The challenges of measuring mental health and wellbeing impact

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The challenges of measuring mental health and
well-being impact

• Lynne Friedli
• Community Health Exchange
• Know it works? Show it works!
• Thursday 4th October 2007
• Glasgow

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Harry Venning Clare in the Community Guardian
Society April 2007
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Positive thinking?
Being happy is more adaptive in certain
situations than in others ... ... Some times may
require a level of misery, dissatisfaction or
discontent (Sonja Lyubomirsky et al 2005)
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Summary

• What is mental health impact?
• Key domains what does mental health influence?
• Key pathways what influences mental health?
• Using scales WEMWBS and others
• Measuring mh impact an example

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Making the links....

• We think because we understand one,
• we also understand two
• because one and one is two
• But it is also necessary to understand and

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Two factor model of mental health
Minimal Mental health problems
languishing
Person with no diagnosable mental health problem
who does not feel good about themselves
Person with no diagnosable mental health problem
with subjective well-being and functioning well
Minimal positive mental health
Maximal positive mental health
Person with diagnosable mental health problem
with subjective well-being and functioning well
Person diagnosable mental health problem who does
not feel good about themselves
flourishing
Maximal Mental health problems
Adapted from Tudor 1996 Keyes 2002
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Spectrum of mental health
(After Keyes 2006)
Appropriate services
mental illness
inclusion
languishing self harm/neglect
quality of life

moderate mental health
lifestyle and skills crisis support wider
determinants
lifestyle and skills wider determinants
flourishing
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Mental health cycles of impact
Its all in the mind, but its written on the
body.
genetic inheritance childhood adversity poverty so
cial exclusion inequality
mental health how we think and feel
behaviour relationships parenting education
employment physical health quality of life
crime
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Assessing (mental) health impact

• Possible pathways

intervention
Economic capital
Human capital
Identity capital
Social capital
Environmental capital
Mental health and well-being
Adapted from research from the Centre for
Research on the Wider Benefits of Learning
(http//www.learningbenefits.net/)
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Strengthening known protective factors

• Psycho-social, life and coping skills e.g.
  self-expression, self-esteem, learning new
  skills, stress or anger management and
  relaxation, agency
• Social support as a buffer against adverse life
  events e.g. building social contacts, self-help
  groups, drop in, home visits, mentoring, time
  banks, volunteering
• Access to resources and services which protect
  mental health e.g. benefit uptake, supported
  employment, access to mainstream services

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Protective factors in different domains?

• feelings confident, understood, respected,
  empowered, safe
• skills life skills, relaxation, help seeking,
  keeping fit, accessing information
• meaningful activity employment, volunteering,
  education, leisure, creativity, spiritual growth
• social support self-help groups, opportunities
  for friendship, faith communities
• access to resources paid work, adequate welfare
  benefits, appropriate services
• influence opportunities to participate, being
  consulted, shared decision making, advocacy,
  complaints procedures

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Equity impact what demonstrates that living in a
community promotes mental health?

• Access to resources who doesnt have a fair
  share?
• Feeling safe who doesnt feel safe?
• Good place to live who doesnt agree?
• Influence local decisions who doesnt have a
  say?
• Feeling supported who is isolated?
• Hopeful about the future who isnt hopeful?
• Feeling valued who isnt valued?
• Feeling respected who isnt respected?
• Being involved who isnt involved and why?
• Knowing where to get help who doesnt know?
• (from Krasner Copeland 2004)

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Using risk and protective factors

• Problem Elderly residents on a local housing
  estate are isolated high levels of anxiety and
  depression among people over 70.
• Risk factor Isolation
• Protective factor Social support
• Intervention Transport scheme luncheon club.
• Rationale To promote social support by
  addressing barriers which prevent older people
  socialising. Social support is a known protective
  factor for depression.
• Impact Numbers of elderly people successfully
  using the scheme and positively evaluating the
  luncheon club.
• Intermediate outcomes Reduction in elderly
  residents who have not left house in the past
  month increase in numbers who say they have
  friends in neighbourhood.
• Long-term outcome Reduction in prevalence of
  depression among elderly people.

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Scotlands National Mental Health and Wellbeing
Indicators
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Positive steps strength of the evidence

• keeping physically active - good
• eating well - promising
• drinking in moderation - mixed
• valuing yourself and others - good
• talking about your feelings - limited
• keeping in touch with friends and loved ones -
  good
• caring for others - negative
• getting involved and making a contribution -
  mixed
• learning new skills - good
• doing something creative promising/good
• taking a break limited/moderate
• asking for help - limited

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Scotlands National Mental Health and Wellbeing
Indicators

• Elements of positive mental health
• positive affect
• life satisfaction
• self-acceptance
• positive relations with others
• environmental mastery
• autonomy
• purpose in life
• personal growth
• http//www.phis.org.uk/info/mental.asp?pbg

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(No Transcript)
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Other examples

• Perceived social support e.g. I can count on
  friends when things go wrong someone to do
  things with
• Sense of coherence e.g. life has no meaning life
  is unmanageable
• Ways of coping e.g. confronting, distancing,
  seeking support, problem solving, avoidance
• Self Esteem e.g. Im no good respect myself, Im
  a failure as good as other people

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subjective
Quality of life surveys, Self esteem/happiness
measures
Personal accounts, stories, observation
quantitative
qualitative
Indices of multiple deprivation, life expectancy,
crime rates, mental illness prevalence
Photographic images, Documents, maps
objective
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Does mental health vary by place?
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What does being in the lowest quartile for mental
health mean?

• Higher risk of long term low mood
• 85 report being sad or depressed for most of the
  last year versus 25 (other quartiles)
• Higher chance of being on medication for
  depression
• 30 versus 6 (other quartiles)
• Consequences of low positive mental health
• 2x? risk of days off in last 30 days, 3x ?
  catching a cold 4x ? risk of high blood pressure
• (Guite et al 2006 Clark et al 2006 Evans 2003)

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Environment

• Control over internal environment
• Design and maintenance
• Noise
• Density and escape
• Fear of crime and harassment
• Social participation
• (Hilary Guite, Greenwich PCT)

• Damp
• Liking the look of the place
• Street level incivilities
• Noisy neighbours
• Feeling overcrowded in the home
• Access to green spaces
• (Transport and movement)
• Afraid to go out day/night
• Syringes left lying around
• Places to stop and chat
• Events to get people together

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Social Capital indicators

• Participation - Have you been involved in any
  local organisation over the past 3 years?
  (Yes/No)
• Control - By working together, people in my area
  can influence decisions that affect the local
  area? (Agree/Disagree Scale)
• Social Networks - How many people did you talk to
  yesterday?

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Before and after establishing a base line

• Knowledge e.g. how to relax, where to get help
• Attitudes e.g. depression is a sign of weakness
• Behaviour e.g. alcohol, exercise, diet, smoking
• Health status e.g. GHQ, SF36
• Socio-economic circumstances e.g. level of
  benefits, networks, employment, debt
• Access to/use of services e.g. primary care,
  voluntary sector, counselling, complementary
  therapies/self help

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Are the conclusions robust?

• How well does analysis explain why people behave
  as they do?
• Would participants in the study understand your
  conclusions?
• How well does the explanation fit with what we
  already know?
• Are the results transferable?

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London Strategy

• how well we live our lives
• physically, and emotionally, how good our close
  relationships are and the extent to which our
  lives have meaning
• how well we connect with each other at a
  community level
• social support, respect, perceptions of crime
  and sense of community
• how well we learn and work
• enjoyment of work and learning, meaningful days
  and financial security
• how much we feel we can make a difference
• participating, volunteering, involved in
  decision making

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MWIA indicators..
So many roads, so much at stake So many dead
ends, Im at the edge of the lake Sometimes I
wonder what its gonna take To find
dignity (Bob Dylan)

• Enhance control
• Build resilience/assets
• Facilitate participation
• Promote social inclusion
• http//www.northwest.csip.org.uk/mwia

Individual/lifestyle Community/social Socio-econom
ic/ environmental
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BT Case study

• Which of the following modules did you look at?
•  
• Keep active 31
• Eat well and drink sensibly 31
• Relax 34
• Keep in touch with friends 19
• Talk about it 27
• Maintain close relationships 22
• Ask for help 24
• Accept who you are 23
• All of the above 70

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BT Case Study

• Which of the positive steps were most and least
  helpful for you
• Most helpful Least helpful
• Keep active 75 25
• Eat well and drink sensibly 66 34
• Relax 81 19
• Keep in touch with friends 70 30
• Talk about it 71 29
• Maintain close relationships 73 27
• Ask for help 65 35
• Accept who you are 79 21

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Email Survey of BT employees

• 374 responses 48 (181) had accessed materials
• Male 65
• Female 35
•  
• Age
• 18 -25 2
• 26 -35 10
• 36 -45 39
• 46 -55 42
• 56 7

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Email Survey of BT employees

• 374 responses 48 (181) had accessed materials
• 56 tried some of the positive steps and
  continued to practice them
• 34 tried but didnt continue
• 10 either couldnt or didnt want to try any of
  the steps
•  
• For those who did make changes
• 51 noticed some positive changes to their mental
  well-being
• 17 noticed an initial benefit which then faded
• 31 noticed no change

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BT Case Study

• If you DID NOT make any changes to your
  behaviour, can you tell us why?
• I didnt believe the positive steps would have
• any impact on my mental well being 12
•  
• The steps suggested were not relevant to me 41
•  
• I like the idea of positive steps but I am unable
  to
• practise them myself 47

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Greater Glasgow and Clyde Well-being Survey 2007

• Happiness/GHQ12/Subjective Well-being
• All low SES indicators associated with
• High GHQ scores
• Lower happiness ratings
• More negative subjective well-being

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This being human is a guest house.Every morning
a new arrival.A joy, a depression, a
meanness,Some momentary awareness comesAs an
unexpected visitor.Welcome and entertain them
all.Even if theyre a crowd of sorrows,Who
violently sweep your houseEmpty of its
furniture.Still treat each guest honourably.He
may be clearing you out for some new delight.The
dark thought, the shame, the malice,Meet them at
the door laughing,And invite them
in. (Jelaluddin Rumi, 1207-73)
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Reviews of Well-being Scales

• Mauthner N and Platt S (1998) Selective
  literature review of measures of mental health
  and emotional wellbeing Edinburgh University of
  Edinburgh
• NHS Health Scotland (forthcoming) Practitioner
  guide to using scales

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Select bibliography
Clark C, Myron R, Stansfeld SA and Candy B
(2007) A systematic review on the effect of the
built and physical environment on mental health
Journal of Public Mental Health 6.2 Friedli L,
Oliver C, Tidyman M, Ward G (2007) Positive steps
for mental health a review Edinburgh NHS Health
Scotland Greenhalgh T and Taylor R (1997) How to
read a paper papers that go beyond numbers
(qualitative research) British Medical Journal
Spencer L, Ritchie J, Lewis J and Dillon L
(2003) Quality in Qualitative Evaluation A
framework for assessing research evidence London
National Centre for Social Research/Cabinet
Office http//www.strategy.gov.uk/downloads/su/qua
l/downloads/qqe_rep.pdf