Abstract

While considerable evidence exists regarding the effectiveness of specific kinds of interventions for mental illness prevention and to a lesser extent mental health promotion, mental health promotion and illness prevention (MHPIP) remain underdeveloped in Western Australia. The aim of this study was to explore the current state of MHPIP in Western Australia and to highlight some of the structural and systemic issues that need to be addressed if MHPIP services are to be progressed further in this state. For this purpose, the study examined the capacity for delivery of MHPIP services. Opportunities and barriers to the further development of MHPIP were also identified. Thirty-four key stakeholders representing a cross-section of local services, central government agencies and universities were interviewed using a semi-structured interview schedule. The interviews were conducted over a 6-week period. The interview schedule included questions on the workforce, agency liaison and project implementation, and priority areas and issues with respect to research and policy setting in MHPIP. In developing the focus of MHPIP services, critical factors that constitute capacity building were identified. These included readiness to participate in MHPIP, service infrastructure development, workforce development, resource allocation, networks and evaluation of programmes.

INTRODUCTION

In Australia, mental health problems and mental disorders are estimated to affect >18% of the adult population, and between 10 and 15% of young people in any 1 year (Rey, 1992; Commonwealth Department of Human Services and Health, 1994; McLennan, 1998). However, only 38% of adult Australians with mental disorders receive help for their problems (McLennan, 1998). The extent of disability associated with mental disorder is high. Of the 10 leading causes of disability in the world in 1990, five were mental disorders; specifically unipolar depression, alcohol use, manic depression, schizophrenia and obsessive-compulsive disorder (Murray and Lopez, 1996). It is clear that both the extent of mental health problems and the enormous associated personal, social and financial cost can not be addressed by treatment services alone. Mental health promotion and illness prevention (MHPIP) approaches offer the potential to decrease the incidence and prevalence of mental health problems, to alleviate some of the burden of mental health disorders and to increase the well-being of the population (Commonwealth Department of Health and Aged Care, 1998). It must be recognized that MHPIP approaches require contributions from a range of sectors and organizations including, but not limited to, education, local government services and workplaces, in line with the strategies affirmed by the Jakarta Declaration (WHO, 1997).

Researchers and government policy makers often assign different meanings to the terms mental health promotion and mental illness prevention (Vlais, 1996; Commonwealth Department of Health and Aged Care, 1998). One popular definition of mental health promotion is ‘action to maximize mental health and well-being among populations and individuals’ [(Australian Health Ministers Advisory Council, 1997), p. 12]. In their well-known work, Mrazek and Haggerty have defined mental illness prevention as those interventions that occur before the initial onset of a disorder and thus prevent the occurrence of the disorder (Mrazek and Haggerty, 1994). In many respects, the goals of decreasing risk and increasing protection in the disease-orientated model and the goals of promoting mental health are not mutually exclusive, either in practice or in outcome (National Advisory Mental Health Council Workgroup on Mental Disorders Prevention Research, 1998). While some writers have made distinctions between MHPIP at a conceptual level, in practice there is a great deal of overlap between prevention and promotion of mental health.

Recently, a growing emphasis has been placed on research to study effective MHPIP interventions within service systems. The Second National Mental Health Plan (Australian Health Ministers, 1998) emphasized the need to include mental health promotion and prevention in the overall planning for mental health services. MHPIP in Australia is developing to the extent that questions need to be asked about the service environment, and effectiveness trials conducted to establish the evidence base for implementing MHPIP interventions. In order for this to take place, the service environment requires the capacity to implement, deliver and evaluate MHPIP interventions. At a state level, future planning in Western Australia has developed in an ad hoc manner, with MHPIP being one of the least developed approaches to mental illness. A need is recognized for the examination of the current state of readiness and capacity in the provision of MHPIP services required to achieve the much sought after health gain for people and their communities.

MHPIP spans the areas of mental health and health promotion, representing two views of health care: one that is population focused and the other that is clinical or treatment focused. Often these views are seen as incompatible and require a reorientation of health care. The Ottawa Charter (WHO, 1986) and Jakarta Declaration (WHO, 1997) provide the framework that underpins the reorientation strategies for mental health promotion, with capacity building being an important priority in health promotion in general, and MHPIP in particular.

Capacity building has been defined as an approach to the ‘development of sustainable skills, organizational structures, resources and commitment to health improvement in health and other sectors, to prolong and multiply health gains many times over’ (Hawe et al., 1999). The goal of reorientation of health services is that besides treating ill health, health services also take greater responsibility for improving the health of the communities they serve. The reorientation of services is essentially a process of systemic change that assists in building a health system’s capacity to achieve health gains (Gray and Casey, 1995). One approach to MHPIP capacity building identifies five key areas: workforce development, service infrastructure development, resource allocation, leadership and partnerships (NSW Health, 2001).

Workforce development refers to a process initiated within organizations and communities in response to the identified strategic priorities of the system, to help ensure that the people working within these systems have the abilities and commitment to contribute to organizational and community goals (NSW Health, 2001). Service development refers to the processes that ensure that the structures, systems, procedures and practices of an organization or agency reflect its purpose, role, values and objectives, and ensure that change is managed effectively (NSW Health Promoting Hospitals Project, 1998). Resource allocation is an economic process, not just a planning one, concerned with the efficiency of allocating financial and human resources, ensuring availability of information, ensuring access to specialist advice in research and evaluation, planning, media, marketing and workforce development, and ensuring administrative and physical resources (Deeble, 1999). Leadership is a function of training, experience and personality and is a critical factor in capacity building. Finally, there is ample evidence in the health promotion literature that partnerships between agencies and within the community are effective in bringing about health gains (Gillies, 1998).

This study examined the capacity for services to provide MHPIP interventions in Western Australia. Furthermore, the study examined the opportunities and barriers that exist to reorientate mental health services from primarily a treatment focus to include prevention at a practical service delivery level. Included in this examination were workforce development, service infrastructure development, agency networks and partnerships, resource allocation, and to a lesser extent leadership.

METHODS

Design

As little is systematically known about the number and extent of organizations involved in MHPIP in Western Australia, a descriptive survey design was used to profile the current situation. Key Western Australian informants across a range of disciplines including mental health and public health, academic, research and service areas were surveyed. Semi-structured interviews were conducted with a sample of key informants. Key informants were asked to describe the workforce, past, current and future projects in which they are involved, priority areas for MHPIP in the next 3–5 years and issues for policy formation in this area. If available, supportive documentation was obtained including strategic plans for MHPIP and an outline of planning, implementation and evaluation of initiatives.

Sample

Respondents came from a variety of government and non-government agencies including education, health, justice, police, academic institutions and research institutions. Representative proportions of metropolitan (n = 22) and rural and remote area (n = 12) respondents were recruited.

There were two groups who constituted the sample. The first sample group were known key informants identified by the position they held. Known key informants identified for this project were: the General Managers of the Division of Public Health and the Division of Mental Health Services, the Director of Healthways, key consumers, academics in the area of Public Health and Mental Health, and key policy people in Mental Health and Health Promotion. Thirteen key informants were initially identified, of which 12 were interviewed.

The second sample was identified by key informants as important people in the field of MHPIP in Western Australia through the use of a ‘snowball’ sampling design. The sampling technique provided information about sample saturation as well as identifying a network for MHPIP in Western Australia. The snowball technique identified 37 individuals in the area of MHPIP, of whom 22 were interviewed.

Data collection

Data was collected from metropolitan, rural and remote regions in Western Australia over a 6-week period using a semi-structured interview technique. Questions asked called for the respondents to express their views on MHPIP in the areas of workforce, policy and research. Where possible a face-to-face interview technique was used. Regional and remote respondents were interviewed by telephone or by video-conferencing. A total of 22 face-to-face interviews, 10 telephone interviews and two video-conferencing interviews were conducted. The interviews took between 1.5 and 2 h to conduct.

Interview tool

A semi-structured interview was developed which comprised questions tapping into the agency and its workforce, other agencies that are liaised with, interventions and research relating to health promotion and illness prevention utilized by the agency, and priority areas for MHPIP over the next 3–5 years. The interview tool was pilot tested with three key informants. Concept validity was examined and questions that were found to be ambiguous were refined.

RESULTS

The four sections of the research tool are presented in the results section. The results include information about the respondent’s agencies, including workforce, agency networks, evaluation status of intervention programmes, and research and service development in Western Australia. In the main, data were analysed using frequency tables and a content analysis approach.

Part 1. Agency and key informants

The first part of the semi-structured interview asked questions about the agency and the workforce of the agency. A diverse group of respondents were interviewed for the project. Of the 34 key informants interviewed, 12 worked in a direct approach agency, 14 in a system approach, six in research and two in an advocacy approach. Direct prevention approaches work directly with individuals at risk, groups or communities in the implementation of programmes or activities. System level approaches work with structures and processes to enhance the capacity of organizational and community systems to initiate and maintain effective programmes (Mitchell, 1999). Advocacy approaches work with social actions designed to gain political commitment, policy support, social acceptance and systems support for a particular health goal or programme [World Health Organization (WHO), 1998]. By including both respondents working directly with individuals and respondents working at a systems level, a broad overview of the area has been attained. The respondents tended to hold high level positions in their agency and were therefore in the position to give an overview of current health promotion and illness prevention activities.

Participants were asked to identify the number of people in the agency workforce that participated in MHPIP. In the main, MHPIP was only part of the work role of the individuals identified. In Table 1, counsellors/health workers were identified as the largest group within the workforce. Research officers/project officers with no specific health qualifications were the next largest group. The workforce, in the main, were not formally qualified in the mental health area, with only 39% of the identified workers being mental health workers (social workers, occupational therapists, mental health nurses, psychiatrists or psychologists). A further 10% of the workforce had qualifications in health promotion/ public health.

Part 2. Networks

Respondents were asked about the organizations with which they liaise in the area of MHPIP. Typically respondents liaised with central government agencies, followed by agencies on a local level.

An examination of agency networks was undertaken by identifying the respondent’s agency type and comparing with whom they networked. Table 2 shows agency networks. Agencies were significantly more likely to network with similar agency types [χ2 = 15.868 (4 degrees of freedom, n = 34); p = 0.003]. Thus, central agencies were more likely to network with central agencies, local agencies to network with local agencies and research agencies to network with research agencies.

Part 3. Evaluation status of programmes

Part 3 of the semi-structured interview asked the respondents for a detailed explanation of one service that they were currently implementing. The 34 respondents identified 20 programmes in all. A number of respondents were involved with basic research or were at the systems level and were not working directly on a programme.

The type of evaluation most frequently used by the respondents is process evaluation (see Table 3). Process evaluation measures the activities of the programme, its quality and whom the programme is reaching. It also measures the dosage needed for a programme to be effective. Impact evaluation measures the immediate effect of the programme (does it reach its objectives?). Outcome evaluation measures the long-term effect of the programme (does it meet its goals of health gain?) (Hawe et al., 1990). Process evaluation is an appropriate form of evaluation at the developmental phase of a programme but should be supplemented by other forms of evaluation as the programme progresses. At present this is happening in only the minority of programmes.

Part 4. Service infrastructure development

Respondents were asked their opinions about priority areas for MHPIP in the next 3–5 years, and issues for research and setting policy at the state level in this area.

Respondents identified children in general and specific children as priority groups for MHPIP. This is not surprising given the relative emphasis to date of MHPIP services towards these target groups. The identification of specific age groups reflects a lack of understanding of the range of population strategies, including universal and selective levels compared with a treatment approach, which emphasizes the individual.

An analysis was performed to determine if there was a preferential bias between working in a specific area and selecting the area as a priority. Table 4 identifies that 39% of respondents selected a priority area due to clinical opinion/ experience, and 26% due to service demand.

A high priority identified by respondents was the need for effective evaluation of the programmes they are presently implementing (see Table 5). Respondents recognized a need for service research that is able to identify why the intervention works, for whom it works and what component of the intervention is effective. Also of particular concern was the need to be assured of the evidence base for the effectiveness of programmes. As one respondent stated ‘we run the programmes but there is a lack of evaluation’. Another respondent said ‘all intervention programmes require research and evaluation. At present few statistics are gathered and there is a lack of qualitative data. There is also a lack of longitudinal data’. Respondents believed that resources and capacity to introduce efficacy and effectiveness research were seriously lacking. Respondents put less emphasis on specific research topics.

The theme of lack of evaluation and lack of evidence base for MHPIP is strong. Respondents identified the need for outcome rather than process evaluation. As seen in Table 5, outcome evaluation was planned to be undertaken in only 20% of current programmes. Respondents stated that there was a lack of dissemination of research. They were frustrated in their attempts to obtain research reports and to find out about latest developments. Lack of long-term evaluation of research was again an issue for respondents. Without long-term evaluation, the sustained effectiveness of interventions can not be established.

Areas of concern in the MHPIP policy setting were explored and are presented in Table 6. Respondents (n = 12) saw the lack of funding for MHPIP as a barrier to undertaking programmes. They identified treatment as the preferred area for fund allocation. A respondent stated that ‘recycling old money was not enough. There is a need for a commitment to prevention and appropriate resourcing of the area at a policy level’. Respondents stated that ‘people do have a genuine commitment to the area but need funding’.

Policy development was the second most frequently cited issue, with nine respondents making comments. The majority of respondents wanted a state policy, although they expressed concern that developing policy at state level will lead to too broad an agenda. Community consultation was an issue throughout the interviews and was seen to be important for research, evaluation and formation of policy. ‘Policy is formed with little consultation on the ground and there is a need for community consultation.’ The difficulty in achieving a balance between forming policy from the top down and the bottom up was discussed by respondents.

Research was identified as the next priority issue, with six respondents citing it as important. Respondents stated there needed to be further research in applied areas of interventions. Evaluation of the programmes needed to be set up concurrent with the implementation of the programme. Evidence-based research was needed in the area of MHPIP.

The need for community consultation was also an issue. Respondents stated there was a need for community consultation with the appropriate people. ‘There is a need to go to the community and find out where people are at.’ Another respondent stated that there ‘needs to be a recognition that every community is different and has different problems and different reasons for these problems’.

Lack of a trained workforce was cited as an issue for four respondents. As respondents stated ‘there is a need to train workforce’ and that ‘there is a lack of expertise in the area of MHPIP, people are willing to engage in the work but do not have the necessary skills’.

DISCUSSION

Overall, the findings reflect an uneven and poorly integrated MHPIP service sector. While it is recognized that curative, personal treatment approaches and rehabilitation will continue to play an important role in mental health services, MHPIP approaches are developing. Capacity building emerged as a key theme for focus in MHPIP services. Service infrastructural development, workforce development, resource allocation, research and evaluation, partnerships and to a lesser extent leadership were themes identified in the data. The study revealed a number of opportunities and barriers for the development of MHPIP services and interventions in Western Australia.

Although respondents were committed to implementing MHPIP programmes, they identified lack of funding and lack of skill in implementing programmes, specifically in the evaluation of programmes, as barriers to undertaking the shift from treatment to a combined treatment prevention focus.

Service infrastructure development

In the main, respondents supported policy development for MHPIP. Respondents offered a cautionary note to the development of a state-wide MHPIP policy with the corollary that their service and the community they serve was unique and that a state-wide policy should take this uniqueness into account. They believed sustainability of programmes was more likely if individuals and organizations were encouraged to take responsibility for identifying, planning and implementing their own initiatives.

Children were emphasized as a priority group for MHPIP programmes. Other groups identified as a priority for MHPIP were families, indigenous communities and adolescents; priority was also placed upon destigmatization and programme evaluation issues. The selection of a priority area was often based on professional opinion or clinical experience.

Workforce development

Respondents stated that the workforce was willing to undertake MHPIP but lacked the necessary skills. Workforce capacity building was an issue identified by respondents when asked to identify the issues for setting policy. Less than half the identified workforce had qualifications in either public health or mental health disciplines. This supports the respondent’s concerns about the capacity for the workforce to undertake MHPIP. MHPIP is a relatively new area and the workforce needs to increase knowledge and skills in this area. Other studies have also identified that mental health services are lacking expertise in MHPIP (Mitchell, 1999).

Resource allocation

Funding was identified as the most important issue in the formation of policy at state level. Lack of funding impacted on MHPIP service development in various ways. Short-term funding affected the sustainability of programmes. Programs that were funded through research grants were particularly difficult to sustain as once the funding ceased the programme ceased. Respondents stated that funding is directed towards treatment and it is difficult to shift funding in the MHPIP direction at this stage. The funding bodies directed services to make do with previously allocated monies while limiting injection of new funding resources. To increase the capacity of a service to deliver MHPIP requires adequate and appropriate funding. Furthermore, there needs to be long-term planning for this capacity. A long-term commitment of resources is needed to allow changes and results to become evident.

Networks and partnerships

The majority of respondents liaised with three or more agencies, however the quality and intensity of their networks was neither evident nor clearly articulated. Even though respondents liaised across agencies they had difficulty in identifying projects or key informants in other agencies. Such data reflect poorly developed collaboration at an organizational level.

Respondents identified liaison between agencies as an issue and called for more integrated approaches across these agencies. Furthermore, respondents identified the need to develop formal and informal partnerships, the need to meet people working in the MHPIP area, and the need for leadership and guidance in this area.

Because MHPIP is a relatively new area of activity in Australia, the levels of expertise are limited. It is of particular importance that research and evaluation professionals are involved in the development of evidence models and evaluation, which are necessary to build up Australia’s capacity to promote mental health and prevent mental disorder (Mitchell, 1999). Furthermore, mental health services could add their specific knowledge and skills to other agencies working in the MHPIP area by entering into further intersectoral partnerships.

Study limitations

A snowball sampling technique was used, therefore the identification of the sample may have been limited. This limitation was ameliorated to the extent that saturation in themes was reached. A second limitation was the depth of data supplied by informants. The depth of information could have been more extensive but was limited by what the informants were able to provide and their own familiarity with the area and programmes being delivered. At the time of the data collection, Michael Marmot had presented his work on the social determinants of health to Western Australian service providers. This impacted on the respondents and saw the social determinants of health as an issue discussed extensively by respondents.

CONCLUSIONS AND RECOMMENDATIONS

Issues identified by respondents in this study reflected priority action areas from the Jakarta Declaration and issues of capacity building. Respondents saw the need for an increase in partnerships, the need for policy and practices to promote health, increased community participation and an infrastructure for MHPIP that encourages sustainability of programmes. They also prioritized research, with specific emphasis on outcome research, as an area of need for MHPIP.

Gray and Casey have identified a range of interrelated measures that determine the success of capacity building in organizations (Gray and Casey, 1995). These include the commitment of senior management, the allocation of resources, coordination to ensure a solid infrastructure to support initiatives, increased skill across the whole organization and working with other sectors to achieve sustainable health gains. The following recommendations address these measures. The recommendations are aimed at increasing MHPIP service capacity in the delivery of MHPIP interventions in the areas of service infrastructure development, partnerships, resource allocation, workforce development, leadership, and research and evaluation.

An accepted definition of the parameters for mental health promotion and mental illness prevention needs to be agreed upon. The parameters should recognize mental health promotion as focused on a population health approach including universal and selected levels. In addition, there needs to be clear demarcation of the boundaries and relationship between mental illness prevention and early intervention.

Networking as a key strategy needs to be developed further, strengthened and evaluated. Indicators and systematic documentation of methodologies for partnerships should be developed. While partnerships need to be established across central government, local and research agencies as well as communities, particular attention should be paid to local partnerships at the local community level.

The expertise in MHPIP service delivery among the workforce needs to be more extensive. There needs to be increased training for MHPIP in relevant areas in public health, service development and change management strategies. Technical support and advice is needed on a state-wide basis to facilitate programme design, service delivery, research and evaluation. Training and development across service networks would add value in providing partnership opportunities for service capacity building.

The placement of MHPIP services requires an upstream approach to the design, delivery and evaluation of MHPIP services. There is a need for resource allocation to build the service capacity for the delivery of MHPIP interventions in areas such as workforce development, programme design, service delivery and evaluation, with the opportunity for service redesign and integration. While some of the resource provided may be of a transitional nature, there is still a requirement for longer term recurrent resource allocation to ensure sustainability of services, interventions and evaluation of outcomes.

Table 1:

Workforce information

Occupation type Number Percentage of agency workforce 
Counsellor or health worker 34 24 
Research/project officer (no specific health qualifications) 30 21 
Psychologist 21 15 
Social worker 16 11 
Health promotion officer 15 10 
Mental health nurse 13 
Nurse (non-mental health) 
Medical doctors/psychiatrist 
Occupational therapist 
Total 143 100 
Occupation type Number Percentage of agency workforce 
Counsellor or health worker 34 24 
Research/project officer (no specific health qualifications) 30 21 
Psychologist 21 15 
Social worker 16 11 
Health promotion officer 15 10 
Mental health nurse 13 
Nurse (non-mental health) 
Medical doctors/psychiatrist 
Occupational therapist 
Total 143 100 
Table 2:

Networking across agencies (n = 34)

Informants agency type Agency identified 
 Central Local Research 
Central 17 
Local 16 17 
Research 
Informants agency type Agency identified 
 Central Local Research 
Central 17 
Local 16 17 
Research 
Table 3:

Evaluation status of current projects reported by respondents (n = 20)

Evaluation status Type of evaluation (nTotal Percentage 
Evaluated Outcome evaluation (2) 40 
 Process evaluation (6)   
In the process of evaluation Outcome evaluation (1) 20 
 Process evaluation (1)   
 Impact evaluation (1)   
 Setting up a database at present (1)   
Not evaluated Program in development phase: evaluation has not been considered (5) 40 
 Program in development phase: will use outcome evaluation (1)   
 Program in development phase: will use process evaluation (2)   
Total  20 100 
Evaluation status Type of evaluation (nTotal Percentage 
Evaluated Outcome evaluation (2) 40 
 Process evaluation (6)   
In the process of evaluation Outcome evaluation (1) 20 
 Process evaluation (1)   
 Impact evaluation (1)   
 Setting up a database at present (1)   
Not evaluated Program in development phase: evaluation has not been considered (5) 40 
 Program in development phase: will use outcome evaluation (1)   
 Program in development phase: will use process evaluation (2)   
Total  20 100 
Table 4:

Reasons for selection of priority area (n = 34)

Reason for selection Tally Valid percentage 
Professional opinion/clinical experience 12 39 
Derived from available data such as service utilization data 26 
Research evidence 23 
Priority area for funding 
Other 
Missing 
Reason for selection Tally Valid percentage 
Professional opinion/clinical experience 12 39 
Derived from available data such as service utilization data 26 
Research evidence 23 
Priority area for funding 
Other 
Missing 
Table 5:

MHPIP research focus identified by respondents as important

Focus Tally Respondent exemplars 
Evaluation   
    Evaluation research: general Programmes run but there is a lack of evaluation 
    Need for evidence base to support programmes Nothing to show what is the best intervention: research is poor here—need evidence-based research 
    Evaluation effectiveness: what works, what doesn’t We don’t know the effectiveness of particular interventions, i.e. how the programmes adapt to real life systems 
    Process rather than outcome evaluation undertaken Behaviour change is not analysed: need to get data that demonstrates you are making a difference 
    Programme research: why it works, what components of the programme are effective, who it works for Need research in transferability of programmes into other ethnic groups, other socio-economic groups 
    Lack of long-term evaluation There is a problem with measuring long-term outcomes of programmes 
Research issues   
    Research is not well disseminated Lots of research being done, but lack of communication between research groups, and from research groups to people working with the problems and the general community 
    Lack of collaboration in research Need for a more systematic approach to research with more collaboration between research institutions 
    Need for community involvement in research There is a need for a forum to discuss a research agenda with community involvement 
    Other specific research projects 12  
Focus Tally Respondent exemplars 
Evaluation   
    Evaluation research: general Programmes run but there is a lack of evaluation 
    Need for evidence base to support programmes Nothing to show what is the best intervention: research is poor here—need evidence-based research 
    Evaluation effectiveness: what works, what doesn’t We don’t know the effectiveness of particular interventions, i.e. how the programmes adapt to real life systems 
    Process rather than outcome evaluation undertaken Behaviour change is not analysed: need to get data that demonstrates you are making a difference 
    Programme research: why it works, what components of the programme are effective, who it works for Need research in transferability of programmes into other ethnic groups, other socio-economic groups 
    Lack of long-term evaluation There is a problem with measuring long-term outcomes of programmes 
Research issues   
    Research is not well disseminated Lots of research being done, but lack of communication between research groups, and from research groups to people working with the problems and the general community 
    Lack of collaboration in research Need for a more systematic approach to research with more collaboration between research institutions 
    Need for community involvement in research There is a need for a forum to discuss a research agenda with community involvement 
    Other specific research projects 12  
Table 6:

Areas of concern in setting MHPIP policya (n = 34)

Issue Tally Respondent exemplars 
aRespondents could select more than one issue. 
Funding 12 At present recycled old money. Need a commitment to prevention and to resource the area appropriately 
Policy development Better policy planning development 
Integrated approach across government agencies Need to have an integrated approach across public health and health education 
Research issues Any programme should be linked to research 
Community consultation Government consultation with the community is weak, often token with predetermined outcomes 
Train workforce Need to train workforce: capacity building and skilling up Lack of expertise in workforce: willing to engage in the work but do not have the skills 
Demarcation issues Demarcation issues: whose responsibility is it to implement programmes? Which agency should be responsible? 
Shift from acute care to prevention A need to demonstrate the need to shift in emphasis from treatment to primary prevention 
Definition of mental health promotion Defining what people mean by health promotion and illness prevention 
Social determinants of health Serious question about how to implement Marmot’s findings: how do you change power imbalance, lack of access to transport 
Partnerships Need for partnerships in prevention 
Demonstrated effectiveness of prevention Need to demonstrate that it is worth investing money in prevention 
National stocktaking of programmes National stocktaking of programmes necessary 
Networking forum Need to not be working in isolation. Need guidance and leadership in this area. Need a forum to meet people 
Other specific issues to the respondents’ work  
Not in the position to answer Not in the position to answer (lack of experience, breadth) 
Issue Tally Respondent exemplars 
aRespondents could select more than one issue. 
Funding 12 At present recycled old money. Need a commitment to prevention and to resource the area appropriately 
Policy development Better policy planning development 
Integrated approach across government agencies Need to have an integrated approach across public health and health education 
Research issues Any programme should be linked to research 
Community consultation Government consultation with the community is weak, often token with predetermined outcomes 
Train workforce Need to train workforce: capacity building and skilling up Lack of expertise in workforce: willing to engage in the work but do not have the skills 
Demarcation issues Demarcation issues: whose responsibility is it to implement programmes? Which agency should be responsible? 
Shift from acute care to prevention A need to demonstrate the need to shift in emphasis from treatment to primary prevention 
Definition of mental health promotion Defining what people mean by health promotion and illness prevention 
Social determinants of health Serious question about how to implement Marmot’s findings: how do you change power imbalance, lack of access to transport 
Partnerships Need for partnerships in prevention 
Demonstrated effectiveness of prevention Need to demonstrate that it is worth investing money in prevention 
National stocktaking of programmes National stocktaking of programmes necessary 
Networking forum Need to not be working in isolation. Need guidance and leadership in this area. Need a forum to meet people 
Other specific issues to the respondents’ work  
Not in the position to answer Not in the position to answer (lack of experience, breadth) 

The Centre for Mental Health Services Research acknowledges the financial support of the Health Department of Western Australia for the research. However, the Health Department of Western Australia is not responsible for the contents of this publication, and any views or opinions expressed herein do not necessarily represent those of the Department.

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