Promoting Mental Health and Well-Being in Public Health Law and Practice

Abstract

This article discusses the relationship between stress, physical health, and well-being in cultural context, offers examples of laws, policies, and programs to promote mental health and well-being, and examines how collective impact supports mental health and well-being.

Mental health, our cognitive and affective tools for processing and making decisions about the world, is one of the most meaningful resources in maximizing our well-being.¹ When we talk about mental health and well-being, too often our conversations move immediately to mental illness. We have neither built a vocabulary to clearly express what “mental well-being” means, nor communicated the findings of scientific research that illuminate the connection between the brain and the body. We have been slow to recognize mental health and well-being as amenable to efforts at disease and injury prevention, health promotion, and population-wide interventions. But, as research finds that mental health is especially influenced by social determinants of health, and related morbidity can be mitigated or entirely prevented, these attitudes are changing.²

This article begins with a review of individual stress and its relationship to well-being in cultural context. It then offers examples of laws, policies, and programs to promote mental health and well-being, and examines how collective impact contributes to well-being.

Individual Stress and Its Relationship to Well-Being in Cultural Context

Our bodily systems are in constant communication, and those studying the interactions of mind, body, and behavior are pushing us to recognize the “biological pathways and mechanisms by which thoughts, emotions and life experiences can influence susceptibility or resistance to disease.”³ As a result of these biological pathways, positive thoughts, emotions, and life experiences — the foundation of mental well-being — can create an “inoculation” effect against disease processes, acting as a wellness reserve from which to draw when experiencing life stress.⁴ Conversely, the presence of stressful, negative thoughts, emotions, and life experiences sets up conditions so that life stress may have a negative effect on health, creating fertile ground for disease processes to put down roots.

Experiencing stress can lead to both physical and behavioral responses. The physical response, often described as the fight-or-flight response, includes increased blood pressure and heart rate as well as the release of stress hormones. Continuous stress exposure leads to ongoing strain on the body's systems. This can eventually affect the body at the genetic level. Although exposure to all types of stress can lead to changes in health and well-being, ongoing strain on the body from routine stress may be the least noticeable, and too often receives inadequate attention.⁵ Behavioral responses may include coping behaviors, such as smoking, drinking, over-eating and overworking, which offer short-term stress relief, but can eventually lead to a course of disease. Both types of stress reactions can lead to diminished mental well-being and set up conditions for chronic diseases to take hold. While stress and its effects are not the only contributors to the disease process, they represent an area of promising intervention.

Two main routes have emerged for addressing negative interactions with stress: managing the stress response and addressing its causes.⁶ Improving one's ability to manage life stress may improve mental well-being. Many stress management methods have demonstrated results, including regular exercise, healthy foods, the Mindfulness-Based Stress Reduction program,⁷ yoga, sufficient sleep, spending time outdoors, and engagement in the arts. Improving relationship skills and addressing social and economic conditions have been effective in addressing causes of stress.⁸

Unfortunately, the persistent connotation of mental well-being and mental health with mental illness prevents many from seeking support because of the social stigma associated with mental illness.⁹ This is especially true in many cultures and communities where using the word “mental,” as in “mental well-being,” may discourage potential engagement before it can start.¹⁰ Also, some cultural groups do not have words for mental well-being, or do not have access to providers familiar with their culture. Research suggests that efforts to promote mental well-being are more likely to succeed when they include culturally and linguistically appropriate frameworks and services.¹¹

While direct legal intervention is one approach to improving population-level mental health and well-being, law can also be used to promote alignment between health care, public health, and other sectors toward maximizing mental health and well-being. This type of approach is known as collective impact, or “the commitment of a group of important actors from different sectors to a common agenda for solving a specific social problem.”

Laws and Programs to Promote Mental Health and Well-Being

Laws and programs may improve mental well-being by bolstering stress management skills or addressing social and economic conditions. This section describes recent examples of legal and policy interventions in the contexts of maternal and child health, education, and law enforcement.

Maternal and Child Health

The parenting support and education provided by evidence-based home visiting programs improve maternal and child well-being. Since implementation of the maternal, infant, and early childhood home visiting block grant program under the Affordable Care Act, home visits have quadrupled.¹²

Recently, the Centers for Medicare & Medicaid Services (CMS) announced that maternal depression screening and family therapy may be covered under a child's Medicaid policy, as a direct benefit to the child.¹³

Inability to afford diapers can lead to rashes and infections for babies and create a reduced sense of competence in parents.¹⁴ The Community Diaper Program involves a partnership with the private and nonprofit sectors to fill the diaper gap. A pilot in San Francisco uses federal TANF dollars to address diaper need, and several states exempt diapers from sales tax.

Education

Changing school conditions may help students affected by trauma to attend regularly and learn effectively.¹⁵ The Every Student Succeeds Act (ESSA), the new federal education law, offers opportunities for state and local education agencies to improve school climate.¹⁶ Importantly, ESSA addresses equity issues with respect to economic disadvantage, race and ethnicity, gender, disability, English proficiency, migrant status, rural status, and homelessness.¹⁷

Social and emotional learning skills include self-awareness, self-management, social awareness, relationship skills, and responsible decision-making. While frameworks for these “soft skills” vary, and assessment poses a challenge, teaching these skills improves academic performance and increases the likelihood of students choosing positive health behaviors.¹⁸ Similarly, delayed high school start times provide opportunities for healthy sleep, with benefits for academic outcomes as well as mental and physical health.¹⁹

Law Enforcement

Improving relationships between community members and police could increase well-being for both. Emerging law enforcement training programs distinguish mental illness from criminal activity, teach de-escalation skills, and address implicit bias. Research should evaluate the comparative effectiveness of mindfulness, Mental Health First Aid, crisis intervention teams, and community policing.²⁰

Public Health, Health Care Reform, and Promoting Mental Health and Well-being

For example, Track 3 of the Accountable Health Communities pilot from the Centers for Medicare and Medicaid Innovation requires health care systems to work with a third-party organization to convene community stakeholders and create a common strategy to meet the community's health-related needs.²² This is significant because health care systems tend to be one of the most well-resourced community stakeholders in terms of financing, technology, and infrastructure. There is also important work in health care reform, such as the “continuously learning system” model in which real-time data within a system is used to identify and scale up effective practices. These practices can be used in collective impact models to help the entire community more effectively promote well-being.²³

Policy influencers can support the success of these new community collaborations and ensure that they focus explicitly on mental health and well-being. First, they can have stakeholders adopt common metrics for understanding problems and measuring success that specifically encompass mental health and well-being. This can be accomplished in part by unifying the many community needs assessments required under laws like the Affordable Care Act and ESSA. For example, the 100 Million Healthier Lives Initiative is developing a community-level well-being metric and provides links to others currently in use,²⁴ and Vermont's new all-payer Accountable Care Organization model focuses on minimizing state-wide rates of suicide and substance use.²⁵ Second, influencers can implement an innovative shared financing model that allows stakeholders to promote greater cross-sector investment and more fairly share the benefits of an intervention, such as a wellness trust in which funds are pooled in order to invest in effective prevention measures.²⁶ Finally, they can require stakeholders to share data in a way that protects individual privacy, but gives access to enough information to allow community-level decision-making and to foster the success of a collective impact model.²⁷

By implementing some of these policies, policy influencers can enable health care, public health, and allied sectors to align so that communities can most efficiently maximize their own well-being.

Conclusion

Mental health and well-being are a crucial part of health and public health. By promoting skills to manage stress and by ameliorating social and economic sources of stress, public health laws and programs, in alignment with laws in other sectors, have already begun to promote well-being in powerful new ways.

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