24 May 2011

Mental Health Impact Assessment: Advancing HIA practice in the US

Improving the consideration on mental health in health impact assessments has long been discussed as an area of practice that requires more attention. Dr Lynn Todman and Dr Eunha Kim from the Institute on Social Exclusion at the Adler School of Professional Psychology in Chicago have written a guest post on their work on Mental Health Impact Assessment (MHIA).

Historically, HIA practice, in the United States and globally, has been dominated by a focus on the impacts of public decisions on the social determinants of physical health outcomes such as cardiovascular, respiratory and infectious diseases; cancers; and HIV/AIDS. By comparison, the practice has not been as actively employed to assess the impact of public decisions on the social determinants of mental health.

This is despite well-established and documented evidence that social conditions have profound impacts on the incidence of such psychological disorders as anxiety, mood disorders (e.g., depression and bipolar), suicidality, substance (ab)use, and cognitive impairments. The relative de-emphasis of mental health in HIA practice is problematic for, at least, two reasons. The first and most obvious reason is that mental health is a critical element of overall health: “Mental health is an integral part of health; indeed, there is no health without mental health”. Second, mental health is an important mediator by which social conditions impact physical health: for instance, the emotional stress associated with poverty has documented relationships to the incidence of HIV/AIDS and cardiovascular disease. Therefore, minimizing or overlooking mental health considerations in HIA practice yields an incomplete understanding of the factors that shape health outcomes, and limits capacity for effective prevention and wellness promotion.

Supported in part by the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation, the Institute on Social Exclusion at the Adler School of Professional Psychology has set out to address the relative neglect of mental health considerations in HIA practice. By synthesizing literatures, frameworks and methods mined from disciplines outside of the field of psychology and psychiatry, we are developing a process – Mental Health Impact Assessment (MHIA) – that will yield more comprehensive, in-depth and systematic considerations of mental health in HIA. In doing so, we are building on the important and pioneering Mental Well-Being Assessment (MWIA) toolkit that was developed in the United Kingdom and used since 2005.

Our work will also advance HIA practice, as implemented in the US, by executing a more rigorous process, impact and outcome evaluation; and by shifting the analytic focus, especially as regards mental health, from” risk and illness” to “protection and wellness” consistent with emergent practice and discourse on population health.

The 18-month MHIA project began in January 2011 and will focus on a legislative proposal that will impact the Chicago community of Englewood which is largely populated by low income African Americans. And, while the community exhibits a number of important strengths that promote its collective mental health and well being, such as dense social networks that embody feelings of pride, rich forms of mutual support, and a commitment to community revitalization, it is also plagued by social conditions that compromise community mental health: crime and violence; underperforming schools; substandard housing stock; joblessness; limited public services; and few neighborhood amenities; as well as broader determinants such as exclusion, racism and classism.

Early challenges and key lessons learned
In executing the MHIA, an early challenge was how best to define community mental health and well-being. Initially, we equated community mental health to population (or collective) mental health only to find out that, in the US, where we are conducting our work, community mental health does not connote population mental health. Instead, it refers to the practice of mental health professionals physically going into the communities where their clients live to dispense individualized care. This way of conceptualizing community mental health is incompatible with HIA practice wherein the unit of analysis is population health. In HIA practice, the relevant unit of analysis is the collective; in mental health practice – including community-based care – as conceptualized and conducted in the U.S., the dominant unit of analysis is the individual. It is our assessment – and the first lesson learned – that the differences in the relevant unit of analysis in HIA practice (the population) and mental health practice (the individual) underlies the relative limited uptake of mental health considerations in HIA.

A second challenge, which stems from the unit of analysis dichotomy, is methodological: How is community or “collective” mental health best measured? What are the appropriate indicators? Our emerging response to this challenge has been to rely on two analytic approaches. One approach involves the aggregation of community residents’ and other key stakeholders’ responses to instruments (e.g., questionnaires, interviews, surveys) informed by those that are traditionally used to assess psychological and emotional functioning, and wherein the unit of analysis is the individual. These will be combined with the results of other instruments designed to assess indicators of collective forms of psychological and emotional functioning (e.g., social capital, psychological sense of community). This analytic approach reflects yet another lesson learned: the importance of mining frameworks, measures, and indicators from disciplines outside of the field of mental health (e.g., political science, sociology, anthropology).

How You Can Get Involved
The Adler Institute on Social Exclusion is creating a Discussion Forum to facilitate exchanges of ideas, best practices, other resources and noteworthy events on the Social Determinants of Mental Health and Mental Health Impact Assessment. The Discussion Forum will help launch a global movement of public sector professionals, academics, communities, and other key stakeholders committed to addressing the social determinants of mental health.

For more information on the Discussion Forum, the MHIA or the Institute on Social Exclusion, please go to our website at www.adler.edu or contact us at ISE@adler.edu.

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