Margaret Barry Challenges and opportunities in strengthening the evidence base for mentaI heaIth promotion I There is an accumulating international evidence base for mental health promotion. Programmes promoting positive mental health have been found to result in impressive long-lasting positive effects on multiple areas of functioning and have also been found to have the dual effect of reducing risk (lUHPE, 2000). The strength of evidence from systematic reviews and effectiveness studies supports the value of such programmes as cost- effective initiatives capable of impacting positively across multiple domains of functioning (Durlak & Wells, 1997; Tilford et al., 1997; Hosman and Llopis, 2000). The recently published World Health Report 2001, is devoted exclusively to mental health. This report calls for global and national initiatives to address the increasing rise of mental and behavioural problems world-wide. The report advocates a comprehensive public health approach and among its recommendations for action is included a call for formulation of policies designed to improve the mental health of populations and ensure access to appropriate and cost-effective services, including mental health promotion and prevention. This report, by its own admission, "focuses upon mental and behavioural disorders rather than the broader concept of mental health» (WHO, 2001 p.lO). However, it does acknowledge that the promotion of positive mental health in all members of society is clearly an important goal, and underscores that much remains to be learned about how to achieve this objective. Mental health promotion has a critical role to play in meeting the global challenge of promoting population level mental health. Wehave at our disposal a substantial body of evidence concerning the effectiveness of mental health promotion activities. The lUHPE Report for the European Commission (2000) clearly endorses that mental health promotion programmes work and that there are a number of evidence-based programmes available to implement mental health promotion practice. Strengthening the evidence base in order to inform best practice and policy is an important challenge. We need to build on the current evidence base in order to both improve practice and knowledge in this area. However, there is considerable debate as to how this is best approached. This paper takes a critical look at some of the key issues, challenges and opportunities in strengthening the mental health promotion evidence base. In particular, the paper calls for a widening of the current evidence base to include: • a more creative approach to adopting an evidence- based approach in mental health promotion; • a clearer focus on positive mental health outcomes; • more rigorous evaluation of programme implementation processes; and • the development of methods for uncovering unpublished evidence from diverse practical applications across cultures. Adopting an evidence-based approach in mental health promotion In health promotion, and indeed in the general area of programme evaluation, there is growing dissatisfaction with the uncritical acceptance of more traditional perspectives on establishing an 'evidence-based' approach (Chen,1995; Nutbeam,1999; Tones, 2000; McQueen, 2001). The unilateral imposition of a hierarchy of evidence approach is being questioned, particularly one which focuses almost exclusively on evaluation outcomes from randomised controlled trials (RCTs).This approach restricts the current body of 'evidence' to published research carried out mainly in high-income countries. More flexible and creative approaches to documenting an evidence-based approach are needed. As highlighted by Friedli (2001), "working more creatively with the evidence base and looking beyond the findings of randomised controlled trials, so that we can address mental health, as opposed to mental illness, is a difficult task" (p. 23). Jenkins et al. (2001) also caution that in the drive towards an 'evidence-based' approach in mental health promotion, there is the danger that promising developmental work may be abandoned because it does not produce evidence from appropriately designed RCTs. This highlights the need for a more flexible approach to documenting evidence, one which embraces the process of programme development and implementation as well as programme outcomes. This calls for an expansion of the current range of methodologies and analytical frameworks applied in the evaluation of mental health promotion programmes and a widening of the evidence base to be more inclusive of the realities of practical applications from a more global perspective. Acontinuum of approaches are required ranging from RCTs to more qualitative process- oriented methods. Standards of rigour Margaret M. Barry, Ph.D Department of Health Promotion National University of Ireland Galway, Ireland Email: margaret.barry@nuigalway.ie IUHPE - PROMOTION & EDUCATION VOL. IX/2. 2002