|Being alive well: Aboriginal youth and evidence-based approaches to promoting mental well-being
Dr Lewis Williams
with Dr Zubia Mumtaz
Prepared by the
Prairie Region Health Promotion Research Centre
National Aboriginal Youth Mental Health Promotion Strategy Symposium hosted by the
First Nations and Inuit Health Branch
Feb 8 and 9, 2007, Saskatoon
Table of Contents
Executive Summary 3
State of the art: issues, developments and leading ideas 12
MHP as an emerging field 14
Aboriginal world views, meanings of health and self-determination 16
Scope of the systematic literature review 20
Inclusion criteria 20
Exclusion criteria 21
Overview of the literature search 21
What might MHP for Aboriginal youth begin to look like: some key ideas 21
Healing and cultural continuity 22
Multiple literacies 23
Showcasing: Four examples 27
Example one 27
Example two 28
Example three 30
Example four 32
Appendix I 41
Table 1: List of databases searched, search items and articles identified. 41
Table 2 43
Appendix II 44
I. Examples of primary prevention programs in Aboriginal youth 44
II. Examples of mental health promotion programs in mainstream youth (international) 46
McCollam A, Friedii L and Woodhouse A. (2004) report seven case studies as examples of effective mental health improvement practice for youth in Scotland, UK (Health Scotland 2004). 52
III. Conceptual ideas for developing mental health promotion program in general population 55
IV Examples of primary prevention programs in the general population 56
This paper was commissioned by the First Nations and Inuit Health Branch (FNHIB) in order to review the current evidence base regarding efforts to promote mental health in Aboriginal youth in Canada. A systematic review of peer-reviewed literature, the grey literature, internet search and key expert opinion was conducted. In total, 28 studies most closely approximating mental health promotion interventions were reviewed in-depth and summarized. In reality however these are primary prevention, tending to focus on individuals and proximal factors rather than collectives and underlying structural determinants of health.
In summary, our review reveals that published peer reviewed ‘evidence based’ evaluations of mental health promotion interventions with Canadian and indigenous youth in other countries are virtually non-existent. The fields of mental health and mental health promotion (MHP) are besieged with conceptual confusion and what is often named as mental health promotion is in fact primary or tertiary prevention. Furthermore, evidence-based health promotion has long been a contested area and perhaps the greatest challenge to the field is finding ways to develop and legitimate approaches to evidence that are congruent with Aboriginal worldviews.
However, our consultations with 42 key experts in the field across Canada, tell us that much is occurring across the country with Aboriginal youth, particularly First Nations, by the way of mental health promoting initiatives. These are largely not named as such, undocumented and under-resourced. Most action is occurring at the individual, family and sometimes community-building levels. Partnerships to assist in building capacity with respect to multi-leveled approaches to mental health promotion, evaluation and general resourcing would greatly benefit many of these fledgling initiatives.
Aboriginal approaches to MHP are complementary but also necessarily distinctly different from mainstream approaches. Two major points of departure are worldview and cultural identity. We offer a tentative definition of Aboriginal MHP both that draws on these and conceptualizes their operation within a population health promotion framework:
An Aboriginal approach to mental health promotion could be conceptualized as a process of enabling individuals and communities to express consciously constructed (cultural) identities and aspirations through access to capacities such as land, language, housing, economic resources and decision making institutions in ways that are mutually empowering (Williams, 2005).
From our review of the literature combined with our own knowledge, we accordingly offer three conceptual framings – healing and cultural connectedness, multiple literacies and power-culture that support the operationalization of this definition and potentially inform approaches to MHP with Aboriginal youth on a broader level.
We recognize that ‘Aboriginal’ refers to a diverse population made up of Inuit, First Nations, Métis, urban and rural youth. MHP is context specific and as such, this definition is broad. If taken up, it should be differentially operationalized in ways relevant to the many cultural contexts and realities that make up day-to-day life for Canada’s indigenous youth. For Inuit who have the highest suicide rates, and face extra-ordinary challenges of remote location and cultural and economic marginalization, this point is particularly significant.
We take the view that strengthening Aboriginal youth MHP is more akin to developing a movement. There are already some excellent initiatives happening within Aboriginal communities. Policy and Programming organizations at the Federal and Provincial levels need to find a way to build on and support the development of these from the ground up. Accordingly, we make the following recommendations:
That communities be consulted concerning their ideas of what might work in MHP interventions
That a series of capacity building activities be undertaken with communities in the areas of intervention development and evaluation.
That participatory action research be a key tool whereby community capacity building occurs
That capacity-building activities be undertaken with those currently engaged in Aboriginal youth MHP to expand their predominant focus on proximal/ individual and intermediary factors to distal / structural factors.
Currently there are numerous unevaluated programs occurring in communities which could be termed MHP but do not see themselves as such. We recommend that such programs are invited to view their activities as MHP related and fine tune them and be resourced to do so.
Expand, build capacity and resource existing promising Aboriginal programs (e.g. friendship centres) to address the larger structural issues that impact on the mental health of Aboriginal youth and their families. This process can be initiated in parts of the country where readiness exists amongst all stakeholders – e.g. policy people, community leaders, program managers etc.
To explore and understand in greater depth why First Nations communities are differentially affected by suicide and in particular further exploration around protective factor.
That further inquiry around what constitutes evidence of best practices be undertaken in ways that address the inherent tensions between evidence-based medicine and population based approaches and indigenous worldviews.
That alongside community capacity-building activities, inter-sectoral action be initiated at Federal and Provincial levels to address the largely systemic (underlying cultural, economic and social determinants) cause of mental health disparities amongst Aboriginal youth relative to Canadian youth as a whole.