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Methodology Paper: Exploring Positive Mental Health

Canadian Population Health Initiative’s Improving the Health of Canadians

Report Series on Mental Health and Resilience

Improving the Health of Canadians 2009: Exploring Positive Mental Health

Methodology Papers Literature Search Data Analyses Policy Scanning

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LITERATURE SEARCH AND CRITICAL APPRAISAL METHODOLOGY The report for which this literature search and review was conducted (Improving the Health of Canadians: Exploring Positive Mental Health) is not a systematic review. It does not seek to present an exhaustive review of the literature. However, the literature search and review did use procedures designed to be both comprehensive and transparent. These procedures are outlined below. 1. IDENTIFICATION OF STUDIES A search protocol was developed to identify studies in the areas of positive mental health, resilience, well-being and mental health promotion. The protocol outlined the published journal literature databases to be searched, along with appropriate search terms, as well as web-based grey literature sources and specific items targeted for hand searching. Different search strategies were developed for each of the journal literature databases. Where possible, database searches were limited to studies published in English or French. The search strategy did not make any distinctions on the basis of publication type or research type/methodology. Search strategies were developed for each of the following journal databases:

• PsychINFO • PubMed/MESH Database • Public Affairs Information Services (PAIS) • Health Sciences: A SAGE Full-Text Collection • EconLit • Sociological Abstracts • Social Services Abstracts

The following web-based resources were searched for books, systematic reviews and grey literature:

• Amicus (Library and Archives Canada) • WHOLIS (World Health Organization library) • Evidence for Policy and Practice Information and Coordinating Centre (EPPI-Centre) • Statistics Canada (www.statcan.ca) • Public Health Agency of Canada/Health Canada • Canadian Best Practices Portal for Health Promotion and Chronic Disease Prevention • Interactive Domain Model: Best Practices for Health Promotion, Public Health and

Population Health • Public Health Portal of the European Union • Google • Cochrane Collaborative

The resource list constructed for an unpublished environmental scan of the mental health field commissioned by CPHI in 2006 was also reviewed for relevant sources.

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http://www.statcan.ca/


1.a. Search Strategies for Each Journal Database PsychINFO: Search 1: Mental Health (Positive) and Contributory Factors DE = (“emotional states” or “mental health” or “emotional stability” or “emotional security” or “psychological endurance” or “quality of life” or “life satisfaction” or “well being” or “emotional regulation” or “emotional maturity” or “self actualization” or “personality traits” or “emotional development” or “psychosocial development”) and DE = (“parental characteristics” or “family relations” or “social processes” or “built environment” or “learning environment” or “social environment” or “life experiences” or “social change” or “social issues” or “sociocultural factors” or “psychosocial factors” or “spirituality”) 3558 hits: peer-reviewed journals only, from 1998 to 2008, Journal Articles Only box was checked, language was English only and population was human (as opposed to animal, female or male)—run on September 27, 2007 Search 2: Mental Health (Positive) and Promotion/Prevention Terms DE = (“prosocial behavior” or “altruism” or “assistance social behavior” or “social support” or “charitable behavior” or “cooperation” or “sharing social behavior” or “trust social behavior” or “positive psychology” or “optimism” or “positivism” or “protective factors” or “prevention” or “primary mental health prevention” or “resilience psychological” or “prosocial behaviour” or “self monitoring personality” or “personality traits”) and DE = (“emotional states” or “mental health” or “emotional stability” or “emotional security” or “psychological endurance” or “quality of life” or “life satisfaction” or “well being” or “emotional regulation” or “emotional maturity” or “self actualization”) 3119 hits: peer-reviewed journals only, from 1998 to 2008, Journal Articles Only box was checked, language was English only, and population was human (as opposed to animal, female or male)—run on September 27, 2007 Search 3 Optional: Promotion/Prevention Terms and Contributory Factors DE = (“prosocial behavior” or “altruism” or “assistance social behavior” or “social support” or “charitable behavior” or “cooperation” or “sharing social behavior” or “trust social behavior” or “positive psychology” or “optimism” or “positivism” or “protective factors” or “prevention” or “primary mental health prevention” or “resilience psychological” or “prosocial behaviour” or “self monitoring personality” or “personality traits”) and DE = (“parental characteristics” or “family relations” or “social processes” or “built environment” or “learning environment” or “social environment” or “life experiences” or “social change” or “social issues” or “sociocultural factors” or “psychosocial factors” or “spirituality”) 2604 hits: peer-reviewed journals only, from 1998 to 2008, Journal Articles Only box was checked, language was English only, and population was human (as opposed to animal, female or male)—run on September 27, 2007

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PubMed/Mesh Database: Search 1: Contributory Factors/Health Promotion and Mental Health (General) (“family” [Mesh] or “peer group” [Mesh] or “community networks” [Mesh] or “schools” [Mesh] or “workplace” [Mesh] or “lifestyle” [Mesh] or “social environment” [Mesh] or “life style” [Mesh] or “early intervention (education)” [Mesh] or “health promotion” [Mesh]) and (“mental health” [Mesh] or “quality of life” [Mesh]) 5723 hits: last 10 years, ENG/FRE, journal articles, human—run on September 27, 2007 PAIS: Search 1: Mental Health (General) and Public Health KW = (“mental health” and “public health”) 36 hits: 1998 to 2008, journal articles only, English only, peer-reviewed journals—run on September 27, 2007 Search 2: Mental Health (General) and Contributory Factors KW = (“mental health” or “quality of life measurement”) and KW = (“family social aspects” or “Canada health conditions” or “socioeconomic status” or “social change”) 8 hits: 1998 to 2008, journal articles only, English only, peer-reviewed journals—run on September 27, 2007 Health Sciences—A SAGE Full-Text Collection: Search 1: Mental Health (General) and Contributory Factors KW = (“mental health” or “mental development”) and KW = (“learning” or “academic performance” or “cognitive development” or “social development” or “social skills” or “socio emotional abilities” or “family networks” or “social networks”) 57 hits: 1998 to 2008—run on September 27, 2007 Search 2: Mental Health and Public Health/Promotion KW = (“health promotion” or “public health” or “health sciences”) and KW=(“mental health” or “mental development”) 60 hits: 1998 to 2008—run on September 27, 2007

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EconLit Search: Search 1: Mental Health (General) DE = (“health” or “public health”) and (KW = “mental*” or KW = “well being” or KW = “quality of life” or KW = “emotion*”) 595 hits: 1998 to 2008, peer-reviewed journals—run on September 27, 2007 Sociological Abstracts: Search 1: Promotion Terms and Mental Health (Positive) DE = (“optimism” or “positivism” or “risk factors” or “prevention” or “resilience” or “health education”) and DE = (“mental health” or “quality of life” or “life satisfaction” or “well being” or “adjustment” or “coping” or “empowerment”) 139 hits: 1998 to 2008, peer-reviewed journals—run on September 27, 2007 Search 2: Mental Health (Positive) and Contributory Factors DE = (“optimism” or “mental health” or “psychological factors” or “quality of life” or “life satisfaction” or “well being” or “positivism”) and DE = (“psychosocial factors” or “family relations” or “built environment” or “social environment” or “sociocultural factors” or “social change” or “social conditions” or “social environment” or “sociocultural factors” or “parental influence” or “interpersonal relations” or “social cohesion” or “social evolution” or “social integration” or “socialization” or “social change” or “social structure” or “social institutions” or “social attitudes” or “social factors” or “social inequality” or “social integration” or “social support”) 597 hits: 1998 to 2008, peer-reviewed journals—run on September 27, 2007 Social Services Abstracts Search 1: Promotion Terms and Mental Health (Positive) DE = (“optimism” or “positivism” or “risk factors” or “prevention” or “resilience” or “health education”) and DE = (“mental health” or “quality of life” or “life satisfaction” or “well being” or “adjustment” or “coping” or “empowerment”) 247 hits: 1998 to 2008, peer-reviewed journals—run on September 27, 2007 Search 2: Mental Health (Positive) and Contributory Factors DE = (“optimism” or “mental health” or “psychological factors” or “quality of life” or “life satisfaction” or “well being” or “positivism”) and DE = (“psychosocial factors” or “family relations” or “built environment” or “social environment” or “sociocultural factors” or

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“social change” or “social conditions” or “social environment” or “sociocultural factors” or “parental influence” or “interpersonal relations” or “social cohesion” or “social evolution” or “social integration” or “socialization” or “social change” or “social structure” or “social institutions” or “social attitudes” or “social factors” or “social inequality” or “social integration” or “social support”) 367 hits: 1998 to 2008, peer-reviewed journals—run on September 27, 2007

Total Hits: 17,110 (Duplicates: 2,389) Total Final: 14,721

1.b. Web-Based Resources Search Strategies/Grey Literature Websites stated in the previously discussed list, such as the World Health Organization, Statistics Canada and the Public Health Agency of Canada were searched extensively by different staff to obtain relevant publications that may not have been picked up by other methods. This search focused on identifying items deemed (with a broad interpretation) to fall within the scope of positive mental health, resilience, well-being and mental health promotion. In the case of web-based search engines such as Amicus and Google, keywords relating to mental health promotion were used to find relevant information. Google search results were limited to the first 100 hits, which had a large amount of overlap with resources found through direct searching of relevant websites. Details include the following:

• Safesearch on, limited to English only, searched on January 8, 2008, 10 a.m. • Search terms: ~mental ~health ~promotion ~policy ~intervention ~program • Results 1 to 100 included of about 222,000 •

Total Resources Deemed Relevant: Approximately 250

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2. SCREENING AND CRITICAL APPRAISAL OF STUDIES A number of steps were undertaken to screen the records retrieved through the search strategy described in the previous section. These included the application of relevance criteria and critical appraisal criteria, and involved initial screening, title screening, abstract screening and critical appraisal stages. 2.a. Initial Screening Due to the large number of references included at this stage, additional pre-screening measures were taken to further reduce the evidence base for title scanning. The following criteria were applied, barring a few exceptions:

• Eliminate literature from 1998 to 1999 • Eliminate literature with a population base in a country typically not comparable to

Canada: o Russia, China, Taiwan, Singapore, Japan, Brazil, India, Mexico, Spain, Israel,

Hong Kong, Poland, Bosnia, Turkey, Caribbean, Czech, South Africa, Uganda • Eliminate specific health conditions:

o HIV/AIDS, cancer, diabetes, heart disease, asthma, respiratory, , stroke, organ donation, transplant, tuberculosis, influenza, tumour, artery, tobacco, epilepsy, surgery, surgical, autism, dental problems, Down syndrome, arthritis, obesity, smoking, SARS

• Eliminate additional terms: o Terrorism, 9/11, homelessness, crime, hurricane

Total After Initial Screening: 10,202 2.b. Title Screening Endnote was used to generate a report listing basic bibliographic data (for example, title, authors, journal) for approximately 10,200 articles. Two staff members independently reviewed the approximately 5,000 titles each, screening them on the basis of broad relevance criteria. The relevance criteria evolved as the review proceeded and as the reviewers compared their experiences and impressions of the literature. The criteria for inclusion, broadly speaking, were as follows:

• Literature that attempts to define “positive mental health” or uses positive mental health–related terminology such as optimism, resilience, hardiness, adaptability and emotional intelligence

• Literature that links “positive mental health” with other outcomes, for example, health, well-being, quality of life, interpersonal relationships and poverty

• Literature that involves potential determinants related to “mental health promotion or prevention” or “positive mental health” (that is, factors that contribute to positive mental health and protect against stress and hardship), including factors like:

• Individual factors—personal health practices, coping skills or protective traits (adaptability, optimism, hardiness, resilience)

• Integration/social inclusion/social cohesion

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• Healthy schools/child development • Healthy workplaces • Engagement and empowerment/social capital/social participation/sense of

belonging • Social services and supports/supportive communities (freedom from

discrimination and violence)/violence prevention • Community networks/community development/cultural identity/spirituality • Familial support/family functioning • Life events and situations (unemployment, housing)

Literature related to mental illness (for example, best practices in treatment of mental disorders or the effects of post-partum depression on spousal relations and mothering) were tentatively marked but discarded pre–abstract review. Literature concerning mental health problems or issues related to disability was also discarded. The lists of the two reviewers were based on a “yes, no, maybe” system. Titles marked as “yes” were included, titles marked as “no” were excluded and titles marked as “maybe” were discussed by both reviewers and where there was agreement, records were excluded. In instances where only one reviewer recommended exclusion, decisions to exclude or include were made following a brief discussion on a case-by-case basis. Total After Title Scan: 2,256 2.c. Abstract Review and Screening After the initial title screen, approximately 2,250 records remained in an Endnote file. A report was generated that included abstracts, in addition to basic bibliographic information. The same two staff members reviewed the list using a process broadly similar to that used for the title screen. The availability of the abstracts provided more information on which to make decisions about inclusion, but the criteria remained the same, with a few exceptions:

• Literature that involves enhancing “recovery” from stressful situations was deemed relevant and

• Literature related to “recovery” from mental illness and “quality of life” of those experiencing mental disorders was tentatively marked for possible future use but was not included in the final collection earmarked for critical review.

At this stage, preference was given to studies that had larger sample sizes, were generalizable, were Canadian, were longitudinal in nature, included a comparison group and focused on a range of age groups. However, it should be noted that given the general comparability of the United Kingdom, Australia, New Zealand, and the United States with Canada and the extensive work in the area of mental health promotion and prevention in these countries, all references using these countries as a study population were included. Total After Abstract Review: 823

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2.d. Critical Review and Appraisal As a result of the abstract review, the total number of records remaining in the database was reduced to approximately 800. Full-text versions of all of the remaining journal articles were ordered through the CIHI librarian. A one-page template was used by CPHI staff to complete an initial screening of articles (Appendix A). The initial screening was carried out in order to assess the following:

• The type of study/study design (RCT, survey, meta-analysis, etc.) and the research purpose or focus

• Location of study • Year of data collection • Sample size/sampling method/sample descriptors • Key dependent and independent variables used in study and analysis methods • Methods/instruments/measures • Main findings • Strengths/limitations/relevance to report

Based on this review, studies were sorted based on similar theme and context including enjoyment of life, coping with challenges, emotional well-being, spiritual well-being, social support and related factors, youth, adults, seniors and individual, family, school, workplace and societal/social contexts. Preference was given to studies that had larger sample sizes; were generalizable; were Canadian; were longitudinal in nature; included a comparison group; focused on a range of populations including children, youth, mid-life, adults or seniors; and used standardized data collection tools and analysis methods. Other studies were marked as less relevant. Literature not specifically on “positive mental health” variables was discarded (for example, research focusing on the reduction of depressive symptoms, or reduced substance and alcohol use, was not included). Relevant studies and resources identified from reference lists were also included at this point.

At the end of the appraisal process, a pool of approximately 275 references was found to be appropriate and suitable for use in the initial drafting of the report.

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APPENDIX A Design: __RCT/Quasi-experimental (for example, control group) __Non-experimental (for example, survey) __Qualitative (for example, interviews) __Lit Review/meta analysis __Other:_______________________

Location of study: Year of data collection: Sample

size: Sampling

Method:

Brief note on research question/ purpose of study:

dependent/outcome independent/factors Key variable(s):

Positive Mental Health as a Determinant or Outcome (circle one)

Sample descriptors: (including age and inclusion criteria)

Methods/Instruments/Measures: (for example, interview, Beck Depression Inventory)

Main Findings:

(list only 1 or 2 main conclusions)

Strengths/limitations: weak methods? small n? weak analysis? non-respondent bias?

Reviewer: Date:

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DATA METHODOLOGY Analyses in this report looked at positive mental health characteristics of the Canadian population. Preliminary analyses looked at three possible indicators of positive mental health from the Canadian Community Health Survey, cycle 3.1, 2005. However, a broader range of questions related to positive mental health used for the bulk of analyses in this report was sourced from the Canadian Community Health Survey, cycle 1.2 on Mental Health, 2002. Detailed descriptions of variables used, analyses conducted and limitations are outlined in this document, first for the CCHS 3.1 and then for the CCHS 1.2, followed by a discussion of limitations. Canadian Community Health Survey, Cycle 3.1 CPHI conducted analyses on the Canadian Community Health survey (CCHS), cycle 3.1, 2005. The population was made up of 132,947 respondents age 12 and over, representing roughly 98% of the Canadian population in all provinces and territories. The three questions of interest were as follows:

• Self-rated health: “By health we mean not only the absence of disease or injury but also physical, mental, and social well-being. In general would you say your health is: excellent, very good, good, fair, poor.”(p. 3) 1

• Self-rated mental health: “In general would you say your mental health is: excellent, very good, good, fair, poor?”(p. 4) 1

• Life Satisfaction: “How satisfied are you with your life in general? Very satisfied, satisfied, neither, dissatisfied, or very dissatisfied?” (p. 7) 1

For these questions, the weighted item non-response rate varied between less than 1% for overall self-rated health to just over 2% for the other two questions. Analyses of CCHS 3.1, Health Indicators Related to Mental Health and Well-Being Descriptive analyses were used to estimate “high” levels of the positive mental health outcomes across different groups by province and census metropolitan area (CMA). Comparisons were made between estimates for provinces and Canada, and 99% confidence intervals were calculated for each CMA to show the variance of each estimate. Bootstrapping techniques were used to estimate variance, via Statistics Canada’s Bootvar macros. Of note, rates of reporting high self-rated health, mental health and life satisfaction were also standardized or reweighed by age group for each province, adjusting each province’s estimate to reflect the national proportions of respondents in each of four age groups: 12 to 24, 25 to 44, 45 to 64 and 65 and up—note that this is consistent with groupings used in previous reports (for example, the Public Health Agency of Canada’s Human Face of Mental Health and Mental Illness 2006). However, age-standardizing had little impact on estimates (see Table 1) and therefore was not used in analyses.

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Table 1 Comparing Crude and Age-Standardized Rates of Self-Rated Health, Mental Health and Life Satisfaction Excellent

Self-Perceived

Health Age-

Standardized

Excellent Self-Rated

Mental Health

Age-Standardized

Very Satisfied With Life

Age-Standardized

CANADA 22% . 37% . 38% .

N.L. 19% 19% 39% 39% 38% 38%

P.E.I. 18% 18% 34% 34% 41% 42%

N.S. 17% 17% 33% 33% 41% 41%

N.B. 17% 17% 32% 33% 38% 39%

Que. 23% 24% 41% 41% 38% 38%

Ont. 22% 22% 38% 38% 38% 38%

Man. 21% 21% 34% 34% 36% 36%

Sask. 18% 19% 33% 33% 36% 36%

Alta. 22% 21% 35% 35% 40% 39%

B.C. 22% 22% 35% 35% 38% 38%

Y.T./N.W.T./Nun.

20% 19% 35% 34% 37% 37%

Source Canadian Community Health Survey, Cycle 3.1 (PUMF), 2005, Statistics Canada. In most recent health indicators reports, CCHS 3.1 questions on self-rated health and self-rated mental health have been used to measure mental health and well-being. A correlational analysis compares 27 CMAs to determine if these two measures are indeed representative of positive mental health as measured by overall life satisfaction. The percentage of respondents in each CMA reporting excellent self-rated health or mental health were compared to the percentage reporting being very satisfied with life.

• Correlation between excellent self-rated mental health and life satisfaction: 0.13. No strong relationship, slight increase in slope, but generally an increase in reports of high self-rated mental health did not mean an increase in life satisfaction.

• Correlation between excellent self-rated health and life satisfaction: -0.40. Perhaps surprisingly, an inverse relationship, where life satisfaction was generally higher for areas with lower rates of “excellent” self-rated health.

Similarly, these three variables were reported and ranked for each province. It was shown that provinces reporting the highest ranking self-rated mental health and health were not the highest in terms of life satisfaction.

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Canadian Community Health Survey, Cycle 1.2 The selection of priority areas for the CCHS Mental Health and Well-Being cycle, in terms of mental disorders as well as mental well-being, was the result of discussions within the Mental Health Expert Group assembled for the survey, as well as the Population Health Advisory Committee. Consultations also included contacts with representatives of the World Health Organization, academia, federal and provincial governments, consumers and professional associations.2 The target population of the survey and of analyses in this report was Canadians living in each of the 10 provinces, age 15 and older, and data were collected between May and December of 2002. It did not include Canadians living in any of the three territories, on Indian reserves or on Crown lands, residents of institutions, full-time members of the Canadian Armed Forces or residents of certain remote regions. The overall response rate for the survey was 77% for a total sample size of 36,984. 2 Table 1 Counts and Population by Province of Sample Used in Analyses

Sample Size Province

Weighted Percent of Total

1,562 Newfoundland and Labrador 2% 1,002 Prince Edward Island 0.4% 2,785 Nova Scotia 3% 1,706 New Brunswick 2% 5,332 Quebec 24%

13,184 Ontario 39% 2,230 Manitoba 3% 2,045 Saskatchewan 3% 3,236 Alberta 10% 3,902 British Columbia 13%

36,984 Source Canadian Community Health Survey, Cycle 1.2, 2002, Statistics Canada. The sample selection covered approximately 98% of the population age 15 or older in the 10 provinces2 and represented roughly 25 million people. Of note, the provinces of Ontario and Nova Scotia provided extra funds for additional sample selection to help provide reliable estimates for sub-provincial areas, thus these areas are slightly over-represented in the sample; however, sample weights are adjusted accordingly. Therefore, the weighted proportions coming from each province are consistent with the census (both 2001 and 2006). Other social and demographic characteristics, as well as mental health service use characteristics of the sample are illustrated in Table 2. For subjective questions on emotional well-being, satisfaction, life enjoyment and other such questions, in particular, understanding the cultural and demographic characteristics of the population may be useful in understanding results. For instance, one-quarter of the interviews were conducted in

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French. A related limitation may be possible different interpretations and translations of concepts like life enjoyment. Table 2 Sample Population Characteristics

Sample Population Characteristics

Percent Sample Population Characteristics

Percent

15 to 19 9% Employed by other employer 60% 20 to 29 15% Self-employed 12% 30 to 39 19% 40 to 49 21% Own home 73% 50 to 59 15% 60 to 69 10% Lowest income 9% 70 to 79 7% Lower-middle income 19% 80 and older 3% Upper-middle income 32% Highest income 30% Females 51% Males 49% Attend monthly religious services 31% Single 25% White 83%

Divorced/separated/widowed 13% North American Indian, Métis, Inuit* 1%

Common law 9% Chinese 4% Married 52% Black 2% South Asian 3% Immigrant to Canada 22% Mental illness reported 16%

Interview in English 75% Used mental health services, last year 10%

Interview In French 23% Used mental health services, lifetime 25%

Source Canadian Community Health Survey, Cycle 1.2, 2002, Statistics Canada.

* Only off-reserve population was in the scope of the survey target population.

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CCHS 1.2 Variables Used in Analyses† A. Positive Mental Health Variables • Life Enjoyment*: CPHI-derived variable based on respondents’ answers to the following

four questions about their feelings during the past month, where they were asked if they almost always, frequently, half the time, rarely or never (i) smiled easily, (ii) found life exciting, (iii) had good morale and (iv) felt self-confident. High: “almost always” to all four questions. Moderate: “frequently” or better to all four. Low: any other combination.3

• Emotional Well-Being*: CPHI-derived variable based on respondents’ answers to the

following four questions about their feelings during the past month, where they were asked if they almost always, frequently, half the time, rarely or never (i) felt emotionally balanced, (ii) felt at peace with themselves, (iii) had pride in self/felt satisfied with accomplishments or (iv) enjoyed life. High: “almost always” to all four questions. Moderate: “frequently” or better to all four. Low: any other combination.3

• Social Well-Being*: CPHI-derived variable based on respondents’ answers to the

following two questions about their feelings during the past month, where they were asked if they almost always, frequently, half the time, rarely or never (i) got along well with others or (ii) listen to friends. High: “almost always” to both questions. Moderate: “frequently” or better to both. Low: any other combination.3

• Coping Ability: CPHI-derived variable based on respondents’ answers to the following

two questions asking them how they would rate (excellent, very good, good, fair or poor) their ability to handle (i) unexpected and difficult problems, for example, a family or personal crisis or (ii) the day-to-day demands in their life, for example, handling work, family and volunteer responsibilities.3 High: reported at least very good to both and said “excellent” to at least one. Moderate: good or better to both. Low: any other combination.

Coping Methods: Analyses also looked at different ways people reported coping, based on responses to questions asking respondents to think about the ways they deal with stress. o Engaging: CPHI-derived variable based on responses to dealing with stress by doing

something enjoyable, talking to others, exercising or praying. Respondents who often reported doing any two of these things were considered to have “high” active coping; those who often did any one were considered to have moderate levels; and low otherwise.

o Problem Solving: Based on responses to a single question related to dealing with stress by trying to solve the problem. Four response categories range from often to never.

o Disengaging: CPHI-derived variable based on responses to four questions asking about coping by eating (more or less), smoking, drinking or using drugs.

† Non-response rate for the derived variables was 100 to 300 out of 36,000.

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Respondents who reported “often” to any of these methods were considered to have “high” disengaging coping levels; those who rarely or never use these methods were considered to have “low” levels; and moderate otherwise.

o Avoiding: CPHI-derived variable based on responses to two questions asking about coping by sleeping or avoiding the problem. Respondents who often reported “often” to either question were considered to have “high” avoidance-based coping; those who rarely or never use these methods were considered to have “low” levels; and moderate otherwise.

• Spiritual Well-Being: CPHI-derived variable based on respondents’ answers to the

following two questions (i) do spiritual values play an important role in your life (yes, no) and (ii) do spiritual values help find meaning in life (a lot, some, a little, not at all).3 High: responses of “yes” and “a lot,” respectively. Moderate: responses of “yes” and “a little” or better. Low: “no” and “not at all” responses.

• Psychological Well-Being Scale: Based on a 25-question scale with scores ranging from

0 to 100.4, 5 These questions include all of those listed previously for life enjoyment, social and emotional well-being as well as others. A possible cut-off for high levels was determined by CPHI based on looking at the 75th percentile for among age groups and selecting the lowest value (90), this resulted in 35% of the population with “high” psychological well-being scores (90–100).

• Life Satisfaction: Single question asking respondents: “How satisfied are you with your

life in general,” with possible responses of very satisfied, satisfied, neither, dissatisfied or very dissatisfied.

B. Social, Demographic and Other Independent Variables • Ethnicity: Responses could be single or multiple and are based on the question, “People

living in Canada come from many different cultural and racial backgrounds. Are you: white, Chinese, South Asian, Black…Aboriginal (North American Indian, Métis or Inuit)…”(p. 238)3

• Immigration Status: Yes/no flag based on a question of age at time of immigration. • Marital Status: Married, common-law, single, divorced, widowed or separated, where

the final three were combined into one group due to sample sizes. • Living Arrangement: Statistics Canada–derived variable with 10 possible categories.

One group of adult responses: single/unattached, unattached individual with others, spouse and partner, spouse/partner and kids, single parent. The second group is child responses: single parent, single parent and siblings, with two parents, with two parents and siblings. An “other” response was also a possibility.

• Hours of Work: Statistics Canada–derived variable based on hours worked where, 30

hours and over is considered full time; anything under is part time.

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• Employment Status: Responses based on a single question asking if respondent is self-

employed or an employee. • Job Security: Working respondents were asked if their job security was good.

Responses of agree or strongly agree were considered “yes” responses and all others “no.”

• Education: Statistics Canada–derived variable for the highest level of education in the

household, based on individual responses and separated into four categories from less than secondary to post-secondary.

• Housing Tenure: Responses to question asking if the dwelling is owned by a member of

the household. • Income Adequacy: Statistics Canada–derived variable based on reported household

income before taxes and household size. o Lowest income: <$15,000 if one or two people; <$20,000 if three or four

people; <$30,000 if five or more people o Lower-middle income: $15,000 to $29,999 if one or two people; $20,000 to

$39,999 if three or four people; $30,000 to $59,999 if five or more people o Upper-middle income: $30,000 to $59,999 if one or two people; $40,000 to

$79,999 if three or four people; $60,000 to $79,999 if five or more people o Highest Income >$60,000 if one or two people; >$80,000 if three or more

people • Community Belonging: Responses to question asking how respondents would describe

their connection to their local community. Analyses used responses of “very strong” and “somewhat strong” as having community belonging, and “somewhat weak” or “very weak” as not having it.

• Religious Services: Respondents were asked how often they participated in religious

activities or attended religious services or meetings over the previous year. Analyses considered responses of once a month or more frequently as regular attendance.

• Available Tangible Support: This variable is a CPHI-modified Statistics Canada–derived

variable. It summarizes a respondent’s available tangible support. Four questions about whether or not the respondent had someone to help if confined to bed, someone to take him or her to the doctor, someone to prepare meals or someone to do daily chores are included. CPHI analyses considered a respondent to have available tangible support if he or she responded most or all of the time to all four questions. Responses of some, a little or none of the time were considered inadequate support.

• Available Emotional Support: This variable is a CPHI-modified Statistics Canada–derived

variable. It summarizes if the respondents received emotional or informational support based on five questions about whether they have someone to listen to them, give advice in a crisis, to confide in and talk to, who understands problems and whose

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advice they really want. CPHI analyses considered respondents to have available emotional support if they responded most or all of the time to all five questions. Responses of some, a little or none of the time were considered inadequate support.

C. General Health and Illness-Related Variables • Mental Illness: Flagged as yes if respondents answered positively to or were screened

into sections on the following disorders: depression, mood disorder, social phobia, panic disorder, agoraphobia, alcohol or drug abuse, schizophrenia, other psychosis, obsessive-compulsive disorder, dysthymia or post-traumatic stress disorder.

• Self-Rated Health: Asked respondents to rate their health as excellent, very good, good,

fair, poor.1 • Self-Rated Mental Health: Asked respondents to rate mental health as excellent, very

good, good, fair or poor.1 • Self-Rated Physical Health: Asked respondents to rate physical health as excellent, very

good, good, fair or poor.1 • Stress: Asked respondents to rate the amount of stress on most days of their lives on a

five-point scale from “not at all stressful” to “extremely stressful.” CPHI analyses used the following three subcategories: high stress—extremely stressful; moderate—a bit or quite a bit stressful; and low—not very or not at all stressful.

• Two-Week Disability/Reduced Activity: Records the number of days in last two weeks

when respondents reported they stayed in bed or cut down on activity. CPHI analyses derived a dichotomous variable where any response of 1 to 14 days as a “yes” response, otherwise “no.”

• Mental Health Service Use: This Statistics Canada–derived flag variable assesses

whether the respondent was ever hospitalized overnight or ever consulted a professional, used internet support group or chat room, went to a self-help group or used a telephone service for problems concerning emotions, mental health or use of alcohol or drugs. Response categories were “yes” and “no”.

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Analysis of Positive Mental Health Figure 1: Framework for Analyses of Positive Mental Health Measures

Individual/social How other health/illness characteristics associated outcomes differ between groups Positive mental health with HIGH positive mental with high/med/low positive measures

health mental health

a b

The framework for the analyses discussed in this report is based on Figure 1. Analyses use the derived measures to:

a. Show that high levels of positive mental health outcomes linked to better health than lower levels; and

b. Discuss the characteristics of people reporting particularly high positive mental health, with emphasis on those characteristics that are consistent across several outcomes.

a. Positive mental health as a factor related to other health and illness outcomes Initially, positive mental health factors are treated as independent variables in relation to other health and illness outcomes. Bivariate associations between positive mental health levels (high, medium, low) and other physical health outcomes (mental illness, disability days, excellent physical and mental health) were calculated and showed a gradient effect. In particular, as positive mental health increased so did positive health outcomes, or negative outcomes decreased. Tests of significance were used to compare high, medium and low levels in the standard manner as was described above for the descriptive analyses. Relative importance of each of the five positive mental health variables on excellent physical and self-rated mental health was considered by constructing multivariate logistic regression models and looking at the resulting Type III Analyses of Effects and the Wald chi-square test. For modelling excellent self-rated physical health the results were as follows:

• Coping Ability (Wald χ22df =444,138, p<.0001)

• Emotional Well-Being (Wald χ22df =139,603, p<.0001)

• Life Enjoyment (Wald χ22df =120,792, p<.0001)

• Spiritual Well-Being (Wald χ22df =11,298, p<.0001)

• Social Well-Being (Wald χ22df =5,921, p<.0001)

In interpreting the Wald Score to mean the higher the score the larger the association in relation to other variables, coping ability has the largest relative effect. Examination of the odds ratios showed that the higher one’s coping ability, the higher the odds of reporting excellent physical health. Further, when looking specifically at all survey questions, it was the coping question related to self-perceived ability to handle day-to-day demands that had the highest Wald score. Results were similar for modelling excellent self-rated mental health.

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b. Characteristics related to reporting high levels of positive mental health High levels of positive mental health, life enjoyment, coping ability and emotional, social and spiritual well-being were also looked at as health outcomes. Descriptive analyses were used to estimate “high” levels of the five derived positive mental health outcomes across different groups by the following:

• Census metropolitan area, province, age, sex, marital status, living arrangement, employment information, income adequacy, education, community belonging, religious service attendance and available emotional and tangible support level.

Estimated rates of high positive mental health outcomes were reviewed for reliability based on Statistics Canada’s suggested criteria.‡ Tests for significant differences were used to assess which social and demographic groups reported significantly higher levels of the five derived positive mental health factors. Bootstrapping techniques as part of the SAS Bootvar macro were used in these analyses to account for the complex survey design in estimating standard errors, coefficients of variation and confidence intervals.

Explanatory multivariate logistic regression models were constructed, for which the dependent variables of interest were the high levels of all five positive mental health outcomes, as well as two other measures: • responses to questions on life satisfaction; and • an overall psychological well-being scale. These two measures were included in order to determine what relationships were consistent for all positive mental health outcomes, whether it was a newly derived variable, a complex scale or a simple question. Independent variables included those that were seen to have strong bivariate associations (age, sex, province, marital status, community belonging, available emotional support, religious attendance). Although income and education did not have strong relationships they were still included in this explanatory model. Current stress levels, presence of mental illness and physical health were also included in the model. Limitations • Derived Variables and Factor Selection

o The psychological well-being scale was broken down here and three of the measures came from this scale, and Cronbach’s alpha values were tested and remained high after separating the questions. However, the components as listed in the original research were not respected in order to look at the questions most representative, in CPHI assessment of literature referenced, of life enjoyment and emotional and social well-being.

o In some research, variables such as attending religious services were used as a proxy for spirituality, and therefore as an outcome. Similarly, having social support available has also been used in other cases as an outcome representing social well-

‡ Coefficients of variation (CV) of more than 33% result in suppressing estimates and those with CVs of between 16.6% and 33% would be appropriately marked.

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being. Here the choice was made to use the presence of a resource as an independent factor relating to people’s mental health.

o In a similar manner, community belonging could be seen as either a potential positive mental health “measure” and outcome, or an independent factor linked to better mental health and positive mental health, or both.

o Ethnic and cultural differences did not seem to be consistently linked to positive mental health outcomes. More culturally considerate scales or questions may be worth exploring.

o Possible issues as a result of translation and language differences may result from using subjective outcomes such as emotional well-being. This might account for some of the different patterns seen for Quebec in looking at emotional and social well-being and life enjoyment compared to other provinces.

• Sample Population

o The CCHS 1.2 did not include respondents who reside in institutions, including care homes. Therefore, the population of elderly people covered is only those living in private homes. Their positive mental health may be significantly different than that of persons living in personal care facilities. Further, this population did not include residents of the territories or youth 12 to 14. This should be considered in making any comparisons with CCHS 3.1 results, which included these populations.

o The cross-sectional nature of this study and survey makes it impossible to say that high positive mental health is a result or precedes other physical health outcomes. The National Population Health Survey is a longitudinal survey, and although fewer possible positive health outcomes are available it would provide a means of looking at determinants of elements of positive mental health.

• Analyses

o Multivariate analyses were of an explanatory nature only, based on frameworks seen in published literature of similar analyses. Analyses did not seek to look for confounding variables. Future analyses specific to gender or that look at interactions between age, gender and marital status may further illuminate associations with gender and marital status that were not seen in these analyses.

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POLICY SCANNING METHODOLOGY CPHI, as a part of CIHI, aims to present policy- and decision-makers with reports that provide the best available evidence on topics related to population health. Consistent with its mandate, CPHI is careful to present evidence in a policy-neutral manner. CPHI does not engage in advocacy or provide policy recommendations on population health issues, but aims to provide decision- and policy-makers with evidence so they may make informed choices. The diagram below is used to describe the extent to which CPHI engages in the policy dialogue—the area beyond the vertical line represents the areas of recommendation, advocacy and policy-/decision-making in which CPHI/CIHI does not engage.

Research findings

Data, information Research

synthesis Policy analysis

What is known/not known?

What has worked/ has not worked?

Recommendation Policy- and decision- making

Advocacy

CPHI’s reports aim to synthesize available research evidence and to present significant findings that have implications for health, ensuring that the “what we know and don’t know” section of our reports reflects the link between relevant research and policy questions.

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1. POLICY INVENTORY The first step in the development of the policy section for this report was to develop an inventory of relevant resources and interventions related to positive mental health, resilience, mental illness prevention and mental health promotion. The purpose of the inventory was to acquire an overview of relevant policies and programs that have been implemented across Canada and in other potentially relevant jurisdictions that were related to the report theme such as the United Kingdom, Australia, New Zealand, and the United States, given their general comparability with Canada and the extensive work in the area of mental health promotion and prevention in these countries. Compiling the inventory involved the following: a. A comprehensive search of government and non-government websites to review the

mandates of relevant federal and provincial departments, as well as to identify policies and programs broadly relevant to the topic of the report: positive mental health, resilience, prevention of mental illness and mental health promotion. Examples include the Mental Health Commission of Canada, Public Health Agency of Canada, Health Canada, provincial and territorial ministries responsible for health and wellness, Centre for Addiction and Mental Health, federal and provincial Canadian Mental Health Association branches, National Aboriginal Health Foundation, etc. International resources were also explored, such as the Clifford Beers Foundation (U.K.), Centre for Disease Control (U.S.), Victorian Government Department of Human Services (Australia), European Network for Mental Health Promotion and Mental Disorder Prevention (EU), the World Health Organization (global), etc.

In addition to publicly available websites, provincial and territorial programs and policies were also identified using an unpublished environmental scan of the mental health field commissioned by CPHI in 2006.

b. As appropriate, individuals in relevant departments of organizations were consulted

with regard to existing policies and programs of relevance to the report topic. For example, the Canadian Mental Health Association branch- or division-level offices (depending on jurisdiction) were contacted for suggestions of positive mental health interventions being offered in those jurisdictions.

A template was used to distinguish items in the inventory and included jurisdictional-level (for example, provincial, local, international), source (for example Health Canada), themes or key areas of interest (for example, mental health promotion in the workplace, resilience programming), type of information (for example, general framework, evaluation, systematic review) and the location of the material. A short sample of this template can be found in Appendix B. Additionally, the research obtained through the search of the published literature (see document on literature search methodology) was screened for reports of evaluated programs and other interventions that could also be used for case studies.

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2. CASE STUDIES The inventory identified more programs and policies than could be included in the report. Specific programs were selected from the inventory to create a master list using a breakdown based on the following categories: program/project title, source (for example, Health Canada), setting (for example, school or community), target group (for example, youth or families), aims and objectives, description of activities, description of outcomes and notes about the evaluation type, if any. From this breakdown, case studies were identified to provide more information about specific programs and interventions. Ideally, for a program to be profiled, it should have, at a minimum, a process evaluation and as much of the following as possible:

• A clearly articulated health-relevant rationale; • Clear health-relevant objectives; • Information about context, such as target population, costs and duration; and • An outcome evaluation.

Case studies were also selected to be representative of Canada’s regions. When appropriate, case studies have been presented from other jurisdictions considered relevant to the Canadian context.

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Appendix B

Sample of Sources Searched and Relevant Policy Information Found∗

Source Themes/Key Interests

Type of Information Location/Website

International

World Health Organization/Victorian Health Promotion Foundation/University of Melbourne

Mental Health Promotion—Concepts, Evidence, Practice

Comprehensive Synthesis of Definition, Research Evidence and Policy/Programming

http://www.who.int/mental_health/evidence/MH_Promotion_Book.pdf

Improving Mental Health Promotion Action, European Commission

Integrating Mental Health Promotion Into Policy, Practice and Care systems

Literature Synthesis http://ec.europa.eu/health/ph_projects/2002/promotion/fp_promotion_2002_frep_16_en.pdf

Victorian Government Department of Human Services

Mental Health Promotion Evidence; Social Inclusions/Connectedness/Economic Participation/Violence Prevention

Comprehensive Literature and Policy Synthesis

http://www.health.vic.gov.au/healthpromotion/downloads/mental_health_resource.pdf

Pan-Canadian

Public Health Agency of Canada

Mental Health Promotion Among Mentally Ill

Literature Synthesis; Policy/Programming Overview; Promising Practices

http://www.phac-aspc.gc.ca/publicat/mh-sm/mhp02-psm02/pdf/mh_paper_02_e.pdf

National Aboriginal Health Organization

Resilience Literature Synthesis—Characteristics and Development Strategies

http://www.naho.ca/inuit/e/documents/2007-08-22ResilienceBook_final.pdf

Canadian Collaborative Mental Health Initiative

Integrating Care System; Restructuring Mental Health Care System/Services

Resource Guide; Inventory of Canadian Initiatives

http://www.iccsm.ca/en/products/documents/05b_CanadianReviewII-EN.pdf

∗ Note the items in this table are only a few examples of the types of information that resulted from our scanning efforts, and their inclusion is meant to be a sample of how policy information was initially organized. Therefore, the inclusion of this information does not relate to its level of importance and it is neither an exhaustive list of the extensive policy information available nor an exhaustive list of our scanning efforts.

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http://ec.europa.eu/health/ph_projects/2002/promotion/fp_promotion_2002_frep_16_en.pdf

















Provincial

British Columbia—Population Health and Wellness, Ministry of Health Services

Mental Health Promotion; Social and Emotional Competence; Resilience

Policy Framework for Public Health Core Functions No Evaluation

http://www.health.gov.bc.ca/prevent/pdf/core_functions.pdf

Alberta—Alberta Mental Health Board

First Nations, Inuit and Métis Mental Health; Cultural Conceptions of Positive Mental Health

Framework for Action No Evaluation

http://www.amhb.ab.ca/Initiatives/aboriginal/Documents/Aboriginal_%20%20Framework.pdf

Saskatchewan—Saskatchewan Health

Mental Well-Being; Resilience; Connectedness; Citizenship

Policy Strategy No Evaluation

http://www.health.gov.sk.ca/population-health-strategy

Manitoba—Manitoba Healthy Living

Child and Youth Development; Mental Health in Promotion in the School; Integration of Services

Provincial Initiative No Evaluation

http://www.gov.mb.ca/healthyschools/index.html

Ontario—Ministry of Health and Long-Term Care

Mental Health Care System Restructuring; Integration of Services

Operational Framework No Evaluation

http://www.health.gov.on.ca/english/public/pub/mental/pdf/MOH-op.pdf

Quebec—Ministère de la Santé et des Services Sociaux

Mental Health Care System Restructuring; Continuity of Service Delivery

Provincial Action Plan No Evaluation

http://publications.msss.gouv.qc.ca/acrobat/f/documentation/2005/05-914-01.pdf

New Brunswick—Health and Wellness

Mental Fitness; Resilience; Wellness

Provincial Strategy/Framework No Evaluation

http://www.gnb.ca/0131/wellness-e.asp

Nova Scotia—Department of Health

Promoting Positive Mental Health; Prevention of Mental Illness; Advocacy and Awareness

Provincial Strategy/Framework No Evaluation

http://www.gov.ns.ca/health/mhs/reports_resources/reports.asp

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Prince Edward Island —Healthy Child Development Advisory Committee

Child and Youth Development; Social Belonging; Supportive Communities

Proposed Provincial Strategy/Framework No Evaluation

http://www.gov.pe.ca/photos/original/ForOurChildren.pdf

Newfoundland and Labrador—Department of Health and Community Services

Mental Health Promotion; Promoting Positive Mental Health

Provincial Wellness Plan No Evaluation

http://www.health.gov.nl.ca/health/publications/2006/wellness-brochure.pdf

Yukon—Health and Social Services

Mental Illness Prevention; Treatment and Recovery Enhancement

Territorial Initiative No Evaluation

http://www.hss.gov.yk.ca/realityrules/

Northwest Territories—Health and Social Services

Social Well-Being; Service Restructuring and Integration; Community Development/ Connectedness

Demonstration Projects Independent Evaluation

http://www.hlthss.gov.nt.ca/pdf/reports/social_health/2006/english/sacdp_inititiave_evaluation_report.pdf

Nunavut Suicide Prevention; Community Capacity and Healing; Social Well-Being

Territorial Framework/Strategy No Evaluation

http://www.gov.nu.ca/annirusuktugut/jun29a.pdf

Municipal/Local West Carleton, Ontario

Communal Coping; Community Resilience; Youth Mental Health Promotion; Restructuring/Integrating Service Delivery and Care

Community Helper Program Evaluation

http://www.phac-aspc.gc.ca/mh-sm/mhp-psm/pub/community-communautaires/pdf/comm-cap-build-mobil-youth.pdf

Hamilton, Ontario

Workplace Mental Health Promotion; Job Quality; Wellness

Healthy Lifestyles Program Evaluation

http://www.clbc.ca/files/CaseStudies/dofasco.pdf

Centre for Addiction and Mental Health

Resilience; Individual, Family and Environmental Protective Factors

Literature Review and Synthesis No Evaluation

http://www.camh.net/Publications/Resources_for_Professionals/Growing_Resilient/index.html

Centre for Addiction and Mental Health

Mental Health Promotion Among Children and Youth

Best Practice Guidelines

http://www.camh.net/About_CAMH/Health_Promotion/Community_Health_Promotion/Best_Practice_MHYouth/index.html

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REFERENCES 1. Statistics Canada, Canadian Community Health Survey Cycle 3.1: Final

Questionnaire (Ottawa, Ont.: Statistics Canada, 2005). 2. Statistics Canada, Canadian Community Health Survey Cycle 1.2 Mental Health and

Well-Being: User Guide for the Public Use Microdata File (Ottawa, Ont.: Statistics Canada, 2004).

3. Statistics Canada, Canadian Community Health Survey Cycle 1.2 Mental Health and

Well-Being: Questionnaire and Reporting Guide (Ottawa, Ont.: Statistics Canada, 2003).

4. Statistics Canada, Canadian Community Health Survey (CCHS) Cycle 1.2 Derived

Variable (DV) Specifications (Ottawa, Ont.: Statistics Canada, 2002). 5. R. Massé et al., "Élaboration et Validation d'un Outil de Mesure du Bein-Être

Psychologique: L'ÉMMBEP," Revue Canadienne de Santé Publique 89, 5 (1998): pp. 352−357.

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