The PROMISE Project research process identified ten final quality criteria around which were then constructed the PROMISE Guidelines for training social and health care professionals in mental health promotion. The first of these criteria (QC1) underlines the fact that training programmes in this area need to embrace the principles of mental health promotion as distinct from mental illness prevention or curative care. Positive mental health is to be seen as a resource, as a value on its own and as a basic human right essential to social and economic development. Mental health promotion seeks to act on the determinants of mental health in order to promote positive mental health and optimise the psychological development of the whole population, including those who are suffering from mental health problems or who are seen to be at risk. A mental health promotion approach thus includes mental illness prevention as one of its expected outcomes, but refuses to equate mental health with the simple absence of illness .
The following three criteria identify different actors that need to be involved in mental health promotion. Firstly, empowering all community stakeholders for effective involvement (QC2) is essential if each is to play a meaningful and sustained role in the programmes being implemented. Secondly, adopting an interdisciplinary and intersectoral approach (QC3) is at the centre of all contemporary mental health promotion capacity building policy. The 2005 WHO European Declaration on Mental Health famously asserts that: “There is no health without mental health. Mental health is central to the human, social and economic capital of nations and should therefore be considered as an integral and essential part of other public policy areas such as human rights, social care, education and employment”. This cannot be achieved by the health sector alone. Indeed, effective mental health promotion involves acting on the social, ecological and economic determinants of health: enhancing social connectedness and social inclusion, fighting against discrimination and violence, adapting the physical environment, living conditions, transport and schools. Given the diversity and multiplicity of the determinants of human well-being in any given situation, mental health promotion is intrinsically intersectoral. It should involve a broad range of professionals not only from the health, education, social and justice sectors, but also other stakeholders such as civil society organisations, and user and carer organisations [3, 7, 21]. Multidisciplinary, intersectoral teamwork should be included in the training of all actors. This is particularly true for mental health staff in the context of deinstitutionalisation, with carers and other community stakeholders, including primary care professionals, playing an increasing role in providing support for people with mental health problems .
An essential component of this training is the development of a common language between specialists from different professional backgrounds working in different sectors, aiming for common core competencies and capacities such as skills in communication, management, facilitating implementation and evaluation in order to strengthen working partnerships in mental health promotion projects . Finally, QC4, Including people with mental health problems, underlines the fact that mental health service users and carers have legitimate roles to play in participating in developing and conducting training for professionals in mental health promotion and also in promoting mental health in general. One of the major reasons why mental health promotion programmes fail concerns the stigma in most European societies with regard to mental health issues. Involving people with mental health problems in the design and delivery of these programmes has been shown to be a key way (a) to combat this stigma and (b) to design messages and actions that avoid creating new reasons for stigmatisation . Service users’ experiences of living with mental illness and of the stigma associated with mental illness, need to be utilised in a proactive way in the design and delivery of mental health promotion programmes. Building user skills for participation in training and advocacy is therefore a priority in mental health promotion . Thus training professionals in mental health promotion necessarily includes a process of inclusion of service user trainers in these programmes.
Capacity building and training are also key issues for effective advocating (QC5) and for consulting the knowledge base (QC6), both of which are identified as specific chapters in the final PROMISE guidelines. Building health promotion advocacy networks based on up-to-date scientific evidence and ethnographic information, drawing from a variety of methods, including epidemiology and social sciences for identifying action strategies are key ways for bringing different sectors to work together effectively. Understanding advocacy skills is particularly important when defending and integrating the point of view of socially excluded groups, such as Roma populations, undocumented migrants or the long-term unemployed. Introducing advocacy skills into front-line services, with the aim of developing effective mental health promotion programmes, requires specific training of both health and social care staff, as well as interpreters .
A weakness of many capacity building programmes in the area of mental health promotion is to neglect questions of training and support with regard to programme implementation. The quality of programme delivery, the skill and style of delivery and the way the programme integrates participants’ and stakeholders’ different points of view, will strongly influence participant responsiveness and engagement . Furthermore, research on this issue is scanty: little is known about the impact of training on knowledge, attitudes and behaviour with regard to mental health promotion . Three PROMISE guideline criteria address these questions. Adapting interventions to local contexts and needs in a holistic, ecological approach (QC7) and identifying and evaluating risks (QC8) are key to promoting programme delivery skills that will empower individuals and communities to decide the level of risk they are prepared to take with their health. This is particularly true with regard to addressing stigma about mental illness and people with mental illness, a major barrier to accessing not only care, but also information on mental health in general. Training professionals in using the media (QC9), including the Internet and online social networks, has proven to be effective in challenging stigma, increasing peer support and promoting positive attitudes towards mental health issues in general . In the same vein, the European Parliament Resolution of 19 February 2009 on Mental Health calls for the development of European guidelines for responsible coverage of mental health by the media.
Finally, quality training for health and social care professionals in evaluating training, implementation and outcomes (QC10) is key to success. Mental health promotion also involves acquiring skills with regard to evaluating not only the training itself, but also the implementation and outcomes of the mental health promotion objectives being targeted in the training. QC10, which asserts the principle of evaluation, also has implications for respecting criteria such as QC7 which insists that the different stakeholders in the communities involved in a given mental health promotion programme should also be involved in evaluating that programme.
There were a number of limitations to the study. In the methodology, the categorisation process inevitably simplified the data, reducing differences of interpretation and the richness of local experiences. The resource kits attached to each quality criterion do to some extent recreate the richness of cultural diversity between sites. However, these are in seven different languages, and remain relatively inaccessible to partners not fluent in these languages. Only the checklists, the EU-funded documents and the English language documents were accessible to all PROMISE partners. Further limitations include the fact that the members of the scientific committee, the local steering groups and local experts were chosen on the basis of local knowledge or research team membership: recruitment was therefore to some extent opportunistic and may have been inconsistent. Finally, the selection of documents to be analysed, consisting almost entirely of EU-funded policy documents and literature reviews, and in spite of continuing to examine further documents exploring specific themes well after saturation had been reached, will inevitably influence external validity. Generalisation to settings outside European contexts should take this into account.
On the other hand, the study does have a number of strengths. A substantial number of professionals and stakeholder groups were consulted across eight sites in seven European countries. The scientific committee was composed not only of mental health professionals, but included representatives from social work, predagogic research and general medical practice, as well as mental health service users. Similarly, partners included a variety of institutional categories including universities providing mental health training programmes, mental health service providers with continuous training remits and a public health organisation. All scientific committee members participated in all steps of developing the document analysis template, coding, identifying themes and the resulting ten quality criteria, and integrating feedback from consultation with partners at local sites. The final list of ten guideline criteria reflects commonalities across countries and research teams despite national, institutional or professional differences, and therefore may be seen to be widely applicable.