Submission to Mental Health and Addiction Inquiry June ALL RIGHT? Campaign

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Winfred Green
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1 Submission to Mental Health and Addiction Inquiry June 2018 ALL RIGHT? Campaign This submission is related to and in support of, submissions by the Mental Health Foundation of New Zealand. It is written as an example of advanced mental health promotion practice at a population-scale, focused on the promotion of mental wellbeing in the general population. As such, it is conceived as a part of an ecology of mental health practice and services in Aotearoa and has lessons to share regarding the successful implementation of positive mental health initiatives. What's working well? All Right? is a health promotion campaign, established in 2013 as a response to the impacts of the greater Christchurch earthquakes 1 on the wellbeing of Cantabrians. The campaign is a joint project between Community and Public Health, the public health unit of the Canterbury District Health Board and the Mental. It builds on existing mental health promotion expertise and efforts by both organisations and is utilising the latest theories and evidence on improving mental wellbeing. It is to date, the most sophisticated and wellresourced post-disaster, population wellbeing campaign anywhere in the world. The greater Christchurch Psychosocial Committee mandated the development of the campaign following the release of the briefing paper from the Prime Minister s Chief Science Advisor on the likely psychosocial effects of the earthquakes in Canterbury and how these could be mitigated. All Right? represents a major leap forward in terms of the practice and theory of promoting mental health in Aotearoa. The body of evaluation evidence it has generated (both process and impact) as well as practice experience gathered by the practitioners, points towards what is possible if strengths-based, population-focused mental health promotion is adequately funded and resourced. There has never been such a well-resourced, concentrated programme of work to specifically promote mental wellbeing, produced in Aotearoa New Zealand. There has been international interest in the successful scaling up of positive psychological theory into a population-based campaign. Based on this experience, evaluation and research, the key elements to the success of All Right? have been identified as the following. 1. Adequate funding to enable the following 2 : 1 In 2010 and 2011, the Canterbury earthquake sequence caused substantial destruction in the greater Christchurch region of New Zealand s South Island. One hundred and eighty-five people were killed in the most destructive earthquake, a 6.3M in February 2011, which destroyed much of the South Island s largest city, Christchurch. Since September 2010, the region has experienced over 13,000 aftershocks, with over 60 registering more than 5M. 2 All Right? receives $1 million per year from Ministry of Health (plus in-kind support from CDHB) to work with a population base of 420,000. This represents a cost per person, per year of $2.38.

2 2. Multi-discipline operations team a) Public Health experts (Health Promotion, Analysis and Management) b) Design and Marketing experts (external agency) c) Market Research experts (external agency) d) PR, Communications, Social Media experts (external agency) 3. Market research to understand communities, language and needs as well as to test concepts and evaluate impact 4. Population-scale advertising in support of key messages 5. Innovative, eye-catching, interactive resources to activate key messages 6. Grassroots activation through relationship and community development facilitated by expert health promoters 7. Active, interactive social media community facilitated by media/communications experts with Public Health oversight 8. Development of stakeholder champions at multiple levels of the community It cannot be emphasised enough that the funding allocated to All Right? is a level of funding far above what most health promotion projects receive currently and yet still represents a tiny proportion of funding allocated to specialist services. All Right? is improving the positive mental health of the population using basic positive psychological interventions and communications working on emotional literacy and intelligence; empathy; character strengths and self-care. The health promotion and marketing strategies used, focus heavily on participation and interaction to achieve lived experience of wellbeing. At the heart of the campaign s theory of change is a psychosocial approach to mental health. Specifically, that promoting wellbeing acts as a natural adaptive buffer to coping with adversity. Wellbeing in basic terms means feeling good and functioning well. The campaign s tactics involve supporting people to have more awareness of, and control over what helps them feel good and function well. While we recognise that there are multiple determinants of wellbeing, which can be beyond individual control, we have utilised evidence-based messages such as Five Ways to Wellbeing to grow and enhance self-efficacy. All Right? is achieving real success and results in the community that, due to adequate funding, can be measured robustly. Awareness of the All Right? campaign continues to build. As at June 2017: o Four fifths of people in Christchurch aged 15 and over are aware of All Right? (81%). This far exceeds expectations of most social marketing campaigns. o 87% believe All Right? messages are valuable for the Christchurch community o 71% believe the campaign has made them more aware of looking after their own mental wellbeing

3 All Right? messages are resulting in behaviour change. As at June 2017: o Two fifths (41%) have acted and done activities or things as a result of what they have seen or heard. Behaviour change is greatest amongst those who have seen more messages. Full peer-reviewed evaluation reports as well as summary documents of the population research commissioned by All Right? are available for download from All Right? has become a powerful champion for wellbeing in Canterbury, helping normalise conversations around both mental wellbeing and distress. Developing trust has taken time and come from working alongside and listening to the local community as well as involving the community voice in the campaign itself. The following is an example of the potential to reach and influence far greater numbers in the population than healthcare services can be expected to. One element of the campaign is the skilful use of social media (note: health promotion expertise collaborating with communications experts) to develop interaction with the key messages and marketing campaigns. Currently All Right? has over 13,000 followers and an active, contributing online community. Following a major aftershock on 14th February 2016, All Right? made a post on Facebook with reassurance and advice on how to reset to calm and enable sleep (a major problem for many following aftershocks). The post was typical of All Right? responses following other aftershocks and unsettling events during the recovery. Having built a significant community on Facebook, All Right? is seen as a trusted source of information and reassurance. This one post was liked by almost 2,000 people and shared more than 500 times and received 172 comments. The reach of the post was over 88,500. Compare this to the cost of trained counsellors, psychiatrists or other health professionals to reach anywhere near this number to provide this basic support. Increased psychosocial skills as well as a better night s sleep equals more resilience and less impact as a result of adverse events. The comments threads for these posts often become a forum of support and communication for members of the community, thereby activating the inherent coping and support mechanisms for those members of the population. This type of community-level health promotion can help reduce the need for expensive clinical intervention. The more often this community participation and self-efficacy can occur the less likely the build-up of distress that can lead to illness and further demand on specialist mental health services. This approach is entirely consistent with the recommendations by Prime Minister s Chief Science Advisor Professor Sir Peter Gluckman in his briefing paper on the likely psychosocial consequences of the earthquakes in Canterbury and later enshrined in the Framework for Psychosocial Support in Emergencies handbook published by Ministry of Health However, it is also entirely appropriate to promoting mental health beyond the circumstances of a disaster or emergency.

4 All Right? is far more than social media however. The successful engagement through media such as Facebook, comes on the back of a widespread presence in the community and a trusted relationship built up by years of campaigning, research and community connection. As the campaign has evolved, it has developed bespoke approaches, messages and ways of engaging with different communities within the population of greater Christchurch. A specific campaign for Māori called Te Waioratanga takes a culture as cure approach, highlighting and strengthening appreciation of cultural values and practices and predominantly speaks to whānau rather than individuals. Work with Pasifika communities takes a similar approach and has mostly been focussed on grass-roots engagement through events, fono and talanoa - an emphasis on faceto-face work supported by physical resources aimed at the family home. Recent research by All Right? has shown the focus on positive mental health for all, has also been a welcome and effective approach for tangata whaiora - those with lived experience of mental illness and distress. This research suggests that while awareness within the tangata whaiora community is comparable to that within the general community in greater Christchurch, the rate of acting on campaign messages is significantly higher for tangata whaiora (68% vs 41%). Furthermore, more than two thirds of respondents (72%) felt that All Right? had helped to reduce stigma around mental illness 3. While the All Right? campaign has had considerable successes to date working with the general population and specific communities within it. It is recognised that to achieve lasting, generational change in promoting mental wellbeing, we need to focus on what and how we are teaching our youngest citizens and what skills we are equipping them with in order to flourish. All Right? works closely with the Canterbury DHB School-Based Mental Health and Health Promoting Schools teams to support the wellbeing and psychosocial needs of young Cantabrians. As part of this work we have created the Sparklers wellbeing toolkit. Developed over two years in consultation and collaboration with experts from the School-Based Mental Health Team, teachers and the mental health promotion expertise of the All Right? team - Sparklers is a free wellbeing toolkit that consists of over 40 evidence backed activities teachers can use in the classroom, and information for parents, that help teach tamariki the skills they need to be happy, well and cope with life s challenges. Sparklers is available for use by educational professionals right across New Zealand. An evaluation of Sparklers will be released mid Preliminary findings clearly demonstrate the impact Sparklers is having: 3 Evaluation of the All Right? campaign for tangata whaiora / mental health service users. May 2018 Community & Public Health, CDHB.

5 a. A principal interviewed stated that the activities were easy to do, helped build a positive culture in their classrooms, and made a positive difference: i. It was really easy. I just flicked out the site to my staff. All the resources are there, there are teacher notes, clips, videos and whatever you need and a variety of activities. That really appealed to me. Principal ii. It s a fantastic resource and probably the only thing I would say is it just needs to be publicised more. Getting the word out is important I think. And why wouldn t you? It s something that kids are going to get use from. Principal iii. If the kids aren t ready to learn, or they don t feel safe, or they feel they don t belong, or you know they can t. they re disengaged we need to focus on wellbeing and I truly believe achievement will take off. It will come if we can set the scene, the culture Principal b. Educators at one school reported that having a Sparklers activity after morning tea and lunch times encouraged students to come back to the classroom quickly in order to enjoy a Sparklers activity an activity that would support them in calming down. i. It s got to the point where the children come in and they just know. They sit and they just relax. Which is great. That s been really beneficial. Teacher ii. We saw some really positive changes. There were a lot of different things happening so what I couldn t say is that Sparklers alone resulted in all these positive changes but it absolutely contributed to, one of the things what we don t have at all and what we haven t had all of Term 4 is kids not coming back to class and that was really bad in Term 1. Principal Sparklers can play an even greater role in building positive mental health and growing resilience amongst New Zealand youth. What's not working well? Nearly all government funding for mental health is focused on supporting people with mental illness.

6 Most high-profile, social marketing about mental health nationally, has focused on specific health issues such as depression and/or on help-seeking related to health issues. There is little to no public discourse on understanding and growing positive mental health. While providing top quality specialist mental health services is crucial, there is a lack of investment in strengths-based approaches that help build resilience and improve mental health for all. Raising emotional literacy and wellbeing can bring people s natural coping mechanisms to the fore, improve quality of life, raise awareness to issues early and reduce the need for servicelevel care. To most people, health services relate to treatment of illness, injury or disease. The vast majority of Government investment in health goes towards these kinds of services. Health Promotion in general is under-funded almost to the point of being essentially ineffectual in achieving social change at scale. Mental health promotion occurs in isolated pockets and usually is not identified as such. Other investment in social, cultural, environmental determinants of health are often not even recognised as being of benefit to health, coming as they do from other ministries such as Social Development, Education or at a local government level through city and district councils. Improving the health and wellbeing of the population takes a cross-sector, whole-of-community approach and is not just the responsibility of healthcare services. Investing more in strengthsbased approaches can relieve the current strain on mental health services in Canterbury and throughout the country. Despite the ability to impact a far greater proportion of the population, mental health promotion has been critically ignored and under-resourced in New Zealand, leading to a widespread lack of awareness and literacy in psychological wellbeing. What could be done better? One of the best ways to prevent people from suffering common mental health problems in the first place is by equipping them with the knowledge and skills to be in charge of their own wellbeing. High levels of wellbeing act as an adaptive buffer to distress as well as equipping people to enjoy a better life overall. Preventative approaches at the population level have the additional advantage of being much more cost effective than individual level interventions. A cost benefit analysis of the Like Minds Like Mine initiative at the height of its investment and activity, calculated a cost-benefit analysis of $13.80 return for every dollar spent 4. 4 Vaithianathan, R. (2010). Cost Benefit Analysis of the New Zealand National Mental Health Destigmatisation Programme. Auckland: UniServices.

7 Improving resourcing of and access to free counselling, and a variety of brief interventions at primary care/gp level in order to increase tools at their disposal and top up their coping resources. Mental health counselling is, on the evidence, the single most cost-effective intervention for reducing suffering and raising well-being in the population 5. However, this will not be as effective as it might be without a population-based approach to reducing stigma, raising understanding, awareness and equipping people to take control of their own wellbeing. As discussed above, cross-sector, equitable approaches to promoting mental health universally (as distinct from specialist services for treatment/intervention for a small percentage of the population) need to be identified and resourced. All Right? is successfully supporting wellbeing in the places people live, work and play. As an example of best-practice, large-scale mental health promotion, All Right? can play an even greater role in building positive mental health and growing resilience at a population level. Investing in efforts to increase the resilience of individuals and communities is increasingly recognised as a critically important adaptive buffer, for things as diverse as coping with the impacts of climate change 6 to helping prevent youth suicide 7. As an established and successful proponent of supporting communities to improve their wellbeing, All Right? is uniquely placed to be part of nationwide discussions on how New Zealand can support communities to flourish and become more resilient. What sort of society would be best for the mental health of all of our people? New Zealand needs to change the perception of mental health so there s widespread acceptance that we all have mental health, and there are things we can do to improve it. It s about changing from a deficit understanding of mental health as merely mental illness or its absence, to one that embraces the full spectrum of human experience and promotes and celebrates wellbeing. A society that understands and supports models of health such as Te Whare Tapa Wha and recognises the value in self-reported, self-defined wellbeing. In such a society, people would talk openly about mental health, and encourage people to share their own stories for what makes them feel good and function well. Likewise, there would be no shame in experiencing distress or illness and the weight of stigma would be lifted from those already coping with the trials of a recovery journey. 5 World Happiness Policy Report (2018) 6 Synthesis: Community Vulnerability and Resilience to Climate Change in New Zealand December The New Zealand Climate Change Research Institute, Victoria University of Wellington 7 (Gluckman, P. (2017), Youth Suicide in New Zealand: a Discussion Paper, Office of the Prime Minister s Chief Science Advisor)

8 In such a society, flourishing and happiness would not be seen as trivial or fluffy but important prerequisites for thriving, indicators of success, and topics worthy of study, investment and effort. International evidence is also clear that a more equitable society is likely to be a happier and healthier one. The World Happiness Report (2018) has demonstrated that a country s ranking on happiness depends on six key conditions: economic prosperity, including decent work for all who want it; the physical and mental health of the citizens; freedom of individuals to make key life decisions; strong and vibrant social support networks (social capital); shared public values of generosity; and social trust, including confidence in the honesty of business and government. Emerging evidence supports the idea that the effects of such wellbeing-eroding experiences as unemployment have a far-reaching negative effect on the general population 8. Equitable and appropriate services that improve outcomes for the most compromised in our society are likely to yield wellbeing results for the whole population. Anything else you want to tell us? The All Right? team extend their aroha, respect, and tautoko to the members of this Mental Health Inquiry panel and supporting team. You are in the unique and demanding position of hearing and carrying the weight of so much expectation, pain and hope and we wish you all strength in the task given to you. It is a great thing you do for all Aotearoa and we are grateful. Ngā mihi. Contact Details We would welcome the opportunity to speak to the Inquiry panel when you are in Christchurch. Our contact details are: Sue Turner Manager Lucy D aeth Public Health Specialist Ciaran Fox Mental Health Promotion Strategist Clark, Fleche, Layard, Powdthavee, Ward - The Origins of Happiness: The Science of Well-Being over the Life Course. Princeton University Press (2018)

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