admit to the parenthood of a child with an emotional disorder"3. The statement, "much needs to be done in providing the mentally ill with adequate protection, care and readaptation opportunities and in informing the public and modifying attitudes towards mental illness"4 could have been written in 2005 rather than over three decades ago.
Yet, mental health continues to be the "orphan child" of health5 and one of the least integrated aspects of health care6. The new reality of mental health care, post deinstitutionalization, is that most care is home based, with many mental health patients discharged with insufficient resources and networks to support their ability to live at home.7
The situation for children and youth with mental health issues is even more difficult than that of adults. Senator Michael Kirby said, "If mental health services generally are the orphan of the health care system, then children's services are the "orphan of the orphan."8
The purpose of this paper is to describe the situations of both the "orphan" and the "orphan of the orphan" and to suggest how they may find a home within a population health perspective. Definitions of mental health and mental illness are provided as well as an introduction to some of the conditions that may be prevented or treated. The prevalence of these conditions is presented from global and Canadian perspectives. Several examples of mental health initiatives that have adopted complex, multidisciplinary approaches are presented. These are followed by a discussion of how the mental health of children and youth is better served by adopting a population health perspective. The conclusion is a series of research questions that may help provide direction for new or modified program development at the three levels presented.
For the purpose of this paper, a child refers to a young person between the ages of 1 and 12. A youth (commonly referred to as an adolescent in the United States) generally refers to someone between the ages of 13 and 18 or 19. Age subgroups are often created as a function of interaction with important social institutions such as daycare and school, thus common groupings are found for children under the age of one, ages 1 to 4, ages 5 to 12, for early teens (13 to 15) and late teens (16 to 19). The term youth sometimes extends to young adults under the age of 25. As such, some sources will provide data for age groups such as 15-24. In general, children are more dependent on a parent or caregiver than a youth, however both children and youth have some level of dependence on a parent or caregiver, and all ages fall along a continuum of social, neurological and physiological development.
Mental health and mental illness
Mental health is one aspect of the holistic health of a human being. One way to think of mental health is that humans are "mental beings" as much as they are "physical beings".9 The World Health Organization's definition of health, endorsed by 191 member states, includes mental health: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."10 The WHO further defines mental health "as a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community."11
The Surgeon General of the United States has adopted a lifespan approach to mental health and mental illness: "Mental health and mental illness are dynamic, ever-changing phenomena. At any given moment, a person's mental status reflects the sum total of that individual's genetic inheritance and life experiences. The brain interacts with and responds-both in its function and in its very structure-to multiple influences continuously, across every stage of life. At different stages, variability in expression of mental health and mental illness can be very subtle or very pronounced." 12
As per the Surgeon General's report, health should be viewed as a continuum over a life span, with greater or lesser health necessitating health care of an appropriate nature. The relationship of the physical and mental components of health cannot be separated. As an example, a physically healthy person may suffer from depression, which if left untreated, may lead to suicide. The disorder in this case is mental rather than physical but may lead to the end of a life in a manner that is no less significant than cancer, heart disease, or infection.
Mental illness is illness. Although manifested differently, the effects of mental illness on overall health, are no less dramatic. There is considerable confusion about the difference between mental health and mental illness. This confusion is similar to that shown in understanding the difference between health and medicine, or the production of health and the consumption of health care services.
Given that mental health is broader than mental illness, one may argue that the production of mental health is not the primary function of most mental health practitioners - psychologists, psychiatrists, social workers, and speech language pathologists, among other professional groupings. While they are an important part of a complex system that builds mental health, they most often deal with the downstream effects of upstream opportunities to prevent or treat, which were missed or ignored. Despite a growing anti-psychiatry movement, mental health workers are neither the cause of nor the final cure for mental illness. Many mental health professionals follow the Western medical model that relies primarily upon the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), produced by the American Psychiatric Association, to diagnose and treat the symptoms associated with mental illnesses and disorders, in a manner similar to how a general practitioner, medical specialist, nurse, or physiotherapist may use guidelines, trials and experience from clinical practice, or various compendia to assist in the creation of health by treating the symptoms, illnesses, and disorders which affect physical health. As with all of these practices, there are things that are working quite well and there is much room for improvement. It is important to recognize that health, health care, medicine, mental health, are all connected parts of a larger enterprise of human activity which happens over time and space.
The above is not a criticism of mental health professionals. Rather, by stating the limits of the current professionals, the door is open to serious conversation of how to best approach mental health from a broad population health perspective that includes social determinants, cultural factors, historical biases, and other factors not part of the "normal" mental illness treatment system. In reality, the exisitng system is suffering and there are too few professionals available to provide treatment when needed. The Canadian Academy of Child and Adolescent Psychiatry estimates the need for child and adolescent psychiatrists at 1 per 4000 youth. That means there should be nearly 2000 psychiatrists to serve the 7.8 million Canadians age 19 and under. In reality, there are about 480. In Ontario in 2002, the latest year for which the Academy has figures, there was 1 psychiatrist for every 32 000 youth. Quebec has 1 for every 11 000.13
Mental illness generally include disorders of the brain that disrupt a person's thinking, feeling, moods, and ability to relate to others, to work, and in the case of children, to play. The WHO states that mental illnesses "affect the functioning and thinking processes of the individual, greatly diminishing his or her social role and productivity in the community. In addition, because mental illnesses are disabling and last for many years they take a tremendous toll on the emotional and socio-economic capabilities of relatives who care for the patient."14
These disorders include, but are not limited to the following:
Alcoholism and Alcohol Abuse,
Alzheimer's Disease,
Anankastic Personality Disorder,
Anorexia Nervosa,
Anti Social Personality Disorder,
Anxiety,
Anxious Personality Disorder,
Attention Deficit Hyperactivity Disorder (ADHD),
Autism,
Avoidant Personality Disorder,
Bipolar Affective Disorder,
Body Dysmorphic Disorder,
Borderline Personality Disorder,
Bulimia Nervosa,
Dementia,
Dependent Personality Disorder,
Depression,
Dissocial Personality Disorder,
Eating Disorders,
Gender,
Grief,
Hearing voices,
Histrionic Personality Disorder,
Hyperactivity,
Impulsive Personality Disorder,
Insomnia,
Mania,
Manic Depression,
Munchausen Syndrome,
Narcissistic Personality Disorder,
Narcolepsy,
Neurosis,
Obsessive-compulsive disorder (OCD), Panic Attacks,
Paranoia,
Paranoid Personality Disorder,
Personality Disorders,
Phobias,
Post Natal Depression,
Posttraumatic stress disorder,
Psychopathy,
Psychosis,
Schizoaffective Disorder,
Schizoid Personality Disorder, Schizophrenia,
Schizotypal Personality Disorder, Seasonal Affective Disorder (SAD),
Self harm,
Sleep Disorders,
Stress,
Substance Abuse,
Suicide,
Tourette's Syndrome
According to the WHO, 25% of individuals develop one or more mental or behavioral disorder at some stage in life. This applies for both developed and developing countries. Some disorders can be prevented; all can be successfully managed and treated.15 The UK's Mental Health Foundation states that on average one in four individuals will experience a mental health problem in the course of a year.16 The Canadian context is similar according to the Canadian Mental Health Association.17
Mental health of children and youth
The "orphan of the orphan" statement by Senator Kirby emerged from the cross-Canada hearings by the Standing Senate Committee on Social Affairs. His observation was that children's mental health services are the "most neglected piece" of the Canadian health care system.18 The stigma accurately noted by Lalonde continues to present day.
The Canadian Psychiatric Research Foundation, in the 1992 Canadian Youth and Mental Health & Illness Survey found that one in five (20%) children and youth have a mental health problem and that this number may be higher due to under-reporting.19, 20. Yet only about one in six of these children and youth receive any service from a mental health professional, whether this is a child and youth worker, psychologist, psychiatrist, nurse, or social worker.
Given the dependence of children and youth on their parents and caregivers, it may not be surprising to some that even childhood accidents can be related to the psychosocial states of parents and to their socio-economic context. Wilkinson points to the Brown study that demonstrated that "psychiatric difficulties in the mother appear to account for much of the class differences in childhood accidents"21 Rates of depression were four times as high among the working-class as middle-class mothers. Because the study followed mothers over a period, it was able to show that accident rates were only higher while the mothers were depressed.22
The definitions of mental health provided above relate to active involvement in society, community, family, while maintaining a sense of individual identity - in other words, a balancing of individual and collective life. The Mental Health Foundation states that individuals with good mental health: should develop emotionally, creatively, intellectually and spiritually; initiate, develop and sustain mutually satisfying personal relationships; face problems, resolve them and learn from them; are confident and assertive; are aware of others and empathize with them; use and enjoy solitude; play and have fun, and; laugh, both at themselves and at the world. 23
With regards to children and youth, much of what constitutes good mental health is found in a balance between actual and potential, between existing conditions and development for future use. The good mental health of children and youth is largely dependent on contexts wider than an individual's genetics or their family situation. As early as 1897, Emile Durkheim wrote about social integration and how it was related to patterns of mortality, especially suicide.24
It is from the perspective of a broader societal view of health that the "orphan of the orphan" statement clearly takes on meaning. Given that mental health is a complex, dynamic process, if the conditions that lead to good mental health in adults are not supported (access to professional support when needed, good living conditions, good working conditions, adequate social networks, etc.) then it follows that the children and youth in families under stress, are more at risk of developing mental health problems. The relationship between unemployment, mental health and well-being has been demonstrated in longitudinal studies.25 Adults with mental health problems are often orphans in the health care system and their offspring are often even further removed from adequate supports. Children and youth appear to be in a state of double jeopardy - affected by their own individual genetic make-up and experience, as well as being directly impacted by the mental state of those upon whom they depend the most. This is despite, in at least developed countries, almost universal access to a health care system and an early-education/school system, which has consistently been identified as important locales of early identification of mental health issues.26 27
The cost of not adequately treating mental illness and mental health problems in children and youth is hard to measure, however some indicators point us to a massive sum. In 1992, Lafleur 28 calculated, using actuarial methods, the cost to Canadians of all children dropping out of school in 1989 would, over their lifetimes, total $4 billion. This is the total from one year's dropouts. Think of the total over a decade or a generation. The costs and loss to Canadian society are extraordinary, yet this has become the norm. While not all cases of dropping out of school are due to mental health problems, there is a strong relationship between the effects of mental health problems and the ability to stay in school.29 30
Mental health problems, such as stress, anxiety, and depression, contribute significantly to youth dropping out of school every year. The effects are not limited only to dropouts however, since students cannot optimize their learning if their mental health needs are not met. This often leads to other behaviors that are then manifested in other areas such as physical health, youth justice, and child welfare.31 More troubling still is when youth take this to another level, not just removing themselves from school but from life, by committing suicide. Statistics Canada 32 reports suicide as the second leading cause of youth death, after fatal motor vehicle accidents.
Continuing with the example of school, school has been identified by youth as both the most positive aspect of their life as well as the most stressful. The 1992 Canadian Psychiatric Association's survey, noted above, demonstrated that for youth, school was seen as the most positive aspect of their life (28.1%), followed by friends/relationships (23.5%), family (15.1%), sports, music, and culture (11.1%), other (12.1%), or none (10.1%). The same survey also identified school as the most stressful aspect of their life (64.6%), followed by home and parents (10.6%), friends and relationships (7.9%), money and work (4.3%), with other or no opinion responses comprising 12.6% of responses.
When it comes to discussing mental health concerns however, teachers, principals, school health workers, appear to be left out of the loop. The first line of discussion is with a friend (43%), followed by a parent or family member (23.9%) or other (1.3%). What is troubling however is that over a third of youth are discussing their mental health concerns with no one (31.8%). 33
When youth are ready to seek help, they go to their family doctor first (32 %). The next most common choices are a mental health professional in a quarter of cases (child and youth worker, psychologist, psychiatrist, social worker) or a counselor (21%). Friends and family (4%), hot lines or teen-health clinic (8%), or other (3%), is how the minority seek help. Seven percent seek help from no one.
Given the central role that school plays in the lives of children and youth, and the prevalence of mental health problems faced by children and youth, it is significant that schools do not generally play a more active role in promoting good mental health, of reducing stigma, of developing help-seeking behaviors, and of providing good data and information into the streams where youth seek advice and help. As indicated above, the challenge of child & youth mental health is not being met. Alternative approaches must be found which build on what works, to eliminate what does not work, and to implement activities that are based on evidence.34
Global context on mental health
There is considerable debate as to whether mental health problems and mental illnesses can accurately be described as epidemics.35 36 Measurement and evaluation is often inadequate and the longitudinal data is often flawed due to changing diagnoses. Despite the debates and the ongoing disagreements, the World Health Organization provides some global estimates on the prevalence of mental health problems that are useful to outlining the scope of the number of individuals affected: 37
* 450 million people worldwide are affected by mental, neurological or behavioral problems at any time.
* About 873,000 people die by suicide every year.
* Mental illnesses are common to all countries and cause immense suffering. People with these disorders are often subjected to social isolation, poor quality of life and increased mortality. These disorders are the cause of staggering economic and social costs.
* One in four patients visiting a health service has at least one mental, neurological or behavioral disorder but most of these disorders are neither diagnosed nor treated.
* Mental illnesses affect and are affected by chronic conditions such as cancer, heart and cardiovascular diseases, diabetes and HIV/AIDS. Untreated, they bring about unhealthy behavior, non-compliance with prescribed medical regimens, diminished immune functioning, and poor prognosis.
* Cost-effective treatments exist for most disorders and, if correctly applied, could enable most of those affected to become functioning members of society.
* Barriers to effective treatment of mental illness include lack of recognition of the seriousness of mental illness and lack of understanding about the benefits of services. Policy makers, insurance companies, health and labor policies, and the public at large - all discriminate between physical and mental problems.
* Most middle and low-income countries devote less than 1% of their health expenditure to mental health. Consequently mental health policies, legislation, community care facilities, and treatments for people with mental illness are not given the priority they deserve.
With specific regard to children and youth mental health globally, the World Health Organization's, Atlas: child and adolescent mental health resources: global concerns, implications for the future, outlines the need for services 38:
* Worldwide prevalence of child and adolescent mental disorders of approximately 20%. Of this 20% it is recognized that from 4 to 6% of children and adolescents are in need of a clinical intervention for an observed significant mental disorder.39
* Half of all lifetime cases of mental disorders start by age 14.40
* Nowhere in the world is the documented need for child and adolescent mental health services fully met.
* In high-income countries child and adolescent mental health service need is identified for between 5 and 20% of the population. This is comparable to the range of estimated service need in the lowest income countries.
* In a European survey of 36 countries (70.5% of all European countries) showed that the degree of coverage and quality of services for the young were generally worse in comparison with adults.41
* In high-income countries the service gap, while substantially less than in low-income countries is still very high.
* European countries, particularly in the Scandinavian region and certain countries, such as Israel with highly developed mental health services approach 80% provision, but others among the high income countries report as low as 20% provision of services.
* The Mental Health Atlas - 2005 showed that 23% of countries in Europe lacked specific programs for child mental health.
* While a services gap exists in all countries in the Americas, 26% of countries lacked basic clinical mental health services for children and adolescents.42
* The Child and Adolescent Mental Health ATLAS documents that countries with the higher proportion of children in the world are the ones that lack both mental health policy addressing the needs of children and adolescents and services for the population.
* In Africa and other countries with a high rate of HIV/AIDS deaths the population of young people will increase disproportionately in the coming years. (UNICEF, 2005) The number of AIDS orphans is currently estimated to be 14 million, and anticipated to rise to 20 million by 2010 (UNICEF).
The WHO, as mentioned earlier, has identified mental health as carrying both an undefined burden of economic and social hardship for families, communities and countries as well as a hidden burden of stigma and violations of human rights and freedoms. These burdens are not effectively or efficiently measured and there are significant difficulties in measuring and evaluating the state of mental health and access to needed services.43
Even in one of the wealthiest nations of the world, the United States of America, the Surgeon General states that: "Tragic and devastating disorders such as schizophrenia, depression and bipolar disorder, Alzheimer's disease, the mental and behavioral disorders suffered by children, and a range of other mental disorders affect nearly one in five Americans in any year, yet continue too frequently to be spoken of in whispers and shame."44
Canadian context on mental health
The Canadian context is similar to that described in the United States and European countries. The Health Canada Report on Mental Illnesses in Canada45 provides an overview of mental health in Canada:
* Mental illnesses indirectly affect all Canadians through illness in a family member, friend or colleague.
* Twenty percent of Canadians will personally experience a mental illness during their lifetime.
* Mental illnesses affect people of all ages, educational and income levels, and cultures.
* The onset of most mental illnesses occurs during adolescence and young adulthood.
* A complex interplay of genetic, biological, personality and environmental factors causes mental illnesses.
* Mental illnesses can be treated effectively.
* Mental illnesses are costly to the individual, the family, the health care system and the community.
* The economic cost of mental illnesses in Canada was estimated to be at least $7.331 billion in 1993.
* Eight-six percent of hospitalizations for mental illness in Canada occur in general hospitals.
* In 1999, 3.8% of all admissions in general hospitals (1.5 million hospital days) were due to anxiety disorders, bipolar disorders, schizophrenia, major depression, personality disorders, eating disorders and suicidal behavior.
* The stigma attached to mental illnesses presents a serious barrier not only to diagnosis and treatment but also to acceptance in the community.
The Canada section of the World Health Organization's Mental Health Atlas provides a synthesis of mental health services.46 Canada has no national mental health program. There is no national therapeutic drug policy or essential list of drugs. Given the context of federal, provincial, and territorial government relations on health, each province frames mental health legislation independently. There are no federal budgets for mental health. Each province has its own health and mental health budgets. The Medicare system pays basic medical and hospital bills however the direct and indirect costs related to mental health problems are estimated be among the costliest of all conditions and represent nearly one-sixth of the national corporate net operating profits.47 Provincial health insurance plans fund general practitioners but do not usually cover services provided by other mental health professionals. There are thirteen interlocking health insurance plans and thirteen separate delivery systems. Mental health services are provided through an often confusing mix of sources: primary care, general hospital care, community service, specialized treatment facilities, psychiatric hospitals, community providers, non-governmental organizations, and consumer-run organizations.48
On a positive note, Canada has disability benefits (although limited, even General Romeo Dallaire, post Rwanda, had difficulty receiving benefits49) for persons with mental disorders, if they can receive proper diagnosis and ongoing treatment. There are specific programs for mental health for minorities, refugees, disaster-affected populations, indigenous populations, elderly and children, and there are services available for mentally disordered offenders. With regards to offenders, one of the few coherent national policy documents, is the 1991 "Report on the Task Force on Mental Health" published by Correctional Services of Canada.
Given the complexity of the legislative, financing, and service-delivery systems for mental health, Dickinson has argued that there is an on-going tension between the medical-scientific model of practice and the multidisciplinary, community-based model of mental health promotion and mental illness prevention originating in the mental hygiene movement.50 This tension is perhaps one reason why mental health services tend to be under-developed.
In the Romanow Report, there is the repeated recommendation that the quality of care and support available to people with mental illnesses be improved by including home mental health case management and intervention services as part of the Canada Health Act.51
Complex, multidisciplinary approaches
Given the prevalence of mental health problems and mental illnesses globally, as well as the gaps in services, access to professionals, competing systems, inconsistent policies, and inadequate financial resources, it is not surprising that a significant number of initiatives have been created in an attempt to leverage existing scarce resources. It is also not surprising that given these scarce resources, there have been few successes in bringing these initiatives together into a comprehensive framework.
The Ontario provincial government has recently begun putting more resources into mental health care, and into child and youth mental health in particular. According to ICES, an under-funding of mental health is consistent with historical perceptions of the mental illness. "Mental illnesses are often perceived as rare conditions and have been characterized historically as afflicting primarily people who are weak or lack moral fibre. These illnesses do not have clear-cut causal agents (such as bacteria or viruses) that are easily identifiable and treatable. Furthermore they are seen as less debilitating..."52
The creation in June 2004, of the Provincial Centre of Excellence for Mental Health53, located at the Children's Hospital of Eastern Ontario, is an example of the adoption of a multidisciplinary approach. With a budget of approximately $6 million per year, this Centre has adopted a four-prong approach to assisting the process of building an integrated mental health system for children and youth in Ontario. The stated strategic directions include:
* Networks and Partnerships
o Create and maintain partnerships and networks among and between mental health stakeholders
o Identify potential partners including parents, children, youth and their families
o Facilitate partnership building as well as provincial and province-wide activities
o Advocate for capacity building
* Research and Development
o Scan mental health research to consolidate and identify gaps
o Undertake leading edge research to fill the gaps
o Support researchers through consultation
o Fund new research
* Intervention
o Champion a fully integrated and collaborative system across the full continuum of needs in child and youth mental health
o Provide interventional consultation
o Ensure cultural and linguistic diversity
o Develop best practices guidelines
* Education and Training
o Scan education and training activities
o Provide mentorship and educational consultation
o Develop web-based training
o Target community awareness of the importance of child and youth mental health
While it is too early to determine whether the activities of the Centre will have the desired effect, there is already clear indication of a shift away from the more traditional hiring patterns of those involved with mental health care. Employees of the Centre come from a range of disciplines: psychology, education, psychiatry, sociology, epidemiology, communications, administration, knowledge exchange, and computer science, among others. The introduction of diverse professional perspectives, as well as the utilization of multiple sector advisory committees (service providers, researchers, consumers and caregivers, etc.), is a strong indicator of the recognition that if one involves only those involved in treating the symptoms of mental illness, it will be difficult to build a system that supports overall mental health.
The co-director of the Centre of Excellence, Drs. Ian Manion and Simon Davidson, were founders, over ten years ago, of a successful program supporting youth mental health. "Youth Net", was started at the Children's Hospital of Eastern Ontario and is now operating in the Ontario communities of Hamilton, Halton, Peel, and Grey Bruce, in the Quebec communities of Montréal, Montéregie, and Montmagny, in Delta, British Columbia and in Newcastle, United Kingdom. This bilingual program is run by youth for youth with an aim to: 1) increase communication and promote awareness among youth regarding mental health and illness issues, 2) identify those youth who are at risk for mental illness and bridge them to appropriate, youth friendly mental health services, 3) reduce the stigma surrounding mental health and illness through education and communication, and 4) attend to what youth are saying in order to make current mental health services more youth appropriate. The program is supported by a safety net of mental health professionals. 54
Another youth oriented program, HealthNet, based in Halifax, "is comprised of a range of programs, workshops, and health materials for young people, parents and teachers. Materials for youth are distributed online through (an) interactive health magazine for youth. Materials for parents and teachers are located and maintained through separate websites." These websites provide "both content and infrastructure that allow young people, teachers and parents to enhance health literacy using novel and interactive technologies as well as to track health needs, outcomes and risk behaviors as required." 55 Combining psychology, computer science, education, sociology, and psychiatry; the stated goal of the websites is "to promote health literacy in youth. Health literacy is a key component of making good choices for health and well-being." 56
As discussed above, schools can play a leadership role in the development of better parenting of children and youth. Programs such as COPE (Community Parent Education Program)57 developed at McMaster University and now operating in cities across Canada (Calgary, Regina, Toronto, Hamilton, and various places in Nova Scotia), the United States (Buffalo and ten sites in Orange County, California), in five cities in Sweden, and Istanbul, Turkey, uses active learning models to develop better parenting skills that have a direct effect on the mental health of families and children. This allows for better school performance as a result of better mental health.
A related program, from Australia, Triple P - Positive Parenting Program58 is an evidence-based parenting program based on over 25 years of clinical and empirical research. The program provides parenting and family support strategies that aim to prevent severe behavioral, emotional and developmental problems in children by enhancing the knowledge, skills and confidence of parents. This program has led to the development of a hit television show in the United Kingdom, "Driving Mum and Dad Mad"59.
Also from Australia, the Australian Broadcasting Corporation's youth radio station, "Triple J" 60, is using podcasts as a method to enable youth to listen to information pieces in a format they want (on their portable devices) and at a time they choose. Recent episodes include a pharmacist's investigation of Australia's depression epidemic. She wonders why over a million Australians now take antidepressant drugs? Other podcasts available include why it's not easy getting off anything that you are addicted to. This podcast includes stories of people who have kicked their drug habits and how they managed it. It was part of a promotion of "Positive Stories" by the Australian National Council on Drugs.
While the relative effectiveness and efficiency of any of the above examples is the subject for another paper, there does seem to be an international trend in dealing with mental health problems that recognizes their complex nature and the need to include a diverse set of perspectives and expertise. The challenge faced by mental health is similar to that faced by many areas of study and treatment: knowledge exchange - how do we know what we know and how do we move this knowledge into policy, practice, and perspectives.
The Centre of Excellence for Child and Youth Mental Health, provided as an example above, has recognized the challenge of knowledge exchange and has created a dedicated Knowledge Exchange Centre to help build the processes and tools to essentially "Do more with what we know."61 The emphasis on knowledge exchange within health care has also been emphasized by many organizations internationally, including in Canada by the Canadian Health Services Research Foundation62 and the Canadian Institutes of Health Research63, among others.
Population health perspective on child and youth mental health
"When people talk about health and health care, they usually think in terms of physical illness and medical treatments. Mental health is usually ignored or added only as an after thought."64 For a population health perspective to be truly adopted in Canada, mental health should be an integrated component of a complex, emergent process that looks at health over the lifespan. Given where we are, how do we do this?
The World Health Organization suggests that the federal government in Canada plays an important role in consensus building and setting priorities for policies, such as health care, including mental health care.65 With regards to mental health, the Public Health Agency of Canada's, Mental Health Promotion Unit appears to have been given the mandate to manage this role of "consensus builder".
The MHPU was created in 1995, as a unit of Health Canada. Their website states that the: "MHPU addresses mental health promotion from a population health perspective that takes into account the broad range of determinants of mental health... the mandate of the unit is to promote and support mental health and reduce the burden of mental health problems and disorders, by contributing to the development, synthesis, dissemination and application of knowledge; the development, implementation and evaluation of policies, programs and activities designed to promote mental health and address the needs of people with mental health problems or disorders."66
While the MHPU's mandate may state that they have adopted a population health perspective, a reading of their research documents and website pages, clearly identifies their activities as health promotion. While an important part of population health, health promotion has a focus on individual behavior: "mental health promotion is the process of enhancing the capacity of individuals and communities to take control over their lives and improve their mental health...our unit emphasizes the following elements: By working to increase self-esteem, coping skills, social support and well-being in all individuals and communities, mental health promotion empowers people and communities to interact with their environments in ways that enhance emotional and spiritual strength. It is an approach that fosters individual resilience and promotes socially supportive environments. Mental health promotion also works to challenge discrimination against those with mental health problems. Respect for culture, equity, social justice, interconnections and personal dignity is essential for promoting mental health for everyone."67
The MHPU clearly has an important role to play in developing a population health perspective for Canadian but it cannot be successful if it is the only section charged with doing this. This "modern" form of organization is often where the intention to action falls apart - how can one manage something that is complex?
Kindig and Stoddart state that a hallmark of the field of population health "is significant attention to the multiple determinants of health outcomes, however measured. These determinants include medical care, public health interventions, aspects of the social environment (income, education, employment, social support, culture) and the physical environment (urban design, clean air and water), genetics, and individual behavior."68 They further state "no one in the public or private sectors currently has responsibility for overall health...the importance of population health ...is that it forces review of health outcomes across determinants."
The Ottawa Charter for Health Promotion outlined the prerequisites for health as: peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity.69
Looking to Graham70, it appear that certain prerequisites need to be met before we can truly have an integrated population health system - one that includes mental health, including the mental health of children and youth. She suggests that the complexity of looking at macro determinants of health inequalities requires new methods and theories. The linking of epidemiology with social policy research may be helpful if one takes into account cumulative exposure over the life course and the effect of state policies to help or hinder health. This is keeping with the perspective that the US Surgeon General has recommended.
New health strategies recognize that the roots of health inequalities "run deep" and there are movements in many jurisdictions from a focus on disease and individuals to the wider determinants of health but clearly building science into policy is not straightforward. Marmot71 states that we cannot ignore how people got where they are and we always need to look upstream. In times of rapid social change, the dynamics of inequality also change. Tax and social security are only two of the measure by which governments can reduce inequalities in living standards - the third is the broad set made of things like education, health care, housing, personal social services, and public transport. This is one reason for the emphasis on the school system as an integral part of the health system that supports good mental health for children and youth. It also supports the emphasis on helping parents become better parents.
The tax system, the social security system, and the welfare system combine in ways that temper the life course effects of social and economic change. Social capital may not be the underlying determinant of the relationship between income inequality and health, although it may be a marker and outcome of the level of investment in systems that redistribute wealth. This is one of the reasons Graham argues for the need for an interdisciplinary science - one capable of capturing both the dynamics and the health consequences of social inequality.
This interdisciplinary perspective is partially captured by the Public Health Agency of Canada.72 They list the key social determinants of health as: income and social status, social support networks, education and literacy, employment/working conditions, social environments, physical environments, personal health practices and coping skills, healthy child development, biology and genetic endowment, health services, gender, and culture. However, they miss many of the connections of these determinants to mental health.
Mental health is linked explicitly to employment/working conditions by stating, "Employment has a significant effect on a person's physical, mental and social health... (a) major review done for the World Health Organization found that high levels of unemployment and economic instability in a society cause significant mental health problems and adverse effects on the physical health of unemployed individuals, their families and their communities." 73
It is also linked to healthy child development: "New evidence on the effects of early experiences on brain development, school readiness and health in later life has sparked a growing consensus about early child development as a powerful determinant of health in its own right. At the same time, we have been learning more about how all of the other determinants of health affect the physical, social, mental, emotional and spiritual development of children and youth."74
The link to health services shows that access to mental health services is inadequate: "Access to universally insured care remains largely unrelated to income; however, many low- and moderate-income Canadians have limited or no access to health services such as eye care, dentistry, mental health counseling and prescription drugs."75 The obvious link to income and social status is not explicitly made in the PHAC materials.
No direct links are made to: income and social status, social support networks, education and literacy, social environments, physical environments, personal health practices and coping skills, biology and genetic endowment, gender, and culture.
All of these have an effect on mental health. The mental health of individuals has an effect on each of the environments encompassed by the social determinants - 20 to 25% percent of people suffering some sort of mental health problem is going to have an impact on social environments, on culture, on gender relationships, on education and the ability to develop literacy.
While the PHAC appears to be moving in the direction of adopting a population health framework, it is too slow given what "we", as a society "know" about the effects of mental health problems, and more importantly, on what we know about the positive impact of early prevention and treatments on children and youth.
Another example, "The Population Health Template: Key Elements and Actions that define a Population Health Approach" from Health Canada76 has no reference to mental health. Two competing assumptions can be made. Either it is included as part of their concept of health or is it completely ignored, as described by Goel and colleagues, either way, it is not clear.
Two examples that demonstrate a movement to adopt a population health perspective for mental health come from the provinces of British Columbia and Quebec.
The Province of British Columbia's, Child and Youth Mental Health Plan77 adopts a long-term view, in which the Ministry of Children & Family Development has applied a population health framework that includes mental health: "Children are British Columbia's most important investment in the future. Families and communities share the responsibility to ensure that children in British Columbia have access to the resources that promote health, well-being and optimal human development. It is our common goal - and in our common interest - to see that children thrive...Mental illnesses now constitute the most important group of health problems that children suffer - superceding all other health problems in terms of the number of children affected and the degree of impairment caused. Currently, one in seven (more than 140,000) children in British Columbia are estimated to have a mental illness serious enough to cause significant distress and impair their development and functioning at home, at school, and in the community. The majority of these children (and their families) do not receive the services they need, with the result that impairments often continue, causing increased suffering and affecting productivity and functioning in adulthood."
In Quebec, recognizing that mental health is an issue of growing importance: "La santé mentale, la violence et le suicide sont devenus des préoccupations de première importance dans notre société. En 1998, 20 % de la population québécoise de 15 ans et plus se situait au niveau de détresse le plus élevé selon l'Enquête Santé Québec. De 1976 à 1999, on a observé une augmentation du taux de suicide de 62 % dans la population en général, plus particulièrement de 25 % chez les femmes et de 78 % chez les hommes. Avec ses 1 500 décès par année, le Québec se retrouve dans le peloton de tête des pays industrialisés pour son taux de suicide." the Institut national de santé publique78, has partnered with the Observatoire pour la promotion de la sécurité et la prévention des traumatismes, to provide expertise, research, and capacity building for a range of stakeholders involved in addressing mental health problems from a population health perspective.
Both of these examples include broad partnerships between diverse actors. Again, they are both too newly implemented to determine whether their approaches will be successful.
Research questions
Population health and mental health are both complex emergent concepts that are not fully defined. As such, there appears to be no silver "implementation strategy" bullet. This however, provides many opportunities to build on what is already known and to venture into the frontier.
The main questions that emerge from the above discussion are the following:
* How to change the culture of stigma against mental health problems and mental illness? What can be learned from other campaigns to reduce stigma? Why is mental health such a difficult issue around which to mobilize?
* How to bridge what is known with what is practiced? What does knowledge exchange and knowledge mobilization look like for mental health presented from a population health perspective? Can the diverse federal, provincial, territorial infrastructures be brought together into a mutually beneficial community of practice? Can organizations such as the WHO improve on their international efforts and what are the responsibilities of member nations to each other and non-member nations, with regards to the mental health of children and youth? What is the role of multinational corporations in developing the conditions for good mental health, both in their workers and the communities where they live?
* Which models are more effective than others? Given that no society appears to be completely addressing mental health issues - is there a fundamental flaw in current endeavors? Do we have the methods and theories to properly address the upstream issues that affect mental health in children and youth?
* The artist and child advocate, Raffi, once asked at a conference79: "Do we have the courage to be a healthy society?" Given that existing incentives in schools and workplaces often run counter to the conditions for good mental health, what is needed to shift the focus from profits and efficiencies, to people and long-term effectiveness? Is this shift possible and if so, what are the timeframes and infrastructure adjustments needed to support such a movement?
* Given the complexity of interactions of the social determinants of health, is it possible for a society to become healthier, both physically and mentally, without first dealing with the power and structural issues of social class and economic inequities?
* What is the role of "community" in causing mental health problems or in creating the conditions for good mental health?
Final Remarks
Health, including mental health, is a continuum over the life course. The ideal of perfect health, physically and mentally, is just that, an ideal: something desired yet almost impossible to attain. This seeming impossibility however, is the very reason to venture forward with the development of further understanding, better tools, creative theories, and resilient practices. Population health is a study of how to live better, with what we have, where we are, and with whom we interact. Health is never complete: it changes as people change, as they move, grow, breathe, interact, and become, whatever they are becoming. This "reality" is a source of frustration in a world where "ends" are rewarded and the "means" or processes are of a secondary importance.
The mental health of children and youth, worldwide, says much about the societies we have built. The rising rate of depression, suicide, anxiety, eating disorders, self-harm, among our children and youth, may simply be a result of better measurement and diagnosis. It may also be that we are creating the conditions that cause more children and youth, to consider suicide and self-harm, as reasonable options to the life that is offered to them.
These questions are only of importance if one considers life, important.
____________________________________________________
Endnotes
1 World Health Organization. Fact sheet No. 218, Mental health problems: the undefined and hidden burden. November 2001. Available from: http://www.who.int/mediacentre/factsheets/fs218/en/print.html
2 Lalonde M. A new perspective on the health of Canadians: a working document (1974). Ottawa: Ministry of Supply and Services Canada; 1981. Cat. No. H31-1374.
3 Lalonde M. A new perspective on the health of Canadians: a working document (1974). Ottawa: Ministry of Supply and Services Canada; 1981. Cat. No. H31-1374. p.61.
4 Lalonde M. A new perspective on the health of Canadians: a working document (1974). Ottawa: Ministry of Supply and Services Canada; 1981. Cat. No. H31-1374. p. 62.
5 Romanow, R. Building on Values: The Future of Health Care in Canada - Final Report. Ottawa: Commission on the Future of Health Care in Canada; 2002. p. 32.
6 Romanow, R. Building on Values: The Future of Health Care in Canada - Final Report. Ottawa: Commission on the Future of Health Care in Canada; 2002. p. 213.
7 Romanow, R. Building on Values: The Future of Health Care in Canada - Final Report. Ottawa: Commission on the Future of Health Care in Canada; 2002. p. 214.
8 Eggertson, L. Children's mental health services neglected: Kirby. Ottawa: CMAJ, Aug. 30, 2005; 173 (5). p. 471
9 Mental Health Foundation [homepage on the Internet]. London: Mental Health Foundation; [updated 5005-10-07; cited 2005-12-28]. Available from: http://www.mentalhealth.org.uk/page.cfm?pagecode=PMWM
10 World Health Organization. Fact sheet No. 220, Mental Health: strengthening mental health promotion. November 2001. Available from: http://www.who.int/mediacentre/factsheets/fs220/en/print.html
11 World Health Organization. Fact sheet No. 220, Mental health: strengthening mental health promotion. November 2001. Available from: http://www.who.int/mediacentre/factsheets/fs220/en/print.html
12 U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General-Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999. Available from: http://www.mentalhealth.samhsa.gov/features/surgeongeneralreport/chapter2/conc2.asp
13 Eggertson, L. Children's mental health services neglected: Kirby. Ottawa: CMAJ, Aug. 30, 2005; 173 (5). p. 471
14 World Health Organization. Fact sheet No. 218, Mental health problems: the undefined and hidden burden. November 2001. Available from: http://www.who.int/mediacentre/factsheets/fs218/en/print.html
15 World Health Organization. Fact sheet No. 265, Mental and neurological disorders. December 2001. Available from: http://www.who.int/mediacentre/factsheets/fs265/en/print.html
16 Mental Health Foundation [homepage on the Internet]. London: Mental Health Foundation; [updated 5005-10-07; cited 2005-12-28]. Available from: http://www.mentalhealth.org.uk/page.cfm?pagecode=PMWM
17 Canadian Mental Health Association. [homepage on the internet]. Toronto: Canadian Mental Health Foundation [cited 2005-12-28]. Available from: http://www.cmha.ca/bins/index.asp?lang=1
18 Eggertson, L. Children's mental health services neglected: Kirby. Ottawa: CMAJ, Aug. 30, 2005; 173 (5). p. 471
19 Canadian Psychiatric Research Foundation. When Something's Wrong: Ideas for Families. Toronto: Canadian Psychiatric Research Foundation, 2004.
20 Davidson, S. & Manion, I.G. (1996). Facing the challenge: mental health and illness in Canadian youth. Psychology, Health & Medicine 1, (1), 41-56.
21 Brown. G.W. Social class, psychiatric disorder of the mother, and accidents to children. Lancet 1:378. 1978
22 Wilkinson, R.G. Unhealthy Societies. London: Routledge. p. 180.
23 Mental Health Foundation [homepage on the Internet]. London: Mental Health Foundation; [updated 5005-10-07; cited 2005-12-28]. Available from: http://www.mentalhealth.org.uk/page.cfm?pagecode=PMWM
24 Berkman, L.F. and I. Kawachi. A historical framework for social epidemiology. In: Berkman, L.F. and I. Kawachi, editors, Social Epidemiology. New York: Oxford University Press, 2000. p. 7.
25 Kasl, S.V. and B.A. Jones. The impact of job loss and retirement on health. In: Berkman, L.F. and I. Kawachi, editors, Social Epidemiology. New York: Oxford University Press, 2000. p. 127.
26 Owens, JS, Richerson, L, Beilstein, EA., Crane, A, Murphy, CE., Vancouver, JB. School-Based Mental Health Programming for Children With Inattentive and Disruptive Behavior Problems: First-Year Treatment Outcome. J Atten Disord, 2005 9: 261-274
27 Weist, MD. Fulfilling the Promise of School-Based Mental Health: Moving Toward a Public Mental Health Promotion Approach, Journal of Abnormal Child Psychology, Volume 33, Issue 6, Dec 2005, Pages 735 - 741
28 Lafleur, B. (1992). Dropping out: the cost to Canada. Conference Board of Canada Report, 83-92-E.
29 Acosta, Olga M., Weist, Mark D., Lopez, Fernando A., Shafer, Micheal E., Pizarro, L. Josefina
Assessing the Psychosocial and Academic Needs of Latino Youth to Inform the Development of School-Based Programs, Behav Modif, 2004 28: 579-595
30 Fremont, WP. School refusal in children and adolescents. Am Fam Physician. 2003 Oct 15;68(8):1555-60.
31 Levesque, P and I. Manion. Better Together: Child and Youth Mental Health. Journal of the Canadian Association of Principals. January 2006. p. 14.
32 Statistics Canada (2005). Major Causes of Death. Available online at: http://142.206.72.67/02/02b/02b_003_e.htm
33 Davidson, S. & Manion, I.G. (1996). Facing the challenge: mental health and illness in Canadian youth. Psychology, Health & Medicine 1, (1), 41-56.
34 Levesque, P and I. Manion. Better Together: Child and Youth Mental Health. Journal of the Canadian Association of Principals. January 2006. p. 15.
35 Weir, E and Wallington, T. Suicide: The Hidden Epidemic, CMAJ; 2001: 165(5):634-6.
36 Sudak, HS. The Invisible Plague: The Rise of Mental Illness From 1750 to the Present. Am J Psychiatry 2003 160: 1017-1018
37 World Health Organization. [homepage on the Internet]. Mental Health: The bare facts. New York: World Health Organization; [cited 2005-12-29] Available from: http://www.who.int/mental_health/en/
38 World Health Organization. Atlas: child and adolescent mental health resources: global concerns, implications for the future. Geneva: World Health Organization, 2005. p. 16.
39 World Health Organization. The world health report 2001- Mental Health: new understanding, new hope. Geneva: World Health Organization, 2001.
40 Kessler RC, Berglund PMBA, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Study Replication. Arch GenPsychiatry, 2005, 62(6):593-602.
41 Levav I, Jacobsson L, Tsiantis J, et al. Psychiatric services and training for children and adolescents in Europe: Results of a country survey. Eur Child Adolesc Psychiatry, 2004, 13:395-401.
42 Rohde LA, Celia S, Berganza C. Systems of care in South America. In: Remschmidt H, Belfer ML, Goodyer I, Eds. Facilitating pathways: Care, treatment and prevention in child and adolescent mental health. Berlin, Springer, Berlin, 2004, pp. 42 - 51.
43 World Health Organization. Fact sheet No. 218, Mental health problems: the undefined and hidden burden. November 2001. Available from: http://www.who.int/mediacentre/factsheets/fs218/en/print.html
44 U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General-Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999. Available from: http://www.mentalhealth.samhsa.gov/features/surgeongeneralreport/home.asp - forward
45 Health Canada. A Report on Mental Illnesses in Canada. Ottawa: Health Canada, 2002. p. 7.
46 World Health Organization. Mental Health Atlas. Geneva: World Health Organization, 2005. p. 120-122.
47 World Health Organization. Mental Health Atlas. Geneva: World Health Organization, 2005. p. 121.
48 World Health Organization. Mental Health Atlas. Geneva: World Health Organization, 2005. p. 120.
49 Royal Bank of Canada. Mental Health Today and Tomorrow. Toronto: RBC Letter, August 2002. Available from: http://www.rbc.com/community/letter/august2002.html
50 Dickenson, H. A sociological perspective on the transfer and utilization of social scientific knowledge for policy-making. In: Lemieux-Charles, L. and F. Champagne, Eds., Using Knowledge and Evidence in Health Care. Toronto: University of Toronto Press, 2004.
51 Romanow, R. Building on Values: The Future of Health Care in Canada - Final Report. Ottawa: Commission on the Future of Health Care in Canada; 2002. p. 171.
52 Goel V, Williams J, Anderson G, Blackstien-Hirsch P, Fooks C, Naylor D. Patterns of health care in Ontario, 2nd edition. Toronto: Institute for Clinical Evaluative Sciences, May 1996. p. 265-286.
53 Provincial Centre of Excellence for Child and Youth Mental Health. [homepage on the Internet] Ottawa: Provincial Centre of Excellence for Child and Youth Mental Health. [cited 2005-12-30]. Available from: http://www.cymh.ca/index_e.htm
54 Youth Net. [homepage on the Internet]. Ottawa: Youth Net [cited 2005-12-30] Available from: http://www.youthnet.on.ca/
55 Yoomagazine. [homepage on the Internet] Halifax: Yoomagazine [cited 2005-12-30] Available from: http://www.yoomagazine.net/page.php?id=12
56 Yoomagazine. [homepage on the Internet] Halifax: Yoomagazine [cited 2005-12-30] Available from: http://www.yoomagazine.net/page.php?id=12
57 Community Education Service. [homepage on the Internet] Hamilton: McMaster University. [cited 2005-12-30]. Available from: http://www.communityed.ca/
58 Triple P International. [homepage on the Internet] Brisbane: Triple P International. [cited 2005-12-30]. Available from: http://www9.triplep.net/
59 Driving Mum and Dad Mad, ITV. [homepage on the Internet] London: ITV. [cited 2005-12-30]. Available from: http://www.itv.com/page.asp?partid=2978
60 Triple J. [homepage on the Internet] Brisbane: Australian Broadcast Corporation. [cited 2005-12-30]. Available from: http://www.abc.net.au/triplej/default.htm
61 Provincial Centre of Excellence for Child and Youth Mental Health. [homepage on the Internet] Ottawa: Provincial Centre of Excellence for Child and Youth Mental Health. [cited 2005-12-30]. Available from: http://www.cymh.ca/index_e.htm
62 Canadian Health Services Research Foundation. [homepage on the Internet] Ottawa: Canadian Health Services Research Foundation. [cited 2005-12-30]. Available from: http://www.chsrf.ca/home_e.php
63 Canadian Institutes of Health Research. [homepage on the Internet] Ottawa: Canadian Institutes of Health Research. [cited 2005-12-30]. Available from: http://www.cihr-irsc.gc.ca/e/193.html
64 Goel V, Williams J, Anderson G, Blackstien-Hirsch P, Fooks C, Naylor D. Patterns of health care in Ontario, 2nd edition. Toronto: Institute for Clinical Evaluative Sciences, May 1996. p. 265.
65 World Health Organization. Mental Health Atlas. Geneva: World Health Organization, 2005. p. 120-122.
66 Mental Health Promotion Unit. [homepage on the Internet]. Ottawa: Public Health Agency of Canada. [updated 2003-01-15, cited 2005-12-30] Available from: http://www.phac-aspc.gc.ca/mh-sm/mentalhealth/mhp/index.html
67 Mental Health Promotion Unit. [homepage on the Internet]. Ottawa: Public Health Agency of Canada. [updated 2003-01-15, cited 2005-12-30] Available from: http://www.phac-aspc.gc.ca/mh-sm/mentalhealth/mhp/faq.html
68 Kindig, D and G. Stoddart. What is Population Health? American Journal of Public Health. March 2003, Vol., 93, No. 3. p. 381.
69 World Health Organization. Ottawa Charter for Health Promotion. Geneva: World Health Organization, 1986. p. 1.
70 Graham, H. Building an inter-disciplinary science of health inequalities: the example of lifecourse. Social Science & Medicine. 55 (2002) 2006-2016.
71 Marmot, M, Shipley, M, Brunner, E, & Hemingway, H. Relative contribution of early life and adult socioeconomic factors to adult morbidity in the Whitehall II study. Journal of Epidemiology and Community Health, 55 (2001), 301-307.
72 Public Health Agency of Canada. [homepage on the Internet] Ottawa: Public Health Agency of Canada. [cited 2005-12-30]. Available from: http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/
73 Public Health Agency of Canada. [homepage on the Internet] Ottawa: Public Health Agency of Canada. [cited 2005-12-30]. Available from: http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/determinants.html#unhealthy
74 Public Health Agency of Canada. [homepage on the Internet] Ottawa: Public Health Agency of Canada. [cited 2005-12-30]. Available from: http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/determinants.html#unhealthy
75 Public Health Agency of Canada. [homepage on the Internet] Ottawa: Public Health Agency of Canada. [cited 2005-12-30]. Available from: http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/determinants.html#unhealthy
76 Strategic Policy Directorate of the Population and Public Health Branch, Health Canada. The Population Health Template: Key Elements and Actions that define a Population Health Approach. Ottawa: Health Canada, July 2001 Draft. Available from: http://www.phac-aspc.gc.ca/ph-sp/phdd/pdf/discussion_paper.pdf
77 Ministry of Children & Family Development. [homepage on the Internet] Victoria: Province of British Columbia. [cited 2005-12-30]. Available from: http://www.mcf.gov.bc.ca/mental_health/mh_publications/cymh_plan.htm
78 Institut national de santé publique. [homepage on the Internet] Quebec: Institut national de santé publique. [cited 2005-12-30] Available from: http://www.inspq.qc.ca/domaines/IndividusCommunautes/SanteMentaleViolenceSuicide.asp?D=8&D8=1
79 Levesque, P. Private notes from attendance at the Canadian Council on Learning, Health and Learning Knowledge Network planning conference, June 2005, Vancouver. ¶ 9:00 p.m. 0 comments
