Applying Salutogenesis in Community-Wide Mental Health Promotion

Abstract

This chapter highlights the relevance of mental health as a resource and risk for population health and describes mental health problems and related financial and social implications for society, which has led to an increased focus on prevention of mental health problems in health policy lately. Using the river metaphor of salutogenesis and a mental health ease–disease continuum, mental health is seen not as a stable trait but rather as a constant process, which needs to be protected and promoted. Thus, mental health promotion is foremost focused on protective factors and promoting mental health resources at different levels of society and is relevant to everyone.

The authors also present and describe the ‘Act-Belong-Commit’/‘ABCs of Mental Health’ Campaign, a world-first comprehensive, population-wide, community-based mental health promotion campaign designed to promote mental health and prevent mental ill health.

Keywords

Introduction

A prosperous and sustainable society requires a mentally healthy population. An individual’s mental health is fundamental to short- and long-term health and thriving. It affects cognition and ability to learn, which in turn affect educational attainment and employment (Chida & Steptoe, 2008; Holstein et al., 2011; Kirkwood et al., 2008; Lehtinen et al., 2005; Stewart-Brown, 2005; WHO, 2005). Mental health and health-risk behaviours are strongly correlated (Hamer et al., 2009; Hoyt et al., 2012; Royal College of Physicians, 2013; Whiteford et al., 2013), with mental health problems shown to be important risk factors for unintentional and intentional injury, and the risk of marginalisation (WHO, 2009). Good mental health and well-being are profoundly important to quality of life, the capacity to cope with life’s ups and downs, and is protective against physical illness, social inequalities and unhealthy lifestyles (UK Faculty of Public Health and The Mental Health Foundation, 2016; Huppert, 2014). In line with these findings, the need to include mental health and well-being among the priorities of the public health agenda has been increasingly recognised in Europe and elsewhere over the past decades (EU joint action on mental health and well-being, 2016; Forsman et al., 2015; Anwar-Mchenry & Donovan, 2013).

The WHO and OECD estimate that approximately 25–50% of the population will experience mental health problems at some time during their life, with half of all mental health disorders having their onset before the age of 14 (OECD, 2019; WHO, 2005, 2014). In the upcoming decade, mental health problems are estimated to constitute one of the major global burdens of disease (Whiteford et al., 2013; WHO, 2003). This has wide-ranging social and financial implications not only for the individual and their families but for society as a whole (WHO, 2005). For example, in the Member States of the European Union (including Denmark), the cost of mental health problems is estimated to be between 3% and 4% of Gross National Product (GNP) due to loss of productivity and increased expenses for social services and the healthcare system (OECD, 2013; WHO, 2003). These costs may be underestimates given that some economic consequences of mental health problems may not be included due to lack of knowledge of various indirect expenses outside these systems (Knapp, 2003).

The increasing burden of disease and monetary costs related to mental health problems has in recent years resulted in an increased focus on population mental health and a dawning realisation that treatment alone is insufficient to halt the escalating worldwide rates of mental health problems (Knapp, 2003; The European Commission, 2005, 2008; WHO, 2005). Whilst not generally matched by actions, there is at least a growing recognition that interventions focusing on prevention of mental health problems and promotion of mental health and well-being are critical in enabling individuals to strengthen and protect their mental health (Anwar-Mchenry & Donovan, 2013; UK Faculty of Public Health and The Mental Health Foundation, 2016; EU joint action on mental health and well-being, 2016; Forsman et al., 2015; Haro et al., 2014; Knapp, 2003; UK Government, 2012; Slade, 2010; The European Commission, 2005, 2008; WHO, 2004, 2005). Further health economic evaluations suggest that investing in mental health promotion is cost-effective in the short term as well as in the long term (Knapp, 2003; McDaid & Park, 2011; Zechmeister et al., 2008).

The Mental Health Ease–Disease Continuum

Similar to the ‘fence on the cliff or an ambulance down in the valley’ prevention analogy, a river analogy is often used in public health in the same way. That is, attempting to focus health authorities on prevention by referring to looking at what is causing people to fall into the river ‘upstream’ rather than focusing on ‘rescue, resuscitation and recovery’ services’ downstream (Donovan & Henley, 2010). However, from a salutogenic approach, the river analogy has been used differently, namely, by suggesting that everyone is always in the river of life. The river is full of risks and resources , and the outcome is largely based on our ability to identify and use the resources to improve our options for health and life (Eriksson & Lindström, 2008). This perspective acknowledges that mental health is not a stable trait but rather a constant process which, like physical health, needs to be protected and promoted. We move up and down the river throughout life, and what we are faced with, the challenges we meet, and the resources available to us determine where in the river we are at any given point in time.

At the top end of the river, the water is shallow and crystal clear with hardly any current. We are, therefore, more likely to have a complete overview of our situation and plenty of mental surpluses. We are what some call flourishing. When we are at this end, we are more likely to be innovative, creative, altruistic and productive. Any society would have an interest in most of the population being located in this part of the river at any given time. However, studies indicate that this generally applies to a small proportion of the population . Most are in the part of the river further downstream, where the water is slightly deeper with an undercurrent beginning to emerge. Here, we still have our heads above water and experience what we might call moderate mental health. We are okay but do not have nearly the same energy to spare as those up the top end. As a result, we may be less altruistic and less resilient if a strong undercurrent suddenly comes our way.

Further down the river, it becomes increasingly deep and difficult to find a foothold, the water is murky, and the undercurrent is strong. Here, we struggle to keep a clear overview of our situation. We may be able to paddle around and fight to keep our heads above the water for a period, but unless something or someone helps us up towards the upper end again, within a reasonable amount of time, we are at significant risk of being drawn out over the edge of a roaring waterfall. This is where we see the most common mental health disorders in terms of, for example, anxiety and depression.

Throughout our lives, we move up and down this river. In other words, we move back and forth on the spectrum between mental health and mental illness on the ease–disease continuum . We may experience periods of flourishing and periods of languishing, depending on what challenges we face and what resources we have available.

Something may always happen in our lives that increases the risk of us ending up in deep water. Most of us will experience this from time to time during our lives. What determines whether we sink or stay afloat is our ability to swim and deal with the challenges we encounter along the way. Being able to identify and use the resources available to us in a mental health-promoting manner is crucial. Mental health promotion is first and foremost focused on protective factors and on promoting mental health resources, rather than on preventing risk factors for mental health illness.

Resources for mental health exist at the individual, group, community and societal levels, and there will always be an interaction between these levels, which is why a singular focus on the individual is not enough. We are influenced by our surroundings, and we influence each other. Mental health is something we create together.

Traditionally, the focus on mental health has been on the deep end of the river, politically and scientifically, with a focus on individual treatment and early intervention among those already struggling. Naturally, these perspectives are important to preserve , but as the increasing number of people with mental health problems worldwide clearly shows, they cannot stand alone. The current strategy may be appropriate if the main goal is to reduce individual suffering once problems occur. However, having a singular focus on the deep end of the river is not an efficient strategy if the goal is to prevent those further up the stream from drifting down to the deep end. And it is most definitely not an appropriate strategy if the goal is to promote a mentally healthy and flourishing population.

Mental health and well-being are more than the absence of mental health problems. Focusing on positive aspects of mental health has added value beyond what is achieved from a pure risk reduction perspective. Having a sense of meaning and purpose in life, good social relations, and a feeling of contributing with and to something or someone, are critical aspects of mental health.

We need to do both more and something else if we want to decrease the number of individuals who experience mental health problems and increase the number who flourish in the population. For example, are we at an increased risk of developing a mental disorder if we have been stressed or bullied for a long time? Yes, to a large extent, and therefore treatment and prevention in the form of stress policies, anti-bullying policies, low-threshold offers, and therapy are crucial. However, does not being stressed or bullied in and of itself result in being mentally healthy or flourishing? Unfortunately, not.

On the other hand, promoting positive aspects and protective factors of mental health (e.g. mental health awareness, self-efficacy, social and emotional competencies, action competencies, good social relationships and inclusive communities) promotes not only flourishing, but also prevents many common mental health problems from arising in the first place . Further mental health promotion may offer a substantial contribution to the recovery process from mental illness. Mental health promotion is thus relevant to everyone, no matter where in the river one may be at any given time, and whether one is young or old or has a physical or a mental health problem.

If more people are to flourish in the future and less languish, we need to broaden our perspective and support a more holistic and salutogenic view of mental health. We need to raise awareness of protective factors for mental health and well-being in the general population as well as in the public and private sectors. We need to work across disciplines and sectors. We need to promote inclusive and nurturing communities, support frontline personnel and volunteers in creating mentally healthy conditions for their target groups, and empower people to move towards the top end of the river. In other words, we need public mental health promotion.

Act-Belong-Commit (Fig. 44.1) is a world-first comprehensive, population-wide, community-based mental health promotion campaign designed to promote mental health and prevent mental ill health (Donovan et al., 2006, 2016). The campaign originated in Western Australia and is now diffusing nationally and internationally (Ekholm et al., 2016; Koushede et al., 2015; Nielsen et al., 2017). It is the first population-wide mental health promotion campaign we are aware of that is consistent with the salutogenic approach of aiming to build positive mental health rather than targeting specific risk factors for specific mental illnesses, and that targets all persons regardless of where they are on Antonovsky’s ‘ease–disease’ continuum (Antonovsky, 1993).

Fig. 44.1

Background: The ‘Act-Belong-Commit’/‘ABCs of Mental Health’ Campaign. (Illustrated by Mads Ortmann. © Vibeke Koushede 2015)

Whilst there are school and worksite interventions that aim to build positive mental health whilst preventing risk factors, past and current community-wide campaigns dealing with mental health tend to focus on issues related to mental ill health, such as increasing awareness about mental disorders, providing education on stress reduction and coping strategies, encouraging help-seeking, early detection and treatment, and reducing stigma (e.g. see Barry et al., 2005; Saxena & Garrison, 2004).

Campaign Origins

The program came about in the early 2000s when Western Australia’s Health Promotion Foundation (‘Healthway’ ) acknowledged that whilst there had been health promotion campaigns for several decades in Australia (and around the globe) targeting physical health issues such as tobacco, alcohol, physical activity, nutrition/healthy eating, obesity, road safety and sun protection, very little attention had been paid to promoting what people can and should do for their mental health. Hence, Healthway posed the question ‘can we promote mental health in the same way as we promote physical health?’ and funded research into people’s beliefs about mental health with a view to answering this question, and, if the answer were ‘yes’, to translate those findings into a framework for a mental health promotion campaign.

Whilst the researchers were unaware of Antonovsky’s work and his salutogenic, ‘what makes people healthy?’ (Mittelmark et al., 2016), the overall approach adopted by the research team, in both the primary and secondary researches, was wholly consistent with Antonovsky’s question. That is, the overall thrust of the research sought to answer the question ‘what makes people mentally healthy?’ and then how that information could be translated into a mental health-promoting framework that was feasible and actionable. Hence, the research first set out to find out what both laypeople and scientific experts in the field believed ‘makes people mentally healthy’.

Qualitative research into laypeople’s understanding of, and beliefs about, factors contributing to good mental health was conducted first, taking a grounded theory approach . Then, a model was developed, which was then confirmed through an extensive review of the scientific literature. Although the language was understandably different, it was found that laypersons’ intuitive knowledge about factors contributing to good mental health was consistent with the scientific literature. This was ‘good news’ for the research team as the primary communication strategy could then be to validate and make salient already held beliefs rather than change established beliefs, and to further reinforce to people that their world was comprehensible and manageable. The grounded theory model developed from the primary research shared a number of features with the published literature, but most significantly with respect to this chapter, postulated an ‘end-point’ labelled ‘coping capacity’ which was influenced by people’s perceived self-worth and self-efficacy, the ability to communicate with others about their problems, and the ability to ask for help when needed. In retrospect, this model can be seen to have had much in common not only with Antonovsky’s overall salutogenic orientation but the dimensions of a sense of coherence (see Donovan et al., 2004).

The ABC Message

The words Act, Belong and Commit , represent the three behavioural domains that laypeople in Australia (Donovan et al., 2007) and Denmark (Nielsen et al., 2017) and the scientific literature around the globe consider the behaviours that contribute to positive mental health. These are articulated as follows:

• Act: keep physically, mentally, spiritually and socially active: ‘do something’

• Belong: keep up friendships, engage in group activities, participate in community events: ‘do something with someone’

• Commit: set goals and challenges, engage in activities that provide meaning and purpose in life, including taking up causes and volunteering to help others: ‘do something meaningful’

Overall, the Act-Belong-Commit message encourages people to be physically, spiritually, socially and mentally active in ways that increase their sense of belonging to the communities in which they live, work, play and recover, and that involve commitments to causes or challenges that provide meaning and purpose in their lives. As noted above there is substantial and increasing evidence that the three Act, Belong and Commit behavioural domains contribute to increasing levels of both physical health and mental health (Barry et al., 2005; Donovan & Anwar-McHenry, 2014), and act as protective factors against mental disorders, such as depression and anxiety, and cognitive impairment (Santini et al., 2017). Furthermore, the three domains are universal across cultures, although the articulation and emphasis of each of the domains may vary between cultures (e.g. Nielsen et al., 2017).

In line with the principles of mental health promotion and the salutogenic approach advocated by Antonovsky, Act-Belong-Commit’s overarching framework was designed to target ‘everyone’, regardless of their mental or physical health status, and acknowledged that even those with a diagnosed mental illness can—and should—be offered opportunities to enhance their health. Follow-up research has revealed that persons with a diagnosed mental illness are significantly more likely to take action to enhance their mental health as a result of exposure to the campaign than the rest of the population (Donovan et al., 2016).

Consistent with an overall health-promoting approach, the ABC framework not only allows for implementation at the population level but also in specific settings and for targeted groups. Act-Belong-Commit provides a framework for individuals, health professionals, organisation leaders and policymakers to take action to build and support good mental health in their organisations, communities and nation-states, and hence can be seen as answering Antonovsky’s question ‘What can be done in this community (factory etc) to strengthen comprehensibility, manageability, meaningfulness of the persons in it’ (Antonovsky, 1996). These three domains can also be considered to build intellectual, social and spiritual capital (Zohar & Marshall, 2005), further illustrating ABC as a salutogenic approach and building a sense of coherence through these three sources of capital.

In short, Act-Belong-Commit can be seen as responding to Antonovsky’s call for the systematic development of programs that strengthen a sense of coherence . That is, we believe—and we think Antonovsky would agree—that by acting, belonging and committing, people will strengthen their view of the world as comprehensible, manageable and meaningful.

How Act-Belong-Commit Operates in Western Australia

The overall strategic framework is a community-based social marketing approach that encourages individuals to engage in mentally healthy behaviours whilst simultaneously partnering with organisations that provide supportive environments for good mental health and well-being (Anwar-McHenry & Donovan, 2019). The campaign is implemented via a hub of five to six individuals based within Curtin University, with ongoing funding from the Health Promotion Foundation of Western Australia (Healthway ) and the Mental Health Commission of Western Australia .

Under a mass and social media advertising and publicity umbrella, the campaign utilises social franchising of government authorities, commercial and not-for-profit organisations, and local community groups to reach both the general population and specific target groups (Donovan & Anwar-McHenry, 2015). Partners are not actively solicited; instead partners respond to the campaign’s advertising, publicity or word-of-mouth with requests to get involved in the campaign. Partners range from statewide not-for-profit organisations and state government departments to local government municipalities, large and small sporting clubs, mental ill health organisations , theatre and arts groups, and small community groups such as knitting groups, stamp collectors, groups in recovery and dragon boat clubs. Any organisation offering mentally healthy activities is welcome as a partner. The campaign has around 270 community and organisational collaborators or partners in Western Australia, several partners in other Australian states, and international partners or collaborators in Denmark, the Faroe Islands, Japan, Norway and the United States.

Act-Belong-Commit partners sign a Memorandum of Understanding to ensure message integrity and brand consistency, the sharing of activities and strategies between partners, and the provision of evaluation data to assess the impact of the campaign (Donovan & Anwar-McHenry, 2015). In return, partner organisations are provided with various supports, such as training, strategic direction, access to resources and assistance with seeking funding. The use of social franchising in this way has enabled the Act-Belong-Commit campaign to expand its impact and geographical reach statewide, nationally and internationally without necessarily increasing the size and hence costs of the franchiser ‘hub’ (Beckmann & Zeyen, 2013).

The campaign also has a number of supporting resources (available in print and online) including a self-help guide (‘A Great Way to Live Life: The Act-Belong-Commit Guide to Keeping Mentally Healthy’), self-assessment questionnaires, a website search tool to find clubs and organisations of interest by geographic area, organisers and planners, factsheets, curriculum materials for schools, and print and video advertisements (see actbelongcommit.org.au). Over the years, the campaign has implemented a school program (currently 52 schools in Western Australia), a Youth Connectors program , an Act-Belong-Commit in Recovery program , and a pilot adaptation in a regional Aboriginal Community.

In Western Australia, the campaign has been supported by a mass media campaign, which, whilst limited in budget, has contributed to high ongoing awareness among the general population and hence sensitising people to on-the-ground activities held under the Act-Belong-Commit banner . Ongoing evaluation of the campaign in Western Australia shows widespread awareness of the campaign (over 80% of the adult population), with 10–15% of those aware taking specific actions to improve their mental health as a result of exposure to the campaign. The campaign is also seen to reduce stigma against mental illness, increase openness about mental health issues, and is changing the way people think about mental health, from a passive ‘illness’ perspective to a belief that they can proactively enhance their mental health (see reports on actbelongcommit.org.au).

How the ABCs of Mental Health Operates in Denmark

Over the past decade, mental health has been declining in Denmark, as in many countries, with vast increases in stress, anxiety, depression and loneliness among all age groups (Jensen et al., 2018; Rasmussen et al., 2019; Twenge et al., 2019). In spite of international recommendations to invest in and prioritise public mental health promotion (EU joint action on mental health and well-being, 2016; Forsman et al., 2015; Haro et al., 2014; WHO, 2004), the primary focus in Denmark , again as in most countries, has been on treatment and targeted prevention for mental illness; for example, Denmark is one of the European OECD countries with the highest use of antidepressants (OECD, 2018). Several other European recommendations on mental health have also largely been ignored, for example, recommendations on bridging the gap between research, policy and practice; strengthening cross-sectoral collaboration; investing in mental health and well-being research and better data; scaling up mental health promotion and prevention efforts; supporting implementation of evidence- and research-based programs; promoting a holistic view on mental health; improving mental health literacy in the population and in the public and private sectors; building capacity to empower end users; and incorporating mental health in all policies at all levels—just to mention a few (EU joint action on mental health and well-being, 2016; Forsman et al., 2015). Reference to universal promotion and prevention has mainly been rhetorical with a scarcity of political action (Eplov & Lauridsen, 2008).

However, in the national goals for health put forward by the Danish Government’s Ministry of Health 2014, mental health goals featured for the first time (The Danish Government, 2014). Further, the Danish Health Authority recommends that Danish municipalities prioritise mental health promotion (The Danish Health Authority, 2018).

When we fall ill, the responsibility to treat us lies firmly embedded in the healthcare sector. Most of the drivers of mental health and well-being, however, lie outside the healthcare sector, in the arenas where we live, love, work and play. In Denmark, the five regions are responsible for the hospitals and treatments that require hospitalisation. Promotion, prevention and community care, on the other hand, are the responsibility of the 98 Danish municipalities.

In April 2014, researchers at The National Institute of Public Health (NIPH), University of Southern Denmark, decided to try and help bridge the gap between research on public mental health and well-being, international recommendations, and national policy and practice (Koushede et al., 2015).

At the time, many service providers in the municipalities voiced uncertainty as to how to implement mental health promotion, resulting in little action (Friis-Holmberg et al., 2013). A major reason for this uncertainty was the perceived complexity associated with mental health, and that service providers did not have an easily understood and practical framework for the implementation of mental health promotion. The Australian Act-Belong-Commit mental health promotion campaign was designed to not only reduce the complexity surrounding mental health for the population at large but also to provide service providers, health professionals and clinicians with a practical framework for doing mental health promotion. Hence, the Danish researchers hypothesised that bringing the Act-Belong-Commit framework to Denmark might enable implementation of mental health promotion across different sectors and disciplines. Denmark , therefore, became the first country outside Australia to sign a memorandum of understanding to adapt and implement Act-Belong-Commit (Koushede et al., 2015).

Adaptation and Implementation of the ABCs of Mental Health in Denmark

After a thorough introduction to the Act-Belong-Commit framework and campaign by the founder and team at Curtin University, the Danish researchers identified initial relevant national Danish stakeholders and potential partners to bridge the gap between mental health and well-being research and practice using the ABC framework. Several meetings were held in order to examine the perceived relevance of and possibilities for initiating a Danish Act-Belong-Commit multidisciplinary partnership with a team of private and public institutions.

As a result of these meetings, an initial funding application to adapt and pilot Act-Belong-Commit in a Danish context was sent in 2014 to the Danish Ministry of Health by the NIPH and involved the following partners: The Danish Healthy Cities Network, The Danish School of Media and Journalism, Public Health Copenhagen, and Red Cross Copenhagen. The application was successful, and funding was granted for a two-and-a-half-year period.

In the first phase, a qualitative study was conducted to determine whether Danish people’s understanding of what constitutes good mental health and what people can do to keep mentally healthy was consistent with the underlying messages in the Act-Belong-Commit campaign. The study showed that the generic nature of the Act-Belong-Commit messages made them readily translatable to a Danish context. Further, the research highlighted that although most Danes intuitively know what activities and social relationships promote their mental health , many forget to prioritise them in a busy day-to-day life. Many stop doing activities known to protect mental health and well-being when feeling under pressure from school or work. These findings underlined a need to raise awareness in the Danish population regarding how to look after one’s mental health; in the same way, the public is given information on how to look after one’s physical health. The Act-Belong-Commit campaign was therefore deemed relevant to implement in Denmark (Nielsen et al., 2017).

Act-Belong-Commit was renamed the ABCs of mental health (In Danish: ABC for mental sundhed), for two main reasons: first, the qualitative research showed that many found using the Australian wording created a sense of distance and expressed a preference for a name in Danish, second. The term mental health was slowly surfacing on the public and political agenda, and hence there was an opportunity to create an ‘ABC’ association with this emerging awareness. The three underlying ABC messages—‘do something’, ‘do something with someone’ and ‘do something meaningful’—are used in Denmark as an articulation of the ABC of mental health branding. The Danish logo was also adapted to accommodate people’s desire for a more Nordic look.

Organisation of the ABCs of Mental Health

The partnership is led by the Department of Psychology, University of Copenhagen (UCPH). Since 2014 the partnership has grown and expanded significantly and currently exists of over 50 partners, including 23 municipalities across Denmark (‘ABC for mental sundhed’, 2019). Funding for further development and dissemination has been granted twice by the Nordea Foundation.

The Danish model differs somewhat from the Australian model, in that various components of the campaign are developed and implemented through one or more of the partners rather than only through the central ‘hub’. Each partner has at least one ABC coordinator. These coordinators meet up four times a year for partnership network meetings. The form and content of the meetings vary, and partners take turn in hosting the events. One result of regular meetings is a strong element of co-creation in the Danish partnership, with many activities being carried out by and across partner organisations.

With so many different personalities, from many different organisations, NGOs and municipalities we’re forced to think outside the box. This has resulted in creative ways of addressing and working with mental health and many of the activities/talks/workshops we have developed have been thanks to the collaboration in the ABC-partnership. (ABC-coordinator, sports association)

There is a steering committee that determines the overall strategy and ensures progress in the partnership. Current committee members represent the following organisations: Department of Psychology, UCPH; The NIPH; the Danish Mental Health Foundation; the Centre of Prevention in Praxis, under KL—Local Government Denmark; DGI, a sports association with more than 6.300 member sports clubs and 1.5 million members; the Danish Scouts Association; The Danish Healthy Cities Network; and Vejle municipality. These organisations all play a central role in the partnership as described below.

The Department of Psychology leads and coordinates the partnership as well as undertakes continuous evaluation and relevant research supporting the partnership. together with NIPH. Further, The Department of Psychology and NIPH are responsible for creating the best possible knowledge base for public mental health promotion and for communicating this knowledge broadly, and particularly to policy and decision-makers. Together with several of the other partners, they also undertake workshops and training of frontline personnel and volunteers in the ABC framework and mental health promotion drawing on a salutogenic approach.

The Danish Mental Health Foundation oversees communication and campaign activities and offers communication workshops to partners. Each year, partners decide on a focus for a joint campaign in the week around World Mental Health Day on October 10. For example, one year, the main message was ‘join the club’ and ‘your old hobby misses you’ followed by the ABC messages; another year, it was ‘do something nice for someone’ followed by the ABC messages, and this year the focus was on ‘meetings across’ generations, cultures, social groups, etc. Campaign messages are supported by local activities across the partnership. Some campaign elements and materials are developed as part of a collaboration with the Danish School of Media and Journalism (Campaign materials and films can be accessed via the website www.abcmentalsundhed.dk).

The Centre of Prevention in Praxis (CPP), under KL – Local Government Denmark, is responsible for counselling municipalities and supporting municipal ABC coordinators in their work. CPP also undertakes workshops and theme days for partners and municipalities that want to learn more about mental health promotion and the ABCs of mental health . DGI and the Danish Scouts Association are responsible for training and supporting volunteers in the ABC framework. The Danish Healthy Cities Network and the municipalities inform one another about the work in the partnership. The representative for Vejle municipality shares valuable knowledge regarding potential political, organisational and practical barriers and facilitating factors for working with mental health promotion at a municipal level.

All partners have a shared responsibility in disseminating the ABC messages to their respective target groups, supporting and empowering their target groups in acting, belonging and committing in their local communities, and promoting mentally healthy activities and surroundings. By supporting frontline personnel and volunteers, and empowering people to act, belong and commit, the aim is to strengthen their view of the world as comprehensible, manageable and meaningful, thereby increasing individual and community resilience and well-being. Apart from organisations that have formally joined the partnership, the ABCs of mental health have also spread through smaller local organisations and individuals who have heard or read about the framework and messages and found them useful in their context.

Overall the ABC framework has provided a mutual and straightforward language, understanding, and focus for mental health promotion. This has greatly helped the cross-sectoral and cross-disciplinary partnership take collaborate action in promoting public mental health and well-being in Denmark. Campaign messages have been well received; they are considered positive, easy to understand and act on, as well as help to destigmatise mental health problems.

Act-Belong-Commit/ABCs of Mental Health in Communities and Cities

The reader will no doubt be aware that the ABC social franchising/community-based approach is relevant to several other chapters in this Handbook. ABC’s community-based approach is all about bringing people together, not just to enjoy themselves but to work towards goals that help the whole community. In that way, ABC contributes towards building generalised resistance resources and a sense of coherence, both at the individual and at the community levels. For examples of this overlap, we have included below several press advertisements that were used in the pilot of the campaign in six regional towns in Western Australia in 2005–2006. Given people’s lack of salience of positive mental health at that time, the communication objectives of these early ads were to increase awareness of positive mental health per se, as well as something they could be proactive about, and to encourage individuals and community groups to engage in mentally healthy activities (see Box 44.1).

Box 44.1: Act, Belong, Commit. © Curtin University, Western Australia, used with permission

Of note is that the introductory ads in Box 44.1 exploited the research finding that whilst not salient, most people had an intuitive notion of what factors kept them mentally healthy; hence, the reference in the ads to ‘Grandma’, Grandpa’ and ‘Aunt Sally’ having such wisdom which ‘health experts’ had ‘finally’ endorsed. These ads aimed to increase the salience of being proactive about mental health and to validate what people intuitively believed about how to keep mentally healthy.

The later press ads in Box 44.2 attempted to increase mental health literacy by posing and/or answering common questions about what it means to be mentally healthy and what is ‘true’ happiness, whilst Box 44.3 specifically focussed on green environment benefits (note that in Australia, feeling ‘blue’ refers to feeling ‘depressed’ or ‘down’/‘unhappy’, etc.).

Box 44.2: Early Press Ads : What Does It Mean to Be Mentally Healthy? What Makes you Happy? © Curtin University, Western Australia, used with permission

Box 44.3: Ad: Feeling Blue, Act Green! © Curtin University, Western Australia , used with permission

However, what is also clear is that the salutogenic model means that we need to intensify on-the-ground activities that bring people together rather than rely only on media advertising to stimulate action.

This intensification is illustrated in the training of volunteers and frontline personnel in both Denmark and Australia, and also in the specific sub-programs in Australia that have focussed on training mental health professionals to help people in recovery to ‘act-belong-commit’ , and the very focussed community approach in a remote Aboriginal community in the North of Western Australia (Wedin et al., 2016; Donovan et al., 2018). The last, in particular, called ‘Standing Strong Together in Roebourne ’, is very focussed on building on existing community strengths, bringing groups together to work on common town issues and fostering community cohesion, resistance resources and shared goals to improve the local physical, social and political environment.