Resarch with Immigrant Populations: The Application of an Ecological Framework to Mental Health...

THE INTERNATIONAL JOURNAL OF

Mental HealthP R O M O T I O N

Promoting MMental HHealthPreventing MMental DDisorders

VOLUME SEVEN

ISSUE TWO

MAY 2005

THE

CLIFFORDBEERSFOUNDATION

THE EDITOR

Michael Murray is Chief Executive of TheClifford Beers Foundation and Head of TheCentre for Mental Health Promotion andResearch at the University of Central England inBirmingham.

He has acted as a member of the ExpertsCommittee of the European Commission, waschair of the Organising Committee for thesecond World Conference on the Promotion ofMental Health and the Prevention of MentalDisorders, and has sat on national andinternational advisory bodies.

EDITORIAL STATEMENT

The aim of the Journal is to nurture andencourage understanding and collaboration in thefield of mental health promotion (and theprevention of mental disorders) within a trulymulti-disciplinary forum.

In this forum, researchers and practitionersfrom different disciplines, cultures and countriescan fruitfully collaborate to make significantprogress towards the achievement of conceptualclarity and in turn advance the development,evaluation, dissemination and implementation ofnew concepts and effective programmes.

Topics of interest for the Journal includetheoretical studies, empirical and appliedoriginal research, evaluative studies ofinnovative programmes, analysis of issuesfundamental to mental health promotion (andthe prevention of mental disorders) and policymaking.

The editorial board aims to be eclecticand academically catholic, with noallegiance to any specific dogma orconceptual framework or ideology.

As the definition and concept of mentalhealth promotion continue to stimulate extensivedebate, often including discussion relating to thedifference and overlap between health promotionin general, mental health promotion, and theprevention of mental health disorders, this lackof conceptual clarity leads to confusion, invalidassumptions and unproductive, even futile,debate. The sources of the controversy arediverse and stem from the different underlyingperspectives, professional roles and philosophiesand beliefs of individuals and sectional interests.

Among scientists, clinicians, practitioners,academics, policy makers and consumer groupsthis discussion will continue, as muchcontroversy exists as to the way mental healthpromotion should be defined – if defined at all.

It is intended that the Journal will addressthese issues to promote progress in achievingconceptual clarity as a crucial prerequisite forfruitful collaboration in the development,dissemination and implementation of effectiveprogrammes.


Mental HealthPROMOTION


Mental HealthP R O M O T I O N

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EditorMichael Murray

The Clifford BeersFoundation

5 Castle WaySTAFFORDST16 1BS

Telephone0044 (0) 1785 246668

Fax0044 (0) 1785 246668

[email protected]

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ISSN 1462-3730

The views and opinions expressed by authors aretheir own. They do not necessarily reflect the

views of their employers, the Journal, the EditorialBoard or The Clifford Beers Foundation.

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[email protected]

PRINTINGJohn Leigh, Stafford

Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

FEATURE Specificity in the Relationships Between Stressors andDepressed Mood Among Adolescents: The Roles ofGender and Self-EfficacyDelia Bancila and Maurice B. Mittelmark . . . . . . . . . . . . . . . . . .4

FEATURE Alone in Canada: A Case Study of Multi-LingualMental Health Promotion Laura Simich, Jacqueline Scott and Branka Agic . . . . . . . . . . . .15

FEATURE Research with Immigrant Populations: The Applicationof an Ecological Framework to Mental Health Researchwith Immigrant Populations Mirsad Serdarevic and Krista M. Chronister . . . . . . . . . . . . . . .24

FEATURE An Evaluation of beyondblue, Australia’s NationalDepression InitiativeJane Pirkis, Ian Hickie, Leonie Young, Jane Burns,Nicole Highet and Tracey Davenport . . . . . . . . . . . . . . . . . . . . .35

FEATURE Preventing Toddler Externalising Behaviour Problems:Pilot Evaluation of a Universal Parenting ProgramHarriet Hiscock, Jordana Bayer and Melissa Wake . . . . . . . . . .54

ANNOUNCEMENT Mental Health Promotion: A Report from WHO . . . . . . . . . . . .61

ANNOUNCEMENT Prevention of Mental Disorders: A Report from WHO . . . . . . . .62

VOLUME SEVEN ● ISSUE 2 ● MAY 2005

Copyright for all published material in this journal is held by The Clifford Beers Foundation

unless specifically stated otherwise. Authors and illustrators may use their own material else-

where after publication without permission but The Clifford Beers Foundation asks that this note

be included in any such use: ‘First published in The International Journal of Mental Health

Promotion, VOLUME 7 ISSUE 2.’ Subscribers may photocopy pages within this journal for

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The Clifford Beers Foundation for permission.

2 International Journal of Mental Health Promotion VOLUME 7 ISSUE 2 - MAY 2005 © The Clifford Beers Foundation

EE DD II TT OO RR II AA LL

Over the past few weeks I have been fortunate enoughto attend a number of meetings and conferences where thesubjects of health promotion and mental health promotionwere debated in some detail.

Two such events stand out. In Dublin, DevelopingMental Health Promotion: Going from Strength toStrength attracted some 250 participants from across theglobe and provided a series of excellent presentations andinformative discussions. At the conference, a number ofleading international organisations, including the WorldPsychiatric Association, the International Alliance forChild and Adolescent Mental Health and Schools, theCarter Center, the Clifford Beers Foundation and theWorld Federation for Mental Health, also expressed theirformal support for the Global Consortium for theAdvancement of Promotion and Prevention in MentalHealth (GCAPP). It was clear that much is being done toprogress mental health promotion.

I was also very pleased to be invited to a meeting of theBoard of Trustees of the International Union for HealthPromotion and Education that took place in Brazil. A widerange of interesting and exciting issues were on the agen-da, and it was clear that there is also tremendous progresstaking place in health promotion and education in general.

To my mind, for far too long there has been a lack ofreal and effective co-ordination and communicationbetween these two fields of interest. Listening to the dis-cussions at the Dublin and London meetings highlightedclearly the real and meaningful synergy between mentalhealth promotion and health promotion and education, and,more positively, there are significant efforts under way totry and ensure that mental health promotion is viewed asan integral, but specialised, section of the health promotionand education field. For example, the 19th IUHPE WorldConference on Health Promotion and Health Education

(Vancouver 2007) plans to follow the initiative of the pre-vious IUHPE (Melbourne) Conference and include a men-tal health promotion stream, while the International Unionwas also one of the signatories to GCAPP in Dublin.

The fields of mental health promotion and health pro-motion and education have for a long time developed sepa-rately, but there is an opportunity to recognise that, becauseof their effects in multiple sectors (for example, economic,political, legal and education), the promotion of mentalhealth and mental health promotion and education areamong the shared interests of a diverse group of stakehold-ers. Although mental health promotion is relatively new as arecognised area of health promotion and education activity,it is an integral part of health promotion and innovations inhealth promotion theory and practice. The challenge nowfacing us is how best to collaborate and exchange skills,knowledge and expertise across the two areas of interest.

When we come from different backgrounds and train-ing we may not always think alike, but we can share acommon goal: ideas which I hope are reflected in this issueof the Journal.

First of all I am very pleased that the Journal is able toact as a vehicle to highlight two publications:

Promoting Mental Health: Concepts, EmergingEvidence, Practice, a Summary Report from theWorld Health Organization, Department of MentalHealth and Substance Abuse, in collaboration withthe Victorian Health Promotion Foundation(VicHealth) and The University of MelbournePrevention of Mental Disorders: EffectiveInterventions and Policy Options, a Summary Reportfrom the World Health Organization, Department ofMental Health and Substance Abuse, in collaborationwith the Prevention Research Centre of theUniversities of Nijmegen and Maastricht.

Michael MurrayThe Clifford Beers Foundation

When we all think alike, no one thinks very much.

Walter Lipman, journalist

3International Journal of Mental Health Promotion VOLUME 7 ISSUE 2 - MAY 2005 © The Clifford Beers Foundation

E D I T O R I A L

These two comprehensive publications provide a wealth ofknowledge and interest, and are certainly worthy of furtherstudy.

In our first feature, Specificity in the Relationshipsbetween Stressors and Depressed Mood amongAdolescents: The Roles of Gender and Self-Efficacy,Delia Bancila and Maurice Mittelmark outline a studyundertaken to test for hypothesised specificity in the rela-tionships of stressors (interpersonal stress and worriesabout daily living) with depressed mood among Romanianadolescents. The data presented indicates that differentstressors have different relationships to a single outcome -depressed mood - conditioned by gender and self-efficacy.

In Alone in Canada: A Case Study of Multi-LingualMental Health Promotion, Laura Simich and colleaguesreport on the development of a popular, multi-lingual self-help booklet for single immigrants and refugees who mayrequire psychological and social support during their settle-ment and adaptation in Canada. The article concludes byarguing that the booklet has been successful by portrayingcommon psychosocial adaptation challenges in a relevantcontext, using accessible language and immigrant voicesthat affirm lived experiences, and offering helpful advicefor overcoming problems.

The purpose of Research with Immigrant Populations:The Application of an Ecological Framework to MentalHealth Research with Immigrant Populations, by MirsadSerdarevic and Krista Chronister, is to outline the benefitsof an ecological model framework for conducting cross-

cultural psychological research with immigrant popula-tions. The paper sets out four approaches which can beused to add to the existing literature, and concludes withrecommendations on how scholars might use the ecologi-cal model to enhance research on immigrants' acculturationexperiences.

An Evaluation of beyondblue, Australia's NationalDepression Initiative, by Jane Pirkis and colleagues,describes the findings of an evaluation of beyondblue, con-ducted four years into its existence. A detailed account ofthe methodology and results is provided. The conclusionrecognises the considerable progress made so far bybeyondblue to achieving its objectives, and proposes thatcareful consideration be given to what action is necessaryto foster positive change that is sustainable to the pointwhen it no longer needs to exist.

The final paper, Preventing Toddler ExternalisingBehaviour Problems: Pilot Evaluation of a UniversalParenting Program, contends that universal parenting pro-grammes can offer effective prevention for externalisingbehaviour problems in children. Harriet Hiscock and col-leagues report feasibility data from such a programme,delivered to 57 mothers of infants at their eight-month visitby nurses in well child clinics, and conclude that a brief,universal, preventative programme for early externalisingproblems is useful for mothers and feasible in primaryhealth care.

As ever, I welcome your views and comments on thisissue and look forward to receiving your comments.

The Fourth Biennial World ConferenceThe Promotion of Mental Health and Prevention of Mental and Behavioural Disorders

11-13 October 2006 Oslo, Norway

The Conference is organised by The World Federation for Mental Health,The Clifford Beers Foundation, The Carter Center and Voksne for Barn.

In 1997, following progress made through the AnnualEuropean Mental Health Promotion Conferences, the CliffordBeers Foundation and the World Federation for Mental Healthagreed on a joint venture to secure recognition of promotionand prevention as an essential part of the global mental healthagenda. With the support of the Carter Center and WHO, aseries of biennial conferences was initiated to pursue thisagenda. The Inaugural World Conference, held in Atlanta,Georgia in 2000, was followed by the London and AucklandConferences in 2002 and 2004 respectively.

From the earliest stages of planning, it has always beenenvisaged that the biennial conferences would form a focus forthis development. The vision has generated significant interestfrom government agencies, NGOs and academic institutionswhich have stressed the need to strengthen ties and expand

collaborative actions internationally. As a result of expandingenthusiasm, a world consortium of international organisations,the Global Consortium for the Advancement of Promotion andPrevention in Mental Health, was formed at a meeting inDublin in 2005 to seek opportunities for joint activities andmutual support.

For the 2004 Conference, the Mental Health Foundationof New Zealand agreed to act as a partner and host andVoksne for Barn, Norway will fulfill this role for the OsloConference in 2006.

For further details about the Oslo Conference please contact:

Randi Talseth, Voksne for Barn, Stortorvet 10, 0155 OsloTel.23 10 06 10 Fax: 23 10 06 11 email: [email protected]

A N N O U N C E M E N T


FF EE AA TT UU RR EE

Key words: interpersonal stress; depressed mood; socialsupport; self-efficacy; gender; adolescents; Romania

Introduction

Sub-optimal adolescent mental health is signalled by self-reported feelings of depressed mood, among other markers.The experience of depressed mood is a risk factor amongsome adolescents for the development of more serious con-ditions, including anxious/depressed syndrome and depres-sive disorder (Boyd et al, 2000; Cicchetti & Toth, 1998;Compas et al, 1993; Petersen et al, 1993). Adolescents’approaches to coping with depressed mood may establishlife-long coping patterns, so the consequences of an ado-lescent’s experience with depressed mood may reach wellbeyond the period of adolescence (Cicchetti & Toth, 1998;Herman-Stahl & Petersen, 1999; LaVome Robinson &Case, 2002; Petersen et al, 1993; Wiliams et al, 2002). Thepassage through adolescence is characterised by a widerange of challenges that cause stress and stimulate copingattempts that are more or less successful for different indi-viduals. Adolescents complain commonly about school,parents, friends and romantic partners, but other stressorsare also reported: personal or parental illness, family con-flict, poor economic situation, self-image, physical andsexual abuse, bullying and so forth. Stress in interpersonalrelationships especially displays a particular dynamismduring adolescence, associated with identity formation,

Specificity in the

Relationships Between

Stressors and Depressed

Mood Among

Adolescents: The Roles

of Gender and Self-

Efficacy

Delia Bancila

Maurice B. Mittelmark

Faculty of Psychology, University of Bergen

AA BB SS TT RR AA CC TT

The study’s aim was to test for hypothesised specificity in the

relationships of stressors (interpersonal stress and worries

about daily living) with depressed mood among Romanian

adolescents. Six hundred and thirty adolescents in grades 7,

9 and 11 in Bucharest schools participated. Structural equa-

tion models assessed the degree to which effects of stres-

sors on depressed mood were mediated through social sup-

port and self-efficacy, and moderated by gender and self-effi-

cacy. Neither social support nor self-efficacy had direct or

mediating roles in predicting depressed mood among girls.

Among boys, social support and self-efficacy played signifi-

cant roles in the connection between interpersonal stress and

depressed mood. Among girls, daily worries were associated

with depressed mood only among those with low self-effica-

cy, and interpersonal stress was associated with depressed

mood only among those with high self-efficacy.The data pre-

sented here show that different stressors have different rela-

tionships to a single outcome – depressed mood – condi-

tioned by gender and self-efficacy.


F E A T U R E

social norms, setting rules, etc (Allison et al, 1997). Highlevels of daily social stress resulting from the types of expe-rience mentioned above may in many cases lead todepressed mood levels that are higher than those caused bymajor life events (such as relocation and parental break-up).

There are at least two ways to conceptualise stressexperienced during adolescence. On the one hand, stressmay be viewed as a diffuse phenomenon of adolescence,characterised by dramatic change in biological aspects ofdevelopment and change in social context, that interact in acomplex environment hosting a large number of stressorsand challenges (Dumont & Provost, 1999; Ge et al, 2001;Petersen et al, 1993; Sandler et al, 1992). This view ofadolescent stress as a relatively amorphous phenomenonencourages research in which stress is assessed with abroad checklist including the widest possible range ofstressors, summed to estimate a total stress load. It is thisview of adolescent stress that seems dominant in the litera-ture (Grant et al, 2003). This approach can be termed non-specific, in contrast to an alternative view of adolescentstress in which specific types of stressor are believed tohave specific types of relationship to specific types of dis-tress. This view encourages research in which evidenceabout such specificity is sought (Garber & Hollon, 1991;McMahon et al, 2003; Sandler et al, 1992). As an exampleof a specificity model, Sandler and colleagues (1992)

hypothesised that a child’s permanent separation from aparent has a specific effect on depression, while familyconflict has a specific effect on conduct disorder (the for-mer hypothesis had the strongest support in their data). Tothe degree that specific associations do exist, researchmodels that do not differentiate particular stressors andparticular types of distress fail to appreciate potentiallyimportant, distinct phenomena in the adolescent stress–dis-tress experience.

In line with the above, authorities in the stress arenahave called for the development of dynamic and integrativetheories of stress processes (McMahon et al, 2003; Sandleret al, 1992). Among the stress–distress models proposedfor adolescent research, the general conceptual model(GCM) of Grant and colleagues (2003) provides a compre-hensive framework of the role of stressors in the ætiologyof child and adolescent psychopathology. The model positsthat the relation of stressors (major events, minor eventsand chronic conditions) to psychopathology (symptoms,syndromes and disorders) is mediated by biological, psy-chological and social processes, and moderated by individ-ual characteristics and environmental contexts. The GCMprovides a good framework to study stress–distress speci-ficity in relationships among all its components.

The general framework of the GCM guided theresearch model of this study, depicted in Figure 1, below,

FIGURE 1 Conceptual Model: Specificity in the Relationship between Stressors and Depressive Mood

The circles represent latent variables. The arrows represent the direction of the relationships between latent variables. The double arrowsrepresent correlations between latent variables. The disturbances associated with endogenous variables, the observed variables and theirerror terms are not represented in the figure. Interpersonal stress, personal worries, self-efficacy and social support on the left side arehypothesized predictors.


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which focuses on specificity in the relationships betweentwo types of stressor and depressed mood among commu-nity-dwelling adolescents in Romania. The two types ofstressor are (1) stress emanating from unresolved interper-sonal problems with significant others, and (2) stress asso-ciated with worry about daily adolescent living (for exam-ple finances, health and body image). The research modelposits that the stressors exert direct effects on depressedmood and reciprocal effects on each other. The stressors’effects are hypothesised to be mediated through personaland social resources (self-efficacy and perceived availabili-ty of social support), and to be moderated by gender andself-efficacy.

Rationale for the model’s elements andhypothesised associations

Depressed mood

Depressed mood refers to a lowering of mood as aresponse to adversity, expressed by sadness, unhappinessor blue feelings for an unspecified period, but not clinicallysignificant. In studies of adults and of adolescents, themoderating effect of gender is consistent. In most studies,girls score higher than boys on depressed mood, reportmore stressors, more interpersonal conflict, less power tocontrol situations, less effective coping strategies, andmore social support and social interaction (Crawford et al,2001; Dumont et al, 2003). The scholarly discourse aboutthese differences between adolescent girls and boys indepression has drawn on possible differences in personali-ty, in biology and in social challenges. For example, social-isation into ‘normal’ feminine and masculine social rolesmay enhance girls’ and inhibit boys’ experience of, andexpression of, depressed mood. Similarly, girls may besocialised to attend closely to their interpersonal world andto accept dependency and lower mastery, while boys maybe encouraged towards independence, exploration andmastery.

Interpersonal stress

Social exchange theory, equity theory, social cognitionmodels and transactional models of stress and coping offerrelevant perspectives for the conceptualisation and study ofinterpersonal stress in relation to depressed mood(Festinger, 1957; Homans, 1961; Lazarus & Folkman,1984; Mittelmark et al, 2004; Thibaut & Kelley, 1959).Interpersonal stress is defined here as a transactional, cog-nitive process involving appraisal and not completely satis-

factory coping, to resolve dissonance among cognitionsabout significant others (Mittelmark et al, 2004). The theo-retical foundations of this definition are found in the trans-actional model of stress (Lazarus & Folkman, 1984), andin aspects of social cognitive theory having to do with cog-nitive dissonance and dissonance reduction through cogni-tive change (Festinger, 1957).

Worries about daily living, not including stressin interpersonal relationships

There are many stressors in an adolescent’s daily life thathave the potential to stimulate depressed mood, and theexperience of concurrent stressors is quite common.Financial problems, school-related problems, crowded andsubstandard housing, self-appearance worries, anxietiesabout school, peer acceptance, romantic connectedness,social responsibilities and worries about others’ problemsillustrate the wide range of possible sources of socialstress. These problems may cause or exacerbate depressedmood. The possibility exists, also, of confusing interper-sonal stress effects with effects of worries about othertypes of matters. For example, the lack of intimacy incrowded housing can result in stress in interpersonal rela-tionships, which in turn can cause depressed mood.

Social support

Social support is a meta-concept, understood in stress andhealth research as a resilience factor or coping resource(Gore, 1992). Two models of social support are describedin the literature to explain its positive effects on emotionalfunctioning: the principal effect model (social supportgives a person a general positive context, which enhanceswell-being) and the stress-buffering model (social supportbuffers the negative effect of stress, but offers no benefitwhen stress is low) (Lakey, 2000). In the study presentedhere, social support is conceived as perceived availabilityof a confidant (having someone with whom to discuss per-sonal problems) and perceived ease in communication withone’s mother and father.

Self-efficacy

Intrapersonal resources such as resilience and hardinessassist individuals to deal successfully with potential andactual stressors, and protect against depressed mood.Among such intrapersonal resources, self-efficacy hasreceived the most research attention (Hobfoll, 2002). Inanalytic models self-efficacy has been hypothesised to


F E A T U R E

mediate and moderate the effect of stress on psychologicaloutcomes, and empirical evidence supports both types ofeffect, at least partly (Bandura et al, 1999; Herman-Stahl& Petersen, 1999; Smith & Betz, 2002). Perceived self-efficacy is the belief in one’s abilities to self-organise andtake action required to produce desired attainment(Bandura, 1997). In Bandura’s original formulation ofsocial cognitive theory, self-efficacy is a domain-specificconstruct (Bandura, 1997), but there is a growing literatureon the notion that self-efficacy also has a general character(Jerusalem & Schwarzer, 1992; Sherer et al, 1982).

Using the constructs just described, the paper wasdesigned to test for specificity in the relationships of twopsychosocial stressors (interpersonal stress and worriesabout daily living) with depressed mood among Romanianadolescents. Structural equation models were developed toassess the degree to which the direct effects of stressors ondepressed mood were mediated through social support andself-efficacy, and moderated by gender and self-efficacy.

Methods

Participants and procedures

The study sample frame was all pupils in grades 7, 9 and 11in all 307 public schools in Bucharest in March 2002. Eightschools were selected at random, and in these schools, sixclasses of seventh graders were selected at random. Alsoselected at random were 25 classes of 9–11th graders. In the31 selected classes, 728 pupils were registered. Of these, the630 pupils in attendance on the day of data collection wereinvited to participate in the study. Participation was volun-tary and anonymous. The participants were told that thestudy was about adolescents’ life style, and that their honestresponses were important to the quality of the research. Itwas emphasised that there were no right or wrong answersand spontaneous answers were best. Self-administered ques-tionnaires were provided to pupils in their classrooms andcompleted during a normal school hour.

Measurements

Depressed moodDepressed mood was assessed using the HBSC SymptomChecklist (SCL), from the cross-national WHO project,Health Behaviour among School-Aged Children (Hauglandet al, 2001; King et al, 1996). In HBSC data, the SCL hasa Cronbach’s alpha = 0.75 - 0.79. The scale consists ofeight items with five response choices (about every day,more than once a week, about every week, about every

month, rarely or never). The scale has a two-factor struc-ture including somatic and psychological complaints. Thefollowing items measuring psychological complaints wereused in this study: ‘feeling low’, ‘irritability or bad tem-per’, ‘feeling nervous’, ‘feeling dizzy’.

StressorsThe Bergen Social Relationships Scale (BSRS) (M = 4.5,SD = 3.7, Cronbach’s = .76; see Mittelmark et al, 2004) is asix-item self-report scale designed to measure interpersonalstress. The scale’s items are prefaced by the instruction:‘Think about everyone (parents, siblings, neighbours,friends, classmates, other persons who are important to you)when you answer the following’. Example items are: ‘Thereis a person I have to be around almost daily, that often hen-pecks me’ and ‘There are people that make my life difficultbecause they expect too much care and support from me’.The four response alternatives range from 0 (describes mevery well) to 3 (does not describe me at all).

The Bergen Personal Worries Scale–Youth (BPWS–Y)measures respondents’ self-rated degree of worry aboutdaily life stressors in their personal lives, but does notinclude items about their interpersonal relationships. TheBPWS-Y was developed from a version used in researchwith Romanian adults (Bancila et al, 2005). The adult ver-sion of the BPWS-Y was tested with three focus groupsdrawn from the adolescent population of this study. Theitems were slightly adjusted on the basis of focus groupfeedback. The BPWS–Y response frame is ‘My feelingsduring the past month’ and has a five–point response for-mat ranging from 0 (not worried) to 4 (extremely worried).The BPWS-Y items are: (a) a member of my family, (b)my financial situation, (c) my physical health, (d) my per-sonal safety, (e) my mental health, (f) my debts, (g) myresponsibilities to my family, (h) my love life, (i) mylook/image, (j) others’ opinion about me.

Perceived self-efficacyPerceived self-efficacy was measured with the GeneralSelf-Efficacy Scale (GSE) (M = 29.46, SD = 5.33,Cronbach’s alpha = 0.86; see Scholz et al, 2002). Therespondents had a four-point response option ranging from0 (not at all true) to 3 (exactly true) with the instruction:‘To what degree are the following statements true/nottrue?’. Examples of items are ‘It is easy for me to stick tomy aims and accomplish my goals’, and ‘I can usuallyhandle whatever comes my way’.

Social supportSocial support was measured by three items, including ‘I


F E A T U R E

have someone I care about, with whom I can talk about mypersonal problems’, using a four-point response scale from 0(does not describe me at all) to 3 (describes me very well);see Magnus et al (2003). The other two items were takenfrom the HBSC: ‘How easy is it for you to talk to the fol-lowing persons about things that really bother you?’ – oneresponse for mother and one response for father, with a four-point response scale: very easy, easy, difficult, very difficult(King et al, 1996). A sum score was composed for use inbivariate correlations and the three items were used as indi-cators of a social support construct in structural equations.

Translation methods

The translation of all scales from English to Romanian fol-lowed the dual-focus approach, which is a concept-drivenrather than a word-driven method (Erkut et al, 1999).Bilingual teams of psychologists and linguists producedtranslations that were evaluated by Romanian focusgroups. Final adjustments were made on the basis of focusgroup feedback.

Analysis methods

SPSS 13.0 was used for descriptive data analysis and relia-bility analysis.

Confirmatory factor analysis and patterns of rela-tionships among the scales were modelled with struc-tural equations (SEM) using Amos 5.0 (Arbuckle &Wothke, 1999). The Maximum Likelihood (ML)method of estimation was used (Yuan & Bentler, 1997).For interpretation purposes, correlation matrices for thefull sample and gender sub-samples including the latentvariables were generated (Kline, 1998). Goodness-of-fitindices used were: chi square (χ2); comparative fitindex (CFI); root mean square error of approximation(RMSEA). In model comparisons, if chi-square differ-ence showed no significant difference between theunconstrained original model and the nested, con-strained modified model, then the modification wasaccepted. CFI values higher than 0.93 suggest accept-able fit (Hu & Bentler, 1999), while values of RMSEAare considered a close fit when lower than 0.05, a fairfit when in the range of 0.05 to 0.08, and a poor fitwhen greater than 0.10 (MacCallum et al, 1996).Evaluation of goodness-of-fit of the SEM’s followedHu and Bentler’s (1999) recommendation of a two-index presentation drawn from two criteria sets. Thoseused in the present study were CFI and RMSEA, amongthe most sensitive indexes available (Byrne, 2001).

Analysis strategy

The main study objective was to test the hypothesisedstructure of the relationships among the study variables.After descriptive statistics, findings regarding the modelmeasurement at item and parcel level are presented. Afterchecking for the measurement model’s suitability, a chainof models was produced to explore systematically the rela-tionships depicted in Figure 1. The first model, to test thehypothesised gender moderation effect and main effectsbetween constructs, used the full data set and multi-groupanalyses. The assessment of self-efficacy moderation effectwas done on the two gender sub-samples separately.

Results

Response rate and descriptive statistics

All pupils in the classrooms at the time of the survey (N= 630) were invited to fill in the questionnaire, and 627of them agreed to participate in the survey, for aresponse rate of 99.5%. Table 1, opposite, presentsdescriptive statistics for all scales; correlation matricesfor study measures are presented in Table 2, opposite.Coefficients above the diagonal are for girls and thosefor boys are below the diagonal.

Testing the measurement model

A confirmatory factor analysis was performed on theitems of each scale as single factor model, and the resultsconfirmed the hypothesised factor structure. Next, a two-step approach to test the hypothesised model was used, inwhich the first step was a confirmatory factor analysis totest the overall measurement model (Anderson &Gerbing, 1988). The purpose was to confirm the uni-dimensionality of the measures of all the hypothesisedconstructs in the model and to produce a baseline model,with which the structural model fit is compared. The itemlevel analysis (33 items) of the structural model’s meas-urement confirmed that each item loaded on the hypothe-sised factor uniquely and the indices showed a close fit:χ2 (485, N = 627) = 980.61, χ2/df = 2.02, CFI = .89,RMSEA = .040.

Under the condition of uni-dimensionality andbecause of our focus on structural relations among con-structs, item parcels were constructed (Little et al, 2002)for latent variables with six or more observed measures.A parcel is made by the average of two or more items.The parcelling procedure employed grouped the items


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according to their shared variance. Consequently, thenumber of indicators for the latent variables was as fol-lows: (1) BPWS-Y, four parcel-indicators; (2) BSRS,three parcel-indicators; (3) GSE, three parcel-indicators.The measurement model including the variables with theitems parcelled (10 parcels) was tested, resulting in a bet-ter fit: χ2 (109, N = 627) = 201,93, χ2/df = 1.85, CFI=.95, RMSEA = .037.

Testing the structural model

In the second step, the hypothesised structural relationshipsbetween the stressors, social support, self-efficacy anddepressed mood were tested, with gender collapsed and allpaths included. As in the basic model shown in Figure 1,all paths were initially included.

Testing for gender moderation

To test for the moderation effect of gender, the associa-tions among stressors, resources and depressed mood

were compared for girls (N = 323) and boys (N = 304). Amodel was estimated with all parameters constrained tobe equal across gender groups and re-estimated with allparameters relaxed.1 The fit statistics for the significanceof the difference between two groups showed that girlsand boys models were significantly different (∆χ2 =19.87, ∆ df = 11, p = .047), indicating the moderationeffect of gender, the details of which are shown in Figure2, overleaf. For girls, the effects of interpersonal stress (β= .37) and worries about daily living (β = .24) ondepressed mood were significant. For boys, a significantdirect effect on depressed mood was found for worriesabout daily living (β = .28). Also for boys, an effect ofinterpersonal stress on depressed mood was mediated byself-efficacy (β = -.41), and by social support (β = -.40).The goodness of fit indices showed close fit of the modelto the data: χ2 (216, n = 627) = 277.04, χ2df = 1.31, CFI =.96, RMSEA = .021.

Number of Cronbach’sMeasures and samples N items Range M SD alpha

Bergen Social Relationships Scale 608 6 18 9.11 3.65 .56

Girls 315 16 9.66 3.58 Boys 291 18 8.51 3.63

Bergen Personal Worries Scale-Youth 593 10 39 20.63 8.05 .83

Girls 310 39 13.2 7.82 Boys 283 38 9.95 7.81

General Self-Efficacy Scale 598 10 37 20.63 5.07 .79

Girls 315 29 20.35 4.90 Boys 283 31 20.95 5.24

Depressive Mood 585 4 16 6.63 4.37 .76

Girls 304 16 7.56 4.37Boys 281 16 5.63 4.16

TABLE 1 Descriptive Statistics for all Scales

Measures BSRS BPWS-Y GSE SS SCL Age

Bergen Social Relationships Scale .35** .02 -.25** .34** .12* Bergen Personal Worries Scale - Youth .26** -.09 -.29** .35** -.04 General Self-Efficacy .02 -.26** .18** -.04 .05 Social Support -.06 -.18** .28** -.17** -.15* HBSC Symptom Checklist .20** .34** -.16** -.22** .00Age .01 -.01 .13* -.19** .16**

NOTE: the coefficients for girls are above the diagonal, and for boys below the diagonal.

*p < 0.05 **p < 0.001

TABLE 2 Correlation among Study’s Measures

1 The same procedure was followed for the test of modification by self-efficacylevel, reported in the next section.


F E A T U R E

Testing for self-efficacy moderation

To assess a possible moderator effect of self-efficacy, adummy variable was created with two levels, representingtwo subsets of cases, high and low on self-efficacy, dividedby the median. There was an association between interper-sonal stress and depressed mood for girls high on self-effi-cacy (N = 139; β = .55), and between worries about dailyliving and depressed mood for girls low on self-efficacy (N= 176; β = .45) (Figure 3, opoposite). The test for the sig-nificance of the difference between girls high and low onself-efficacy was significant (∆χ2 = 9.89 with 4 degrees offreedom, p = .042). The goodness of fit indices showedclose fit of the model to the data: χ2 (80, N = 315) = 86.31,p = .295, χ2/df = 1.08, CFI = .99, RMSEA = .016; 35% ofvariance in depressed mood is explained by the predictors.

For boys low on self-efficacy (N = 143), interpersonalstress and worries about daily living were related todepressed mood (β = .31 and β = .30, respectively; seeFigure 3). For boys high on self-efficacy (N = 139), onlyworries about daily living was associated with depressedmood, mediated by social support (β = .50). The test forthe significance of the difference between boys high andlow on self-efficacy was significant (∆χ2 = 15.33 with 7degrees of freedom, p = .032). The goodness of fit indicesshowed close fit of the model to the data: χ2 (140.44, N =304) = 203.28, χ2/df = 1.45, CFI = .92, RMSEA = .040,and explained 29% of variance in depressed mood.

Discussion

As mentioned in the introduction, this paper aimed to test

for specificity in the relationships of interpersonal stressand worries about daily living with depressed mood.Structural equation models were used to examine thedegree to which the direct effects of stressors on depressedmood were mediated through social support and self-effi-cacy, and moderated by gender and self-efficacy.

The data clearly support the specificity hypothesis, withimportant nuances illustrated in Figures 2 and 3. Turning firstto Figure 2, while it has long been known that girls reporthigher level of depressed mood than do boys (Cicchetti &Toth, 1998; Dumont et al, 2003; Petersen et al, 1993;Torsheim et al, 2005), these are among the first analyses toshow clear gender differences in the structural relationshipsamong stress, coping and distress constructs. Interpersonalstress is associated directly with depressed mood only amonggirls. Further, neither social support nor self-efficacy hasdirect or mediating roles in predicting levels of depressedmood among girls. The picture then is quite straightforwardfor girls; higher levels of stress of either type are associatedwith higher levels of depressed mood. Interestingly, socialsupport plays no structural role among girls.

Among boys, social support and self-efficacy playsignificant roles in the connection between interpersonalstress and depressed mood. Thus, in the prediction ofdepressed mood, social support is not a coping resourceamong girls, but is a key coping resource among boys.This may seem paradoxical, as girls are commonlythought to live more in the social world than boys, and tobe more closely tuned to relationship building and nur-turing (Nolen-Hoeksema & Gircus, 1994). However,there is evidence from other studies that boys benefitmore than girls from social support from parents, which

FIGURE 2 Moderation Effects of Gender

The circles represent latent variables. The arrows represent the direction of the relationships between latent variables. The double arrows repre-sent correlations between latent variables. The disturbances associated with endogenous variables, the observed variables and their error termsare not represented in the figure. All the path coefficients are significant at the p < .05 level. The models are significantly different across gender.


F E A T U R E

could explain the seeming paradox in the present data(Frey & Rothlisberger, 1996; Jenkins et al, 2002).Parental stereotypes about proper gender roles for theirmale and female offspring may lead them to supportboys’ explorative behaviour and independence (stress-inducing), while sanctioning similar behaviour in girls(Nolen-Hoeksema & Gircus, 1994; Windle, 1992).Experimental data show that adults’ expectations (espe-cially men’s) about appropriate behaviour for boys andgirls may lead them to reward boys who ‘act like boysshould’ and discourage similar behaviour when per-formed by girls (Mittelmark & Pirie, 1988). Followingfrom this, boys in stressful situations may be thought ofby others as deserving social support to cope with aboy’s ‘normal’ world, and girls in similar situations mayreceive no support, to discourage adventuresome behav-iour, risk-taking and experimentation.

As Figure 3 illuminates, this explanation is not at oddswith the self-efficacy moderation effect observed in this

study. Boys with high self-efficacy seem to have socialsupport available to mediate depressed mood, which girlsdo not. Figure 3 shows also a striking difference amonggirls in the stress–distress link for those with high ratherthan low self-efficacy. One explanation for the lack ofconnection between interpersonal stress and depressedmood among low-self-efficacy girls is that they do notengage in the challenging social relations that produceconflict, because they lack the confidence to manage inter-personal stress (Bandura, 1997; Bandura et al, 1999).Girls with high self-efficacy may, on the other hand, feelcompetent to handle daily hassles, and also to engage oth-ers in ways that may lead to interpersonal stress. However,there is no clear evidence for this in the present data, andthese explanations remain pure speculation, calling foradditional research.

The overall pattern of findings described above is con-sistent with theory about human agency. Compared withpeople high in self-efficacy, those low in self-efficacy

FIGURE 3 Moderation Effects of Self-efficacy (High versus Low), Tested Separately for Boys and Girls

The circles represent latent variables. The arrows represent the direction of the relationships between latent variables. The double arrowsrepresent correlations between latent variables. The disturbances associated with endogenous variables, the observed variables and theirerror terms are not represented in the figure. All the path coefficients are significant at the p < .05 level. The models are significantly differ-ent for high versus low self efficacy groups, for girls and for boys.


F E A T U R E

believe less in their ability to control stressors, partlybecause they underestimate the resources they have to doso (Bandura, 1997). They are less effective at finding orcreating supportive relationships, they tend not to attemptactive coping, and they seem resigned to feelings of help-lessness, anxiety and depressed mood (Bandura et al,1999; Schwarzer, 1997; Shelton, 1990). People with high,rather than low, self-efficacy have greater confidence intheir capacities to control events, they engage in action tosolve problems, and they operate in pro-social ways tocope with challenges (Bandura et al, 1999). For example,adolescents high on self-efficacy communicate well withtheir parents in seeking support to overcome difficult times(Caprara et al, 1998).

The findings of this study not only support the speci-ficity hypothesis, they also suggest that a research modelis essential that can and does permit the search for spe-cific relationships between stressors, coping resourcesand psychological distress. The critical role played byself-efficacy, as discussed above, would not have beenappreciated in any analysis which assumed generalised(non-specific) relationships between various stressorsand distress.

A criticism of any cross-sectional study such as this isthat causal relationships among predictor and predictedvariables cannot be confirmed. However, even a soundlongitudinal study cannot confirm causal direction, espe-cially in transactional phenomena – that is, phenomenawhere variables have reciprocal influence on one another.In such cases researchers are trapped by terminology andways of conceptualising their phenomena that are toosimplistic. The stress–distress relationship, conceived ofas in this study, is profoundly reciprocal. Relationshipproblems, for example, can lead to depressed mood,which in turn can worsen relationship problems, and soon in a vicious cycle. The initial precipitant may bedepression, or relationship problems, but that ratherquickly loses practical significance. It is the ongoing,dynamic transaction between relationship problems anddepressed mood that is of greatest interest, not what camefirst at the start of the transaction.

A more serious criticism of this study has to do withits inclusion of a single measure of psychological dis-tress: depressed mood. We have earlier in the paper illus-trated the specificity model with an example in which onestressor causes a specific outcome and another stressorcauses a different outcome. However, in our previousresearch with adults in Romania, Russia and Thailand, wehave observed consistently that relationship problems andpersonal worries, as assessed by the BSRS and the

BPWS, are associated significantly with depressed mood,and also with anxiety and with loneliness (Bancila et al,2005). That is evidence for non-specificity as regards psy-chological distress outcomes. However, the analyses ofthe adult studies were not conducted with specificityquestions in mind, as the specificity issue has onlyrecently become salient to us. We should perhaps re-examine the adult data in light of the present findings, butcan only regret that we decided to assess just depressedmood while designing this study.

Another lesson is that a larger sample size would havebeen preferable, to increase the statistical power of thestudy. Path coefficients smaller than β = .25 (for examplesocial support’s relationship with psychological distress forboys low on self-efficacy) were not statistically significantand, following strict practice, such paths are not included inthe final models shown in Figures 2 and 3. We might haveincluded all paths regardless of coefficient size, but thatwould have defeated the spirit of the exercise: to eliminateall but the most robust paths in the search for specificity.

Despite these and other limitations, the study does seemto add in an important way to the debate about specificity,by offering unambiguous evidence in favour of the speci-ficity hypothesis, at least for one of the three specificitymodels identified by McMahon et al (2003). The presentdata provide evidence for the stressor-specific model, thatis, different stressors have different relationships to a singleoutcome – depressed mood – conditioned by gender andself-efficacy. Left untested by this study are two additionalmodels identified by McMahon et al (2003), an outcome-specific model and a stressor-outcome-specific model.Future studies aimed at exploring these models fully willneed to assess a range of stressors and a range of outcomes,hypothesise various types of specificity based on empiricaland/or theoretical grounds, and conduct analyses suited togenerate evidence for or against specificity.

Acknowledgments

The authors would like to thank ‘Youth for YouthFoundation Romania’ for the remarkable work done bycontributing to the questionnaire translation process anddata collection.

Address for correspondence

Delia Bancila, Research Centre of Health Promotion,Faculty of Psychology, Christiesgt. 13, Bergen 5015,Norway. Tel: +47.55589969, fax: +47.55589969, e-mail:[email protected]


F E A T U R E

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Key words: immigrants; refugees; mental health; health pro-motion; cross-cultural; social support; psychosocial adaptation

Introduction

With the growing importance of migration around the world,the need to promote mental health for immigrants and otherethnocultural minority populations also grows. Lack of fore-sight, lack of multicultural competencies and implementa-tion challenges tend to hinder such health promotion efforts.Most health care policy-makers and service providers lackunderstanding of immigrant and minority mental health andrelated social and cultural health determinants (Kirmayer etal, 2003; Center for Mental Health Services, 2001).Immigrant groups may possess limited or variable awarenessof mental health issues, and may not respond to educationalmaterials and services that have not been developed withtheir cultural knowledge and social circumstances in mind(Masi et al, 1993). As a result, successful mental health pro-motion initiatives for immigrants and minorities that demon-strate respect for cultural values as well as understanding ofcommunity needs remain limited (Kreps & Kunamoto,1994). In this article, we describe the development of a mul-tilingual resource, Alone in Canada: 21 Ways to Make itBetter, A self-help guide for single newcomers, that webelieve has helped to build awareness of the factors thatinfluence immigrant mental well-being and fills a criticalneed for mental health promotion for immigrants in Ontario.

Alone in Canada: A

Case Study of Multi-

Lingual Mental Health

Promotion

Laura Simich

Scientist, Culture, Community and Health Studies Program,Centre for Addiction and Mental Health, and Assistant

Professor, Department of Psychiatry, University of Toronto

Jacqueline Scott

Consultant, Praxis Research and Training Inc, Toronto

Branka Agic

Community Health and Education Specialist, Centre forAddiction and Mental Health


This article describes the development of a popular, multi-

lingual self-help booklet for single immigrants and

refugees who may require psychological and social sup-

port during settlement and adaptation in Canada. First we

explain the need for this type of mental health promotion,

with reference to immigration patterns in Ontario, Canada,

and social determinants of immigrant mental well-being.

We then describe the collaborative process by which the

booklet was developed, and some of the adaptation chal-

lenges addressed, offering practical tips for producing sim-

ilar resources. We conclude that the booklet has been

successful because it portrays common psychosocial

adaptation challenges in a relevant context, using accessi-

ble language and immigrant voices that affirm lived experi-

ences and offer helpful advice for overcoming problems.

We suggest that such health promotion resources are not

only helpful for individuals, but may also help engage new-

comer communities and others in understanding the com-

plex factors affecting immigrant mental health.


F E A T U R E

Migration is a major life transition that can alter funda-mental social determinants of health, but does not neces-sarily jeopardize mental health. Research on immigranthealth indicates that, in general, newcomers in Canada arehealthier than the native-born (Perez, 2002). However,some newcomers’ mental health may be affected negativelywhen they encounter stressful post-migration conditionssuch as discrimination, poverty, family separation and mar-ginalization, unless appropriate support is provided (Ali,2002; Canadian Task Force, 1988). Ethnocultural groups,including immigrants, may also be vulnerable to substanceabuse because of economic and social disadvantages,racism, discrimination and cultural pressures (NationalInstitute on Drug Abuse, 2001).

Immigrant health is a crucial issue in Canada today, par-ticularly as many immigrants are experiencing prolongedperiods of low income and social exclusion (Kazemipur &Halli, 2000; Kunz et al, 2002; Li, 2002), which increasehealth disparities. Moreover, research indicates that immi-grants under-use existing health services, face significantcultural and linguistic barriers and feel a lack of trust in for-mal mental health services (Beiser et al, 2003; Hyman,2001). Immigrants who are isolated and living without fam-ily members or like-ethnic community support may be espe-cially vulnerable, because of the absence of social ties thatprotect mental health (Baker, 1993; Beiser, 1999; Kawachi& Berkman, 2001). Under these circumstances, newcomersmay feel that they have nowhere to turn. Alternative socialsupports and health promotion resources that help immi-grants cope with these challenges must be devised.

Evidence shows that health promotion can reduce over-all vulnerability and improve the general mental health ofthe population (World Health Organization, 2001).

Health promotion is the process of enabling peopleto increase control over, and to improve, theirhealth. To reach a state of complete physical mentaland social well-being, an individual or group mustbe able to identify and to realize aspirations, to sat-isfy needs and to change or cope with the environ-ment. Health is, therefore, seen as a resource foreveryday life, not the objective of living. Health is apositive concept emphasizing social and personalresources, as well as physical capacities. (WorldHealth Organization, 1986).

Similarly, appropriate social support can make a differenceduring crises and life transitions that may increase risks tohealth. As a basic, often under-estimated, determinant ofhealth, social support is defined as:

... interactions with family members, friends, peersand... professionals that communicate information,esteem, practical, or emotional help (Stewart &Lagille, 2000).

Social support enhances coping, moderates the impact ofstressors and promotes health (Bloom, 1990). Optimally,social support acts not just as a ‘safety net, but as spring-board’, enabling people to overcome challenges to theirhealth and well-being (Wilkinson & Marmot, 2003). Ourexperience with Alone in Canada suggests that health pro-motion in the form of self-help resources for isolatedimmigrants functions as an important type of ‘surrogate’social support by raising awareness of potential healthproblems and providing information to help prevent orovercome them.

The popularity of commercial self-help books testifiesto the fact that many people who may not be in contactwith the health care system seek personal, accessible waysto manage health problems, everyday stress, crises and life-transitions. Although not necessarily ‘evidence-based’,popular self-help materials are appealing and empoweringfor consumers because they emphasize well-being andrecovery. According to the professional literature, self-helpgenerally falls into two categories: professional healthcounselling tools and patient-centred philosophies(Richards, 2004). Professional health care providers havetypically used self-help resources as a means of comple-mentary, cost-effective counselling for mental disordersand substance abuse problems, and as coping assistance forother illnesses. Though they are sometimes perceived as athreat to formal service provision, studies show that self-help increases satisfaction with mental health services(Hodges et al, 2003).

Based on principles of cognitive behavioural therapy,professional-oriented resources appear to play a helpfulrole for patients in recognizing problems and enhancingself-efficacy. However, most professional self-helpresources have specific objectives, such as increasing com-pliance with formal treatment programs. Like much healthcare for disadvantaged groups, such narrowly targeted self-help resources may not address underlying social and cul-tural determinants of health (Kliewer & Jones, 1997). Ifthey are not able to situate mental well-being or healthproblems in a meaningful social context (in this case, thepost-migration context in which immigrants experienceadaptation difficulties, social disadvantages and mental dis-tress), the resources may be perceived as irrelevant. Neitherpopular nor professional self-help resources are, in anycase, ordinarily accessible to immigrants or ethnocultural


F E A T U R E

minorities, despite the growing need for health promotionresources for culturally diverse groups.

Demography is destiny: the need for multilin-gual health promotion in Ontario

Multilingual resources are a pressing need in Canada,which receives a higher proportion of newcomers relativeto its total population than most other immigrant-receivingcountries. Currently, the proportion of foreign-born inCanada is 18.4%, second only to Australia (StatisticsCanada, 2003). The need for multilingual health promotionresources is particularly great in Ontario, the provinceserved by the Centre for Addiction and Mental Health(CAMH), Canada’s largest mental health education, teach-ing and research institution.1 Although it accounts for only37% of Canada’s population, Ontario receives 60% ofCanada’s immigrants, most of whom settle in the urban-ized areas of Southern Ontario (Citizenship andImmigration Canada, 2002).

Ontario also receives most of Canada’s refugees, morethan 20,000 each year, including government-assistedrefugees and refugee claimants (asylum seekers).Undocumented and non-status immigrants, who are mostlynot eligible for regular settlement and health services, arealso concentrated in Ontario cities. Approximately half ofCanada’s annual intake of immigrants and refugees settlein Toronto, Ontario, where 44% of its current population of2.4 million is foreign-born, making it the most diverse cityin North America (Statistics Canada, 2003). As well, 44%of 250,346 new immigrants who arrived to Canada in 2001spoke neither English nor French (CIC, 2002). The Reporton Language Barriers in Access to Health Services (HealthCanada, 2001) indicates that a significant proportion ofCanada’s population experiences language barriers inaccess to health services. The report states that at least oneCanadian in fifty requires an interpreter for health care;this number is actually as high as one in ten in the urbanareas where newcomers settle.

Many immigrants to Canada are helped in the adapta-tion process by formal settlement services, family membersor other social networks from which they can receive infor-mation, counselling and emotional support. Immigrant set-tlement service providers and policy-makers have realized,however, that such formal supports may not be accessibleor appropriate for all newcomers, and that other ways tomeet their needs and to promote well-being are needed.

Developing Alone in Canada: defining the tar-get populations, approach and content

In 2000, the Ontario Settlement Directorate of Citizenshipand Immigration Canada (CIC), a federal agency, circulat-ed to immigration researchers working in various institu-tions a Request for Proposals for development of a self-help guide for single newcomers. The Culture, Communityand Health Studies Program at the Centre for Addictionand Mental Health responded with a proposal to developAlone in Canada, a self-help booklet written in simpleEnglish and French, including anecdotes and exercisesabout the settlement and adaptation process. Research-based knowledge of the psychosocial needs of immigrantand refugee groups provided a foundation for the undertak-ing. From the original circle of investigators (a psychiatricepidemiologist, an anthropologist, a social worker and ahealth promotion specialist), the research team quicklyexpanded to include a professional writer/project coordina-tor, community-based consultants and production staffinside and outside the institution.2 Cooperative relationsamong team members, including community-based organi-zations that organized valuable focus groups to help devel-op the booklet’s content, produced smooth collaboration.

The target audience for the booklet was defined as asingle immigrant or refugee (female or male) who hadbasic proficiency in understanding written English.Government statistics indicate that the proportion of singleor unattached immigrants and refugees is relatively high inall immigrant categories. More than 30% of refugees, 23%of skilled workers and 44% of those in the ‘other’ class(usually live-in caregivers and some refugees) were single(Citizenship and Immigration, 1998). Single individuals inthese categories are more likely to be in need of social andpsychological supports. The tone of the guide was intendedto validate feelings of emotional fragility, and to offer posi-tive insights, encouragement and activities that enhancemental well-being and social integration. To accentuate thepositive, the basis for our approach was a strengths ratherthan a deficit model to describe migration stress and pro-tective factors. This model takes into account the personaland social resources that help the individual cope in theadaptation process (Beiser, 1999; Ahearn, 2000).

1 The Centre for Addiction and Mental Health is a public hospital providing directpatient care for people with mental health and addiction problems. It is also aresearch facility, an education and a training institute providing health promotionand prevention services across the province of Ontario, Canada.

2 We acknowledge Citizenship and Immigration Canada for its generous financialsupport of this project. Jacqueline Scott was project coordinator and author of Alonein Canada. Katherine Babiuk was the program consultant for CIC. Dr Morton Beiserwas the principle investigator (PI) for the first phase of development. Laura Simichwas PI for the translation phases. Rhonda Mauricette and Cristina De Sa, CAMH,also provided invaluable assistance. In addition to many CAMH staff, individualsfrom the following organizations served as community advisors: Hong Fook MentalHealth Association, Mt. Sinai Hospital, the Canadian Centre for Victims of Torture,Ontario Self-help Network, Self-help Resource Centre, the Ontario Council ofAgencies Serving Immigrants and Toronto Public Health.


F E A T U R E

Alone in Canada is now available in 18 languages inprint and electronic versions. As of October 2004, CAMHhad distributed 58,000 print copies of Alone in Canada onrequest. The booklet is also downloaded electronically inall languages, hundreds of times each month. Researching,translating and producing the booklet occurred in threestages. In the first stage, the booklet was written in Englishand then translated into French. The success of the Englishand French versions came as a pleasant surprise, and thedemand for the booklet quickly exhausted the printed sup-ply. The second stage of the project was fuelled by the ini-tial success of the English and French versions. In 2002CIC provided additional funding for the booklet to betranslated into seven new languages (Arabic, Chinese,Farsi, Somali, Spanish, Tamil and Urdu).

The demand for Alone in Canada continued unabated.Even though the booklet was distributed free of charge byCAMH, this fact alone was insufficient to account for thepopularity of the booklet. It appeared that Alone inCanada had tapped into an unmet need for mental healthinformation among many newcomer communities. In thethird stage of the project, the booklet was translated intoa further nine new languages in 2003 (Bengali, Dari,Hindi, Korean, Punjabi, Russian, Serbian, Tagalog andTwi). The selection of the languages for translation wasdetermined in a number of ways, including analysing thelandings statistics from CIC to determine which recentlyarrived immigrant groups, based on country of origin, hadlarge proportions of singles. Service providers were alsoconsulted to determine which groups were most at riskand under-served. These tended to be less establishedimmigrant communities that had been in Canada a shorterperiod of time.

Although we cannot fully describe the contents ofAlone in Canada in this article because of space limita-tions, some aspects of the adaptation process that areaddressed in the booklet and supported by longitudinalpsychosocial research (Beiser, 1999) and other studies ofimmigrant mental health include the effects of social isola-tion, phases of emotional adjustment, maintaining self-esteem, negotiating cultural identity and coping with dis-crimination. Being single or isolated during migration andsettlement magnifies stress that is otherwise lessened bysocial support from family members or like-ethnic commu-nity. Regardless of marital status, seniors or women whoimmigrate with children/families may be especially isolat-ed because of barriers to movement, work, language class-es and therefore social integration. Some also may beinvolved in problematic or abusive relationships that exac-erbate feelings of isolation.

The manual conveys the idea that adaptation and inte-gration is a process (Thompson & MacDonald, 1990). Aspart of the transition through this stage of life, newcom-ers can expect to go through several phases: elation (the‘honeymoon’ phase), grief, regret, emotional ups anddowns, exhaustion, confusion and fear, perception orexperiences of discrimination based on race or ethnicorigin, disorientation, disappointment, loneliness andphysical and emotional health problems as a result ofstress. It may help immigrants to know that it takes timeto adapt successfully, measured by external factors suchas finding acceptable work and being linguistically profi-cient, and by the internal feeling of being generallyhealthy. A newcomer’s time perspective also is critical tothe adjustment process, and how thoughts of past, pres-ent and future are managed affects the experience ofstress (Beiser, 1999).

Difficulties in securing appropriate employment tend totake their emotional toll on newcomers, now more thanever. The primary target audience for the manual is theyounger labour force groups (age 24–45), as people out-side those age groups tend to enter Canada as part of fami-lies. Immigrants are on average better educated than theCanadian-born population, yet many immigrant profession-als are suffering debilitating underemployment (Badets &Howatson-Leo, 2000; CIC, 2004), which can contribute tomental distress.

The negotiation of cultural identity is a potential mentalhealth protective factor (Kassabian, 1996; Rummens,2003). Immigrants, as well as health care providers, mayexpect new Canadians to go through an orderly process ofshedding country of origin identifications in favour of‘Canadian’ identity. However, there is ample evidence tothe contrary, as well as evidence linking the vicissitudes ofidentity formation to compromised mental health (Ujimoto,1999; Waters, 1990). The extent to which newcomers expe-rience discrimination from the host society or other minori-ty group members also influences their sense of identityand emotional well-being (Krieger, 2001; Noh et al, 1999).

Methods

Given the demographics of the target group, it wasimportant that the booklet reflected the lived experiencesof single newcomers and that its language was accessi-ble. To this end, the 50-page booklet was subdivided into21 short chapters (most were 2–3 pages long), was illus-trated and contained ample white space to complete theself-help exercises or to make notes. The booklet was writ-ten in the second person and used simple straightforward


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language. Anecdotes and exercise ideas for Alone inCanada were collected with the help of focus groups foreach language group, organized under the auspices of com-munity-based organizations, using community develop-ment principles that encourage social groups to identifytheir own needs and to develop health promotion resourcesin culturally and linguistically appropriate ways.3

The project used two types of focus group. Focusgroups of the first type were conducted in English, andwere used to test the relevance and appropriateness of thetopics for the target audience and to ensure that the lan-guage was clear and straightforward. The second type offocus group was monolingual and was used to test theaccuracy and the spirit of the translation from English tothe other target languages. Each focus group consisted ofbetween five and eight people who were single newcomersto Canada. During the group they discussed words andphrases that were unclear or did not have an equivalentmeaning in their culture.

Because the booklet addresses some Canadian socialpractices that are not familiar in all cultures, many groupshad lively discussions about such concepts and terms as‘dating’, ‘potluck dinner’ and ‘same-sex relationship’.These concepts are culturally based and were seen as notexisting or as inappropriate for discussion in some cul-tures. Some translators and editors were resistant to trans-lating these topics, as they did not wish to be seen as pro-moting unacceptable behaviours in their community. Inthese instances, the project writer acknowledged the deli-cacy of the topics and reiterated that Alone in Canada waswritten for a general audience of newcomers and not aspecific ethnic group. All the focus groups were able toreach consensus on the appropriate term to use in thetranslation for describing these topics. Some groups addedextra sentences to the text to explain why these topicswere included in the booklet.

Practical tips for developing multilingualhealth promotion resources

Producing the multilingual editions of Alone in Canada

was a complex task. Many lessons were learnt along theway, and the most practical of these include the following.

Overview of each language

It helps to have a basic overview of each language, includ-ing the countries where it is spoken, which way to read thescript and differences in regional dialects. This informationis invaluable for gaining credibility from the focus groupsand with the community agencies involved in the project.For example, Farsi or Persian is spoken in Iran and in someparts of Afghanistan. It uses the Arabic script and is readfrom right to left. To an English reader, a book printed inFarsi will be read from back to front. Somali is anotherexample. It is spoken in Somalia and uses the Latin script,like English.

Community involvement

Alone in Canada was produced with the help of manycommunity organizations that were either providers of set-tlement services or served a specific language group.Involving a large number of agencies took extra time andeffort. However, it was an invaluable way of reaching outto communities who were marginalized or who did not usemainstream mental health services because of cultural andlinguistic barriers, and of ensuring the validity of the con-tent. Many of the agencies were surprised and pleased thata large institution such as CAMH, cared enough about thetranslation to involve them in the process. The communityagencies also recommended translators, organised focusgroups and assisted with the promotion of the booklet.

Acknowledgements

All organizations, translators and editors who worked onAlone in Canada were listed in the acknowledgementspage in the booklet. This was done to demonstrate that theproject was a team effort and also to show that the targetcommunities were consulted on including information inthe booklet that may be culturally sensitive.

Translators

Alone in Canada was translated by independent translators,all of whom were recommended by community agencies.While this created extra administration, as the project hadto manage 17 translators and not just one translationagency, it increased the confidence in the accuracy of thetranslation. All the translators were experienced and had

3 We would like to thank the community organizations participating in researchand development focus groups: Woodgreen Community Centre, Ontario Councilof Agencies Serving Immigrants, Elspeth Heyworth Centre for Women, ChristEmbassy Church, COSTI, the Eritrean Canadian Community Centre, Kingstonand District Immigrant Services and St. John Settlement Services, and communi-ty organizations participating in translations focus groups: Arab CommunityCentre of Toronto, Iranian Community Association of Ontario, QuakerCommittee for Refugees, Somali Immigrant Aid Organization, Vasantham TamilSeniors Wellness Centre, Council of Agencies Serving South Asians, BengaliFamily Support Services, Afghan Women’s Organization, Hindu Sabha, KoreanCanadian Women’s Association, North York Sikh Temple, Russian CanadianTheatrical Community Centre, Family Services Association of Toronto, FilipinoWorkers Support Committee and Rexdale Women’s Centre.


F E A T U R E

handled similar projects. The translators were also requiredto liaise with the printer to ensure that the printed bookletswere accurate.

Editors

Each translator was required to work closely with an edi-tor. The editors were an additional pair of eyes, used toreview the translated text. This made the differencebetween a polished translation and one that was so literalthat it missed the point and was thus incomprehensible. Itwas important that the target audience for the bookletshould be able to read it easily in their language withoutreferring to an English version.

Gender

The translators and editors were given the gender of allpersons quoted in the booklet. In many languages, such asFrench and Spanish, the spelling of a word can changedepending on the gender of the subject.

Graphic design

Different languages require varying amount of space to saythe same thing on the printed page. For instance, French andTamil are ‘wordy’ languages and require about one-third morespace than English. These space variations need to be consid-ered at the start of the graphic design process. If not, the con-tent may have to be cut or the typeface reduced to make thefull content fit the page. Neither of the latter scenarios is ideal,as they compromise the integrity of the project.

Typesetting and printing

The multilingual editions of Alone in Canada requiredextra time and money for typesetting and printing. It prob-ably would have been more economical and faster to haveeach booklet printed by a language-specific company – thatis, the Russian booklets printed by a Russian printer.However, it was important that the quality of the printedbooklets was consistent in all 18 languages, so one typeset-ter and one printer handled the contract.

Print run

We attempted to establish a realistic figure for the numberof books to be printed. The initial cost of printing can behigh, but it decreases substantially with volume. The costof reprinting can be just as high as the initial printing costs.

Name each language

We ensured that the title of the book and the name of thelanguage in which it was printed were included in Englishon the front or back cover of the publication. People dis-tributing the booklet may not recognize Bengali, Twi orUrdu scripts; naming the languages in English makes iteasier for them to use.

The dissemination of mental health resourcesin multicultural Ontario

The production and distribution of Alone in Canada andother resources developed for culturally diverse communitieshave helped to send a message to ethnocultural communitiesand health care professionals in Ontario that CAMH is pre-pared to break down barriers to mental health services andreach out to newcomers. CAMH has used Alone in Canadawith other health promotion resources for ethnoculturalcommunities in an attempt to maximize mental health andwell-being among members of culturally diverse communi-ties. Currently, all 18 languages are available in print form.PDF versions in 18 languages are also available online atwww.camh.net/about_addiction_mental_health/alone_in_canada_0804.html. CAMH plans to conduct anevaluation, secure additional funding for future reprintingand amend the booklet with general information on whereto seek help when needed. As this booklet is one of a veryfew health promotion resources available in multiple lan-guages and is accessible to non-English speaking newcom-ers, it is widely used by organizations providing services toimmigrants and refugees, such as settlement agencies, lan-guage programs for newcomers, community health centres,international schools and colleges, adult learning centresand women’s shelters.

Reflections on the effectiveness of Alone inCanada

The primary goal of this self-help booklet is to decreasepost–migration stress, facilitate resettling in Canada andpromote the physical and mental health of single, hard-to-reach newcomers. Evaluating self-help resources hasproven difficult. Opinions on the effectiveness of self-helpmethods are currently divided, because there is little agree-ment on how the content and process of self-help actuallywork (Richards, 2004, p120). Though preliminary, an eval-uation of Alone in Canada by 22 mixed focus group partic-ipants who were recent newcomers to Canada in 2003 sug-gests that the booklet reinforces positive thinking, prob-


F E A T U R E

lem-solving, active help-seeking, stress reduction andphysical and emotional health.4

Available in 18 languages in print form and on theInternet, the self-help guide fills a distinct void in multi-lingual health promotion resources in Ontario, a fact thatmay help account for the high demand. However, morethan filling a void, Alone in Canada is evocative. The evi-dent emotional appeal of the booklet may lie in the per-spective adopted and the social context described. Thepower of the immigrant voices of experience captured inthe text, that is, who is providing guidance and support,not just what (content) or how (process), is significant.As we know, sociocultural and situational similaritiesenhance perceptions of empathic understanding (Thoits,1986). Focus group participants who helped to developthe booklet by expressing their feelings and offering prac-tical advice are quoted throughout the booklet. Althoughnot an unusual presentation technique, this affirmationalsocial support may be especially effective for immigrantsor refugees who may need help with navigating a newsociety (Simich, 2003). Affirmational social support issimilar to the help provided by experienced self-helpgroup members to potential group members in other suc-cessful health interventions (Powell et al, 2000, 2001). AsHumphreys and colleagues note, this social referencepoint is especially valued and effective when situated insomeone ‘who has been there, too’ (2004).

Placing mental health challenges in a familiar socialcontext may also be crucial for creating understanding andawareness. Challenges associated with migration andadaptation may be hard to recognize and to communicatefor any immigrant, particularly if family members backhome have high expectations of the lone person settling inCanada, who may be unable to share or express the extentof his or her individual difficulties. Alone in Canadadescribes adaptation challenges in accessible written formand in recognizable social situations, which allows theindividual reader to acknowledge potential risk factors andmental distress without the personal risk of shame andstigma that is attached to mental illness in many commu-nities (Australian Transcultural Mental Health Network,1997; World Health Organization, 2001). Moreover, plac-ing adaptation challenges in a multifaceted social contextexpands the perspective beyond a medical focus on ill-ness, to help the reader recognize multiple influences onmental well-being, providing a useful health promotionperspective for professionals as well (Khanlou, 2003).

The occasionally light-hearted depiction of commoncultural adaptation problems combined with ways of man-aging more serious migration stresses is also persuasive, asthe manner conveys a sense of social learning and psycho-logical flexibility. The experience of migration is, after all,not an experience of illness, but a social transition in whichthe self is recreated in a new society and acculturation tohealth behaviours proceeds in complex ways dependent onconditions in both sending and receiving societies (Porteset al, 1992). Immigrants negotiate new and different envi-ronments using a ‘dual frame of reference’ to draw on oldand new parts of the self and behaviours in order to cope(Suarez-Orozco, 1997). Coping with the settlement andadaptation process also requires the psychological flexibili-ty to shift from external to internal concerns, from themundane to the profound, such as managing practicalitiesof food, finances and winter weather, as well as the exis-tential need for affirmation and spiritual sustenance.

Alone in Canada thus strikes a good balance as a per-sonal yet community-informed resource that is based onpsychosocial research evidence and advice from newcomersand potential health care consumers. The booklet offers amoving and accessible way to approach the complex chal-lenges of a serious and potentially hazardous life transition,and for this reason can influence the individual reader. Itsgeneral approach, that promotes well-being but also gentlyintroduces a discussion of serious and possibly stigmatizingmental distress, may also be a way of building ‘communityreadiness’ for subsequent implementation of health promo-tion or prevention programs (Edwards et al, 2000).

Conclusion

Designed for individual self-help, Alone in Canada may alsobe an effective resource in group settings, judging by theenthusiasm of project participants who helped to developand validate the content and of newcomer language classesthat have used the booklet as a discussion tool. The bookletmay also be used effectively as a starting point to discussmental heath and mental illness in group sessions with newimmigrants, to reduce the stigma attached to mental illnessand to encourage people to seek help when needed.Furthermore, the booklet is not only an excellent resourcefor individuals who are new to Canada, but is also a valuabletool for service providers which enables them to understandbetter the problems and difficulties that face their clients inthe settlement process. Incorporating Alone in Canada inclinical settings and measuring its effectiveness as part ofspecific interventions, while not on the immediate researchagenda, are also worth considering for the future.

4 Baerlocher, M. (2003) Evaluation of Alone in Canada: 21 Ways to Make it Better -A Self-Help Guide for Single Newcomers. Determinants of Community HealthResearch Project, Faculty of Medicine, University of Toronto (unpublished report).


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As Richards (2004) points out, self-help is a suitableapproach for many purposes: mental health promotion, acompanion to therapy and an empowering philosophyavailable as a social resource to communities that mayhave faced discrimination or marginalization. For someimmigrant and ethnocultural groups in Ontario, Alone inCanada is probably the only tool currently available tocommunity members that is written in an accessible lan-guage that speaks of their own experiences of social adap-tation and isolation and their mental health effects. It hasserved to build bridges into immigrant communities, help-ing individuals along the way.


Dr Laura Simich, Culture, Community and Health StudiesProgram, Centre for Addiction and Mental Health, 250College Street, Toronto, ON M5T 1R8, Canada, tel: (416)535-8501 x6421, fax: (416) 979-0564, email:[email protected]

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Key words: acculturation; ecological; immigrant health;mental health research

The application of an ecological frameworkto mental health research with immigrantpopulations

Immigration is deeply rooted in U.S. national identity.Most Americans have stories about immigrant ancestorswho came to the United States generations ago, and stillothers have more recent stories about their own immigra-tion experiences. This casual knowledge of immigration,however, is only a brush stroke on a canvas that revealsmore depth and complexity than are revealed at firstglance. If immigration stays constant at the current level,61% of the population increase between 1990 and 2050will be accounted for by immigration (Isbister, 1996). TheU.S. population will grow by 133 million over the next 60years and 81 million people will be immigrants or the off-spring of immigrants (Isbister, 1996). Changes in U.S.demographics will require the U.S. to organize its educa-tional and health care systems and public policies to pro-vide for the needs of new immigrants. Such increases inglobal diversity will also result in multi-layered and com-plex changes in U.S. culture.

Culture is an essential construct to consider whenexamining immigrants’ experiences. Fiske et al (1998)argued that cultural expressions are continuously present inan individual’s interactions in work, school and home set-

Research with

Immigrant Populations:

The Application of an

Ecological Framework

to Mental Health

Research with

Immigrant Populations

Mirsad Serdarevic

Krista M. Chronister

University of Oregon


The purpose of this article is to outline the benefits of an

ecological model framework for conducting cross-cultural

psychological research with immigrant populations. There

are four ways we hope to add to the existing literature. First,

we propose an ecological framework to assess the develop-

mental processes and mental health outcomes for immi-

grants over time. Second, we present interdisciplinary and

international research on immigrants’ experiences to further

efforts to share knowledge and enhance understanding of

the impact of globalization on immigrants’ experiences.

Third, we describe factors leading to immigrants’ positive

and negative mental health outcomes. Fourth, we discuss

the processes of acculturation and adaptation using an eco-

logical framework. We conclude with recommendations for

how scholars may use the ecological model to enhance

research on immigrants’ acculturation experiences.


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tings. Further, cultural norms and customs are symbiotical-ly related to political, educational and legal systems. Thepurpose of this article is to propose an ecological frame-work for conceptualizing the common and varied experi-ences over time of those who immigrate to the UnitedStates. There are three primary ways in which we hope tocontribute distinctly to the existing literature on immi-grants’ experiences.

First, we describe an ecological framework(Bronfenbrenner, 1979) to help conceptualize systemati-cally the diverse developmental processes experienced bymany immigrants over time. Bronfenbrenner’s ecologicalmodel (1979) incorporates all the components of culturein an integrated way that allows for bidirectionalexchange between an individual and all levels of his/herecology over time. Bidirectionality is of special interestin immigrant research, which emphasizes the importanceof culture of origin as well as an exchange between theindividual immigrant and the absorbing or host society(Ben-Sira, 1997; Berry, 1997). To conceptualize cross-cultural comparative studies better, researchers may usethe ecological model as a guide, because it is applicableto the field of immigrant research and acculturation andthe model is versatile enough to capture a broad range ofcross-cultural factors.

Second, we use the acculturation process and exist-ing research to support the use of an ecological frame-work in research investigations with immigrant popula-tions. Acculturation is a complex, ever-changingprocess, and consequently demonstrates our need asresearchers to use a comprehensive framework to cap-ture accurately the richness of immigrants’ experiences.Third, we use interdisciplinary and internationalresearch to describe acculturation processes and ecologi-cal factors that lead to positive and negative immigrantmental health outcomes. Much of the existing researchon immigration provides valuable information about thenegative health outcomes and contextual barriers thatimmigrants experience, particularly immediately afterarriving in a host country. There is significantly lessresearch, however, on immigrants’ longer-term mentalhealth outcomes, positive aspects of their immigrationexperiences and resiliency.

Immigrants’ experiences in context

Migration is the process by which people move from onelocation to another (Marsella & Ring, 2003). There aremany different types of migrant, including immigrants,refugees, emigrants, international workers, businessper-

sons, diplomats and exchange students (Schmitz, 2003).We have chosen to focus on the experiences of adult immi-grant individuals who move from their country of origin(home country) to another country (host country).Immigrants’ experiences may differ from those of some ofthe other migrant groups, because immigrants may be doc-umented or undocumented, may migrate under dangeroussituations, may legally return to their home countriesand/or do not leave their home countries to seek politicalasylum or escape persecution.

Immigration may be a time of crisis and/or opportunityfor individuals and families (Darvishpour, 2002).Researchers have attempted to create immigration modelsthat not only focus on the individual immigrant’s experi-ences and mental health outcomes, but also attend to theimmigrant’s environment (Guarnaccia, 1997; Portes et al,1992; Rogler, 1994). These models have focused primarilyon causal variables and processes related to immigrants’help-seeking behavior or mental health outcomes. Berry’swealth of research (1991; 1997) has focused on building ataxonomy of intervening and moderating variables ofacculturative adjustment processes. Although Berry’smodel contains the necessary complexity for discussingimmigration and acculturation, it is less effective in inte-grating Lazarus’ model of coping (Lazarus & Folkman,1984) with a social learning paradigm in relation to accul-turation (Schmitz, 2003). Lazarus’ model is of specialimportance, as it emphasizes the person’s ongoing relation-ships with the environment and the variability of outcomesin different contexts.

We expand the study and understanding of immigrants’experiences and mental health by applying an ecologicalframework (Bronfenbrenner, 1989 – Figure 1, overleaf) toimmigrants’ mental health development, migration andacculturation experiences. Bronfenbrenner’s ecologicalframework provides:

a visual representation of how different individualand contextual variables are related to immigrants’developmenta framework for examining multiple individual andcontextual factors affecting immigrants’ accultura-tive adjustment and mental healtha focus on immigrants’ mental health outcomes overtime, not only immediately following migrationan illustration of bidirectionality – the impact oflarger social contexts on individual immigrants andthe impact of immigrants on larger contexts, includ-ing their families, communities and host societies(Figure 2, overleaf).


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The ecological model

The ecological model articulated by Urie Bronfenbrenner(1989) suggests that individuals are embedded in multiple

ecological contexts which exert influence on individualdevelopment. In turn, individuals also have the power andagency to exert influence and make changes in their envi-ronments, processes termed bidirectionality. Immigrationis a bidirectional exchange between immigrant individualsand families and their host countries (Ben-Sira, 1997;Darvishpour, 2002). The five levels of ecology that makeup the ecological framework are the micro-, meso-, exo-,macro- and chrono-systems (Figure 1). The microsystemconsists of individuals and communities with whom theindividual immigrant comes into direct contact. Examplesof microsystemic factors include family members, friends,co-workers, employers and clergy. People and communitiesin the microsystem often exert a more direct and frequentinfluence on individual development.

The mesosystem represents the type and quality ofrelationships among microsystems, but does not includethe individual. For example, an immigrant’s mesosystemmay consist of the quality of the relationship between herparents’ and spouse, between her siblings and friends, andbetween her parents and extended family members (grand-parents, etc). The ecological model proposes that individ-ual development will be affected more positively ifmesosystemic relationships are positive.

The exosystem consists of the interconnectionsbetween one or more settings in which the individual is not

FIGURE 1 Ecological Model (Bronfenbrenner, 1989)

FIGURE 2 A Theoretical Conceptualisation of the Roleof Context in Immigration Processes

Note: Because immigrants’ micro- and meso- systems are often uprooted with immigrants (for example when they immigrate with familymembers) and remain somewhat of a constant in the host country (for example families remain constant, especially older generations suchas parents and grandparents), we recommend emphasizing research that focuses on exo- and macro- levels of ecology, as these levelswill have more variability between the home country and the host country.


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directly involved. Public policy and government activitiesare examples of exosystemic factors. For example, stateand federal policies are made every day regarding immi-gration restrictions, health care provisions and housingresources. Such policies affect the immigrant’s develop-ment directly, but s/he is not necessarily present in govern-ment sessions when these decisions are made.

The macrosystem represents our social blueprint, andconsists of our values, cultural beliefs and norms, socialstructures, gender-role socialization, race relations andglobal resources (Bronfenbrenner, 1989). Macrosystemicfactors include Americans’ beliefs about immigrants and theprejudices, racism and xenophobia towards immigrants thatmay result at the micro-, meso- and exosystemic levels.Similarly, Americans’ attitudes and behaviors in the micro-and meso- systems are affected by the values and norms putforth by U.S. government policies and the larger society.

Finally, the chronosystem represents the developmentof interconnections among individuals and their environ-ments over time (such as historical eras, changing globaleconomies and political relations). With regard to immigra-tion, acculturation is a clear example of how time affectseach level of the ecology and individual development.

Defining acculturation

One of the most critical processes affecting immigrants’ men-tal health is the acculturation process. For these reasons wefocus on the application of an ecological framework to exam-ination of acculturative processes. Acculturation refers toimmigrant adaptation of cultural attributes (the way of talk-ing, dressing, societal values, etc) of the host society resultingfrom continuous contact between immigrants and membersof the host society (Ben-Sira, 1997). It is important to under-stand that acculturation is an individual-level occurrence asmuch as it is a social phenomenon. For example, Berry(1991) refers to ‘psychological acculturation’ to describechanges in the life of individuals who are members of largercultural groups undergoing cultural change. Unlike assimila-tion, acculturation does not necessarily imply loss of all cus-toms and values from the home culture, but rather is a com-plex process that can take many shapes, including integrationof customs from both the home culture and the host culture,an adaptation that is increasingly viewed as optimal andhighly adaptive (Magana et al, 1996).

One way to conceptualize acculturation is as a three-level process that consists of initial joyful relief, followed bydisillusionment with the host society and then acceptance ofthe good and the bad in the host society over time (Espin,1999). The initial stages of immigration are characterized by

lack of understanding of the host society, which often trans-lates into an idealized view of the host country (Ben-Sira,1997). As immigrants constantly come into contact with thereceiving society, their expectations and the reality of thehost country are incongruent. This incongruence leads todisappointment and disillusionment with the host country,and if it persists over longer periods of time it may con-tribute to development of psychological maladjustment andother psychological problems (Ben Sira, 1997) over time. Asthe host society becomes normative to the individual,acceptance is achieved. This description of acculturation isoften described as unidimensional and linear.

Acculturation is not a linear process, however, but a com-plex process that is constantly oscillating, or changing overtime, and it is tied to developmental and psychological con-structs such as language and identity. Research (Schnittker,2002) has challenged the single continuum model of accul-turation, and we argue that researchers need to examineacculturation contextually to capture a more accurate pictureof immigrants’ experiences (including biculturality) and men-tal health development (Wallen et al, 2002).

The acculturation process

It is important to think of acculturation stages as perme-able, interchangeable and changing over the course of theindividual immigrant’s life, rather than as an impermeableand linear progression of immigrants’ experiences as theyoccur over a finite span of time. An individual may gothrough all three levels of acculturation and reach accept-ance but, over time, as the economic climate of the hostsociety changes, so too may the society’s perception of theimmigrant change. As a result of the host society’s chang-ing views of immigrants, immigrants’ physical, mental andeconomic well-being are affected. In other words, accultur-ation cycles oscillate over time as immigrants’ contextschange. Similarly, having experienced one three-level cycleof acculturation, an individual immigrant may be facedwith new challenges over time and in different contexts.For example, an immigrant who initially had to adjust tolife in a host society, but in an ethnically homogenousneighborhood consisting mostly of members of the immi-grant’s home culture (such as an immigrant from Chinaliving in a U.S. Chinatown), may go through anotheracculturation process(es) in a new context and setting,where the host culture is more salient in daily living anddifferent demands are placed on the individual (residentialsetting, employment setting, etc).

For research scholars, increasing our awareness ofchanges in immigrants’ experiences over time (chronosys-


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temic changes) is critical to improving our investigationsof immigrants’ development and mental health needs, andthe impact of changes in mental health and immigrationpolicies and services (exosystemic changes). Much of theextant immigration research focuses on immigrants’ migra-tion experiences and the time immediately after arrival in anew country, because these experiences can be extremelystressful and traumatic. There is evidence that suggests,however, that the beginning stages of acculturation are notalways the most stressful, and that immigrants do not nec-essarily experience less stress as they acculturate (Burnamet al, 1987; Escobar et al, 2000; Williams & Berry, 1991;Mirsky & Kaushinsky, 1989). For example, Williams andBerry (1991) hypothesize that refugees, during the finalstages of their resettlement, experience higher prevalenceof anxiety and depressive disorders. Escobar et al (2000)found that the prevalence of psychiatric disorders is lowerif the time since immigration to the U.S. is shorter forMexico-born immigrants.

Similarly, a recent study of adolescent immigrants byGfroerer and Tan (2003) confirms previous findings thatreveal lower rates of substance use among foreign-bornyouths compared with youths born in the U.S., butincreased risk of substance use as foreign-born youthsbecome acculturated. Gfroerer and Tan (2003) also foundthat, among Hispanics living in the U.S, the prevalence ofsubstance use was lower for those who responded inSpanish than for those who responded in English. Burnamand colleagues (1987) found that prevalence rates for diag-noses of alcohol abuse and dependence, drug abuse anddependence, antisocial personality and phobia increased indirect proportion to acculturation level among the partici-pants, of whom about half were of Mexican origin (eitherMexico- or U.S.-born) and the other half were largely non-Hispanic whites. This research on acculturation and immi-grants’ mental health outcomes over time debunks our prej-udices that adjusting to American culture and values ispreferable and leads to better mental health outcomes forimmigrants. Moreover, this research challenges researchersto expand their investigations to immigrants’ longer-termexperiences in a host country.

Understanding the role of context and social support inthe immigration process is also critical to improving ourresearch on immigrants’ experiences and mental healthneeds. Recent research (Majercsik et al, 2003) indicatesthat immigrant patients treated with psychopharmacologi-cal medications for mental health problems showed betteroutcomes if their therapy was supported by relatives. Thisis consistent with earlier research done by Tate (1982),who reported from a sample of immigrants that life satis-

faction is predicted by the number of friends, while anxietyis associated with the loss of friends (Steinberg, 1994).These outcomes have serious implications for immigrantswho immigrate either alone or with few family members.Often immigrants live in social isolation, which some stud-ies speculate may affect the serotonergic system bydecreasing serotonin release in specific brain areas(Majercsik et al, 2003). An imbalance of serotonin hasbeen proven to be associated with anxiety disorders, andthus may have profound and adverse effects on the mentalhealth of immigrant populations. Moreover, interconnect-edness between social stressors, such as social isolation,poor language skills and health, has been documented bymany researchers (Gunnar & Vazquez, 2001; House &Landis, 2003; Lupien et al, 2001).

Cultural segregation in a new country and homoge-neous communities such as ‘Little Tokyo’ or ‘Little Italy’may contribute to increased isolation from the dominanthost society. As a result, immigrants may experiencegreater challenges and stressors when they do come intocontact with members of the host society, because theyhave significantly less experience with members of thehost society than do immigrants who are less isolated. Theinsular enclave economy, such as that of New York’sChinatown, also does not help immigrants learn English,and may trap them in dead-end jobs in poor working con-ditions (Foner, 2002). The interconnectedness of variousenvironments (for example mesosystem) highlights theimportance of using the ecological model to analyze com-plex immigration issues.

For example, Ying (1996) explored Chinese immigrantsin the U.S. and found that those who experienced problemswith language, discrimination and social isolation wereless satisfied, and therefore more vulnerable to maladjust-ment. In addition, Ying (1996) found that those Chineseimmigrants who had both Chinese and non-Chinesefriends, and enjoyed more Chinese and mainstreamAmerican-oriented activities, were more satisfied with theirlives. Ying’s findings are consistent with research support-ing biculturalism as an optimal adjustment for immigrants(Wallen et al, 2002). Using the ecological model,researchers may ask how the benefits of different levels ofacculturation vary with different time points in the migra-tion process and with individual development. This is anarea of immigrant research that needs further investigation.The quality of immigrants’ social relationships is a func-tion of broader ecological factors. The state of immigrants’mesosystem, or interrelationships among contexts, is deter-mined by their positions in a larger social structure that isarranged by age, race, sex and socioeconomic status and


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organized through residential communities and largersocial structures (House & Landis, 2003).

John Berry, a cross-cultural psychologist, was the firstpsychologist to write about the necessity for a comprehen-sive conceptualization of research on immigration. Byusing the ecological model in this article, we attempt toaccount for acculturation, identity development and lan-guage use over time, and describe a comprehensive frame-work that can guide immigration research. AlthoughBerry’s model reflects the complexity necessary to discussimmigration and acculturation, it is less effective in inte-grating Lazarus’ model of coping (Lazarus & Folkman,1984) with a social learning paradigm in relation to accul-turation (Schmitz, 2003). Lazarus’ model is of specialimportance, as it emphasizes the person’s ongoing relation-ships with the environment and variability of outcomesacross different contexts. Our application of the ecologicalmodel to immigrants’ experiences (see Figure 2) attemptsto capture both the complex interrelationships of contextu-al factors influencing immigrants’ mental health and thechanging nature of immigrants’ experiences and mentalhealth outcomes, by examining how context and timeinfluence immigrants’ development.

Research from around the world: the influenceof the exo- and macro-systems

Research that includes the examination of microsystemicfactors and mesosystemic relationships is critical forgaining a more comprehensive understanding of immi-grant populations’ mental health development. It is notenough to describe a participant sample based on demo-graphic characteristics; we must also identify anddescribe with our research the more distal contexts inwhich immigrants are living. Cross-cultural studies pro-vide us with important insight into immigrants’ accultur-ation in different countries by illuminating how largerexo- and macro-systemic factors such as the host soci-ety’s views of immigration and economic, political andcultural environments affect immigrants’ acculturationprocess(es). For example, some studies conducted inNew Zealand (Pernice & Brook, 1996) reported that, astime of residence in the host country grew longer, immi-grants’ mental health improved.

It is important to note that the ethnic groups exam-ined in this study consisted of Southeast Asian, Britishand Pacific Island immigrants who were perceived posi-tively by the host society. Pernice and Brook’s (1996)findings suggest that immigration processes are tied tothe host country’s views and reception of specific ethnic

groups. It can be argued that the host society’s percep-tion of immigrants is one of the primary determinants ofimmigrants’ mental health status (Ben-Sira, 1997). Thisargument has been confirmed by other researchers, whofound that the best predictors of psychological well-being of Moroccan and Peruvian immigrant women inSpain were the number of Spaniards in their support net-work and their perception of personal control (MartinezGarcia et al, 2002).

Schnittaker (2002) showed that Chinese immigrants’English language use and Chinese cultural participationaffected their self-esteem. He argues, however, that theseeffects are contingent on the Chinese ethnic group com-position of the neighborhood in which the immigrantlives. For example, English language use may lead tohigher self-esteem if the individual lives in a predomi-nantly English-speaking neighborhood, but may lead tolower self-esteem if the individual lives in a predomi-nantly Chinese or non-English-speaking neighborhood.These findings highlight the influence of context onimmigrants’ language choice and self-esteem, whichhelps explain the oscillating nature of acculturation andimmigrants’ psychological adjustment; immigrant’s psy-chological outcomes constantly change and range frompositive to negative depending on, among other factors,the environment in which they live.

The Schnittaker (2002) study illustrates the relativity ofacculturating across different environments, as what is per-ceived as adoptive in one setting may not be adoptive inanother. Similarly, Bradley (1999) found that negativemacrosystemic influences such as poverty can be assuagedwhen an individual’s proximal (or more immediate) envi-ronment is supportive and responsive (for example family,neighbors). Research suggests that there is a bidirectionalinfluence across the different levels of the ecology, but atthe same time these bidirectional influences are asymmetri-cal (Wachs, 1999) and fluctuate over time and across dif-ferent sociopolitical contexts. Proximal and distal contextswill exert different levels of influence on the individualimmigrant at different times and with regard to differentdevelopmental processes. This is a critical point, because itinfluences how, with whom and in which contextsresearchers target their intervention and prevention efforts.

The bidirectional nature of acculturation is essential toour analysis of immigrants’ experiences, because it isimportant to study the acculturation levels of the host soci-ety. This is especially important because positive mentalhealth outcomes for immigrants require simultaneous re-adjustment by both the host society and the individualimmigrant. The process of immigration is unlikely to be


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successful if the host society resists all change (Ben-Sira,1997). For example, the European Community, faced withincreased immigration, is becoming increasingly aware ofpsychological and social problems related to migration(Schmitz, 2003). Coincidentally, many European countrieshave negative views of immigration and so may impedeimmigrants’ adjustment to the host culture. Changes at theexosystemic level (public policy, for example), in particu-lar, reflect a host society’s acculturation level and views ofcertain ethnic groups. Developing more efficient healthinterventions must be accompanied by concomitantchanges at the macro- and exo-systemic levels of the ecol-ogy to promote positive and accepting attitudes towardsimmigrants, and ultimately, improve immigrant mentalhealth outcomes.

In summary, acculturation is an ambiguous constructintegrating multiple factors such as ethnic identity, cogni-tive style, language and so on (Escobar et al, 2000). Byapplying an ecological framework to our research withimmigrant populations, we understand acculturation as acomplex, multidimensional, cyclical and oscillatingprocess. An ecological conceptualization of acculturation,for example, illustrates that the individual undergoing theprocess of acculturation, informed by previous cycles ofacculturation, possesses strengths that are helpful in meet-ing future demands. On the other hand, individuals whostruggled or who were unsuccessful in meeting challengesthey faced throughout different acculturative cycles aremore likely to struggle with future barriers and challengeswhich, when accumulated, may lead to maladjustment. Anindividual immigrant can go towards each end of the spec-trum from maladjustment to adjustment and change severaltimes, depending on multiple factors (ecological influ-ences, personal development, etc) (Table 1, opposite, andFigure 2).

Implications for research

Immigrants’ psychological and social outcomes are highlyvariable (Berry, 1997). The ecological model of accultura-tion and immigrant mental health that we describe in thisarticle (Figure 2) accounts for the complexity that is inher-ent in the study of immigration and acculturation. Thewell-structured and well-defined ecological model, whichincludes changes over time and acknowledges the asym-metric and bidirectional exchange across ecological sys-tems, serves as a useful theoretical framework with theflexibility and generalizability needed to guide futureresearch. Moreover, our application of the ecologicalmodel points to the inadequacy of measuring acculturation

at one time point and assuming that acculturation is aone–time occurrence.

It also is difficult to conceptualize the individual immi-grant and host society as completely separate in the accul-turation process, as described by Berry (1997). The ecolog-ical model describes the individual and host society as dis-tinct and part of a unified person–environment system inwhich bidirectional exchange is the constant. Our critiqueof the extant research using this ecological lens sets thestage for improving research, such that researchers’ designsand assessments of context capture better the complexityand richness of immigrants’ experiences and mental healthneeds. In this section we will outline various research rec-ommendations based on the application of an ecologicalframework to the experiences of U.S. immigrants. For amore complete and in-depth discussion of ecologicalassessment, in general, and related research methodologyissues we refer the reader to Friedman & Wachs (1999).

An ecological conceptualization of immigrants’ experi-ences requires researchers to make certain choices aboutassessment of context, as well as certain assumptions aboutindividual development and immigrant mental health. First,we recommend that researchers bring the influence of bothproximal and distal contextual factors together in singlestudies (Wachs, 1999). No single study can include assess-ment of all contextual factors at all ecological levels, butresearchers who use an ecological framework can begin toconduct practical, comparative studies which examine dif-ferences between proximal (micro- and meso-systemic)and distal (exo- and macro-systemic) environments, andhow those influences change over time (chronosystem).Moreover, research that includes comparative studiesbetween assimilated immigrants and those at different lev-els of acculturation would help illuminate the similaritiesand differences between these two constructs and immi-grants’ experiences as a result of their experiences ofacculturation and assimilation.

For example, researchers might examine the accultura-tion experiences of immigrants who are living with extend-ed family or culturally isolated communities (such asChinatown), alone, or living in an neighborhood compris-ing mostly citizens from the host country. This exampleillustrates how researchers can examine the impact of amultilevel process (acculturation) by examining a specific,microsystemic factor (living arrangements) on immigrants’mental health. One critique of the ecological model is thatthe exo- and macro-systems have no direct connection withthe individual (Super & Harkness, 1999). The way we con-ceptualize the ecological model, however, suggests that themacrosystem is so pervasive that it encompasses and


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affects all the other ecological systems in which the indi-vidual is embedded. This does not make the macrosystemless important or more distant from the individual. Rather,cultural and political contexts influence an individual’s val-ues, beliefs and behaviors via the impact on all the othercontexts in which the individual is developing. That is, theindividual is so immersed in the macrosystem, and soaffected by it, that macrosystemic influences affect everyaspect of individual development.

Second, we recommend that researchers examine immi-grants’ experiences longitudinally, as well as the experi-ences of immigrants at different developmental time points(for example five, ten, thirty years after migration).Researchers need more information about how immigrants’acculturation and ethnic identity change over time andacross contexts, how family structures, gender roles andaccess to resources and support vary with immigrants’experiences in different host societies, and how immigrantsconceptualize their mental health needs and access mentalhealth resources as their acculturation, ethnic identity andlanguage use vary. Conducting multiple longitudinal andcomparative studies may help researchers empirically iden-tify factors and the varying degrees of magnitude of effect

that diverse ecological factors have on the person-environ-ment exchange.

It is also important that longitudinal studies of immi-grants’ experiences, and all studies for that matter, assessimmigrants’ subjective perception of their context, as wellas objective measurements of context. Assessment ofobjective structures and subjective experiences involvesmeasurement of immigrants’ experiences that are obtainedacross multiple time points or from multiple observers(Wachs, 1999). Combining this information will help illu-minate how individual factors and perceptions affect immi-grants’ mental health across contexts, such as coping effi-cacy, perceptions of barriers and support, and resiliency.

Third, we recommend that researchers use advancedresearch designs and statistical analyses, such as growthcurve modeling and structural equation modeling, to cap-ture complex relationships, across ecological levels, inimmigrants’ acculturation experiences. Such advanced sta-tistics are congruent with the ecological framework andconceptualization of immigrants’ experiences and mentalhealth outcomes. Fourth, because different societies havedifferent cultural values, norms and public policies (macro-and exo-), we recommend that researchers from around the

TABLE 1 An Assessment Checklist for Immigrants’ Individual Strengths, Contextual Supports and Risk Factorsat Each Level of the Ecology

Individual

Microsystemic

Mesosystemic

Exosystemic

Macrosystemic

Personality traits (e.g., optimism)HealthHigh self-efficacy and self-worth

Fair and just employmentSupport networkBilingual/bicultural abilitiesAvailability of social services

Social service liaisons at different agencies communi-cate with one another to provide multiple services to animmigrant individual and his/her familyRelationships among family members and host cultureare strong and positive

Legal immigration status

Social and economic policies that allow for safer migra-tion and greater access to services and contextual sup-ports

Members of the host culture feel neutral to generallypositive about immigration

Personality traits (eg, pessimism)Poor health, chronic conditionsLow self-efficacy and self-worth

UnemploymentGeographic distance from familyMonolingual/isolationFew social services available

Social service liaisons do not communicate, and conse-quently, provide individuals with an overlap in services,a useless array of services, and do not assess theinfluence of the contexts in which the individual immi-grant lives and worksIntergenerational conflict with little resolve and relation-ships with host culture are strained

Undocumented immigrant status

Strict or harsh social and economic policies restrictingimmigration and immigrants' access to resources inhost country

Host culture has a history of harsh feelings towardimmigrants and society evidences xenophobic attitudes

Level Strengths and supports Risk factors

Note. There is an ongoing bi-directional exchange between an immigrant and all levels of the ecology. Changes in one level of the ecologymay lead to changes in other levels of the ecology. The chronosystem of the Ecological Model is not depicted in this table, but representsoverall changes in all levels of the ecology across time


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world collaborate and engage in cross-cultural research tocompare immigrants’ acculturation experiences in differenthost societies (Carter, 2003a, 2003b; Prilleltensky, 1997;Prilletensky & Nelson 2002).

Such collaboration is also critical for conductingresearch using an ecological framework. As our worldbecomes more connected and smaller because of technolog-ical advances, researchers must examine the impact of theglobal environment on immigrant’s development (Wachs,1999). For example, macrosystemic and exosystemic effectson the acculturation of Bosnian immigrants living in the U.S. may only be understood by conducting comparative stud-ies with the same immigrant population in host societiesthat have different social and political structures from thoseof the U.S. (Canada, Norway, Sweden, etc). Furthermore, itis important to evaluate differences within host societies,such as similarities and differences between the experiencesof an immigrant living in a metropolitan area and those ofan immigrant living in a rural area, or differences in immi-grants’ mental health needs and outcomes based on othermicrosystemic experiences (working or not working, livingwith family or living alone, etc).

Fifth, we recommend that researchers use multiplemethods for their research. Super and Harkness (1999) out-line comprehensively how different research methodolo-gies, such as ethnographic methods, qualitative and quanti-tative methods and participant observation, can capturechanges in individual development and the influence ofculture on such developmental changes. Specifically, Superand Harkness describe the inseparability of culture fromour conceptualization of individual development, mentalhealth outcomes, and research and assessment. Rather thantrying to remove our cultural values, beliefs and assump-tions from research and assessment activities and identifyindividual developmental norms without considering cul-tural context (statistical isolation), scholars (Prilleltensky,1997; Prilleltensky & Nelson, 2002; Super & Harkness,1999) recommend that researchers identify the cultural val-ues and assumptions that influence their research to ensurethat context and culture are not denied.

Finally, we’d like to comment on the cultural contextsin which we conduct research with immigrant populations.The process of becoming more critically aware of how ourcultural values, beliefs and assumptions as researchersinfluence our investigations, assessment and conceptualiza-tions of immigrants’ mental health has been identified as anecessary component for the empowerment of immigrantpopulations (McWhirter, 1994, 1997). Prilleltensky (1997;Prilleltensky & Nelson, 2002) and other social justiceresearchers (Carter, 2003a; Chronister & McWhirter, 2003;

Chronister et al, in press; McWhirter, 1994, 1997) cautionresearchers to think critically about how their researchreinforces the status quo. Research might maintain the sta-tus quo by reinforcing negative stereotypes, prejudices andbiases, by ignoring important cultural and contextual vari-ables influencing immigrants’ mental health, and insteadattributing differences to individual factors only. Researchalso might maintain the status quo by identifying positivemental health outcomes for immigrants that require immi-grant individuals to assimilate and merge into a society thatdoes not value their diversity or welcome their presence.Finally, researchers must be careful that their research doesnot ignore the influence of oppressive social systems thatmaintain low-paying jobs and poor working conditions forimmigrants, create significant barriers for immigrants try-ing to obtain citizenship and ignore or encourage racistbeliefs and values towards immigrant groups.

Conclusion

By examining the most recent immigrant research fromaround the world, we have illustrated that immigrants’ migra-tion and acculturation experiences are complex processes andrepresent multifaceted interrelationships among ecologicalconstructs. Our attempt was to provide a model and frame-work that allow counseling psychology scholars more com-prehensively to conceptualize and examine immigrants’ men-tal health outcomes across ecological contexts and over time.Counseling psychology scholars must acknowledge andembrace the complexity of immigrants’ experiences andengage in collaborative, multi-systemic and longer-term pre-ventive intervention efforts if we are to improve immigrantmental health services and advance justice for all those whoimmigrate into the host society.


Mirsad Serdarevic, Counseling Psychology, 5251University of Oregon, Eugene, OR 97403-5251, USA,email: [email protected], tel: 310-795-2580

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Keywords: depression and related disorders, national ini-tiatives, prevention

Introduction

The population health approach to mental health promotion

is based on the understanding that the influences on mentalhealth are many and varied, resulting from the complexinterplay of biological, psychological, social, environmen-tal and economic factors. It recognises the importance ofmental health issues across the lifespan. It also recognisesthat a mix of universal, targeted and selective interventions

An Evaluation of

beyondblue, Australia’s

National Depression

Initiative

Jane Pirkis1, Ian Hickie2,3, Leonie Young2, Jane Burns2,4,Nicole Highet2 and Tracey Davenport3

1Program Evaluation Unit, School of Population Health,The University of Melbourne, Australia

2beyondblue: the national depression initiative,Melbourne, Australia

3Brain & Mind Research Institute, The University ofSydney, Australia

4Division of Adolescent Medicine, University of Californiaat San Francisco, United States

beyondblue is a five-year Australian initiative which takes a pop-

ulation health approach to combating depression.This paper’s

aim is to describe the findings of an evaluation of beyondblue,

conducted four years into its existence.The achievements of

beyondblue were examined in the light of its objectives, using

synthesised data from 15 secondary sources.

Many of beyondblue’s lower-level objectives have been

completely achieved, with a plethora of key initiatives in

place that have led to greater availability of information

about depression, improvements in consumer networks,

better support for mental health care delivery in primary

care settings and increases in targeted research. Most of its

intermediate-level and high-level objectives have been partly

achieved, with headway made in terms of the community’s

‘depression literacy’, acknowledgement of the

consumer/carer perspective, the degree to which the health

workforce is equipped to deal with depression, the likelihood

that individuals will seek help, the range of prevention and

early intervention options, the role of primary care practition-

ers in mental health care, and scientific knowledge about

depression. However, in all these areas, ongoing efforts are

required. beyondblue’s vision, or highest-level objective, has

not yet been realised. Society does not optimally under-

stand, respond to or work actively to prevent depression.

beyondblue has begun to make an impression, but it is

unrealistic to expect systemic and cultural change of this

magnitude to occur quickly.

beyondblue has partly achieved its goals, and careful

consideration should be given to what action is necessary

to foster sustainable positive change.



F E A T U R E

is required to modify relevant risk and protective factors,and that particular target groups warrant special attention.Such interventions must cross sectors, venturing into areaslike workplaces and schools, must be comprehensive andmulti-faceted, and must encompass the entire spectrumfrom prevention to recovery. It also stresses the importanceof research and evaluation, to ensure that interventions aresupported by an appropriate evidence base (Scanlon &Raphael, 2002; Secker, 1998).

beyondblue, Australia’s national depression initiative,takes a population health approach to combating depres-sion, on the grounds that this provides a theoretically soundframework within which to raise awareness, build networksand motivate action around depression prevention. Fundedfrom July 2000 to July 20051, beyondblue’s vision is:

a society that understands and responds to the per-sonal and social impact of depression, and worksactively to prevent it and improve the quality of lifeof everyone affected by it

and its mission is to:

provide national focus and leadership that increasesthe capacity of the broader Australian community toprevent depression and respond effectively to it(beyondblue, 2000).

Five priority areas underpin its mission:

community awareness and destigmatisationconsumer and carer participationprevention and early interventionprimary caretargeted research (beyondblue, 2001, 2002, 2003b).

beyondblue’s Strategic Plan (beyondblue, 2000) suggests that,towards the end of its first five years, an evaluation should con-sider the extent to which it has achieved its goals of bringingabout the structural change and community motivation neces-sary to prevent depression and minimise its effects. If it has fullyachieved its goals, it should hand back its activities to the com-munity. If it has made no inroads into achieving them, it shouldnot continue to be funded. If it has partly achieved them, consid-eration should be given to what action is necessary to foster pos-itive change that is sustainable to the point that beyondblue nolonger needs to exist (beyondblue, 2001, 2002, 2003b).

This paper aims to describe the resultant evaluation2 interms of its methods, findings and implications for thefuture directions of beyondblue.

Method

In evaluating an initiative as complex as beyondblue, it wasnot feasible or appropriate to mount a randomised con-trolled trial or even a quasi-experimental study. Instead,consistent with contemporary program evaluation theoryand practice, an objectives-based evaluation was conducted(Owen, 1999). This involved developing an objectives hier-archy (see Figure 1, opposite), in which beyondblue’svision constituted the highest-level objective, its missionthe next level, and intermediate- and lower-level objectivesrelated to each of beyondblue’s priority areas.

Next, a single evaluation question was posed in relationto each objective, namely, ‘Was beyondblue successful inachieving the given objective?’. To answer this question foreach objective, it was considered important to use triangu-lation, or ‘the combination of a number of methodologiesin the study of the same phenomenon’ (Ovreteit, 1998;Patton, 1990). As a result, 15 evaluation components wereidentified, with the latest cut-off point for data from anycomponent being 30 September 2004. The evaluation com-ponents were as follows, and Figure 1 shows their rela-tionship to the objectives.

Review of beyondblue program and projectdocumentation

Relevant beyondblue program and project documenta-tion – for example beyondblue’s Strategic Plan (beyond-blue, 2000), Annual Reports (beyondblue, 2001, 2002,2003b) and project implementation reports and updates(beyondblue, 2003a) – were retrieved and reviewed.Information was also sought and synthesised frombeyondblue’s website.

Evaluations of selected beyondblue programsand projects

Findings from selected local evaluation reports wereextracted to inform the evaluation exercise, as relevant.Specific reports were chosen on the basis that they repre-sented evaluations of initiatives that were of particularnote, either because of their magnitude or because of theirnovel approach.

1 beyondblue is funded at approximately $AUD39m (primarily from theCommonwealth and Victorian governments), with additional corporate in-kind sup-port of $AUD3-5m.

2 The full evaluation report is available from the authors (Pirkis, 2004).


F E A T U R E

FIGURE 1 Relationship of Evaluation Components to the Objectives Hierarchy for beyondblue


F E A T U R E

Monitoring data on beyondblue media cover-age, media releases and community serviceannouncements

Since January 2001, beyondblue has maintained aninternal system for tracking direct media stories, count-ing the first time a given story occurs on a particularradio or television station, or in a particular newspaper,but not any subsequent occurrences (Hickie et al, forth-coming). Supplementary data have been provided byRehame (2004). In addition, Neilsen Media Researchhas ‘tracked’ beyondblue’s community serviceannouncements (Neilsen Media Research, 2004). Datafrom all these sources informed the current evaluation.

Data on media coverage of depression in gener-al, and beyondblue in particular

Quantitative and qualitative data on how Australiannewspapers (n=184), radio stations (n=225) and televi-sion stations (n=106) report and portray depression werecollected and analysed in 2000 by Blood and colleagues(Blood et al, 2003; Hickie et al, 2004) and Francis andcolleagues (Francis et al, 2005; Francis et al, 2002).Additional data were collected on newspaper items froma restricted range of newspapers (n=11) by Blood in2001 and 2002. beyondblue itself continued this datacollection during the whole of 2003 and up until andincluding April 2004 (beyondblue, 2004a), and supple-mentary data were available from Rehame and beyond-blue (Rehame, 2004). Together, these data provide a pic-ture of the coverage of depression in general, andbeyondblue specifically, over time, thereby informingthe current evaluation.

Data on the use of beyondblue’s website

Since beyondblue’s website was launched in April 2001, theindependent company that hosts the website server hasmonitored the number of visits to the site every month(Hickie et al, forthcoming). In addition, visitors to the sitehave been offered the opportunity to provide feedback. Datafrom both sources were included in the current evaluation.

Independent assessments of the quality ofbeyondblue’s website

A study of Australian Internet depression websites was con-ducted in 2001 by Griffiths and Christensen. These authorsidentified 15 sites in total, including beyondblue’s site.

They rated the sites systematically for quality and accessi-bility, providing information on the relative (and absolute)quality of the beyondblue site (Griffiths & Christensen,2002). In addition, an assessment of beyondblue’s websitewas available from HealthInsite (Smith, 2004). HealthInsiteis an Australian Government initiative, funded by theDepartment of Health and Ageing. It aims to improve thehealth of Australians, acting as a single entry point to quali-ty information to facilitate access to approved sites. Sitesare approved on the basis that they satisfy various contentand process criteria (HealthInsite, 2004). In the currentevaluation, data from these sources complemented theabove quantitative data on visits to the beyondblue website.

Data from the Australian National MentalHealth Literacy Survey (ANMHLS)

Jorm and colleagues developed a survey instrument tomeasure various aspects of ‘mental health literacy’, andprovided baseline information collected via face-to-faceinterviews with a community sample of over 2,000 in1995 (Jorm et al, 1997). Since then, they have given par-ticular consideration to ‘depression literacy’ (Parslow &Jorm, 2002). In 2004, they conducted a repeat surveywith over 4,000 respondents (Jorm, 2004). The surveysinclude questions about depression, most of which relateto vignettes. Data from these surveys were used in thecurrent evaluation to explore changes in ‘depression liter-acy’ over time.

beyondblue’s national telephone survey (NTS) data

beyondblue has conducted two cross-sectional nationaltelephone surveys examining the community’s awarenessand understanding of depression and its treatments, anddetailing factors that contribute to attitudes towards depres-sion, the first in 2001 (with 901 respondents) and the sec-ond in 2002 (with 2,003 respondents). Several of the ques-tions in these surveys are identical to those used in themental health literacy surveys of Jorm and colleagues(Jorm et al, 1997; Parslow & Jorm, 2002), enabling somecomparisons over time that were of value in the currentevaluation.

beyondblue’s consultative processes with con-sumers and carers

beyondblue has been responsible for a variety of con-sultative processes with consumers and carers, includ-ing 21 public meetings with 1,529 participants, 41


F E A T U R E

focus groups with 177 attendees, written feedback, andwebsite-based interactions and consultations with con-sumer and carer organisations. These processes havebeen designed to elicit information from consumers andcarers about their experiences with depression, anxietyand bipolar disorder (McNair et al, 2002). They there-fore provided useful baseline information for the cur-rent evaluation.

Other consultative processes with consumersand carers

More recently, other key mental health advocacy organi-sations have conducted consultations with consumersand carers. In 2002, the Mental Health Council ofAustralia consulted with over 400 organisations andindividuals nationally (Mental Health Council ofAustralia, 2003a). In the same year, SANE Australiaconducted around 200 interviews and analysed datafrom approximately 6,000 calls to their helpline (SANEAustralia, 2003). Data from these consultative processeswere used in the current evaluation to provide someinsight into whether the experiences of consumers andcarers are changing over time.

blueVoices membership data

beyondblue’s virtual consumer and carer network,blueVoices, collects membership data. These data wereused in the current evaluation as a simple measure of the‘reach’ of the network.

A review of beyondblue’s project funding

In 2003, the Population Health Committee of theVictorian Public Health Research and EducationCouncil (VPHREC) was commissioned to conduct areview of beyondblue’s project funding. Specifically, itconsidered:

… whether the engagement of priority areas,program principles and a population frameworkwould, through effective early intervention andprevention strategies, enable beyondblue toreduce the incidence and/or prevalence and/orharmful impact of depression and related men-tal disorders (Population Health Committee,2003).

The current evaluation incorporated key findings from thisreview, as relevant.

Data from evaluation activities associated withthe Better Outcomes in Mental Health Care(BOiMHC) Initiative

Evaluation activities associated with the BOiMHCInitiative yielded data that proved valuable for the currentevaluation, permitting a description of the extent to whichGPs (and allied health professionals) are providing mentalhealth care for people with depression and related disor-ders (Health Insurance Commission, 2004; Hickie et al,2004; Morley et al, 2004).

Data from the Bettering the Evaluation andCare of Health (BEACH) Project

The BEACH Project continuously collects informationabout general practice encounters in Australia, using adesign in which 20 general practitioners collect data on100 consecutive encounters each week. In total, 1,000general practitioners are involved. Relevant data fromthe BEACH Project are reported annually by theAustralian Institute of Health and Welfare (2004).BEACH data were used in the current evaluation toexplore changes in the level of depression-related GPencounters over time.

An audit of research activities in the area ofdepression

Jorm and colleagues reviewed research activities in thearea of mental health in the period prior to the establish-ment of beyondblue (Jorm et al, 2001). Specifically, theyexamined academic journal articles published in 1998 andacademic grants awarded or renewed in 2000, and consid-ered the related research projects in terms of the type ofmental disorder being investigated, the goals of theresearch, the participant type and setting where theresearch was carried out, and the inclusion of special inter-est groups in the research. They then assessed the extent towhich the profile of existing research matched the identi-fied need, in terms of the relative prevalence, burden andcost of particular disorders and the stated priorities ofstakeholders. The current evaluation drew on this work inits examination of the research initiatives put in place bybeyondblue.


F E A T U R E

RESULTS

Objective 1: Community awareness and des-tigmatisation

Objective 1.1: Key initiatives in place

Mass media initiativesThrough its mass media strategy, beyondblue has:

hosted a two-day media seminar called Blueprint,designed to engage media professionals in responsi-ble reporting of mental health issues (beyondblue,2004b) been an active commentator about depression inprint/broadcast media (Hickie et al, forthcoming) disseminated information about depression throughvarious promotional materials including brochures,pamphlets, posters and its website (Fulcher, 2004a) broadcast various general television and radio com-munity service announcements (CSAs) (Hickie etal, forthcoming) aired a national public awareness campaign (BlueSkies) via television and cinemas, in order toimprove community knowledge about depression(beyondblue, 2004b) used the entertainment media to raise awareness, forexample supporting Dr Cade, a play about the psy-chiatrist who discovered Lithium treatment (beyond-blue, 2004b) supported four supplements on depression in theMedical Journal of Australia (MJA) (Hickie et al,forthcoming).

Community activities beyondblue has conducted various community activities,including:

Ybblue, beyondblue’s youth program, which involvesa multi-faceted campaign designed to increase aware-ness about youth suicide and provide assistance forat-risk individuals (beyondblue, 2004b)metropolitan/rural/regional community forumsaimed at increasing awareness and decreasing stig-ma associated with depression/anxiety (beyondblue,2003b, 2004b) forums with 1,200 Rotary clubs (beyondblue,2004b) the Lifeline Depression Awareness Program, whichis a partnership between beyondblue and Lifeline

aimed at improving Lifeline’s support/assistance forconsumers/carersthe Depression Awareness Research Project(DARP), conducted by the Mental Health ResearchInstitute with the aim of emphasising that depres-sion is a serious, but common and treatable illness(beyondblue, 2004b) the Melbourne Fringe Festival’s Volunteer Program,which involved beyondblue staff briefing volunteerswho communicated relevant messages about depres-sion to Fringe artists and audience members(beyondblue, 2004b) World Mental Health Day, at which beyondbluepartnered with the Mental Health Council ofAustralia (MHCA) to pursue the theme ‘Protectingand Promoting the Health of All Children’ (beyond-blue, 2004b).

Objective 1.2: Increase in the quantity andquality of information available about depres-sion through media and educational sources

The above initiatives have led to an increase in the quantity(and often quality) of information available about depres-sion through media and educational sources.

Print/broadcast mediaFigure 2, opposite, shows that in beyondblue’s lifetime therehas been increased coverage of depression in print/broadcastmedia, with month-by-month variability associated withbeyondblue’s activities (Hickie et al, forthcoming; Rehame,2004). Blood and colleagues observed that early reportsfocused on personalities and later ones emphasised depres-sion’s public health significance. They were unable to ascer-tain whether the quality of reporting improved over time, butnoted that it was variable, commenting on stories framingdepression as ‘odd’ or violence-related (Blood et al, 2003).

Promotional materialsPromotional materials have been distributed through a vari-ety of agencies (for example the MHCA mailing list, whichhas 400 individuals/organisations who forward content totheir networks) and at beyondblue events, including distri-bution of 80,000 items on World Mental Health Day 2003(Mental Health Council of Australia, 2003b). beyondblue’smaterials are all evidence-based and reviewed by experts.

The InternetFigure 3, opposite, shows that 643,153 individuals visitedthe beyondblue website between April 2001 and June 2004,


F E A T U R E

FIGURE 2 beyondblue Media Stories (Featuring in Newspapers and on Radio and Television) by Month,January 2001 to June 2004

FIGURE 3 Visits to beyondblue’s Website by Month, April 2001 to June 2004

Source: adapted from Hickie et al (forthcoming)

Source: Adapted from Hickie et al (forthcoming) and Rehame (2004)


F E A T U R E

the culmination of an increasing trend over time (Hickie et al,forthcoming). There was, however, month-by-month variation,with several peaks explained by beyondblue’s activities.

beyondblue monitors the website’s quality, checking theaccuracy and accessibility of information via recourse toevidence-based literature, peer review and user feedback(Fulcher, 2004c; Lee, 2004). The website was rankedamong the top four of fifteen reviewed by Griffiths andChristensen, readily met HealthInsite’s criteria for approvalas a partner, and has received positive user feedback (seeBox 1, below) (Griffiths & Christensen, 2002; HealthInsite,2004; Smith, 2004).

The Blue Skies campaignIn July 2004, the Blue Skies CSA was aired 1,209 times onAustralian commercial television stations (Neilsen MediaResearch, 2004), and some stations have continued to air itsince. The campaign generated considerable media activityand encouraged people to access beyondblue’s website(many of whom then joined the consumer/carer network,blueVoices, which experienced a 400% membershipincrease during this time). Campaign feedback via thewebsite, email and letter was generally positive (Fulcher,2004b, 2004d; Peck, 2004).

Specialist mediaThe Medical Journal of Australia (MJA) supplements had abroad reach (the journal’s circulation being 28,000 – MJA,2004), and all articles in the supplements were peer-reviewed.

Community activitiesThe reach of beyondblue’s community activities has beenbroad (for example, 314 Rotary community forums havebeen held nationally, attracting over 38,000 people(beyondblue, 2004b; Highet, 2004b), and DARP hastrained 260 community educators who have delivered morethan 400 presentations to 7,540 community members(Mental Health Research Institute, 2004). Many such activ-ities have proved effective in promoting the organisation;for example, Ybblue has been evaluated as highly success-ful in terms of increased website visits and calls to otherservices, and feedback from young Ybblue steering com-mittee members (Burns & Stewart, 2004).

Objective 1.3: Increase in awareness of the preva-lence, symptoms, causes, treatments and prognosisof depression

The above increase in the quantity and quality of infor-mation about depression appears to have translated into

gains in the community’s ‘depression literacy’ (Jorm etal, 1997; Parslow & Jorm, 2002), according to data frombeyondblue’s NTS (Hickie et al, forthcoming; Highet etal, 2002), the ANMHLS (Jorm, 2004; Jorm et al, 1997)and evaluations of beyondblue programs (such as DARP).During beyondblue’s lifetime, there have been increasesin the proportion of community members and programparticipants who:

can distinguish symptoms of depressionrecognise distal/proximal causes of depressionbelieve that mental health professionals can be help-fulrecognise counselling, psychotherapy and anti-depressant medication as valuableare familiar with the prognoses of depression.

However, little shift has occurred in the proportion con-tinuing to underestimate depression’s prevalence/burden.

‘Thank you for such a well-planned and professional site! Ifound the information presented very useful. I have sufferedfrom depression since years ago, and I wish I had hadaccess to this site then!’

‘I found the fact sheets extremely helpful. Having informa-tion and tools to work with gives hope and a sense of hav-ing some control’.

‘As someone who has been in and out of darkness, I wasamazed how much information and help there was on onewebsite. It’s like the bible to all sufferers. Just reading andsearching the site lifted my mood.’

‘An excellent website! My best friend has depression, and Ihave been finding it hard to deal with because I feel sohelpless. This gave me heaps of great information andhelped me realise that I’m not the only one who feels likethat in this situation.’

‘As a sufferer of anxiety and depression for the last 10months (since diagnosed) I found the site quite informativeand helpful. The site has increased my motivation to keepplugging away with the program I already had from my psy-chologist in place to beat my demons and return to thehappy times I still remember. I’ve had several minor set-backs and relapses, but simply knowing that the site is herefor me to visit any time is reassuring as just reading aboutthings can be motivational. Keep up the good work! ANDTHANK YOU!!’

‘Very helpful and informative. I will continue to use this siteto gather further information, to assist with my treatment. Ihave found this so helpful, and I will download informationto help my parents understand my condition.’

BOX 1 Feedback from Visitors to the beyondblueWebsite (source: Fulcher, 2004b)


F E A T U R E

Objective 1.4: Increased understanding of expe-riences of people whose lives have been affectedby depression

beyondblue’s programs incorporate evidence from its quali-tative research on the experience of people with depression(see below), and there are indications from evaluations ofthese programs that this has increased awareness andreduced stigma among program participants (Highet,2004a). Less evidence is available to determine whetherthe broader Australian community has increased its under-standing of the experience of depression. Indirect evidence,however, indicates movement in the right direction.According to NTS and ANMHLS data, an increasing pro-portion of the population report that they or someone closeto them has experienced depression, auguring well forimproved understanding (Hickie et al, forthcoming; Highetet al, 2002; Jorm, 2004; Jorm et al, 1997).

Objective 1.5: Decrease in levels of stigma anddiscrimination associated with depression

There is insufficient evidence to ascertain directly whether,during beyondblue’s existence, there has been a decrease inthe stigma and discrimination experienced by people withdepression. Again, however, some indirect evidence bodeswell. ANMHLS data point to increased communityacknowledgement that people with depression experiencediscrimination (Jorm, 2004; Jorm et al, 1997). There isalso evidence of change in systems that foster discrimina-tion; for example, beyondblue and the MHCA negotiatedwith the insurance industry to achieve equity for peoplewith depression, and, consequently, detailed guidelinesnow govern risk assessment and claims disputation regard-ing insurance products (Hickie et al, forthcoming). Thatsaid, consultations with consumers/carers (see below) sug-gest that, overall, discrimination remains problematic(McNair et al, 2002; Mental Health Council of Australia,2003a; SANE Australia, 2003).

Objective 2: Consumer and carer participation

Objective 2.1 Key initiatives in place

beyondblue has introduced various initiatives to promoteconsumers’/carers’ roles in planning, delivering and evalu-ating mental health services and reduce the stigma associ-ated with depression, by:

developing blueVoices, a national organisation with

consumer/carer membership in each state/territoryand content-specific reference groups, which aimsto raise depression awareness by encouraging con-sumers/carers to voice their experiences and con-tribute to service system improvements by provid-ing information, contributing to policy/programdebates, partnering with other groups in an advoca-cy role and providing a network for experience-sharingsupporting consumers’/carers’ participation inresearch via the Depression and Anxiety ConsumerResearch Unit (DACRU) (see below) and variousresearch projects that explore consumers’/carers’experiences of living with depression, bipolar disor-der, anxiety and eating disorders (Highet &Thompson, 2004a, 2004b, 2004c; Highet et al, inpress; Highet et al, 2004a; Highet et al, 2004b)bringing consumers/carers to policy/planning tables,through membership on and support for existingconsumer/carer organisations and funding for con-sumer/carer positions on other key bodies.

Objective 2.2: Improved consumer and carernetworks

There is evidence that the above initiatives – particularlythe establishment of blueVoices – have led to improvedconsumer/carer networks. At 10 August 2004, blueVoiceshad a membership of 9,650, and had developed close linkswith other organisations (such as the MHCA), broadeningavailable consumer/carer networks.

Objective 2.3: Genuine participation by con-sumers and carers in depression-related initiatives

beyondblue has a strong consumer/carer arm, with numer-ous major activities that are led by, or involve close collab-oration with, consumers/carers. This focus on involvingconsumers/carers in meaningful collaborations extendsbeyond the activities classified as being within the con-sumer/carer priority area, and permeates all beyondblue’sinitiatives and many of its collaborations (for example,blueVoices has collaborated with organisations like theMHCA to lobby for policy/practice change).

Objective 2.4: Genuine acknowledgement ofproblems faced by consumers and carers

beyondblue itself has acknowledged the problems faced byconsumers/carers, but there is less evidence of broader


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community acknowledgement. In 2001, consultations con-ducted by beyondblue identified stigma as the main prob-lem experienced by consumers/carers, followed by inade-quacies in treatment systems (McNair et al, 2002).Although beyondblue has not repeated these consultations,later consultations conducted by the MHCA and SANErevealed ongoing discrimination and deficiencies in treat-ment systems (Mental Health Council of Australia, 2003a;SANE Australia, 2003).

Objective 3: Prevention and early intervention


The VPHREC Population Health Committee commendedbeyondblue’s population health approach in its review ofthe organisation’s project funding. Within this approach,beyondblue has given particular emphasis to preventionand early intervention, changing community knowledge,attitudes and behaviour within particular sub-groups andin specific settings (Population Health Committee,2003).

Young peoplebeyondblue has sponsored several initiatives aimed at pro-moting mental health among young people, including:

the Schools Research Initiative, a research part-nership between school systems, local communi-ties, the health sector and academics, designed toexplore ways of increasing individual and socialenvironmental protective factors in the schoolcommunity in order to increase resilience anddecrease depression in children/adolescents(beyondblue, 2004b) the Compass Strategy, which aims to increasehelp-seeking and reduce treatment delays inyoung people using various media (beyondblue,2004b) the Aspire, Achieve, Affect Program, the RoleModels for the Future Project, the AffirmingDiversity project and Positive Choices, all ofwhich increase young people’s life skills and con-nectedness, using sports people as role models(beyondblue, 2004b; Field & Highet, 2002)Reach Out!, whose website provides a source ofhelp for young people, and whose rural/regionalVictoria tours have promoted positive mental healthoutcomes for young people in these areas (beyond-blue, 2004b; O’Brien, 2002)

the Every Family Initiative, which involves health,education and media professionals delivering theinternationally-recognised Triple P PositiveParenting Program (Sanders, 2002) to parents(beyondblue, 2004b) the Children of Parents with a Mental Illness initiative,which increases resilience/coping among this group viastrategies like peer support (beyondblue, 2004b).

People in the workplacebeyondblue has fostered two workplace initiatives, namely:

the National Depression in the Workplace Program,which aims to increase understanding about depres-sion and its appropriate management in a workplacesetting (beyondblue, 2004b; Highet, 2004a) the Work Outcomes Research and Cost-benefitProject, which will assess the cost-benefit of work-place screening/treatment for depression (beyond-blue, 2004b; Highet, 2004a).

Women at risk of postnatal depressionbeyondblue has supported the National PostnatalDepression Prevention Program, which is evaluating theuse of the Edinburgh Postnatal Depression Scale to identifywomen at risk of postnatal depression and the provision ofinformation, resources and referral options for 100,000women (beyondblue, 2004b; Buist et al, 2002).

Indigenous communitiesbeyondblue has funded projects targeting Indigenous com-munities, including:

Ngaripirliga’ajirri, or ‘helping each other clear apath for the future’, a Tiwi Islands early interven-tion program attended by young people with a par-ent/caregiver (beyondblue, 2004b)the Aboriginal Mental Health Program, which sup-ports community-based Aboriginal mental healthworkers in the early detection of depressive symp-toms (beyondblue, 2004b; Robinson et al, 2003).

Health professionals beyondblue has supported health professionals who arewell-placed to recognise early warning signs of depression,for example assisting the National Heart Foundation topilot workshops with cardiac rehabilitation professionals toimprove their identification and management of depressionin consumers with cardiac disease (beyondblue, 2004b;Collins et al, 2002 ).


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Objective 3.2: Increase in the number andrange of effective prevention and early inter-vention initiatives for depression

VPHREC’s review suggested that beyondblue’s projectscomplemented state-funded ones (implying a net increasein prevention and early intervention initiatives) and praisedtheir contribution to improved evidence, commending theirintervention models, population targets and value formoney. The corollary is that beyondblue’s efforts would belikely to contribute to the future suite of effective proj-ects/programs on which others could draw (PopulationHealth Committee, 2003).

Objective 3.3: Systemic changes in the healthsector and beyond (for example in families,schools, workplaces and communities) that sup-port prevention and early intervention efforts

beyondblue’s prevention and early intervention initiativesaim to increase the capacity of systems (health services,families, schools, workplaces and communities) to combatdepression. Systems change occurs gradually, but evalua-tions of beyondblue’s initiatives suggest they are beginningto have an impact. For example:

the VicChamps project (one of two funded toachieve the goals of the Children of Parents with aMental Illness initiative) has implemented variousstrategies designed to increase the involvement ofadult mental health and community services inaddressing the needs of children of parents with amental illness (Brann, 2004) the training provided through beyondblue’s NationalDepression in the Workplace Program (which aimsto achieve systemic changes to improve workers’responses to colleagues, subordinates and managersliving with depression) has been shown to lead toincreases in participants’ knowledge of helpful andunhelpful responses for a person with depression,willingness to engage with a person with depressionand likelihood of assisting a person with depressionto access appropriate help (beyondblue, 2004b;Highet, 2004a).

Objective 3.4: Increase in the proportion of peoplewith depression who seek professional help early

The evaluation reports from many of the above preventionand early intervention projects provide indirect evidence

that those who have participated in the projects would belikely to seek professional help early if they experienceddepression. For example, the evaluations of the CompassStrategy (beyondblue, 2004b; Compass Strategy, n.d.), theReach Out! Presentations (beyondblue, 2004b; O’Brien,2002), beyondblue’s National Depression in the WorkplaceProgram (beyondblue, 2004b; Highet, 2004a) and DARPreported that exposure to these initiatives increased partici-pants’ awareness of appropriate sources of assistance. Suchfindings are consistent with those of the above community-based surveys, which showed that the general population isbecoming increasingly aware of where to turn for depres-sion treatment (Hickie et al, forthcoming; Highet et al,2002; Jorm, 2004; Jorm et al, 1997). It must be acknowl-edged, however, that these results relate to attitudes andintentions, not behaviour.

Objective 3.5: Reduction in risk factors andpromotion of protective factors

Consistent with the population health approach, much ofbeyondblue’s work seeks to modify risk and protective fac-tors at different levels. For example, the Schools ResearchInitiative is concerned with building resilience in youngpeople, in order to lay the foundations for later positiveoutcomes. Currently, there is a dearth of evaluative evi-dence that examines whether beyondblue is successfullymodifying risk and protective factors, because short-termoutcomes like resilience are difficult to measure, and it ispremature to be evaluating longer-term outcomes. Thesound evidence base upon which the Schools ResearchInitiative is drawing bodes well for its success, but ongoingevaluation is necessary.

Objective 4: Primary care


beyondblue aims to equip primary care providers to delivermental health care to people with depression. Specifically,beyondblue has:

commissioned a set of evidence-based guidelineswhich recommend treatment choices for consumerspresenting to primary care with depressive disorders(beyondblue, 2004b; Ellis & Smith, 2002) acted as a partner in the trial of MoodGYM, anInternet-based intervention designed to treatand prevent depression and/or anxiety (beyond-blue, 2004b)


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installed ‘informboards’ in 300+ Australian generalpractices, with the aim of educating consumersabout depression, and prompting them to discussconcerns with their GP (beyondblue, 2004b) funded the Mental Health Aptitudes into Practice(MAP) Training Program, which is a training andcapacity-building project targeting the community-based primary care workforce (beyondblue, 2004b;Meadows, 2003; Mitchell, 2004) supported the employment of community-basedAboriginal mental health workers to work in healthclinics in partnership with other health profession-als, via the Aboriginal Mental Health Program(Robinson et al, 2003) tried to address the paucity of relevant data avail-able in primary care by funding the development ofa novel classification and a nation-wide system forlongitudinal data collection in primary care(beyondblue, 2004b).

Importantly, beyondblue has also supported parallel pri-mary care initiatives. Most prominent is the BOiMHC ini-tiative, which provides education and training for GPs,removes systemic barriers to their providing mental healthcare and provides access to specialised psychological treat-ments for consumers (Commonwealth Department ofHealth and Ageing, 2004). beyondblue acted as a catalystfor the BOiMHC initiative by highlighting the significanceof depression, assembling the evidence to support theplanned future directions and engendering the support ofpolicy-makers and politicians. It also brought its partners(such as the Australian Divisions of General Practice andthe MHCA) together to advance the advocacy for the ini-tiative, for example funding key meetings without whichthe initiative might never have happened (Hickie & Groom,2002). beyondblue has continued to support the initiative.

Objective 4.2: Improvements in systems of careand service initiatives that promote participa-tion by primary care practitioners in preventingand treating depression

The above-mentioned initiatives are beginning to address bar-riers to primary care professionals providing mental healthcare (Australian Medical Workforce Advisory Committee,1999; Joint Consultative Committee in Psychiatry, 1997). Forexample, education and training needs are being met in sev-eral ways. beyondblue’s evidence-based guidelines can beconsidered an educational tool, and have the potential toimprove GPs’ ability to provide care for people with depres-

sion (beyondblue, 2004b). Likewise, the MAP project is fill-ing a gap in education/training that may have flow-on effectsin terms of the capacity of non-medical primary careproviders to deliver services (beyondblue, 2004b).

In fairness, bigger systemic changes have been achievedby initiatives for which beyondblue is not solely responsible(but has strongly advocated for and promoted). A primeexample is the BOiMHC initiative, which has substantiallychanged the primary mental health care landscape(Commonwealth Department of Health and Ageing, 2004).

Objective 4.3: Increase in community educationand treatment roles of primary care practitioners

There is evidence that the absolute number of primary carepractitioners who feel equipped to take on treatment roles(and potentially community education roles) is increasing.Some of these increases can be attributed directly tobeyondblue, such as the doubling of Aboriginal mentalhealth workers in the Northern Territory’s Top End(Robinson et al, 2003). Other increases are not solely dueto beyondblue, although the organisation can claim somecredit; for example, an interim evaluation of the BOiMHCinitiative showed that in its first 15 months, 15% of all GPsin Australia had received the training required for partici-pation (Hickie et al, 2004).

The evidence on whether these primary care practi-tioners are fulfilling their potential regarding these rolesis more equivocal. On the one hand, there has been muchactivity associated with the BOiMHC initiative. On theother hand, overall levels of depression-related GPencounters have remained essentially unchanged overtime (accounting for four per cent of all encounters andtwo per cent of all problems managed), according to datafrom the BEACH Project (Australian Institute of Healthand Welfare, 2004).

Objective 5: Targeted research


beyondblue has a commitment to supporting the develop-ment of evidence-based practice in Australia, and hassupported various targeted research initiatives and part-nerships in addition to those mentioned previously (forexample the research-focused prevention initiatives).beyondblue:

auspices the Victorian Centre of Excellence inDepression and Related Disorders (VCoE), which


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funds inter-disciplinary research to improvedepression prevention and treatment (beyondblue,2004b) supports various other strategic research initiativesinvestigating how better to deliver services, how toimprove measurement of key outcomes, how toinclude consumer/carer perspectives and whetherthe efforts deliver genuine population health out-comes (beyondblue, 2004b) conducts some of its own research, and requiresevaluation of all its funded programs/projects(beyondblue, 2004b) has supported the establishment of the DACRU atthe Australian National University’s Centre forMental Health Research, which is staffed by aca-demics with personal experience of depressionand/or anxiety and is researching consumers’ pri-orities and needs (beyondblue, 2004b; Griffiths etal, 2004).

Objective 5.2: Increase in targeted research activi-ties aimed at increasing knowledge about depression

Jorm and colleagues reviewed mental health research activ-ities in the period prior to beyondblue’s establishment,using explicit criteria. They found that depression wasunder-researched, despite its high disease burden and pri-oritisation by stakeholders. In addition, scant research wascarried out in primary care or community settings, andstudies on prevention and promotion, evaluations of mentalhealth services and investigations of the education andtraining of mental health professionals were under-repre-sented (Jorm, 2001).

Box 2, overleaf, shows that beyondblue has fundedaround 50 studies

3, each of which has undergone a rig-

orous selection process. It is reasonable to assume thatthis equates to an increase in targeted research activi-ties. Even if there had been a commensurate decrease infunding for depression-related studies by other bodies,a net gain is likely (Population Health Committee,2003).

The profile of these projects matches many of Jorm andcolleagues’ identified priorities (Jorm et al, 2001). Manyare being carried out in primary care or community set-tings, evaluate prevention and promotion initiatives ormental health services, and/or investigate education andtraining of mental health professionals. That said,VPHREC’s review criticised beyondblue’s research pro-

gram for lacking strategic direction (Population HealthCommittee, 2003).

Objective 5.3: Increase in knowledge aboutdepression, particularly re the evidence forcommunity education, prevention and treatment

Some of the above-mentioned research is beginning toaddress gaps in knowledge about depression (particularlyregarding the evidence base for community education, pre-vention and treatment), although much remains unknown.For example, preliminary results from the VoCE-fundedstudy of therapeutic family involvement in the manage-ment of 40–60 year olds with persistent clinical depressionsuggest that this group is characterised by complex andmulti-faceted disorders, traumatic experiences and relation-al/social dislocation. They are generally offered individual-ly-focused treatments, creating opportunities for the studyto contribute to knowledge about multi-family interven-tions (Couchman, 2004).

beyondblue has drawn on new knowledge fromresearch that it has funded/conducted to inform its pro-grams. For example:

its research on the experiences of consumers/carersaffected by particular disorders has shaped a varietyof initiatives, highlighting the need to increaseawareness of mental health problems and leading tothe emphasis on the experience of mental healthproblems in initiatives like blueVoices (Highet &Thompson, 2004a, 2004b, 2004c; Highet et al, inpress; Highet et al, 2004a; Highet et al, 2004b) its project entitled ‘Preventing depression in youngpeople’ shaped the Schools Research Initiativethrough its conclusions that negative life events,early adversity and parental depression can lead todepression in children; negative cognitive schemata,pessimistic attributional style and ruminativeresponse style (in combination with negative lifeevents) can lead to depression in teenagers; schooland family environment can mediate the effect ofnegative life events and early adversity; preventionprograms targeting cognitive restructuring and prob-lem solving may be advantageous in preventingdepression, and prevention programs promoting pos-itive school and family environments may be benefi-cial in preventing depression (Burns et al, 2002).

Other research efforts supported by beyondblue have not yetled to increases in knowledge, but, perhaps just as impor-

3 This figure underestimates the research support of beyondblue as it does not include theevaluations of funded projects; nor does it include projects conducted by the DACRU.


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Consortium grants

The Primary Care Evidence–Based PsychologicalInterventions (PEP) Collaboration (03–04)Diagnosis, Management and Outcomes of Depression inPrimary Care (DIAMOND) (03–04)

Funded projects

A collaborative therapy treatment package for peoplewith bipolar affective disorder (03–04)Depression and heart disease collaboration (03–04)Health problems among patients with a dual diagnosis:to what extent do these patients slip through the net?(03–04)The prevention of depressive relapse in young peopleusing mindfulness-based cognitive therapy (03–04)Screening for co–morbid affective disorder and sub-stance abuse by GPs (03–04)Depression and musculoskeletal pain in primary care: anexamination of practitioner, patient and socio–economicinfluences on detection and management (03–04)The integration of cognitive behavioural therapy forobsessive compulsive disorder into the primary care con-text: an evaluation of three models (03–04)Pathways of care for socially marginalised people withdepression and related disorders (03–04)Caring for the depressed elderly in the emergencydepartment: establishing linkages between sub-acute,primary and community care (03–04)The emotional and lifestyle impact of type 2 diabetes:exploring the association between diabetes and depres-sion (03–04)A training program for professional carers in recognisinglate-life depression: impact on the delivery of health careservices for depression among older people (03–04)Models of care: evaluating a best practice model fortreating postnatal depression (03–04)Depression in people living with HIV/AIDS: outcomes,risks, and opportunities for intervention(03–04)The development and evaluation of an interventionaimed at improving the mental health of a group ofrefugee women presenting to the Royal Women’sHospital for obstetric care (03–04)Overcoming barriers to care: towards optimal practicesfor paramedics treating people with depression and relat-ed non-psychotic disorders (02–03)An integrated approach to young people presenting withdepression and substance use (02–03)A self-management package for people with bipolaraffective disorder (02–03)Finding out what experienced GPs mean by ‘depression’:a step towards developing a meaningful taxonomy ofdepression in primary care (02–03)Exploring Melbourne’s hidden epidemic: medication over-dose, depression and their management by paramedics(02–03)A randomised controlled trial of a brief psycho-educa-tional intervention to prevent the development of depres-sion in anxious first-time mothers of newborns (02–03)Diagnosis, management and outcomes of depression inprimary care (DIAMOND): a longitudinal study (02–03)

Attitudes towards and pathways to and from a youngpeople’s mental health service (02–03)Comprehensive GP shared care following stroke: selec-tive secondary intervention for depression and othermorbidities in a high-risk group (02–03)Depression in farmers and farming families (02–03)Shared care pathways for depression and related disor-ders (02–03)Models of collaboration between general medical practi-tioners and psychologists in the delivery of cognitivebehavioural treatment for obsessive compulsive disorder(02–03)An interdisciplinary approach to recognising and treatingdepression among older Australians living in residentialcare (02–03)Recognising and screening for depression among olderpeople living in residential care (02–03)Early detection and treatment of depression in mildlyintellectually disabled adults (02–03)A randomised controlled trial of mindfulness-based cog-nitive therapy and adherence therapy for the preventionof relapse and recurrence of depression in primary care(02–03)Models of care: evaluating a best practice model fortreating postnatal depression (02–03)Supporting mental health care in general practice in rela-tion to Australian ethnic minority communities (02–03)Therapeutic family involvement (TFI) in the managementof persistent clinical depression: psycho-education, fami-ly support and multi-family group intervention (02–03)Evaluation of the efficacy of an Internet-based treatmentfor panic disorder in general medical practice (02–03)National study into the management of depression ingeneral practice: extension and follow-up (02–03)Staying well with a ‘Stay Well Plan’ (02–03)Young people’s responses to emotional distress: adescriptive study (02–03)Linking the health and leisure sectors: using physicalactivity in the management of depressed older people(02–03)Time for a future: effective treatment of depressed youthin urban and rural primary care settings (02–03)Diagnosis and treatment of depression in adults withintellectual disability through GP and psychiatric collabo-ration (02–03)

Strategic research

beyondblue National Telephone SurveyDepression as a risk factor to heart diseaseDepression and child sexual abuseDepression and changing familiesPreventing depression in young peopleDepression and heroin useA brief perceived need screening and assessment instru-mentAttachment of unit costs to the National Survey ofMental Health and Wellbeing

Source: beyondblue website (2004)

BOX 2 Research Funded through the beyondblue Victorian Centre of Excellence in Depression and Related Disorders,2002-03 and 2003-04 and through beyondblue’s Strategic Research (source: beyondblue Website, 2004)


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tantly, have increased research capacity. The DIAMONDand PEP collaborations, for example, have joined forces tostrengthen primary mental health care research. The projectsare still in their early stages, but they have begun to increasecapacity by developing websites, supporting higher degreestudents, obtaining collaborative grant funding, hosting aca-demic visitors, establishing national/international researchernetworks and contributing to state and national policy(Blashki et al, n.d.; Gunn, 2004).

High-level objectives

Increased capacity of the broader Australian commu-nity to prevent and respond effectively to depression

Given beyondblue’s achievements in relation to many ofthe objectives lower down the hierarchy, it is likely that theorganisation has, at least partly, achieved its mission (thatis, has increased the capacity of the broader Australiancommunity to prevent and respond effectively to depres-sion). That said, no data sources were available to quantifythis increase.

A society that understands and responds to thepersonal and social impact of depression, andworks actively to prevent it and improve thequality of life of everyone affected by it

Similarly, no data were available to inform the question ofthe extent to which beyondblue has achieved its vision.However, the above evidence suggests that it is doubtfulthat society currently understands and responds to the per-sonal and social impact of depression and works actively toprevent it and improve the quality of life of everyone affect-ed by it. beyondblue has made good inroads, but the cultur-al change required for such a societal response is substan-tial, and would be unlikely to be achieved within four years.

Discussion

In interpreting the above findings, it must be acknowledgedthat the evaluation had limitations. It relied on secondarydata analysis. It could not always demonstrate that changeswere attributable to beyondblue. Its objectives-basedapproach militated against exploring unintended conse-quences, and emphasised current achievements rather thanpotential sustainability.

These limitations aside, it is evident from the evalua-tion that beyondblue has made considerable progress inachieving its objectives (Figure 4, overleaf). Many of its

lower-level objectives have been completely achieved. Ithas key initiatives in place across its five priority areas, andthese have led to increases in the quantity and quality ofinformation available about depression, improved con-sumer/carer networks, systemic improvements that supportprimary care practitioners to prevent and treat depression,and increases in targeted research.

Many of its intermediate-level objectives have beenpartly achieved. Some headway has been made in increas-ing the community’s ‘depression literacy’ and understand-ing of the experiences of people with depression, and thereis evidence to suggest that this may be reducing stigma anddiscrimination, but the situation is still far from perfect.beyondblue has worked hard to include consumers/carersin all its activities, and has genuinely acknowledged theproblems they experience. There is evidence that the incor-poration of consumer/carer perspectives is beginning tospill over into external arenas as well. There are indicationsthat the health workforce is becoming better equipped torecognise and deal with depression, that people withdepression are beginning to seek help earlier and that therange of prevention and early intervention options isincreasing, but there is still some way to go. The role ofprimary care practitioners in community and education isincreasing, although it is not yet optimal. New knowledgeis emerging, but there remains much to learn. Together,these achievements are gradually increasing the capacity ofthe broader Australian community to prevent and respondeffectively to depression, but ongoing efforts are required.

Despite these major successes, it is fair to say thatbeyondblue’s vision, or highest-level objective, has not yetbeen realised. Society does not yet understand and respondto the personal and social impact of depression, nor does itwork actively to prevent it and improve the quality of lifeof everyone affected by it. beyondblue has begun to makean impression, but it is unrealistic to expect systemic andcultural change of this magnitude to occur rapidly.

To put these achievements in context, it is worth con-sidering comparable international initiatives. A number ofcampaigns have been conducted elsewhere that have aimedto improve depression literacy, or, more broadly, mentalhealth literacy. They include the Defeat DepressionCampaign (Paykel et al, 1988, 1997) and the ChangingMinds Campaign (Crisp et al, 2000) in the UK, theDepression Awareness, Recognition and TreatmentCampaign (Regier et al, 1988) and National DepressionScreening Day in the US, the Norwegian Mental HealthCampaign (Fonnebo & Sogaard, 1995; Sogaard &Fonnebo, 1995) and the Like Minds, Like Mine project(Vaughan & Hansen, 2004) in New Zealand. Where these


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FIGURE 4 Achievement of Individual Objectives within beyondblue’s Objectives Hierarchy


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campaigns have been evaluated, there is evidence that atbest they have achieved small gains in mental health litera-cy. Parslow and Jorm (2002) have argued that such cam-paigns must employ a range of theoretically sound educa-tional strategies designed to motivate attitude and behav-iour change in order to be effective. The population healthapproach of beyondblue does exactly this, which mayaccount for its success.

To conclude, beyondblue’s achievements should beconsidered in the light of the three scenarios outlined inits Strategic Plan (beyondblue, 2000). Even consideringthe earlier caveats, it is clear that the third scenario mostaccurately describes the current situation; beyondbluehas partly achieved its goals, and careful considerationshould be given to what action is necessary to foster pos-itive change that is sustainable to the point that it nolonger needs to exist.


Associate Professor Jane Pirkis, Program Evaluation Unit,School of Population Health, The University of Melbourne,Victoria 3010, Australia, tel. 61 3 8344 0647, fax 61 39348 1174, email: [email protected]

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Key words: externalising behaviour, parenting, toddler,prevention, universal

Introduction

Externalising behaviour problems such as oppositionaldefiance, hyperactivity and aggression are common inchildhood. Clinically significant problems occur in up to14% of children, while up to 50% experience subclinicallevels of problems (Sawyer et al, 2000). If left untreated,about 50% of preschool externalising behaviour problemspersist (Campbell, 1995). Long-term sequelae include

poor peer relationships, school drop-out, unemployment,conduct disorder, drug misuse and emotional problems(Coie & Dodge, 1998; Stattin & Magnusson, 1996;Stewart-Brown, 1998). Families of children with external-ising problems are more likely to experience maternaldepression, family stress and family breakdown (Campbell,1995). In addition, the pathways to juvenile crime oftenbegin with early externalising problems, and a third of allcrime committed in Australia is by juveniles, at an estimat-ed cost of AUD $1.5 billion per year (Bor et al, 2001).

Two recent systematic reviews have shown that groupparenting programs can successfully reduce established

Harriet Hiscock

Jordana Bayer

Melissa Wake

Centre for Community Child Health, Royal Children’sHospital Melbourne, Murdoch Childrens Research Institute

and Department of Paediatrics, University of Melbourne

Preventing Toddler

Externalising Behaviour

Problems: Pilot

Evaluation of a

Universal Parenting

Program

Universal parenting programs could offer effective pre-

vention for externalising behaviour problems in children.

Demonstration of effectiveness requires formal trials,

but feasibility data are essential to fund such trials. We

report feasibility data from a universal prevention pro-

gram on parenting, delivered to 57 mothers of infants at

their eight-month visit by nurses in well child clinics,

Melbourne, Australia. The paper reports on maternal

views of the program’s usefulness for managing child

behaviour, nurse reports of program feasibility and com-

petence in managing child behaviour, and barriers to

program implementation.

Strategies to encourage positive behaviour and man-

age misbehaviour in young children were rated as ‘quite’ to

‘extremely’ useful by 89% and 91% of mothers respective-

ly. Nurses reported that the program was feasible to con-

duct and increased their competence to prevent behaviour

problems. Mothers who attended the program were less

likely to report continuity of difficult child behaviour from

eight to eighteen months of age. Barriers to implementa-

tion included lack of after-hours sessions (75%) and child-

care (57%). We conclude that a brief universal preventa-

tive program for early externalising problems is useful for

mothers and feasible in primary health care.



F E A T U R E

externalising behaviour problems for children aged fromthree to ten years (Barlow, 1999; Barlow & Parsons, 2002).Maternal depression, parenting efficacy and relationshipsatisfaction are also improved (Barlow et al, 2002).However, these programs are intensive and expensive, havehigh drop-out rates and are not widely available (Barlow,1999; Sawyer et al, 2000). Thus there is an urgent need todesign and evaluate preventative approaches to externalis-ing behaviour problems.

Prevention can be targeted (offered to high-risk familiesonly) or universal (offered to all families). In a comprehen-sive, integrated, public health approach to reducing exter-nalising behaviour problems, universal prevention strate-gies would be partnered by targeted secondary preventionand skilled tertiary services (Bayer & Oberklaid, 2004).Universal strategies could offer a number of advantages.First, they avoid stigmatising parents as ‘high risk’(Barlow, 1999; Stewart-Brown, 1998). Second, they avoidmisclassification of children with early markers of difficultbehaviour (such as infant temperament) who in up to 50%of cases grow up to have no behaviour problems (Bennettet al, 1998). Third, a universal program is available to ‘lowrisk’ families (for example families with two parents andno unemployment) who care for the most children withbehaviour problems, simply because low-risk familiesmake up the bulk of the population (Offord et al, 1998).

As a novel approach, universal preventative strategieswould require rigorous evaluation within the confines ofseveral randomised controlled trials prior to widespreadadoption. However, to justify the significant financial out-lay of such trials, the feasibility and acceptability of a briefuniversal approach to both parents and providers must bedemonstrated and any barriers addressed. To this end, wereport on the design and pilot findings of a universal par-enting program (the first of which we are aware) aiming toprevent development of externalising behaviour problemsfrom very early childhood. We hypothesised that in a com-munity sample of children aged eight to fifteen months theprogram would be acceptable to and useful for parents andfeasible to deliver in a primary health care framework. Wealso hypothesised that barriers to recruitment and retentionwould exist. We aimed to identify modifiable barriersbefore conducting a randomised effectiveness trial of theprogram.

Methods

The pilot study was conducted in Moonee Valley, an eco-nomically diverse local government area of Melbourne,Australia, with an annual birth rate of 1,400. As in the rest

of Melbourne, Moonee Valley’s Maternal & Child Health(MCH) nurses provide a universally available service ofdevelopmental surveillance and advice, with individual keyvisits scheduled at two weeks, two, four and eight months,one year, eighteen months and two, three and a half andfour to five years.

Timing and setting of the program

The optimal timing for delivery of a universal parentingprogram to prevent child behaviour problems is unknown.From eight months, babies become mobile, strive forautonomy, and oppositional behaviours emerge (Dixon,1992; Stein, 1992). These behaviours can provoke parentsto perceive their baby as difficult and lead to inappropriateparenting responses (Fonagy, 1998; Sanson et al, 1991).Many parents start to discipline their children between theages of 10 and 24 months (Sanders et al, 2000a). It is like-ly that anticipatory guidance for externalising behaviourbefore eight months may not yet be relevant for parents,yet guidance delivered after eighteen months could be toolate. We chose, therefore, to deliver the program betweeneight and fifteen months. This timing allowed recruitmentof a broad sociodemographic sample; 84% of familiesattend their MCH nurse at the eight-month key visit, drop-ping to 76% at the next 12-month visit with families oflower socioeconomic status under-represented (Departmentof Human Services, 2003), at an age when it is unlikelythat parenting discipline styles are too entrenched tochange. A number of models can be adopted to deliver par-enting advice (such as booklets, telephone advice, groupsrun by parenting specialists). We chose to deliver our pro-gram in a well-established and well-attended existing pri-mary health care service, and designed the content so thatthe program could work largely within its existing con-straints.

Program content

Our program’s parenting strategies were drawn from thelarge body of empirical research reported in existing sys-tematic reviews of group-based intervention studies forestablished behaviour problems (Barlow & Stewart-Brown,2000; Sanders et al, 2000a). We selected aspects of parent-ing most conclusively shown to predict child externalisingbehaviour problems (lack of parental nurturing and respon-siveness, inappropriate expectations of normal develop-ment, and harsh and inconsistent discipline) (Sanders et al,2000a). Targeting these particular aspects of parenting sig-nificantly reduces established child externalising problems,


F E A T U R E

parental stress, maternal anxiety and maternal depression(Barlow & Stewart-Brown, 2000; Barlow et al, 2002). Wedeveloped three structured anticipatory guidance ‘pack-ages’ for use when children were approximately eight,twelve and fifteen months old. Content and design wereoverseen by a steering committee comprising paediatri-cians, psychologists, parenting experts and MCH nurses.

At the eight-month individual scheduled visit, thenurse discussed four handouts with the parent. These out-lined normal child motor development, normal social/emo-tional development including limits to toddlers’ behaviour-al self-control, ways to enhance language development andexamples of a toddler’s view of the world, to encourageparental empathy and understanding of young children. At12 months, parents attended a two-hour group session runby their nurse at the local MCH centre, which emphasisedhow to develop a warm and positive relationship with tod-dlers, and how to plan for and encourage desirable behav-iours from toddlers. Strategies such as ‘catch your childbeing good’ were discussed, in which parents aim to praisetheir child daily for their good behaviour. ‘Planned activi-ties’ were also discussed; parents plan ahead for challeng-ing situations by engaging their child in appropriate activi-ties to prevent misbehaviour (Sanders et al, 200b). A fur-ther two-hour parent-group session at 15 months was co-facilitated by a health professional with expertise in con-ducting parenting groups. This session emphasised theneed for parents to act immediately, consistently and deci-sively when child early externalising behaviour occurs,with responses other than harsh discipline. Strategiesincluded setting basic rules and limits, providing simpleand effective instructions, using ‘planned ignoring’ forminor misbehaviours (such as toddler whining) and using‘quiet time’ for ‘high priority’ misbehaviours known topredict later externalising behaviour problems (such as hit-ting, kicking and biting). Information was conveyed to par-ents through handouts, group discussion, nurse-parent role-play (for example practice in praising a toddler) and videovignettes (from the widely-available Triple P Program –Sanders et al, 2000b) of parental responses to child behav-iour (for example use of ‘time out’ for aggression).

Nurse training

Training consisted of one half-hour and two two-hour ses-sions with MCH nurses. At the first, a paediatrician and apsychologist outlined the content of the parent handoutsfor the eight-month session and ways to discuss them withparents. A psychologist expert in parenting groups thenconducted training for the 12- and 15-month group ses-

sions, approximately three to four weeks before nursesdelivered each session. A training manual facilitated pro-gram integrity.

Participants

In May/June 2002, the 10 MCH nurses in Moonee Valleyinvited all parents of children aged six or seven monthswho attended their MCH centre to participate in the pilot.Contact details of interested parents were faxed to theresearch team, who then contacted the parents to obtaininformed consent. As well as a baseline questionnaire andwritten informed consent, parents completed question-naires two weeks after the 12-month group session andthree months after the 15-month group session, to detectoutcomes of the program. Approval was obtained from theEthics in Human Research Committee, Royal Children’sHospital, Melbourne.

Measures

Outcomes were measured when children were 12 and 18months. Primary outcomes included usefulness of the pro-gram’s strategies (reported by mothers on a study-designed 5-point scale, where 1 = ‘not at all useful’ and 5= ‘extremely useful’), helpfulness of the program’s hand-outs (helpful or unhelpful), the ideal timing in their child’slife for the program and whether the program’s strategieswere useful for older children. Mothers completed astudy-designed 10-item scale measuring the help-givingbehaviours and attributes of the nurses who conducted thegroup sessions (Dunst, 1996). Nurses completed question-naires before and after training to assess their self-per-ceived competence in preventing child behaviour problemsover time, their comfort in broaching child behaviourproblems with parents and their optimism that interventionfamilies would have more positive parenting. Responseswere measured on a study-designed, 4-point scale where 0= ‘not at all competent/comfortable/optimistic’ and 3 =‘very competent/comfortable/optimistic’. Nurses alsoreported on the feasibility of conducting the program.Parents who dropped out were contacted by telephone toascertain why.

A number of measures were included to pilot theiracceptability for the planned randomised effectiveness trial.They included the Child Behaviour Checklist (CBCL/1.5-5) (Achenbach & Rescorla, 2000), measured at 18 monthsand the Parent Behaviour Checklist (Fox, 1992), measuredat 12 and 18 months. At baseline, child temperament wasassessed (Sanson et al, 1987), together with potential mod-


F E A T U R E

ifiers of the program’s effectiveness, including domesticviolence, maternal depression (measured by the Kessler –K10) (Furukawa et al, 2003) in half the sample and theDepression Anxiety Stress Scale - DASS (Lovibond &Lovibond, 1995) in the other half to compare acceptability,family drug use and parenting conflict (Dadds & Powell,1991). Socioeconomic data were also obtained.

Results

Sample characteristics

Of the 81 mothers approached by nurses, 70 agreed to becontacted by the study team and 57 consented to take part(response rate 70%). Mothers who consented to take partwere more likely to have a boy (69% vs 29%, p=.001) andfewer children (p=.003) than non-consenting mothers.

Mean maternal age was 33 years (range 23-44), 97% ofmothers had partners and 49% had completed tertiary edu-cation. The majority of children were boys (70%) and 48%of children were first-born. Seventy-eight per cent of moth-ers were not working and 12% of fathers had been ‘unem-ployed but wishing to work’ over the past year. Annualhousehold income ranged from less than $AUD35,000(19% of families) to more than $AUD55,000 (58%). Fifty-nine per cent of mothers were Anglo-Australian, 24% wereEuropean, 5% were South East Asian and 5% wereAfrican. Twelve per cent of mothers mainly spoke a lan-guage other than English in the home. At baseline, sevenmothers reported having no social support in their role as aparent, four reported experiencing domestic violence in thepast year and one reported a drug problem.

Parent program evaluation

Overall acceptability and usefulnessFifty-five mothers received the eight-month package (96%),42 attended the 12-month group (74%) and 27 attended the15-month group (47%). Fifty mothers (88%) completed thefollow-up questionnaires. Acceptability and usefulness of theprogram were unrelated to the number of children in thefamily, maternal perception of infant temperament orwhether the family was under stress at the time (for examplesingle parent, depressed mother, domestic violence). Mostmothers (74%) reported that the timing of the program wasideal. Of the mothers with older children (n=16), 86%reported using the program’s strategies with them and allrated the strategies as ‘quite’ to ‘extremely’ useful.

Parents who rated their nurse’s helping style as low inwarmth, empathy and listening skills found the programless useful for understanding why a child can be opposi-tional (p =.08), knowing how to encourage good behaviour(p =.04) and knowing how to manage unwanted behaviour(p =.02), compared with parents who reported more posi-tively about their nurse.

Usefulness of 8-, 12- and 15-month componentsAt eight months, most mothers rated the program informa-tion as ‘quite’ to ‘extremely’ useful for understanding whya child has tantrums and is non-compliant (76%) and howa child develops (65%). All mothers reported that the hand-outs on motor, social and language development were help-ful, and all but two that the handout on a child’s view wasuseful. Mothers were also overwhelmingly positive aboutthe 12- and 15-month groups (see Table 1, below).

Maternal Usefulness:report Mean

Target behaviour Strategies %1 (SD)2

12 monthsDevelop a positive relationship with child Hugs, praise, short bursts of one-on-one time 91 3.8 (.9)Encourage good behaviour ‘Catch toddler being good’ 89 3.7 (.9)Play ideas Age-appropriate engaging activities 94 3.5 (.8)Manage difficult situations Planned activities 80 3.2 (.9)Parent coping skills Simple cognitive re-structuring for unhelpful thoughts 83 3.3 (1.0)

15 monthsDecrease toddler misbehaviour Keep precious things out of reach, keep a daytime sleep, set simple rules 91 3.9 (.9)Identify high- and low-priority misbehaviours Write list of child’s minor (eg whining) and major (eg aggression) misbehaviour 91 3.9 (1.0)Manage low-priority misbehaviours Ignoring, distraction, logical choices 91 3.9 (.9)Manage high-priority misbehaviours Planning ahead, using flowchart for biting/hitting 91 3.9 (1.0)

1 Quite to extremely useful2 Range from 1 = ‘not at all useful’ to 5 = ‘extremely useful’

TABLE 1 Maternal Report of Usefulness of Parenting Strategies in the 12- and 15-Month Group Sessions


F E A T U R E

The majority of mothers reported that written informationsupporting parenting strategies was helpful at 12 months(range 88% for planned activities sheet to 94% for playideas) and 15 months (range 83% for flowchart on managinghigh-priority misbehaviour to 91% for prioritising low- andhigh-priority misbehaviour). Ninety-five per cent reportedthat they would recommend the program to their friends.

Videotape and role-play were rated as less useful thanthe other strategies. At 12 months, 76% and 50% of moth-ers respectively rated these strategies as ‘quite’ to‘extremely’ useful. At 15 months, 67% and 45% respec-tively rated these strategies as ‘quite’ to ‘extremely’ useful.

Nurse program evaluation

All nurses reported that it was feasible to deliver the pro-gram in their practice. After the program, all nurses were‘quite’ to ‘very’ optimistic that intervention families wouldhave more positive parenting, 90% felt ‘quite’ to ‘very’ com-fortable about broaching the issue of a child’s behaviourproblems with parents, and 80% felt ‘quite’ to ‘very’ compe-tent about preventing behaviour problems over time. On astudy-designed, 4-point scale (0 = ‘not at all’, 3 = ‘very’),nurses felt slightly more competent about preventing behav-iour problems after delivering the program than before(mean pre = 1.67, mean post = 2.00, t(8) = -2.00, p=.08).

Drop-outs

The 30 parents who missed one or both group sessionswere contacted by telephone to ascertain reason/s for miss-ing sessions. They included lack of evening or weekendsessions (reported by 75% of drop-outs), work commit-ments (60%), lack of child care (57%), the child being sick(32%), the family being under too much stress (14%), lackof confidence in the program (14%) and a perception thattheir baby was too young (14%). When parents did notattend group sessions, continuity of temperament difficultyat eight months to behavioural difficulty at eighteen monthsappeared greater (r =.58, p =.06, n = 11), than when parentsattended group sessions (r =.32, p =.05, n = 37).

Discussion

This is the first reported pilot of a universally availableparenting program designed to prevent externalising behav-iour problems from early childhood. The program was per-ceived as useful and relevant by a diverse range of parents.Primary health care nurses reported that the program wasuseful and could feasibly be delivered in a busy communi-

ty practice. It is important to note that we found no evi-dence of harm arising from the program, which could havemanifested as negative ratings of the program.

An important question to address in group-based par-enting programs is why parents drop out (Barlow &Stewart-Brown, 2000). The two most common barriersreported in this study (lack of evening/weekend sessionsand lack of on-site childcare) can both easily be addressedin our planned larger, randomised trial assessing the pro-gram’s effectiveness to prevent externalising behaviourproblems. In addition, acceptability of the program wasaffected by parents’ ratings of their nurse’s group facilita-tion skills. Parents who rated their nurse as having fewergroup facilitation skills found the program to be less use-ful. Similar findings have been reported elsewhere (Dunst,1996). Specific training in facilitation skills and/or co-facilitation of sessions with a professional expert in parent-ing groups could solve this problem.

Given that externalising behaviour problems are com-mon, are potentially serious, often go unmanaged and,once established, can prove difficult to treat, an effectiveprogram offering universal primary prevention couldmake a considerable contribution (Offord et al, 1998). Itmust be feasible (in brief) to deliver such a program in abusy primary care setting and the program must be sup-ported by childcare and flexible session times to max-imise parent attendance. Coupled with targeted secondaryprevention for families facing multiple stresses and clini-cal tertiary services for established child behaviour prob-lems, a universal approach has the potential to lessen theburden of externalising problems for children and theirfamilies. Having demonstrated feasibility and acceptabili-ty, we are now rigorously evaluating our parenting pro-gram in a cluster controlled trial with a sample largeenough to detect change, and follow-up long enough toassess effectiveness.

Acknowledgments

We sincerely thank all the participating parents and mater-nal and child health nurses of the City of Moonee Valley.We also acknowledge the William Buckland Foundationwho funded the study.


Dr H Hiscock, Paediatrician and Research Fellow, Centrefor Community Child Health, Royal Children’s Hospital,Parkville, 3052, Australia, tel: 001 61 3 9345 6150, fax:0011 61 3 9345 5900, email: [email protected].


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Like health promotion, mental health promotion involvesactions that support people to adopt and maintain healthylifestyles and which create supportive living conditionsor environments for health. This report describes theconcepts relating to promotion of mental health, theemerging evidence for effectiveness of interventions andthe public health policy and practice implications. Itreviews the available evidence from a range of countriesand cultures. This includes evidence on the relationshipbetween social and cultural factors and the mental healthof individuals and communities. The report documentshow actions such as advocacy, policy and project devel-opment, legislative and regulatory reform, communica-tions, research and evaluation may be achieved and mon-itored in countries at all stages of economic develop-ment. It considers strategies for continued growth of theevidence base and approaches to determining cost-effec-tiveness of actions.

Promoting Mental Health: Concepts, EmergingEvidence, Practice is the result of collaboration with sci-entific contributors from sectors outside as well as withinhealth. The editors consulted a group of senior projectadvisers and contacted a wide group of interested peopleand organizations: professional, government, non-gov-ernment and others. The aims of the project were tofacilitate a better understanding of the evidence andapproaches to gathering local evidence, activation of thescientific community and growth in international cooper-ation and alliances.

The report is divided into three parts. Part one intro-duces the topic and describes a number of concepts associ-ated with health, health promotion and mental health, aswell as their use across different cultures, countries andsubpopulations. The aim is to locate mental health withinthe larger area of health promotion, and mental health pro-motion within overall mental health.

Part two focuses on evidence for mental health promo-tion. It begins with examining the nature of evidence inmental health promotion and then goes on to reviewing theavailable evidence in two specific areas - social determi-

nants and the interface with physical health and illness.Part two also reviews the literature on indicators for mentalhealth promotion and identifies their strengths and weak-nesses and the evidence on effectiveness of interventionsusing available information from the published literature.There is special focus on evidence accumulating in devel-oping countries where interventions are most urgentlyneeded. Part three takes the concepts of evidence forwardto examine and suggest actions for policy and practice thatserve the needs of mental health promotion. Since nationalmental health policy often forms the blueprint for allactions in this area, it describes how mental health promo-tion can and should be an important component of policy.The historical basis for mental health promotion withininternational charters and the relevance and limitations ofthese approaches for policy and practice are covered.Sections of Part three focus on community development asan important strategy for promoting mental health, sustain-ability of interventions and the importance of intersectoralapproaches in developing and implementing mental healthpromotion programmes.

Promoting Mental Health: Concepts, EmergingEvidence, Practice has been written for people working inhealth and non-health sectors whose decisions affect men-tal health in ways that they may not realize. It is also asympathetic account for people in the mental health profes-sions who need to endorse and assist the promotion ofmental health while continuing to deliver services for peo-ple living with mental illnesses. It is relevant to peopleworking to develop policies and programmes in countrieswith low, medium and high levels of income and resources,as well as those concerned with guidelines for internationalaction. It uses a public health framework to address thedilemma of competing priorities that is often a concern forplanners and practitioners in low income as well as affluentsettings.

Promoting Mental Health: Concepts, EmergingEvidence, Practice has 59 contributors from all regions ofthe world and is edited by Helen Herrman, ShekharSaxena and Rob Moodie.

Mental Health Promotion: A Report from WHO

Promoting Mental Health: Concepts, Emerging Evidence, Practice. A Summary Report from the World HealthOrganization, Department of Mental Health and Substance Abuse, in collaboration with the Victorian Health Promotion

Foundation (VicHealth) and The University of Melbourne.

This WHO publication, a summary of a larger volume in press, aims to bring to lifethe mental health dimension of health promotion.

This WHO publication can be downloaded from the WHO website- http://www.who.int/mental_health/evidence/en/promoting_mhh.pdf

To obtain a hard copy, please contact Dr Shekhar Saxena (Email: [email protected]) / (fax: +41 22 791 4160).



One of the primary goals of the World Health Organization(WHO) Department of Mental Health and SubstanceAbuse is to reduce the burden associated with mental, neu-rological and substance abuse disorders. Prevention ofthese disorders is obviously one of the most effective waysto reduce the burden. This report attempts to provide acomprehensive overview of this field, especially from theperspective of evidence for effective interventions andassociated policy options. In an area like prevention ofmental disorders, this task is especially critical since muchevidence is recent and untested in varied settings.

Prevention of Mental Disorders: Effective Interventionsand Policy Options focuses on primary prevention of mentaldisorders. It reviews universal, selective and indicated inter-ventions and proposes effective strategies for policy-makers,government officials and practitioners to implement acrosscountries and regions. It describes the concepts relating toprevention; the relationship between prevention of mentaldisorders and the promotion of mental health; malleable indi-vidual, social and environmental determinants of mental dis-orders; the emerging evidence on the effectiveness of preven-tive interventions; the public health policy and practice impli-cations; and the conditions needed for effective prevention.

Prevention of Mental Disorders: Effective Interventionsand Policy Options includes a selective review of the avail-able evidence from a range of countries and cultures.Current knowledge is still mainly based on research inhigh income countries, although new research initiativesare emerging in developing countries. The current trend toexchange evidence-based programmes across countrieschallenges us to expand our understanding of the role ofcultural and economic factors in prevention.

The Summary Report has been written for people in themany health and non-health sectors of governments andnongovernmental agencies in countries with low, mediumand high levels of income and resources. These people arein a position to significantly influence the determinants ofmental and behavioural disorders and the effectiveness ofprevention efforts in ways that may not be obvious tothem. It also offers insight into the spectrum of opportuni-ties for health and mental health professionals to contribute

to primary prevention and early intervention alongsidetreatment and rehabilitation. It supports health promotersin integrating mental health issues into their national andlocal health promotion and prevention policies and activi-ties. It stimulates prevention and health promotionresearchers to expand their knowledge of the designing andimplementation of effective interventions. Prevention ofMental Disorders: Effective Interventions and PolicyOptions is written with the conviction that reducing theincidence of mental disorders in populations worldwide isonly possible through successful collaboration between themultiple parties involved in research, policy and practice,including community leaders and consumers.

Key Messages of the report are as follows:-

1. Prevention of mental disorders is a public healthpriority.

2. Mental disorders have multiple determinants; pre-vention needs to be a multi-pronged effort.

3. Effective prevention can reduce the risk of mentaldisorders.

4. Implementation should be guided by availableevidence.

5. Successful programmes and policies should bemade widely available.

6. Knowledge on evidence for effectiveness needs fur-ther expansion.

7. Prevention needs to be sensitive to culture and toresources available across countries.

8. Population-based outcomes require human andfinancial investments.

9. Effective prevention requires intersectoral linkages.10. Protecting human rights is a major strategy to pre-

vent mental disorders.

Prevention of Mental Disorders: Effective Interventionsand Policy Options has 37 contributors from all regions ofthe world and is edited by Clemens Hosman, Eva Jané-Llopis and Shekhar Saxena.

Prevention of Mental Disorders: A Report from WHO

Prevention of Mental Disorders: Effective Interventions and Policy Options. A Summary Report from the World HealthOrganization, Department of Mental Health and Substance Abuse, in collaboration with the Prevention Research Centre

of the Universities of Nijmegen and Maastricht.

This WHO publication, a summary of a larger volume to be published by Oxford University Press, offers an overview ofinternational evidence-based programmes and policies for preventing mental and behavioural disorders.

This WHO publication can be downloaded from the WHO website-(http://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf).

To obtain a hard copy, please contact Dr Shekhar Saxena (Email: [email protected]) / (fax: +41 22 791 4160).

NOTES FOR CONTRIBUTORS

Preparation and submission of articles

The aim of The International Journal of Mental HealthPromotion is to establish a high quality source of informa-tion and intelligence for managers and practitionersinvolved in the policy-making and implementation ofmental health promotion and mental disorder prevention.The intention is to link theory and practice.

Article submitted to the journal must be original work(not published or simultaneously submitted to anotherjournal) and must be copyrighted to this journal unless theauthors reserve the rights to themselves, before publica-tion, by agreement with the editor.

Any illustrations, charts or graphs that are beingreprinted from elsewhere will need copyright clearance.Obtaining permission to reproduce such items is theresponsibility of the author, together with any paymentsthat the copyright holder deems necessary. If you have dif-ficulty obtaining permission to reprint an item, pleaseinform the editor.

Original papers should normally be no more than 5,000words in length. Two copies of the manuscript should beaccompanied by a covering letter detailing permissions toreproduce published material or to use illustrations thatmay identify individuals. A disc of the article in any wordprocessing or text-only format must accompany the twocopies of the manuscript.

Manuscripts should be typed in the English language,on one side of the paper only and double-spaced with aminimum of 3cm-wide margins. The following informa-tion should also be included: name, address, status ofauthor, e-mail address and address for correspondence.

Articles should be prefaced with an abstract, ofbetween 100 and 150 words in length, summarising themain points discussed in the article. This will greatly helpthe speed and accuracy with which the article can beincluded on major library databases.

All references cited should be included in full at the

end of the article and give the following information:author, date, title of book or title of article and journal,journal volume, page numbers, place of publication andpublisher.

Example:

Emerson, E., Beasley, F., Offord, G. & Mansell, J. (1992)An evaluation of hospital-based specialised staffed hous-ing for people with seriously challenging behaviours.Journal of Intellectual Disability Research 36 291–307.

In the text, refer to references by name and date; forexample: (Smith, 1994) or (Emerson et al, 1992).

Where there is more than one reference by the sameauthor, add a, b or c to distinguish them: (Smith, 1994a).

Formatting and layout should be kept to a minimum.This will be done at a later stage. Line figures should bein black ink with clear symbols and lettering. Black andwhite photographs should be supplied as black and whiteprints and not as photocopies or previously publishedmaterial. Both drawings and photographs should beclearly identified with the author’s name and the figurenumber. Legends should be typed on a separate sheet andbe clearly identified for the appropriate figure. Tablesshould not repeat data that are available elsewhere in thearticle eg in a line drawing.

Copyright

Copyright for all published material in the journal isheld by The Clifford Beers Foundation unless otherwisespecifically stated. Authors and illustrators may usetheir own material elsewhere after publication withoutpermission but The Clifford Beers Foundation asks thatthis note be included in any such use: ‘first published inthe International Journal of Mental Health Promotion…issue no…’

THE

CLIFFORDBEERSFOUNDATION

ISSN 1462-3730

The Journal co-ordinates the dissemination of new research

outcomes to all those involved in policy making and the implemen-

tation of mental health promotion and mental disorder prevention

policies. It is essential reading for those with a personal or profes-

sional interest in this work.

Peer reviewed by an expert international editorial board, the

Journal is a comprehensive information system which publishes

material of distinction submitted by clinical/medical staff, health

service researchers, managers, health promoters, educationalists,

sociologists, health economists and practitioners from all branches

of health and social care.

The International Journal of Mental Health Promotion is

designed to increase awareness, foster understanding and promote

collaboration between the different disciplines engaged in this

diverse activity of study and practice.

EDITORIAL BOARDMichael Murray

Editor, Chief Executive Clifford BeersFoundation, Stafford, England

Professor Almeida-FilhoBrazil

Professor George AlbeeUniversity of Vermont, USA

Dr Margaret BarryNational University of Ireland, Galway, Ireland

Dr Carlos BerganzaGuatemala

Professor Lynne A. BondUniversity of Vermont, USA

Dr Bela BudaSemmelweis University of Medicine, Budapest,

Hungary

Professor Odd Steffen DalgardFolkehelse, National Institute of Public Health,

Norway

Professor Steve EdwardsUniversity of Zululand, South Africa

Dr Bret HartNorth Metropolitan Health Service, Australia

Professor Clemens HosmanUniversity of Nijmegan, The Netherlands

Dr Moshe IsraelashviliTel Aviv University, Israel

Dr Rachel JenkinsWHO Collaborating Centre at the Institute of

Psychiatry, London, England

Professor Natacha JoubertHealth Canada

Dr Michael Killoran RossGreater Glasgow Health Board, Scotland

Dr Eero LahtinenMinistry of Social Affairs and Health,

Helsinki, FinlandProfessor Dusica Lecic-Tosevski

University of Belgrade, Yugoslavia

Professor Maurice B. MittelmarkUniversity of Bergen, Norway

Professor Ricardo MuñozUniversity of California, San Francisco, USA

Dr John OrleyThe Clifford Beers Foundation, Guernsey

Associate Professor John RaeburnUniversity of Auckland, New Zealand

Professor Beverly RaphaelNew South Wales Health Department, Australia

Dr Colin ReedThe Clifford Beers Foundation,Stafford, England

Professor Irv RootmanUniversity of Toronto, Canada

Professor David SeedhouseUniversity of Auckland, New Zealand

Professor Leslie SwartzUniversity of Stellenbosch, South Africa

Professor John TsiantisAthens University Medical School, Athens, Greece

Professor Katherine WeareUniversity of Southampton, England

Professor Mark D. WeistUniversity of Maryland, USA

The Clifford Beers FoundationMariazell5 Castle WayStafford ST16 1BS

Telephone/Fax 0044 (0) 1785 246668

Email [email protected]

Journal website www.ijmhp.co.uk

Clifford Beers Foundation website www.charity.demon.co.uk

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