by SB Savannah · Cited by 2 — FEDERAL RESERVE BANK OF SAN FRANCISCO. 21. Catalyzing Community Action for. Mental Health and Wellbeing. Sheila B. Savannah and Larissa J. Estes.

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21 Catalyzing Community Action for Mental Health and Wellbeing Sheila B. Savannah and Larissa J. Estes Prevention Institute Our nation has elevating rates of despair, forcing us to take a broader approach to address the foundational issues driving such conditions and challenges as depression, anxiety, opioid misuse, and suicide. Community environmentsŠ the social, physical, and economic conditions in communitiesŠhave tremen-dous in˚uence on the stressors that people experience in their daily lives and on the devel-opment of mental and emotional disorders. A zip code has the ability to predict whether someone is likely to suffer from a preventable illness and live a shorter life. Community environments drive higher rates of illness, injury, and mental health challenges for popula -tions that face bias and discrimination, including people of color, those living with low incomes, immigrants, and the LGBTQ community. By improving community conditions, and pairing this with high-quality mental health services, our society can reduce the likeli -hood, frequency, and intensity of mental health challengesŠand at the same time improve physical health outcomes.The World Health Organization (WHO) de˜nes mental health as fia state of wellbeing in which every individual realizes their own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to their community.fl 1 We use the WHO de˜nition throughout this paper, while also recognizing that in practice the term fimental healthfl re˚ects different understandings. Clear de˜nitions of mental health have not been standardized, and varied understandings of mental health carry divergent assumptions and implications for our collective capacity to proactively and reactively respond to the needs of the population. In general, fihealthfl has a positive conno -tation; however, the term fimental healthfl is often con˚ated with mental illness, reinforcing a focus on treatment rather than an emphasis on wellbeing as a community-wide goal.Perceiving mental health to be the sole province and responsibility of the individual diminishes our recognition of the ways community conditions create and exacerbate many mental health challenges. This perspective treats trauma, stigma, shame, and discrimination as issues an individual must solveŠnot as factors that are created, shaped, or exacerbated by the environment. Essentially, then, the predominant understanding of fimental health,fl and the resulting clinical approach, fails to underscore opportunities for primary prevention and interrupts our ability to achieve population-wide mental health and wellbeing. Mental health and wellbeing is at the heart of thriving individuals, families, and commu -1 World Health Organization (WHO), fiMental health: a state of well-beingfl (Geneva: WHO, 2014), http://˜les/mental_heal th/en/. Accessed May 30, 2018.

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22nities. The WHO de˜nition of mental health is the state that many seek to attain, and the community development sector has an important role to play in achieving this possibility across entire neighborhoods. Community development can tap into resident voices and community assets, extending its reach beyond improving the physical and economic poten -tial of communities and supporting durable impacts that foster hopefulness, dignity, respect, and safetyŠhelping an entire population improve. Collective community action as part of community development is a strategy that meaningfully engages residents and community organizations to transform environmental conditions into those that promote their health, quality of life, and ability to thrive. Done intentionally, community action is work that nurtures mental wellbeing and the ability to in˚uence the events that shape life™s circumstances; it re-weaves the social connectedness among efforts in community development and embeds social justice in assuring economic vibrancy. In neighborhoods that have suffered from disinvestment and prolonged despair, this type of engagement does not degrade by asking, fiWhat is wrong here?fl Rather, commu -nity action and development moves beyond the trauma-informed question, fiWhat happened here?fl to ask the more important question, fiWhat is the untapped potential here that can be activated?flIf intentionally leveraged, community development approaches, coupled with resident community action, can reach across multiple sectors to measurably in˚uence mental well -being at a community level. The ˜eld is well positioned to leverage its expertise in commu -nity organizing, engagement, and collaboration across sectors to guide partnerships that improve the community determinants of health associated with mental wellbeing. This article describes community-level factors that in˚uence mental health and wellbeing; it also outlines examples of how the community development sector is engaging in strategies that impact mental health and wellbeing. In addition, it highlights speci˜c opportunities for community development to advance upstream solutions that can reduce the incidence and intensity of mental health challenges, create health and equity, and foster resilience (the ability to adapt, recover, and thrive in spite of adverse events or experiences). Mental Wellbeing and Community Determinants of Health There are many ways to describe communities. A community is a group of people with something in common, be it geography, history, experience, purpose, or passion. Regardless of whether community is de˜ned by geographic boundaries or based on population charac -teristics, there are factors that directly impact the health and wellbeing of the entire commu-nity and in˚uence the formation of norms, which also strongly impact health outcomes. 2 The public health approachŠand, in particular, Prevention Institute™s approach for exploring challenges and solutions to improving population wellbeingŠdescribes community envi -2 Prevention Institute, fiCountering the Production of Health Inequities: A Framework of Emerging Systems to Achieve an Equitable Culture of Health.fl (Oakland, CA: Prevention Institute, 2016).

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23ronments as the social, physical, and economic conditions in communities that in˚uence health, safety, wellbeing, and equity outcomes. 3The Tool for Health and Resilience in Vulnerable Communities, or THRIVE, framework offers a systematic method in accessible language for working alongside community resi -dents and organizations to explore the factors that are impacting their health and wellbeing (Figure 1). Within a planning process, THRIVE can be instrumental in assisting groups in developing strategies to reduce mental health stressors, improve options for coping, and enhance resilience factors in a community. 4 For many people living with mental illness or experiencing mental health challenges, the community determinants that surround them can have a tremendous impact on recovery and resilience, or further deterioration of mental wellbeing.5Figure 1: Tool for Health and Resilience in Vulnerable Communities (THRIVE) Framework Assessing and addressing community determinants of health can help reduce mental health stressors and enhance resilience factors across a community. Looking at the commu -nity environment through a mental health and wellbeing lens can help to identify condi-tions that impact mental health outcomes. For example, the filook, feel, and safetyfl of a place is critical. Surroundings that are appealing, well maintained, and perceived to be safe and inviting for all community residents foster mental wellbeing, whereas disinvestment 3 L. Cohen et al., fiA Time of Opportunity: Local Solutions to Reduce Inequities in Health and Safetyfl (Oakland, CA: Prevention Institute, 2009). 4 Prevention Institute, fiBack to Our Roots: Catalyzing Community Action for Mental Health and Wellbeingfl (Oakland, CA: Prevention Institute, 2017). 5 Prevention Institute, fiBack to Our Roots.fl People Place Equitable Opportunity Community Structual DriversPeople Social networks & trust Participation & Willingness to act for the common good Norms & culture Place Look, feel & safety Getting around/Transportation HousingWhat™s sold & how it™s promoted Air, water, soil Arts & cultural expression Equitable Opportunity Living wages & local wealth Education

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24by public and private investors in schools and community infrastructureŠwhether in rural, urban, or suburban areasŠcontributes to feelings of hopelessness and impacts feelings of self-worth. Another community determinant is figetting around,fl or the availability of safe, reliable, accessible, and affordable means of transportation. Engaging in walking and biking can help improve mood and reduce anxiety and depression; at the same time, the realities and perceptions of geographic isolation or lack of safety do the opposite. Addressing the community determinants of health is key to helping communities navigate adversity, restore assets, and assure they have the opportunity to ˚ourish. Structural drivers, such as bias, discrimination, and concentrated poverty, shape these determinants at the community level, pointing to interventions that address and redress such conditions. 6,7 Mental health and well -being is created and reinforced by the same community environments that the community development sector seeks to transform.Communities of color and communities with concentrated poverty often face the compounding challenges of the physical/built environment (e.g., poor housing stock, deterioration of infrastructure, toxic land use, inadequate availability of affordable healthy food and transportation options) and limited equitable opportunity (e.g., quality education and employment opportunities that provide a living wage). These challenges contribute to geographic concentration of higher levels of chronic illness, exposure to violence, substance misuse, mental health challenges, trauma, and multigenerational poverty. 8 Ensuring inten-tional engagement that advances a community™s own priorities into the neighborhood devel -opment process can support mental wellbeing, foster stability, preserve the cultural heritage of communities, and mitigate large-scale displacement of residents. Pillars of Wellbeing Prevention Institute™s work with the Making Connections for Mental Health and Well -being initiative9 has led to the identi˜cation of a set of value-based characteristics that must be taken into consideration, alongside the community determinants, to build resilience to withstand stressors that can emerge through the social, political, and economic contexts of society. 10 These essential elements have been clustered into the following: 6 Prevention Institute, fiCountering the Production of Health Inequities.fl 7 WHO and Calouste Gulbenkian Foundation, fiSocial Determinants of Mental Healthfl (Geneva: WHO, 2014). 8 Centers for Disease Control and Prevention (CDC), fiAdverse Childhood Experiences (ACEs)fl (Atlanta, GA: CDC, 2016), Accessed April 26, 2018. 9 The Making Connections for Mental Health and Wellbeing among Men and Boys initiative, funded by the Movember Foundation, uses a gendered approach to mental health, allowing for a focus on the unique norms and experiences of men and boys in coping, help-seeking behaviors, social pressures, and social connections. We recognize that women™s experiences are distinct from men™s and that mental illness can affect men and women differently. Although this initiative focuses on men and boys, the pillars of wellbeing have been resonant with practitioners who focus on mental wellbeing among women and populations across the gender continuum.10 Prevention Institute, fiBack to Our Roots.fl

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25The Emerging Pillars of Wellbeing BELONGING/CONNECTEDNESSŠFeeling part of a community; a sense of acceptance; a belief that you are accepted as you are; having a place or group that is restorative or acts as a refugeCONTROL OF DESTINY ŠA sense of purpose; the ability to in˚uence the events that shape life™s circumstances; the ability to make and take action; agencyDIGNITYŠA sense of one™s own value; the quality of being worthy of honor and respect; living in a climate of mutual respect and regard for all HOPE/ASPIRATION ŠA reassuring belief that something better is possible and achiev -able; optimism that allows forward movementSAFETYŠThe experience of security: interpersonally, emotionally, and with one™s surroundings; possession of a sense of stabilityTRUSTŠA belief in the reliability, truth, ability, or strength of self and others; the ability to count on the circumstances surrounding youUnderstanding and committing to these pillars enables the community development sector to strengthen its efforts to be more speci˜c and precise and to have a long term, multi-generational impact in protecting health and wellbeing. When intentionally embedded in community development strategies, the pillars can strengthen the community determinants to protect health, particularly for those living with mental health challenges. For example, the community development sector™s investment in affordable housing is important; however, the pillars as core values evoke that housing must also be safe to avert distress, and that the built environment in the development and its surrounding neighbor-hood must support dignity, belonging/connection, and trust to reinforce thriving. Healing values like the pillars can assist the community development sector with achieving its mandate to improve living conditions in underserved communities by intentionally shaping community-driven strategies to shift community culture and facilitate community transfor-mation. Several examples across the country re˚ect the embedding of these values to the bene˜t of residents and project outcomes.BRIDGE Housing is a nonpro˜t committed to ensuring that public housing residents live in high-quality buildings that meet the same standards for design and safety that resi -dents in market-rate housing enjoy. BRIDGE™s Trauma-Informed Community Building (TICB) model emerged from the need to acknowledge and address the trauma that public housing residents had experienced due to concentrated poverty, violence, low levels of education, displacement, and structural racism and isolation. More broadly, the TICB model uses pillars like belonging/connectedness, dignity, trust, and safety to improve upon tradi -tional resident engagement by considering emotional needs and recognizing the impact of pervasive trauma. In working with residents of the Potrero Terrace and Annex public housing complex, BRIDGE began to engage them in a way that felt comfortable to them. By holding

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26activities in neutral spaces, and ensuring that staff was consistent, BRIDGE created localized fiZones of Safety,fl which helped to promote cohesion and connectedness among residents. As a result of participating in TICB activities, BRIDGE residents have improved health and safety outcomes, including reduced depression, improved self-esteem, greater feelings of happiness and relaxation, increased physical activity, a healthier diet, and maintenance of a healthy weight. Residents also reported that they felt a sense of safety while participating in the activities, even if the immediate surroundings were unsafe. 11People United for Sustainable Housing (PUSH Buffalo) in Buffalo, NY, is a local, membership-based community organization ˜ghting to make healthy affordable housing a reality on Buffalo™s West Side. PUSH was founded to create strong neighborhoods with quality affordable housing; decrease the rate of housing abandonment by reclaiming empty houses from neglectful public and private owners and redeveloping them for occupancy by low-income residents; and develop neighborhood leaders capable of gaining community control over the development process and planning for the future of the neighborhood.12 PUSH explores and experiments with different models of governance and participation to ful˜ll the organization™s vision for ficommunity control of resources,fl especially as they engage tenants and develop tenant leaders who fiknow what they need where they live.fl This level of engagement and shared leadership reinforces social cohesion, trust, local wealth, and willingness to advance work for the common good.Common Wealth Development in Dane County, WI, was founded to protect the Williamson Street neighborhood from disinvestment, concentrated poverty, and violence.13 Common Wealth developed a three-pronged approach to create jobs in the neighborhood: business development, community development, and housing improve-ments. Common Wealth has renovated and rehabbed 146 properties for rent and supported families with one-on-one counseling for ˜rst-time home buyers. Common Wealth recog -nizes the investment in equitable opportunity through economic self-suf˜ciency and its capacity to simultaneously build self-esteem and self-con˜dence.14 Sparked by local parents seeking support in ˜nding employment for their children, Common Wealth established the Youth-Business Mentoring program as its core community development initiative. The program serves over 300 young people annually, training them in job searching skills and ˜nancial management. Young people are placed with area employers, who serve as mentors and participate in employment and ˜nancial management workshops, realizing multigen -erational bene˜t. Although the development of ˜nancial knowledge (often referred to as ˜nancial literacy) is necessary, there is growing recognition that the desired outcome is more 11 E. Weinstein, J. Wolin, and S. Rose. fiTrauma Informed Community Building: A Model for Strengthening Community in Trauma Affected Neighborhoodsfl (San Francisco, CA: BRIDGE Housing, 2014). 12 PUSH Buffalo, (Buffalo, NY: PUSH Buffalo, 2018), Accessed May 30, 2018. 13 Common Wealth Development, (Madison, WI: Common Wealth Development, 2018), https://www.cwd. org/. Accessed May 30, 2018. 14 Clubhouse International, fiWhat Clubhouses Dofl (NY: Clubhouse International, 2016), https://clubhouse- Accessed April 26, 2018.

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28Kokua Kalihi Valley (KKV), a Federally Quali˜ed Health Center that serves the diverse residents of Kalihi Valley in Honolulu, HI, is addressing the mental health and wellbeing of men and boys through the creation of a youth leadership development program nested within the Kalihi Valley Instructional Bike Exchange, better known as KVIBE. KVIBE is a natural gathering place where multiple generations of boys and young men come together to socialize and repair bikes. KVIBE was established as part of KKV™s commitment to providing community-based health initiatives that honor the development of personal relationships and respect for cultural values to support physical and emotional wellbeing.15 Through its commitment to leadership and connection to land, the young people at KVIBE have cata -lyzed improvements to the neighborhood™s physical environment, having successfully advo -cated for the installation of a bike lane on a major road that was formerly unsafe to ride. By nurturing young leadership, entrepreneurial spirit, civic engagement, and healing connec -tions within the community, KKV improves mental wellbeing in Kalihi, while also inspiring and empowering the next generation of leaders and advocates embedded in the community. Hilltop Urban Gardens (HUG) in Tacoma, WA, is using food sovereigntyŠthe produc -tion of healthy and culturally appropriate food through ecologically sound and sustain-able methodsŠto strengthen authentic social connections; improve access and utilization of quality resources, such as food; and improve civic engagement among men, boys, and LGBTQ people of color. 16 By understanding the root causes of concentrations of poverty and structural oppression, HUG focuses on interrupting those root causes by concentrating on food independence, anti-displacement strategies, community building, leadership develop-ment, and interdependence through social connectivity. 17Engagement to assess local needs and to develop environments that support wellbeingŠ through direct action and advocacy on matters such as social justice, community safety, housing restoration, fair wages and workplaces, food sovereignty, improved schools, and access to healthy foodsŠcan contribute to strengthening a sense of belonging and shared community agency. The community development sector can ˜nd ways to invest in grassroots leadership, avoid distrust and competition, and recognize that the most impacted communi-ties are most capable of leading real solutions to restore mental health and wellbeing. In addi -tion, the sector can facilitate the design of supportive community environments, including recognizing the impact of and mitigating resident displacement, reducing isolation, recon -necting to land, and valuing culture and traditional ecological knowledge.15 Kalihi Valley Instructional Bike Exchange (KVIBE), (Honolulu, HI: KVIBE, 2017), http://k-vibe.blogspot. com/. Accessed May 30, 2018. 16 R. Cantu et al., fiCultivating Our Roots: Leveraging a Gendered and Cultured Lens to Advance Community Strategies to Improve Population Wide Mental Health and Wellbeingfl (Oakland, CA: Public Health Institute, 2018), Accessed May 30, 2018. 17 Hilltop Urban Gardens (HUG), fiAbout HUGfl (Tacoma, WA: HUG, 2018), http://www.hilltopurbangardens. com/about-hug/. Accessed May 30, 2018.

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29These examples not only highlight existing efforts to improve mental health and well -being in partnership with community development, but they also reveal opportunities to adapt these strategies for other communities that are experiencing similar conditions. Many health-oriented collaboratives want to work on these same strategies to improve the commu -nity determinants of health but are uncertain how or where to get started on engaging in strategies. Community development organizations are natural partners to move this work forward and can help the health sector as it seeks to foster vibrant communities.Time of Opportunity with Natural Partners The goal of improving mental health and wellbeing at a community level is aligned with the community development sector™s origins and mission, and it builds the social capital necessary to sustain its investments. Generally speaking, the environments that community development creates and reinforces are the same neighborhood environments that support mental health and wellbeing. A supportive, thriving communityŠone that facilitates equi -table opportunities for achieving health, wellbeing, and social mobilityŠis a vision that no sector or neighborhood can achieve alone. Intentionally engaging residents in processes that re˚ect values (pillars of wellbeing) and approaches that share leadership and extending multi -sector partnerships with others could further improve outcomes in community endeavors.Finding partners with synergies in values is essential to this work. Early theorists and prac-titioners in the community mental health movement fed the momentum that guided both public health and community development as distinct ˜elds of practice. Thought leaders, such as Drs. George Albee, Stephen Goldston, and Marshall Swift, emphasized that the interactions within a community environment could have a positive or negative effect on health and wellbeing, recognizing the impact of political and economic stressors in society on mental health and wellbeing.18 Over the years, the ˜elds of community development, public health, and community mental health have moved in parallel patterns, sometimes overlapping but most often without intentional shared outcomes. It is time to create new alignments across these sectors. As we re˚ect on current conditions within communities across the country, as well as the emergence of exemplary efforts, we see opportunities for community development to intentionally partner and engage with public health and commu -nity mental health. This mutually bene˜cial partnership will foster economic development, provide safe and affordable housing, and transform community environments to promote social connectivity and resilience through a set of equity-driven principlesŠpurpose, people, practice, and platform.18 S. Goldston, Concepts of Primary Prevention: A Framework for Program Development (Sacramento, CA: Of˜ce of Prevention, California Department of Mental Health, 1987).

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30Purpose Ł Apply a health, equity, and wellbeing lens to support the ful˜llment of mission Ł Address bias, discrimination, and institutional and structural racism and classism Ł Acknowledge the systematic production of inequities by accounting for impact of community trauma and mental health and wellbeingŁ Foster connections and facilitate collaboration between people, systems, issues, and opportunitiesPeople Ł Create a shared vision that galvanizes partners and holds others accountable to mental health and wellbeingŁ Lift and activate community voice, participation, and leadershipŁ Engage in inclusive multisector partnerships Practice Ł Develop tools and approaches that build and sustain health, equity, and wellbeing Ł Train and build capacity across systems and sectors to engage in community preven -tion strategiesPlatform Ł Make the case for community strategies through communications and mediaŁ Leverage ˜nancing and funding across sectors to support equityŁ Identify existing and establish new metrics and measurement to support impact of strategiesCommunity development™s efforts and alignment with other sectors working to impact community environments reinforce the need for community prevention strategies. Engaging in comprehensive, multisector community prevention strategies elevates the community development sector™s capacity to ful˜ll its mission by promoting thriving community envi-ronments through improved individual, family, and community mental health and wellbeing, supporting its mission to improve the living conditions of the most vulnerable communities. Now is the time for the community development sector to actively seek these synergies to advance upstream prevention and community-driven solutions to ful˜ll the WHO de˜ -nition of mental healthŠfostering resilience and supporting those who are tremendously impacted by inequities, those living with mental illness and mental health challenges, and the broader community.

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31Sheila B. Savannah, Director, provides leadership on health equity, mental health, and violence preven -tion focus areas. In her leadership role on mental health, she focuses on its intersection with community resilience and on the social determinants of health, with projects aimed at improving outcomes for boys and men of color, veterans, and service members and addressing trauma through a public health approach. Larissa J. Estes is Manager of Community Partnerships at UCSF Benioff Children™s Hospital Oakland, where she cultivates and maintains community partnerships associated with several health equity programs including injury prevention, transportation, trauma-informed systems, food security, and early literacy. Prior to this, Larissa served as Prevention Institute™s Health System Transformation program manager and served as a key author of several publications on accountable communities for health, medical high utilization, and mental health and wellbeing. Acknowledgements The authors received funding support by the Blue Shield of California Foundation, Well Being Trust, and the Movember Foundation. Larissa Estes co-authored this article during her tenure at the Prevention Institute; she has since become the Manager of Community Partnerships at UCSF Benioff Children™s Hospital Oakland. Special thanks to Rob Baird, Alexis Captanian, Ruben Cantu, Justice Castañeda, Rachel Davis, Sonja Lockhart, and Lisa Fujie Parks for their support and guidance in the development of this contribution.

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