The Roles of Public Health in Population Mental Health and Wellness Promotion
This report represents a guidance document on the roles of public health in population mental health and wellness promotion (PMHWP) across Canada. In the context of the current COVID-19 pandemic, which has brought mental health to the forefront of countries’ responses to the pandemic, building the workforce and organizational capacity in public health for PMHWP is even more relevant now than ever before.
This document was developed by the National Collaborating Centre for Healthy Public Policy (NCCHPP), and builds on conversations which occurred at a Forum on Population Mental Health and Wellness Promotion (the Forum), in February-March of 2018. The Forum was organized by the six National Collaborating Centres for Public Health (NCCs), in collaboration with four partner organizations: the Canadian Mental Health Association (CMHA), the Centre for Addiction and Mental Health (CAMH), the Mental Health Commission of Canada (MHCC), and the Public Health Agency of Canada (PHAC). The event was based on a two-eyed seeing inspired process meant to support the value of considering the intersection of population mental health promotion and mental wellness promotion (the preferred formulation identified by Indigenous partners). It was designed to create opportunities to learn from experts to inform the work in population mental health and wellness promotion in Canada.
The Forum asked two essential questions of participants, the responses to which form the empirical basis of this guidance document:
- From the perspective of your own practice setting, geographical context, and/or experience and expertise, what do you think are the key roles, functions, or specific actions public health actors at various levels must play or must implement in order to integrate and mainstream PMHWP work into their practices?
- What is needed to support public health for PMHWP work in terms of four topics: 1. skills, knowledge, and values; 2. systems-policy supports; 3. implementation structures; 4. science and research paradigms?
Qualitative analysis software (NVivo) was used to help analyze and classify the elements of conversations collected on flipcharts during the event. Seven competency documents were used to support the analysis of the empirical material which was coded using both open- and close-ended procedures.
Certain particularities of PMHWP were also voiced during conversations amongst experts at the Forum, and were supported by an overview of the literature also provided in this report. These particularities shaped how roles were framed and described.
First, exchanges highlighted many similarities between population mental health promotion and mental wellness promotion. Population mental health promotion and mental wellness promotion have in common certain processes, values and approaches. Both require understanding, considering or addressing, in partnership with various stakeholders, complex historical, cultural, social, economic, political, geographical, biological, spiritual, genetic, and environmental factors. Both rely on interacting components operating through a socioecological approach. They also rely on community-based and led initiatives, long-term partnerships which build on trust, engaging and capacity-building processes, and competence enhancement approaches.
The complex nature of both perspectives was expressed. This complexity requires understanding and addressing individuals and communities through holistic, multifactorial, non-fragmented and empowering interventions. It involves pluralistic systems of knowledge, respect for cultural meanings, intersectoral collaborations, cross-jurisdictional scope, and multi-level, multi-component and participatory programming. To produce and apply knowledge relevant to such interventions, both Forum participants and the literature emphasize the importance of a multiplicity of voices, of the role of communities and of people delivering interventions, and of recognizing the ongoing interactions between contexts, interventions, and mechanisms for studying these. A systems approach to implementation and research, implementation science and research, as well as community-based participatory research, were viewed and emphasized by participants as a path forward.
The incorporation of such perspectives in mainstream public health approaches is a first step in bringing mainstream interventions closer to Indigenous considerations of wellness and adopting and incorporating a PMHWP perspective.
Although similarities were identified between population mental health promotion and mental wellness promotion, the importance of also learning from Indigenous perspectives on mental wellness, for the benefit of all populations, was also strongly voiced.
The First Nations Mental Wellness Continuum Framework offers a comprehensive understanding of wellness (Health Canada & Assembly of First Nations, 2015). It suggests that mental wellness is shaped through “a balance of the mental, physical, spiritual, and emotional” aspects of life which everyone, even the more vulnerable can aspire to achieve. It suggests mental wellness is made possible when people have purpose, hope, a sense of belonging and connectedness and a sense of meaning. This perspective, which highlights balance and harmony, is considered not only foundational for Canada’s Indigenous people, but also beneficial for the wider population (Short, 2016). Hope, belonging, meaning and purpose were identified during the Forum as a useful guiding orientation for all future PMHWP work in Canada.
Integrating Indigenous and Western knowledge systems in practice and research has been deemed critical to effecting change within the Canadian system and moving forward together in reconciliation, in accordance with the Truth and Reconciliation Commission’s Calls to Action (Rogers et al., 2019).
Building on the analysis of conversations, five broad public health roles or competencies for PMHWP were identified. These are:
Partner and bridge for PMHWP: PMHWP requires the establishment of meaningful and respectful partnerships with stakeholders from the entire broad workforce involved in PMHWP (various policy sectors; the health and mental health and substance use sectors; Indigenous partners and communities; non-Indigenous communities, civil society and target populations; other public health actors and research actors). Working in collaboration, through participatory and empowering approaches, is at the core of PMHWP. Sharing practice-based evidence and expertise amongst public health actors; as well as continuously sharing and developing knowledge about implementation practices with researchers is also central to PMHWP. Time is a crucial factor in any partnership, and in particular in building respectful and trusting relationships with communities.
Exchange knowledge for PMHWP: PMHWP requires continuously exchanging knowledge with partners. This role implies two-way communication and a bridging function, as public health actors continuously exchange evidence about population mental health with their partners; they learn from the expertise of their various partners, and they exchange and bridge emerging knowledge about their practices.
Collectively integrate and embed PMHWP into public health practices: This role focuses on how activities, from assessment, to planning, to implementing, to evaluation, which are recognized public health practices, can be thought out and implemented while integrating a PMHWP perspective and content. Adding a PMHWP lens in public health practice was discussed as a process of integration, since it is not viewed as “entirely new work.”
Enable change for PMHWP: Enabling change is a process role which emerged as central and linked to all roles involved in PMHWP. PMHWP implies ways of engaging with others which look beyond mental health or wellness outcomes alone. Such ways of engaging with others aim at building capacity, and at enabling and empowering others to act in favour of their mental health and wellness. All roles and activities surrounding PMHWP call for such enabling capacities.
Co-lead and advocate for PMHWP: PMHWP requires strong leadership and advocacy. Public health leaders wishing to advance PMHWP co-lead with their partners: Indigenous and non-Indigenous communities, professionals from various sectors, or institutions. Co-leading implies the need to partner and to continuously exchange knowledge with all relevant partners and communities. As public health actors co-lead and advocate, they essentially work in collaboration to raise awareness of and support for a shared vision and strategic direction for PMHWP; they support action towards PMHWP; and they establish links with equity work. They also work towards forging structures, processes, science, research, and a workforce which can support the needed shifts (in perspectives, meanings and approaches) for PMHWP.
This document provides a guiding orientation to support the work of public health in PMHWP. It is not the outcome of a research project or process. It can support professional development in PMHWP and, in time, eventually serve as a basis for the concretization of a formal competency framework for PMHWP. It is primarily intended for public health professionals who participate in framing both organizational and professional development (which includes public health practitioners in various levels of practice, but also in academia). It aims at supporting upstream interventions to promote mental health and wellness. It does not cover the whole continuum of interventions considered within a population mental health perspective, which could include prevention of mental illness, early identification, and treatment or recovery activities. It recognizes the important needs of those who suffer from severe mental illness or those who have common mental health problems with co-occurring substance use disorders. Although these groups will be reached and supported by PMHWP interventions, they often need specific interventions beyond those that are commonly part of PMHWP approaches.
There is presently a much-needed call to integrate a population approach to mental health and wellness within general health action and to invest in building the workforce and organizational capacity. This guidance document is one contributing step in that direction. It broadly upholds a perspective that advocates the mainstreaming into the public health field of a health promotion perspective, of a population mental health promotion approach, and of Indigenous knowledge and processes regarding mental wellness to favour population mental health and wellness. It identifies the importance of strengthening and forging structures, processes, research, science and a strong workforce to facilitate the adoption of the five roles identified in this report and advance the work of PMHWP. It emphasizes collaboration, participation, capacity building, and co-production at all levels and through all implementation and research activity surrounding PMHWP. It highlights the use of formal spaces of exchange to share knowledge, learn, and act as an ally to Indigenous, community, sectoral, health and mental health partners; i.e., participants from the entire broad workforce involved in PMHWP. Hope, belonging, meaning, and purpose have been suggested as key notions for orienting PMHWP work in Canada. In this particularly challenging time of the COVID-19 pandemic impacting mental health outcomes and exacerbating mental health inequities, collaboratively operationalizing these perspectives and documenting their implementation is not only timely but necessary