70 years on: do we understand prevention?
At the Mental Health Foundation we are all about prevention.
As a charity we focus on communities of people connected by certain characteristics they share. We do not deliver clinical services for people who are in distress. When one takes a 'macro' view like this, we don’t forget the individuals, rather we invest energy in understanding what makes people who belong in certain communities or walks of life more vulnerable to developing mental health problems than others.
For example, we know that 'determinants' (a factor which decisively affects the nature or outcome of something) like living in poverty, not receiving a full education, or belonging to a group that is 'marginalised' or discriminated against puts us at a higher risk of experiencing distress. And there has never been a more urgent time than now to focus on preventing this distress and subsequent problems.
However, when we talk about prevention we don’t follow the narrow sense of the term. We know that mental health problems affect millions of us, in our families, communities and workplaces. We all have mental health that will fluctuate in response to life events. It would be unwise to suggest that prevention is only for those who currently feel 'in good health'.
We define prevention in the 'public health' (the health of the population as a whole) sense of the term. Under this lens, there are three types of prevention.
1. Primary prevention: preventing problems before they emerge
Primary prevention focuses on stopping problems before they emerge. Primary prevention is relevant to all of us – often whole societies or nations – and, hence, solutions (or in our jargon: 'interventions') targeting primary prevention are called 'universal'.
Examples of universal solutions include a national anti-stigma campaign that makes sure we all follow the same standards when talking about mental health. Our universal work in the Foundation includes the Peer Education Project which delivers courses enhancing 'mental health literacy' (knowledge and beliefs about mental ill-health which aid their recognition, management or prevention) in schools for all the students in Year 7.
Universal solutions neither discriminate nor focus, rather their intention is to protect. We can all identify non-mental health related universal solutions already in our lives as they include things like banning smoking across whole buildings, and making it mandatory to wear seat belts in the car.
Often, a universal approach will aim to protect the most vulnerable members of a community in a non-stigmatising way, thus benefitting everyone. For example, mandating that all buildings have an accessible entrance means that people using wheelchairs can access a space, but this is also handy for those carrying a large suitcase or delivering a large package.
This can be extended to how we talk about health and illness. In mental health, ensuring that the language that we use is thoughtful and appropriate (e.g. on days when we struggle, saying 'I am feeling low' instead of 'I am so depressed') respects those who experience disabling symptoms while enabling an inclusive community. Mirroring this with our actions and legislations goes a step further to apply a protective 'filter'.
2. Secondary prevention: prevention for people exposed to inequality
Secondary prevention is the type of prevention that focuses on the people who share characteristics that place them at higher risk of developing a mental health problem. Thus, secondary prevention solutions (interventions) are often called 'targeted' or 'selective'.
Examples of targeted solutions include enabling support for those who are lonely or marginalised, giving access to higher quality education for young people who are excluded from schools, or ensuring quick access to support for those who have experienced trauma or have been victims of hate crime. This is a big area of focus for us at the Foundation, for example in our work with refugees.
A range of experiences or characteristics we are born with, place us at an increased risk of developing mental health problems. These in public health are called “inequalities” because they mean that certain groups of people face an unequal risk of becoming unwell. They can include being LGBT (as we know people might face a higher chance of being bullied) or having a physical health condition like diabetes (where we know that there is a 30% higher chance of developing a mental health problem like depression).
Tackling inequalities in our communities means that we need to look into all these social, economic, environmental and other factors and invest a higher amount of energy to engage people who might not immediately engage with universal approaches. Hence, these targeted solutions are often aimed at people who are experiencing some symptoms of distress, and they are about intervening when it matters most.
3. Tertiary prevention: goes at a deeper level
The third layer of prevention is called tertiary. This type of prevention has a lot to do with our quality of life when we have experienced a problem, and also with reducing the risk for recurrence. Solutions (interventions) in tertiary prevention focus on people who are already affected by mental health problems and are often called 'indicated' solutions.
Indicated solutions aim to reduce symptoms that can be disabling, limit complications of an illness, and empower people experiencing problems to manage their own symptoms as much as possible. Even though tertiary prevention works with people wo may have a diagnosis, it is seen as distinct from treatment, but complementary in that the goal is shared in reducing the severity of an illness and the risk of relapse. Indicated solutions are, more often than not, set in communities and not in clinical settings.
Some of our work at the Foundation which focuses on enhancing self-management (the taking of responsibility for one's own mental health support and well-being) is framed around the principles of tertiary prevention. Often the aim is to shift the focus of control from the clinician to the person who is using services in identifying what works best for them in their circumstances. For example, this year we are starting a new project working with Irish men in Camden & Islington. This is a community that is known to have mental health issues who don’t traditionally engage with clinical mental health services.
Making decisions with prevention in mind
The three types of prevention are not in competition or clashing in scope. Rather, to tackle an issue as common and widespread as mental health problems, we need whole society plans that invest in all layers of prevention. Working together at the level of national government, local authorities, and bigger or smaller third-sector organisations, we need to be focusing efforts on rolling out universal solutions that protect everyone, while enabling targeted and indicated solutions supporting those at risk or experiencing problems.
In public health, we call this holistic approach 'proportionate universalism'. This principle suggests that our actions should be universal (i.e. benefitting everyone), but with a scale that is proportionate to the level of disadvantage (i.e. more intensive for those experiencing higher risk or problems).
Tackling mental health problems as a society
The evidence is clear that although some of us are born with a higher genetic risk to develop a mental health problem, this is not deterministic. Even in the most “likely” cases (e.g. an identical twin whose sibling lives with a diagnosis of schizophrenia), the hereditary risk (characteristics or diseases passed from the genes of a parent to a child), seems to be less than 50%. Hence, we need to invest more in the relationship of these internal factors with the societal factors that shape our lives.
This is well understood in physical health, when talking, for example, about prevention of heart disease or lung cancer. However, globally, mental health still lags behind physical health in terms of spending and funding.
To address mental health problems we would need a concentrated effort as a society, tackling those persistent inequalities with prevention and early intervention. Let’s make a world with good mental health everyone’s business.
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