Determinants of mental wellness in pregnancy

For most of history, governmental priorities related to mental health were limited to the management of mental health illness, often for the benefit of society at the expense of the rights of the individual living with the illness. The Alberta Mental Health Act, established in 1990, is one such example of this type of legislative thinking.  Canadians are now experiencing a shift in thinking and priorities towards positive mental health, or mental wellness. In 2013, the Government of Canada allocated $6 million dollars to improve collaboration, data collection, and information sharing of positive mental health determinants and outcomes (1).  As part of this process, the Public Health Agency of Canada developed the Positive Mental Health Surveillance Indicator Framework. In today’s post I would like to explain how the socioeconomic model developed within this framework applies to the mental wellness of pregnant Calgarians. 

The framework was built to bridge the gap in describing and measuring positive mental health and its determinants in Canada (1). It is built on 4 foundational concepts, 3 of which I will explain in greater detail. The first concept is that positive mental health is about more than the absence or presence of illness. As described in the framework, The Public Health Agency of Canada defines mental health as

the capacity of each and all of us to feel, think, and act in ways that enhance our

ability to enjoy life and deal with the challenges we face. It is a positive sense of

emotional and spiritual well-being that respects the importance of culture, equity,

social justice, interconnections and personal dignity. (2)

Using this definition, the authors prioritized 5 outcomes to measure a state of positive mental health: self-rated mental health, happiness, life satisfaction, psychological well-being, and social well-being (1). The outcomes used to measure positive mental health in this framework allow for the possibility of individuals living with chronic mental illness to also experience positive mental health. Not only is this view necessary for legislative and funding changes, it is also an empowering statement for those living with a chronic mental illness. 

The second and third foundational concepts of the framework emphasize the importance of considering positive mental health determinants, otherwise referred to as risk factors and protective factors, and their interactions with each other (1). As depicted in Figure 1, the framework's 25 determinants of positive mental health are presented in a socioecological model that contains 4 nesting domains or levels.

Figure 1: Positive Mental Health Framework for Surveillance. Adapted from Orpana et al., (2017). Measuring positive mental health in Canada: construct validation of the Mental Health Continuum-Short Form. Health promotion and chronic disease prevention in Canada: research, policy and practice, 37(4), 123–130.

A contemporary definition of health, one in which social, economic, and environmental determinants influence the health of the individual, is clearly visualized in the Positive Mental Health Model. Determinants related to an individual's health status, health behaviours, life experiences, and skill set are included in the inner domain. Relationships, number of family members, health status of family members, and household income are all measurable family determinants that can influence the mental health of the individual. How families interact with their communities also influences the mental health of the individual. Community domain determinants include things such as the built environment, school and work setting, social supports and networks, and involvement in the community. The societal domain is where broad legislative, funding, and regulatory activities of governments and non-governmental organizations influence the mental health of communities, families, and individuals. Measurable determinants in this domain include the experience of inequities, stigma, or discrimination and the individual's participation in political topics.

Before applying the Positive Mental Health Model to pregnant Calgarians, it is important to note the limitations of its use to explain a multilevel perspective of health.  The primary purpose of this model is to identify indicators that can be used to capture data related to positive mental health in Canadians. The determinant list is not exhaustive, rather it has been reduced from an initial list of 77 to 25 that can be easily measured (1).  In addition, the model does not offer specific strategies to promote the positive determinants of health. There are other models that do include such strategies, such as the Population Health Promotion Model developed by Public Health Agency of Canada and the Population Mental Health Promotion Model proposed by the National Collaborating Center for Healthy Public Policy (NCCHPP). I chose to present the Positive Mental Health Model for two reasons. The first is that it focuses specifically on mental wellness. The second is that it describes mental wellness as achievable by all instead of looking at wellness and illness as two separate continuums. Orpana and colleagues believe the Positive Mental Health Model "has the potential to inform mental health promotion and mental illness prevention programs and policies at multiple levels” (1, p.9). I agree.

The four domains presented in the Positive Mental Health Model are a good way to organize the determinants of, and current health promotion strategies for, the mental wellness of pregnant Calgarians. Table 1 contains a sample of these determinants and strategies. The table does not provide a complete list of all health promotion strategies available. Rather, the purpose of this table is to demonstrate how multiple stakeholders are promoting mental wellness in pregnant Calgarians. With an estimated 25-47% of low-income and minority pregnant individuals experiencing mental health challenges, this health issue is an important one to address from a multilevel approach (3).

Click on the image of Table 1 to open a PDF with functional links.

The Positive Mental Health Surveillance Framework, although primarily intended to guide surveillance of positive mental health, can also be used to guide strategic planning and policy development related to mental wellness throughout Canada. Stakeholders at all socioecological levels have a role to play in promoting mental wellness. The city of Calgary is home to a number of initiatives that foster positive mental health in pregnant individuals, their families, and their communities. These initiatives are offered through local, provincial, and national partners.

References

1. Orpana, H., Vachon, J., Dykxhoorn, J., & Jayaraman, G. (2017). Measuring positive mental health in Canada: construct validation of the Mental Health Continuum-Short Form. Health promotion and chronic disease prevention in Canada: research, policy and practice, 37(4), 123–130. doi:10.24095/hpcdp.37.4.03

2.  Public Health Agency of Canada. (2014). Mental Health Promotion. Retrieved from https://www.canada.ca/en/public-health/services/health-promotion/mental-health/mental-health-promotion.html. 

3. Lenze, S. N., & Potts, M. A. (2017). Brief Interpersonal Psychotherapy for depression during pregnancy in a low-income population: A randomized controlled trial. Journal of affective disorders, 210, 151–157. doi:10.1016/j.jad.2016.12.029

4. National Collaborating Centre for Healthy Public Policy. (2014). Defining a Population Mental Health Framework for Public Health. Retrieved from http://www.ncchpp.ca/docs/2014_SanteMentale_EN.pdf

5. Mukherjee, S., Trepka, M.J., Pierre-Victor, D., Bahelah, R., &  Avent, T. (2016). Racial/Ethnic Disparities in Antenatal Depression in the United States: A Systematic Review. Maternal and Child Health Journal, 20(9), 1780-1797. doi: 10.1007/s10995-016-1989-x

6. Hodgkinson, S., Beers, L., Southammakosane, C., & Lewin, A. (2014). Addressing the mental health needs of pregnant and parenting adolescents. Pediatrics, 133(1), 114–122. doi:10.1542/peds.2013-0927

7. O’Connor E., Senger C.A., Henninger M.L., Coppola E., & Gaynes B.N. (2019).  Interventions to Prevent Perinatal Depression: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA, 321(6):588–601. doi: 10.1001/jama.2018.20865

8. Knight, L. (2018). Environmental Scan of Prenatal Services for Marginalized Women in Alberta. Retrieved from https://pdfs.semanticscholar.org/290f/c748f120224785f61a390b82b36772609c54.pdf

9. Balaam M.C., Akerjordet K., Lyberg A., Kaiser B., Schoening E., Fredriksen A.M., Ensel A., Gouni O., & Severinsson E. (2013). A qualitative review of migrant women's perceptions of their needs and experiences related to pregnancy and childbirth. Journal of Advanced Nursing, 69(9), 1919-1930. doi:10.1111/jan.12139

10. Ickovics, J. R., Reed, E., Magriples, U., Westdahl, C., Schindler Rising, S., & Kershaw, T. S. (2011). Effects of group prenatal care on psychosocial risk in pregnancy: results from a randomised controlled trial. Psychology & health, 26(2), 235–250. doi:10.1080/08870446.2011.531577