CHAPTER 1

Introduction

The Public Health Approach

The public health field in the United States traces its origins to attempts to control infectious diseases in the late 18th century (Mullan, 1989). Its expansion during the 19th and 20th centuries was tied to the growing awareness of the importance of income, employment, lifestyle, and diet in health and disease (Porter, 1997). The first reports on public health documented higher rates of disease in impoverished, overcrowded communities. The documented effects of population growth, migration to cities, and industrialization brought to light the roles of social forces and the environment in disease causation. By the mid-19th century, public health became a new field grounded in scientific observation and stunning developments in bacteriology (Institute of Medicine [IOM], 1988).

Today the public health approach underpins the Nation’s commitment to health and medicine. This population-based approach is concerned with the health of an entire population, including its link to the physical, psychological, cultural, and social environments in which people live, work, and go to school (Chapter 2).

Public health focuses not only on traditional areas of medicine — diagnosis, treatment, and etiology or cause of an illness — but also on disease surveillance, health promotion, disease prevention, and access to and evaluation of services (Last & Wallace, 1992). The public health approach is premised on the conviction that it is inherently better to promote health and to prevent illness before it begins. Prevention also holds the promise of being more cost-effective.

Promoting Mental Health and Preventing Mental Disorders

The mental health field traditionally focused on mental illness in an attempt to serve individuals with the most severe disorders. As the field matures, however, it has begun to embrace activities that may promote mental health or prevent some mental illnesses and behavioral disorders. More specifically, it is employing the public health approach to identify problems and develop solutions for entire population groups. This approach:

• Defines the problem using surveillance processes designed to gather data that establish the nature of the problem and the trends in its incidence and prevalence;
  
• Identifies potential causes through epidemiological analyses that identify risk and protective factors associated with the problem;
  
• Designs, develops, and evaluates the effectiveness and generalizability of interventions; and
  
• Disseminates successful models as part of a coordinated effort to educate and reach out to the public (Hamburg, 1998; Mercy et al., 1993).

Just as mental health and mental illness are points on a continuum, so too are the public health goals of mental health promotion and mental illness prevention. Promotion refers to active steps to enhance mental health, while prevention refers to active steps to protect against the onset of mental health problems or illnesses.¹⁰

Promotion and prevention hinge on the identification of modifiable risk and protective factors, i.e., characteristics or conditions that, if present, increase or diminish, respectively, the likelihood that people will develop mental health problems or disorders (see full discussion in DHHS, 1999, p. 63–64). The modifiability of a risk or protective factor is a prerequisite for developing interventions targeted at these factors.

Risk and protective factors may be biological, psychological, or social in nature. They can operate within an individual, family, community, culture, or the larger society (Boxes 1–4, 1–5). A single risk or protective factor, in most cases, increases the probability, but is not necessarily the cause of a harmful or healthful effect. That is, one factor rarely is either necessary or sufficient to produce a given outcome. Each person is exposed to a unique constellation of risk and protective factors that act not in isolation, but rather through complex and often perplexing interactions. It is the accumulation and inter-action of risk and protective factors that contribute to mental health, mental health problems, or mental illness, not a single risk or protective factor (IOM, 1994).

Risk and protective factors not only vary across individuals, but also across age, gender, and culture. A prime goal of the SGR was to sift through risk and protective factors affecting different age groups. This Supplement focuses on risk and protective factors that disproportionately affect racial and ethnic minorities. Such risk factors include poverty, immigration, violence, racism, and discrimination, whereas protective factors include spirituality and community and family support (Chapter 2).

Several well-designed studies have demonstrated that interventions can successfully reduce the severity of certain mental disorders and enhance mental health. Some of these studies have been conducted with ethnic and racial minority samples. For example, low-income minority adults at risk for depression participated in a course on cognitive-behavioral methods adapted to their culture to control their moods. At the end of the course and at 1-year followup, these adults showed fewer symptoms of depression than did a control group (Munoz et al., 1995). For low-income, Spanish-speaking immigrant families at risk for attachment disorders, a home visitor program for mothers and infants led to more secure attachments (Lieberman et al., 1991). These findings, while quite promising, must be understood in context: At this point, the mental health field does not have sufficient knowledge of causation to prevent the onset of major mental disorders like schizophrenia and bipolar disorder (DHHS, 1999).

The recently issued report, Youth Violence: A Report of the Surgeon General, spotlighted 27 effective interventions designed to prevent youth violence (DHHS, 2001). Many of these programs target high-risk racial and ethnic minority youth. Violence in youth not only produces injuries, disability, and death, but it also often has enduring negative consequences for the mental health of victims, perpetrators, their families, and their communities. There is little doubt that our poorest neighborhoods, where a disproportionate percentage of minorities live, are fraught with violence. Preventing violence is a vital public health goal with the potential to improve the mental health and overall health

Box 1–4: Examples of Risk Factors Common to Mental Health Problems and Mental Disorders

Individual
Genetic vulnerability*
Gender
Low birth weight
Neuropsychological deficits
Language disabilities
Chronic physical illness
Below-average intelligence
Child abuse or neglect

Family
Severe marital discord
Social disadvantage
Overcrowding or large family size
Paternal criminality
Maternal mental disorder
Admission to foster care

Community or social
Violence
Poverty
Community disorganization
Inadequate schools
Racism and discrimination
* Genetic vulnerability varies by mental disorder
Sources: DHHS, 2001; DHHS, 1999; IOM, 1994

Resilience

One area of mental health promotion that has received considerable attention in recent years is resilience, or the capacity to bounce back from adversity. Increasingly researchers emphasize that resilience is by no means a fixed trait of an individual. Rather, resilient adaptation comes about as a result of an individual’s situation in interaction with protective factors in the social environment. Resilience research and programs take a “strengths-based approach” to human development and functioning: Rather than focusing on deficits and illnesses, they seek to understand and promote “self-righting tendencies” in individuals, families, and communities (Werner, 1989).

Box 1–5: Examples of Protective Factors Against Mental Health Problems and Mental Disorders

Individual
Positive temperament
Above-average intelligence
Social competence
Spirituality or religion

Family
Smaller family structure
Supportive relationships with parents
Good sibling relationships
Adequate rule setting and monitoring by parents

Community or social
Commitment to schools
Availability of health and social services
Social cohesion

Sources: DHHS, 2001; DHHS, 1999; IOM, 1994

The formal study of resilience stems from research begun in the 1970s on children of parents with schizophrenia (Garmezy, 1971). The investigator found that having a parent with schizophrenia does indeed increase someone’s risk for the illness, yet about 90 percent of the children in the study did not develop the illness. Further, most fared well in terms of peer relations, academic achievement, and other measures of mental health (Garmezy, 1971, 1991). This seminal research spawned a new line of investigations on children and other groups living in high-risk conditions such as poverty, war, and natural disasters.

Consistent with the public health approach, resilience research focuses on the promotion of protective factors. Key protective factors in racial and ethnic minority communities are supportive families, strong communities, spirituality, and religion.

Supportive Families and Communities

Researchers find that the support of other people is key to helping people cope with adversity. According to a nationally representative survey, families and friends are the first sources to which people say they will turn if they develop a mental illness (Pescosolido et al., 2000).

As early as 1983, researchers identified the following 10 characteristics of resilient African American families:

(1) Strong economic base

(2) Achievement orientation

(3) Role adaptability

(4) Spirituality

(5) Extended family bonds

(6) Racial pride

(7) Respect and love

(8) Resourcefulness

(9) Community involvement

(10) Family unity (Gary et al., 1983)

Other researchers have looked at the role of extended family members and other people in the community in helping children function well. A literature review on resilient African American children raised in inner-city neighborhoods concluded that “there was at least one adequate significant adult who was able to serve as an identification figure. In turn, the achieving youngsters seemed to hold a more positive attitude toward adults and authority figures in general” (Garmezy & Neuchterlein, 1972). In another study, African American children of low-income, divorced or separated parents were less likely to drop out of school if influenced by grandparents who provided continuity and support (Robins, et al., 1975). Similarly, for urban elementary students chronically exposed to violence, sup-port of teachers enhanced their social competence in the classroom, as did support from peers and family. Family support was also critical in relieving the children’s anxiety (Hill & Madhere, 1996; Hill et al.,1996).

One ground-breaking ethnographic study focused on the children of Vietnamese refugees who were forced to leave Vietnam when Saigon fell in 1975. Many parents were subjected to severe trauma prior to immigration and then to the stress of resettlement in the United States. The children of these refugees showed remark-able resilience, at least in terms of school performance and academic ambitions. In an examination of Vietnamese students attending public high schools in a low-income resettlement area in New Orleans, approximately one-fourth of the students had an A average, and over half had a B average. Only 5 percent did not want to go to college. This study concluded that several factors contributed to the resilience of these children, including strong family and community ties, and “selective Americanization,” i.e., integrating the best of American values while maintaining the best Vietnamese values (Zhou & Bankston, 1998).

For racial and ethnic minority groups, supportive families and communities help arriving immigrants with practical assistance in housing, transportation, and employment. In addition, they offer enduring emotional support and a haven against racism and discrimination. They also affirm cultural identity. The contributions of family and community are so ubiquitous and expected, that they only become obvious by their absence. A recurring theme of this Supplement is the essential nature of community and family support.

Spirituality and Religion

Spirituality and religion are gaining increased research attention because of their possible link to mental health promotion and mental illness prevention. Research findings, while somewhat equivocal, suggest that various aspects of religious practice, affiliation, and belief are beneficial for mental health. The findings are strongest for a link between spirituality and certain aspects of mental health, such as subjective well-being and life satisfaction (e.g., Witter et al., 1985; Koenig et al., 1988; Ellison, 1991; Schumaker, 1992; Levin, 1994).

Research findings are somewhat contradictory about whether spirituality is associated with less psychological distress and fewer symptoms of depression in adults (e.g., Idler, 1987; Williams et al., 1991). For prevention purposes, the role of spirituality may be tied to family relationships, as demonstrated by one recent, long-term study. It examined whether the mother’s religious devotion was correlated with whether her children developed depression. The study found, over a 10-year period, that two factors were correlated with the children’s not developing depression — the mother’s religiosity and her having the same religious denomination as her children (Miller et al., 1997).

The association between religious involvement and mental health also has been studied directly in African Americans. Using data from five large national samples, researchers found that African Americans report significantly higher levels of subjective religiosity than do whites (Taylor et al., 1999). Other studies show that religious factors are strong predictors of life satisfaction for African Americans (St. George & McNamara, 1984; Thomas & Holmes, 1992). Studies also find that public and private aspects of religious involvement are associated with improved self-perceptions and self-esteem (Krause & Tran, 1989; Ellison, 1993).

Spirituality plays a prominent role in the lives of the majority of Americans, including many racial and ethnic minorities. For example, many American Indian and Alaska Native communities participate in spiritual and religious traditions, including the Native American Church, where Christian and Native beliefs coexist. Less is known about how these traditions relate to mental health. To study the relationship, researchers may need to develop new approaches and different types of out-come measures (The Fetzer Institute & National Institute on Aging, 1999).

How might spirituality and religion exert an influence on health? This provocative question has led to the development of theories to guide empirical research. Some hypotheses are that spirituality and religion influence health by adherence to health-related behaviors and lifestyles, by having an impact on marriage patterns and hence heritability, by providing social support, by psychophysiology via ritual, or by promoting healthy cognitions via belief or faith (Levin, 1996).

¹⁰ This definition technically refers to primary prevention, i.e., prevention of a disorder before its initial onset. Secondary prevention refers to the prevention of recurrences or exacerbations of already diagnosed disorders. Tertiary prevention refers to the prevention or reduction of disability caused by a disorder. There also are other ways to define comprehensive efforts at prevention (IOM, 1994).