Depicting mental health promotion within the spectrum of mental health interventions
Within the mental health promotion framework, recognition of the broader determinants of mental health has led to a growing emphasis on models of mental health promotion that seek to intervene in strengthening individuals and communities and removing the structural barriers to mental health through initiatives to reduce poverty, discrimination, and inequalities (Barry and Friedli 2008; Barry 2009; Herrman et al. 2005; Lahtinen et al. 2005). The existence of review-level evidence of the effectiveness of mental health promotion across these multiple levels strengthens the case for action (WHO 2004a; Jané-Llopis et al. 2005; Keleher and Armstrong 2005; Barry et al. 2009a).
The Evidence Base for Mental Health Promotion Practice
Systematic reviews and effectiveness studies have been published that show many examples of effective interventions which promote and enhance mental health and lead to wider social and health gains. The evidence supports the value of programs promoting positive mental health, demonstrating that many of these initiatives have a positive impact on mental health and have the dual effect of reducing risks of mental disorders (Durlak and Wells 1997; Hosman and Jané-Llopis 1999; Friedli 2003; Herrman et al. 2005; Jané-Llopis et al. 2005; Keleher and Armstrong 2005; Barry 2009). The available evidence supports the view that competence-enhancing programs carried out in collaboration with families, schools, and wider communities have the potential to have an impact on multiple positive outcomes across social and personal health domains (Jané-Llopis and Barry 2005; Barry 2009). This section reviews the evidence across life stages from the early years through adulthood and considers the findings in terms of effective interventions that promote positive mental health in the early years, in school, at the workplace, and in the community and broader society.
Promoting Positive Mental Health in the Early Years
A number of interventions have been developed which promote positive mental health in the early years of life, through empowering parents and enhancing resilience and competence in both children and parents (Kendrick et al. 2000, 2007; Barlow et al. 2003; Elkan et al. 2000; Ciliska et al. 1999; Olds et al. 1997). Systematic reviews indicate that interventions that provide quality family support programs, including parenting support, home visiting, and quality preschool programs, have the potential to achieve long-term mental health benefits for both children and their parents (Barry et al. 2009a). The value of these interventions lies not only on their ability to reduce the risk factors for negative developmental outcomes, such as delinquency, substance misuse, teenage pregnancy, violence, and school failure, but also in their potential to enhance positive child and family functioning through promoting competence, positive relationships, and supportive environments for development (Barry and Jenkins 2007; Jané-Llopis et al. 2005).
Home Visiting Programs
Systematic reviews of home visiting programs for parents of children in the first 2 years of life show robust evidence of improved parenting skills, improved child development, reduced behavioral problems, and improved maternal health and social functioning (Ciliska et al. 1999; Elkan et al. 2000; Kendrick et al. 2000, 2007; Bull et al. 2004; Tennant et al. 2007). Positive findings with medium to strong effect sizes are particularly evident for programs which start antenatally, are of high intensity, are of medium to long duration (up to at least 12 months), and are designed for parents considered to be at higher risk, for example, low-income parents, teenage parents, single parents, and mothers coping with postnatal depression (Tennant et al. 2007; Waddell et al. 2007).
Intensive and comprehensive programs, such as the Prenatal and Infancy Home Visitation by Nurses program (Olds et al. 1997, 1998, 2004), have established strong evidence over 30 years of their cost-effectiveness in terms of long-term positive health, social, and economic gains for pregnant women and their children up to 15 years postintervention. Findings from a number of randomized controlled trials with participants from diverse backgrounds (Olds et al. 2006) not only support the program’s impact on reducing negative outcomes, such as child abuse, behavioral problems, and substance misuse, but also report a number of positive outcomes including improved prenatal health, enhanced child development, and mothers’ personal development. A report from the Rand Corporation estimated that the cost savings on this intervention, due to reduced welfare, health care, crime costs, and increased taxes, are four times the original investment by the time a child reaches the age of 15 years (Karoly et al. 1998). Alongside such structured programs, which are delivered by trained nurse home visitors, there is also some convincing evidence concerning the effectiveness of peer-led interventions involving trained volunteer visitors, such as the Community Mothers Program (Johnson et al. 1993, 2000).
Parenting interventions have also been found to have a significant impact on positive mental health, including improving maternal psychosocial health (Barlow et al. 2002) and the emotional and behavioral adjustment of children (Barlow and Parson 2003; Tennant et al. 2007). Based on a meta-analysis of 213 programs, Barlow et al. (2003) concluded that there is clear evidence of the impact of parenting programs in improving psychosocial outcomes for mothers of children aged 3–10 years, including; improved self-esteem, reduced anxiety, stress, and depression, and improved relationship with spouse and marital adjustment. Programs such as the Triple P Positive Parenting Program have been successfully incorporated into service delivery in a range of health and community services. Findings from a number of randomized controlled trials (Sanders 1999; Sanders et al. 2000; Dean et al. 2003) and a meta-analysis (De Graaf et al. 2008) have demonstrated that the Triple P Program results in increased positive parenting practices, which in turn result in improved children’s behavior, lower levels of dysfunctional parenting, reduced parental conflict, and gains in parental mental health.
Systematic reviews demonstrate the effectiveness of early childhood and preschool education programs in enhancing the cognitive and social skills of children under 5 years of age, improved academic achievement, school readiness, and mental and social development (Anderson et al. 2003; Nelson et al. 2003; Karoly et al. 2005; Schweinhart et al. 2005; Sylva et al. 2007). Impressive long-term results have been achieved by programs, such as the High Scope Perry Preschool Project, that address preschool development, including enhancing language, cognitive, and social skills in children aged 3–4 years from disadvantaged backgrounds (Schweinhart et al. 2005). With follow-ups over 40 years, the High Scope Perry Preschool Project has been found to positively impact school success, improve employment rates and earnings, increase social responsibility (including fewer criminal arrests), reduce the need for social service benefits, and improve family functioning. The majority of preschool programs are designed for children from disadvantaged backgrounds, and the duration and intensity of the interventions are related to outcomes (Nelson et al. 2003). With regard to positive mental health impact, it is interesting to note that relatively large effect sizes are reported for social–emotional impacts (ES = 0.27–0.33) and cognitive outcomes (ES = 0.30) (Tennant et al. 2007).
Longitudinal studies not only show that the benefits from early years interventions can be long-lasting in multiple domains, but they also show that the savings the programs generate can be substantial. Economic analyses of several early childhood interventions demonstrate that effective programs, particularly those with long-term outcomes, can repay the initial investment with savings to governments and benefits to society, with those at most risk making the greatest gains (Karoly et al. 2005; Galinsky 2006; Friedli and Parsonage 2007).
The roll-out of multicomponent support interventions, such as the Sure Start programs for young children and their families living in deprived communities in England (Melhuish et al. 2008), has also reported improved social development outcomes for children, improved parenting, better home-learning environments, and greater use of support services. These findings are encouraging because they support the feasibility of scaling-up such interventions on a national scale.
Early interventions have an important role to play in addressing child health inequities. As home visiting and parenting programs often deal with the most vulnerable families, such as those living in socially and economically disadvantaged communities, these interventions are viewed as having the potential to break cycles of disadvantage and social exclusion. However, the effectiveness of these interventions needs to be viewed in the context of wider policy initiatives, addressing poverty and the wider structural determinants of child health inequities.
Promoting Positive Mental Health in Schools
Schools are one of the most important settings for promoting the mental health of young people. Schools have an important function in nurturing children’s social and emotional development as well as their academic and cognitive development. Enhancing children’s mental health will improve their ability to learn and to achieve academically as well as their capacity to become responsible adults and citizens (Weissberg et al. 1991; Zins et al. 2004; Payton et al. 2008).
There is a growing body of evidence that mental health promotion in schools, when implemented effectively, can produce long-term benefits for young people, including emotional and social functioning and improved academic performance (Tilford et al. 1997; Durlak and Wells 1997; Lister-Sharp et al. 1999; Greenberg et al. 2001; Harden et al. 2001; Wells et al. 2003; Payton et al. 2008). Reviews of the evidence show that comprehensive programs that are implemented continuously for more than one year, are aimed at the promotion of mental health as opposed to the prevention of mental disorder, and that target multiple health outcomes in the context of a coordinated whole-school approach, offer the most consistently effective strategies (Wells et al. 2003; Jané-Llopis et al. 2005). The evidence indicates that long-term interventions promoting the positive mental health of all pupils, and involving changes to the school environment, are likely to be more successful than brief class-based prevention programs.
Social and Emotional Learning Programs
A number of successful universal school-based programs targeting all pupils have employed cognitive skills training in promoting social and emotional competencies (Shure and Spivack 1988; Kellam et al. 1994; Bruene-Butler et al. 1997; Greenberg et al. 1995, 2001; Aber et al. 1998; Mishara and Ystgaard 2006; Clarke and Barry 2010). Many of these programs have been evaluated using randomized controlled trials and have been replicated with a wide range of children in different school settings across countries. Three large-scale meta-analyses of research on the impact of social and emotional learning (SEL) programs on children in the United States aged 5–13 years were conducted by Payton et al. (2008). These reviews confirm that SEL improves students’ social–emotional skills, attitudes about self and others, connection to school, positive social behavior, and students’ academic performance by 11 percentage points. SEL programs were also found to reduce students’ conduct problems and emotional distress and to be effective in both school and after-school settings, for racially and ethnically diverse students and for students with and without behavioral and emotional problems.
Programs adopting a whole-school approach seek to enhance the social and emotional well-being and positive life skills of pupils and work to create supportive environments that foster positive youth development and a sense of connectedness with the family, community, and broader social context of young people’s lives (Rowling et al. 2002). Review evidence supports the effectiveness of mental health promotion programs in schools that take a whole-school approach (Wells et al. 2003; Lister-Sharp et al. 1999). Examples of whole-school programs that have been implemented at a national level include the Australian MindMatters program (Wynn et al. 2000) and the Social and Emotional Aspects of Learning (SEAL) initiative in England (Department for Education and Skills 2005). While evidence relating to programs that adopt a trulywhole-school approach (i.e., include all elements) is quite limited, those that have been identified provide indication of a positive impact, with small to medium effect sizes being reported on outcome measures (Adi et al. 2007). Interventions employing a whole-school approach are more likely to be effective in decreasing bullying than curriculum-only programs. The Olweus Bullying Prevention Program (Olweus et al. 1998) is one such example of a comprehensive whole-school intervention designed to reduce bullying at the level of the individual pupil, the classroom, and the school as a whole.
A review of the cost-effectiveness of whole-school approaches by McCabe (2007) suggests that interventions of this type can lead to health, academic, and social gains, which lead to savings for health and social services and for the criminal justice system. Lack of investment in mental health promotion in schools is likely to lead to significant costs for society as children who experience emotional and social problems are more likely, at some point, to misuse drugs and alcohol, to have lower educational attainment, and to be untrained, unemployed, and involved in crime.
To date, there has been comparatively little research on mental health promotion in schools outside of the USA. There is a need for high-quality studies with longitudinal designs to assess the impact of school-based interventions across education systems, cultures, and structures. While there is still much to learn regarding how best to implement and support the effective implementation of school-based mental health promotion programs, the current evidence clearly demonstrates their value in promoting the mental health and well-being of young people.
Promoting Positive Mental Health in the Workplace
The workplace is a key environment that affects the mental health and well-being of working adults (WHO 2000). The importance of work in terms of role fulfillment, self-identity, sense of purpose, and participation in society is well recognized. Traditionally, many workplace health initiatives have placed more emphasis on physical health and safety issues in the workplace than on mental health. The promotion of positive mental health is relevant to many aspects of employment, including health and safety, equal opportunities, bullying and harassment, and work–life balance initiatives. Creating a healthy workplace entails creating an environment that is supportive of the psychosocial aspects of work, recognizing the potential of the workplace to promote workers’ mental health and well-being and to reduce the negative impacts of work-related stress. Many of the factors that influence the positive health and well-being of workers relate to the social environment at work, such as style of management, working culture, the psychological demands of work, work overload, levels of social support, and job security.
Effective workplace interventions address the physical, environmental, and psychosocial factors influencing mental health. They strengthen modifying factors such as social support, control over decision making, and effort–reward balance, and they provide skills and competences for addressing short-term and long-term responses to work-related stress. Additionally, they enhance role clarity, staff involvement, and policies designed to tackle bullying and harassment (Stansfeld et al. 1999; Van Der Klink et al. 2001; Michie and Williams 2003). A poor work environment characterized by features such as high demand/low control (Karasek 1990; Karasek and Theorell 1990) and effort–reward imbalance (Siegrist 1996) is one of the main factors explaining the higher prevalence of depressive symptoms among participants in lower employment grades (Stansfeld et al. 1999).
Promoting workers’ well-being and mental health requires change at the organizational level as well as more individual-focused approaches (Giga et al. 2003; Bambara et al. 2007). A systematic review by Bambra et al. (2007) reports that while microlevel interventions that change the psychosocial work environment and enhance employee’s level of control have a positive impact on self-reported mental and physical health, the interventions that had more positive effects were those in which the macroenvironment was also supportive of employee control and participation. A comprehensive policy of mental health at work includes addressing the mental health of the organization itself as well as that of the individual employees (WHO 2000). The gain to both employees and the organization is reflected in reduced absenteeism, improved well-being, and productivity.
The macroeconomic labor market conditions and employment policies, including issues of salaries, career opportunities, and job security, also have a significant influence on employee well-being, and interventions addressing these structural factors need to be considered (Marmot et al. 1999). Policy initiatives, legislation, and regulatory mechanisms are required to safeguard the rights of workers against the negative impact of effort–reward imbalance, especially among vulnerable groups, such as migrant and contract workers.
The mental health impact of unemployment is well documented, including a higher risk of suicide, higher levels of anxiety, depression, uncertainty about the future, anger, shame, and loss of self-esteem (Murphy and Athanasou 1999; Jané-Llopis and Barry 2005, 2005; Paul and Moser 2009). Interventions, such as the JOBS program (Caplan et al. 1989; Vinokur et al. 2000), that combat the negative impact of unemployment on mental health and facilitate reemployment, are the most effective way of promoting the mental health of the unemployed. The JOBS program, which promotes the mental health of unemployed people and is cost-effective in terms of increased economic benefits for participants and the state, has been applied successfully in a number of countries (Vinokur et al. 2000; Vuori and Silvonen 2005; Barry et al. 2006; Reynolds et al. 2010).
The evidence for interventions promoting mental health in the workplace is only partial, and many authors comment on the poor-quality implementation of the interventions in many of the studies, with lack of management commitment being frequently cited as a specific problem. In particular, there is a paucity of studies that assess organizational-level approaches and organizational-level outcomes (Graveling et al. 2008). There is need for more evaluation of the impact of changes in employment practices and management style and of the inclusion of longer-term follow-ups and economic evaluations (Michie and Williams 2003). While acknowledging that the evidence needs to be strengthened, it can be concluded from the current evidence that a comprehensive and integrated approach to mental health promotion, which combines both individual- and organizational-level interventions, will be more effective in improving and maintaining positive mental health at work.
Promoting Positive Mental Health in the Community
The community setting offers important opportunities to work with diverse population groups in strengthening social networks and in addressing systems of socialization, social support, participation, and socioenvironmental influences on mental health and well-being. Interventions addressing community-level determinants of mental health aim to improve people’s sense of social belonging, strengthen community networks, build social capital, improve neighborhood environments and community safety, and promote services and support networks to promote mental well-being.
Communities with high levels of social capital, including trust, reciprocity, participation, and cohesion, have important benefits for mental health (Morgan and Swann 2004; Whiteford et al. 2005; Friedli 2009; Wilkinson and Pickett 2009). Social support and social inclusion play a significant role in maintaining positive mental health (Lehtinen et al. 2005; Wilkinson and Marmot 2003). There are a number of review studies of social support interventions for older people which demonstrate their positive impact on mental health (Cattan et al. 2005). Research findings also support the effectiveness of peer-support programs for diverse groups delivered by trained community volunteers, including bereavement support (Vachon et al. 1980), self-help groups, and care for older people (Cattan et al. 2005; Wheeler et al. 1998).
A culture of cooperation and tolerance, a sense of belonging, and strong social relationships are protective of positive mental health (Moodie and Jenkins 2005). Stigma and discrimination are identified as one of the most important barriers to well-being and quality of life in the community for people who experience mental health problems (WHO 2001). Tackling stigma in public attitudes to mental health and raising public awareness of the importance of positive mental health require focused interventions approaches, ranging from sophisticated mass media campaigns to more local initiatives involving community models of participation. Campaigns or social marketing interventions, particularly if they are supported by local community action, have been shown to have a significant impact on public knowledge, attitudes, and behavioral intentions (Wyllie et al. 2008; Myers et al. 2009) and are cost-effective (Vaithianathan and Pram 2010). Such interventions can increase understanding and tolerance, reduce stigma, and increase knowledge of sources of support. They also have the potential to positively impact on mental health literacy at the wider community level.
Community development programs, based on the participation and empowerment of local community members, including those who are socially marginalized, provide a useful model for promoting mental health in disadvantaged community settings (Arole et al. 2005). Community empowerment initiatives entail individuals and organizations working together to gain increased control over the quality of life in their community. Effective interventions include economic empowerment initiatives, such as microcredit schemes and community banks, literacy promotion, policies that promote gender and racial equality, violence prevention, and crime reduction in marginalized communities (Patel et al. 2005; Barry et al. 2007).
Environmental factors including access to open spaces and the quality of buildings and other structures have a beneficial impact on mental health (Dalgard and Tambs 1997; Ellaway et al. 2001; Weich et al. 2002; Whitley et al. 2005). Neighborhood disorder, mistrust, and powerlessness have negative impacts on mental health and serve to amplify a sense of hopelessness and alienation (Friedli 2009). Urban regeneration projects, which address the psychosocial aspects of deprivation, can have a significant mental health impact. A systematic review by Thomson et al. (2001), and a number of subsequent studies (Thomson et al. 2003, 2006), reports evidence that improving housing can lead to positive mental health impacts. Further mental health impact assessment of community-level initiatives, such as urban regeneration, which typically may not assess the impacts on health and well-being, is required if the potential of such initiatives to improve mental health and well-being is to be demonstrated.
Although the evidence is quite limited in terms of the documented impact of interventions on positive mental health, community initiatives aimed at building social capital, strengthening community networks, and increasing participation by excluded groups have an important contribution to make in promoting community mental health and well-being.
Promoting Positive Mental Health at the Societal Level
At the societal level, mental health promotion entails addressing the structural determinants of mental health. This includes reducing the structural barriers to mental health through initiatives to reduce poverty, discrimination, and social inequities and to promote access to education, meaningful employment, housing, and services and support for those who are most vulnerable. Poor mental health is consistently associated with poverty, unemployment, low levels of education, low-income or material standard of living, poor physical health, and adverse life events (Melzer et al. 2004; Patel et al. 2005; Kessler 2007; Prince et al. 2007). Recent studies across a number of countries also report that higher levels of positive mental health are associated with higher levels of education, paid employment, and higher social and economic position in society (Keyes 2002; Lehtinen et al. 2005; Barry et al. 2009b). Higher national levels of income inequality have also been found to be associated with a higher prevalence of mental disorders (Pickett et al. 2006). The experience of inequity is corrosive of good social relations and has a negative impact on people’s mental health and their sense of emotional and social well-being. The experience of racial harassment and perceptions of racial discrimination have also been found to contribute to poor mental health outcomes (Chakraborty and McKenzie 2002; Aspinal and Jacobson 2004).
Responsibility for promoting mental health at the societal level extends across sectors and all government departments and encompasses a concern with the impact of economic and social policies on population well-being and the quality of people’s lives. The evidence indicates that higher levels of education, improved standards of living, freedom from discrimination, fewer adverse life events, and good physical health enhance positive mental health (Barry and Friedli 2008). An integrated policy approach is required to address these structural factors and underlines the need for cross-sectoral policy implementation. The WHO Commission on the Social Determinants of Health report (World Health Organization 2008) concluded that the impact of daily living conditions on health, and the impact of inequitable distribution of power, money, and resources in particular, acts as structural drivers of inequity. Friedli (2009) argues that mental health is directly and indirectly related, at every level, to human responses to inequity, influencing people’s sense of agency, self-esteem, efficacy, and connectedness, and their ability to deal with chronic stress and adversity. Wilkinson and Pickett (2009) posit that as inequity is an aspect of the broad structure of society, the powerful mechanisms that make people sensitive to inequity cannot be understood in terms of either social structure or individual psychology alone. Therefore, understanding the effects of inequity means understanding how individuals are affected by social structure, and this may produce useful policy insights into the well-being of whole societies. The impact of inequity on mental health and the role of psychosocial mechanisms in mediating the impact of inequity are under-researched and require further investigation.
International Policy Developments in Mental Health Promotion
The growing emphasis on the need for mental health promotion is both explicit and implicit in a wide range of policies on population health and mental health. There is also a growing interest in how a well-being focus could influence the future direction of public policy in areas such as education, employment, culture, and sustainable development (Marks and Shah 2005; Layard 2005; Dolan et al. 2006; Pickett et al. 2006; Eckersley 2006; Marks et al. 2006; Carlisle 2007; Friedli 2009). Greater integration of social, economic, and ecological policies is being advocated in order to maximize population well-being (New Economics Foundation 2003). The increasing focus on well-being is also reflected in the development of national well-being indicators, which seek to capture people’s sense of well-being and how their lives are progressing, alongside indicators of economic growth (e.g., the National Accounts of Well-being by the New Economics Foundation 2008). A number of countries have developed national well-being indices, including countries as diverse as Bhutan and Canada. Such measures serve as national indicators of social progress, which can usefully inform policy making, and are designed to go beyond a traditional “silo approach” to public policy decisions.
Mental health policies, which embrace a positive well-being focus and advocate for a flourishing society based on promoting population mental health and well-being, have been introduced and are being strengthened in a number of countries (see, e.g., Towards a Mentally Flourishing Scotland, Scottish Government 2009). A review of international policy developments in mental promotion (GermAnn and Ardiles 2009) outlines the different types of policy models that have been adopted across a number of high-income countries (including Australia, Ireland, New Zealand, Scotland, and England) when incorporating the promotion of mental health into population health and mental health policies. Across all of these jurisdictions, there has been a focus on developing a population-based approach to mental health improvement, whether this be through a stand-alone mental health promotion policy as in Scotland (Scottish Government 2009) and Northern Ireland (Northern Ireland Association for Mental Health 2009) or as part of a more comprehensive mental health policy as in Australia (Council of Australian Governments 2006), New Zealand (Ministry of Health 2005), England (NIMHE 2005), and Ireland (Department of Health and Children 2006). It is noteworthy that in Australia (Commonwealth Department of Health and Aged 2000) and New Zealand (Ministry of Health 2002), specific policies for mental health promotion have also been developed in order to strengthen mental health promotion action. In a number of countries, there is also a stated aim to integrate mental health promotion into public health policy. In England, the New Horizons initiative (Department of Health 2009) presents a cross-government vision for mental health and well-being in England from 2010 onward. As part of the New Horizons initiative, a public mental health framework for developing well-being and resilience, and reducing inequalities, is presented. Based on a vision to create flourishing connected communities, a framework for promoting well-being is outlined which includes ensuring a positive start to life; building resilience and a safe, secure base; integrating physical and mental health and well-being; developing sustainable connected communities; and promoting meaning and purpose.
A number of national population health policies also include a focus on promoting positive mental health, underscoring the critical contribution of good mental health to population health and well-being. The relevance of the mental health improvement agenda to the broader policy context of addressing health inequities and the social determinants of health is also evident in a number of policies, recognizing that mental health is both a contributor and a consequence of social inequity. In such policy models, a whole-government approach is advocated, with responsibility for promoting mental health extending across government departments and encompassing a concern with the impact of economic and social policies on population mental health and well-being.
An overview of international policies clearly shows that, in almost all countries, the effective implementation of policy is identified as a key challenge (GermAnn and Ardiles 2009). While well-designed policies and plans give a mandate for action at a national level, implementation can be variable, particularly at the regional and local levels. A number of key influencing factors are identified, which include the need for sustained leadership for the implementation process, sufficient financial and human resources to support delivery, effective engagement across sectors, and the need for coordination of actions at multiple levels (national/state/local), especially across the service delivery and public health fields of practice. Building and strengthening an infrastructure for policy implementation is required, including sustained leadership and cross-sectoral partnerships, investment in research and evaluation to guide the implementation of policy and best practice, and building workforce capacity for quality implementation across sectors.
Building Capacity for the Effective Implementation of Mental Health Promotion
There is a growing body of knowledge from research and practice which shows that high-quality comprehensive programs promoting mental health, carried out in collaboration with individuals, families, and communities, can produce lasting positive benefits for mental health and social well-being. When these interventions are implemented effectively, they lead to improvements not only in mental health but also to improved social functioning, academic and work performance, and general health behaviors. The effects are especially evident in relation to the early years and for families from disadvantaged backgrounds, indicating that investment in such initiatives is cost-effective. The critical issue is ensuring that these interventions can be effectively implemented and sustained. It is, therefore, important to consider what is needed to ensure that effective policy and practice is at a scale, scope, and intensity to make a critical difference for population mental health.
Implementing programs in complex multilevel systems, such as schools, workplaces, and communities, requires a focus on the complex interaction of characteristics of the intervention, the implementer, the participants, the organizational capacity, and support of the delivery system (both general and intervention-specific capacity) and the specific contexts in which the intervention is being implemented (Chen 1998). The recognition of implementation complexity and the importance of relevance to the local context and community are critical considerations (Fixsen et al. 2005; Clarke et al. 2010). Current research indicates that implementation is often variable and imperfect in field settings and that the level of implementation influences outcomes (Durlak and DuPre 2008; Durlak 1998; Domitrovich and Greenberg 2000). The importance of a supportive implementation system in ensuring successful program implementation and replication is underscored by the literature (Mihalic et al. 2002; Barry et al. 2005). Influencing factors include; the quality of training and support, facilitatory and inhibitory factors in the local context such as readiness, mobilization of support, ecological fit of the program, cultural sensitivity, and the extent of participation and collaboration with key stakeholders. The level and extent of all these aspects of the implementation system need to be carefully planned and documented in order to ensure the quality and sustainability of program delivery. The generic processes underpinning the effective implementation of mental health promotion interventions are identified by Barry and Jenkins (2007) through examining a number of model programs and case studies to determine how effective implementation can be ensured through the use of research-based, theoretically grounded, and culturally appropriate interventions.