The MINDMAP project: mental well-being in urban environments

The following theoretical constructs were considered in the survey design: (a) the public health perspective, such as the WHO “Mental Health Action Plan” [11], the WHO “Global age-friendly cities” handbook [26], (b) in behavioural sciences, such as the salutogenesis concept [27], the model to promote social equity in health [28], and (c) the geriatric perspective for understanding frailty as a spectrum of conditions within the geriatric functional continuum [29, 30].

These recommendations and strategies resulted in a survey questionnaire divided into two parts. Part 1 addressed policies and strategies related to mental health promotion and mental disorder prevention on national and city levels according to the structure of the 12 work packages addressed in the interdisciplinary MINDMAP consortium (Fig. 2, questions part 1). Part 2 focussed on mental health programmes and providers. Extremely helpful for the actual survey design was the national questionnaire “Inventory taking of health promotion and prevention – offers and accessibility for older people in the community” edited by the Federal Centre for Health Education in Germany [31]. Fig. 2 also gives a rough overview of evaluating the broad variety of programmes and providers in each MINDMAP city (questions part 2).

The questionnaire was pretested by public health experts from one city in Germany (member of the German Healthy City Network) and in Denmark. After the pretesting, the experts clearly recommended performing the survey as by a semi-structured telephone interview instead by using a written questionnaire. Therefore, the questionnaire layout was structured into a) summarising tables for each question supporting the interviewer to navigate through the semi-structured interview, and b) a written outline about the survey topics to help the interviewee to prepare the information to be retrieved in the semi-structured telephone interview.

There was agreement to perform a comprehensive and complete (12 out of 12) survey in all European MINDMAP cities (in alphabetical order, geographic regions see Fig. 1):

All European MINDMAP consortium partners responsible for their 12 cities were invited to identify the most suitable expert in their city with an overview on the current mental health sector, and broad knowledge of healthcare planning policies, strategies and programmes in their city. We emphasised to consider the older population’s heterogenity as expressed as robust or non-robust (prefrail/frail) but predominantly not disabled. Therefore, depending on the administrative city structure, the MINDMAP partners searched for senior policy makers (persons working for the head of the city/regional health department or social affairs), representatives in a public health institute or a mental health care umbrella organisation/network. The MINDMAP partners provided the contact details of the experts (name, institution, e‑mail address, telephone extension) to the Albertinen-Haus (survey leader, work package 9).

Information about the MINDMAP consortium and the survey was distributed to each interview partner (interviewee), including an arrangement for a telephone appointment from the Albertinen-Haus. After interview acceptance, the interviewee received the written outline about the survey topics in order to support the interviewee in preparing the information according to the semi-structured telephone interview. All interviews (1–2 h/city) were in the English language, tape recorded and transcribed by the same PhD student (WJ) from the Albertinen-Haus from November 2016 to May 2017. In a few cases, two interviews took place in a single MINDMAP city if the first interviewee had referred.

To assure high quality evaluation, the analysis of the transcribed interviews was performed in a structured way. For this purpose, the summarising tables for each question which helped the interviewer to navigate through the semi-structured interview were used as evaluation matrix. Two independent researchers (WJ and LN, PhD students) worked on each transcript while extracting and transforming the information given according to this evaluation matrix. Also, national and local strategy papers and local programmes referred to by the interviewees were intensively studied for this evaluation process. Then, the results of both the independent evaluations were collected and cross-checked. In cases of unequal assessment, a third researcher (UD, PhD) was involved to reach concordance. Finally, all interview transformation results as summarised in tables were submitted to the corresponding MINDMAP city interviewee to assure that all information given in the interview was correctly understood and reported. All interviewees from the 12 European MINDMAP cities gave their approval before all survey results were compared. Then, mainly descriptive methods were used for the comparison (e.g. absolute numbers, percentages and means), and all data were recorded in a data base, analysed and visualised using MS Excel 2010.

Each city referred to at least one (1–7) policy and strategy on the city level but the experts also mentioned national policies and strategies. All addressed the range from mental health promotion, mental disorder prevention, treatment, recovery and care (Table 2, 3, 4 and 5). Out of 41 policies and strategies 32 identified at city level explicitly had older persons as a target group (older population) or senior citizens as a subgroup. The other nine were on general public health issues for all citizens. The older population was included in each policy/strategy on the city level in Hamburg (7 out of 7), Nord-Trøndelag (5 out of 5), Turin (3 out of 3), Helsinki (2 out of 2) and Eindhoven (1 out of 1) (Table 2, 3, 4 and 5). If the city level put minor emphasis on the older population (e. g. London and Kaunas) healthy ageing was covered on the national level instead. Mental health promotion and prevention was covered by 8 out of 41 policies/strategies (e. g. Hamburg “Pact for Prevention”), mental health diseases (22 out of 41) as by action plans on loneliness, depression or dementia (e. g. Prague “Professional Dementia Strategy”) (Table 2, 3, 4 and 5). More than half of the policies/strategies had a general targeting approach including aspects of health promotion, health prevention, treatment, recovery, rehabilitation and care but did not differentiate within the heterogeneous groups of senior citizens. However, six strategies explicitly focussed on mental health promotion and prevention (e. g. Amsterdam “Action Plan for the Prevention of Anxiety and Depression”) including early detection of risk groups, for example, older people living alone at home (Table 2, 3, 4 and 5).

According to the MINDMAP consortium structure WP 6–WP 10 (Fig. 2) mental health on the city level was categorised into behavioural (26/41), psychosocial (27/41), physical urban environmental (25/41), geriatric medical determinants (28/41), and linked to local and/or national policies and strategies (32/41). In Helsinki, explicitly all five determinants were part of each policy and strategy. For example, its “Action Plan of Older People’s Health and Well-being” addresses (1) care services, (2) living and housing conditions, (3) public transportation and physical well-being, (4) equal rights for people with memory problems, (5) information and knowledge on healthy ageing and (6) referring to additional policies on city and national level. In Amsterdam, Hamburg, Krakow, London, Nord-Trøndelag, Paris and Rotterdam, at least three of these determinants were addressed in the context of half or more of the policies (Table 2, 3, 4 and 5).

A total of 280 programmes to promote mental well-being, prevent mental disorders or provide mental care were reported of which 197 were exclusively for the older population. Others included older age in cross-generational programmes. There were 91/280 programmes (32.5%) explicitly dedicated to health promotion and prevention for older people, in particular (e. g. Turin: outdoor physical activity group exercise at the river Po waterfront; London: “Fit as a Fiddle” focussing either on cognitive training using tai-chi, physical activity or social participation). Programmes for selected groups, mainly diagnosis-based, were also offered (128/280, 45.7%), e. g. Nord-Trøndelag region: dementia teams performing case management including home visits and Eindhoven: specific architectural design of nursing homes for patients who suffer from dementia. Nearly no programme had predefined indicators for future outcome measurements.

Each of the 280 city programmes was allocated by the interviewees to one of the 15 domains, depending on its main intervention issue (Fig. 3). For example, the 12 cities provided 49 programmes (1–7 programmes/city) to support social participation (e. g. Paris: senior ambassadors to overcome social isolation by bringing two older persons together; senior centers in 8/12 cities where older persons can meet) (Fig. 3, domain 3).

All European MINDMAP cities have policies and strategies addressing the older population, ranging from 1–7 policies/strategies on city level. However, this analysis revealed that merely half of the policies and strategies integrated at least three out of the five determinants specified by the MINDMAP consortium work packages WP 6–WP 10 (Fig. 2; Table 2, 3, 4 and 5). Mental health as an essential component of healthy ageing does require both physical and mental capacities for functional ability [1, 11]. Yet, this has not been appropriately addressed in the policies/strategies identified. The major focus of most policies was on diseases without also emphasising and strengthening old persons’ mental resources [27]. Both these aspects should be considered in healthcare planning policies and strategies [1].

Both the public health [26, 28] and geriatric perspectives do consider the relationship between physical syndromes, including frailty and mental health [29, 30]. Multiple determinants must consider interacting health conditions (diseases, disorders and injuries), external environmental and internal personal factors (ICF model) [3]. Life-course determinants as emphasised in the Canadian Initiative on Frailty and Aging could also be considered in the analyses addressed in MINDMAP WP 6–WP 10. Promotion of healthy ageing and disease prevention, and thereby, the preservation of physiological reserves do have an impact on frailty which is closely related to adverse outcome, morbidity, disability, hospitalisation, nursing care and death [30]. Therefore, components of the frailty process might also be on the agenda of the MINDMAP analyses (harmonised data platform), and in strategies and intervention programmes on the MINDMAP city level. An example of policies and interventions on the MINDMAP city level to be mentioned is the European Innovation Partnership on Active and Healthy Ageing platform “Innovation for age-friendly buildings, cities and environment” the MINDMAP cities Krakow and Hamburg are engaged in (https://​ec.​europa.​eu/​research/​innovation-union/​pdf/​active-healthy-ageing/​d4_​action_​plan.​pdf; access: 05.06.2017). In Germany, a National Dementia Strategy is currently planned as part of the federal government’s demography strategy (http://​www.​allianz-fuer-demenz.​defileadmin/​de.​allianz-fuer-demenz/​content.​de/​downloads/​GemeinsamfuerMen​schenmitDemenz-Handlungsfelder-deutsch.​pdf; access: 05.06.2017).

The heterogeneous spectrum of the 280 city programmes was allocated to the 15 domains addressed in the interviews (Fig. 3). Most common were mental disorder treatment programmes or care provision to support social participation (49 programmes, domain 3) or to assist with activities of daily living (37 programmes, domain 9), followed by information campaigns (21 programmes, domain 2) and training for relatives, caregivers (20 programmes, domain 13) and healthcare professionals (17 programmes, domain 15).

Combinations of interacting medical, functional, psychosocial and environmental factors contribute to the development of disability and dependency. Therefore, it is unlikely that a focus on single factors might lead to meaningful results. Instead, successful preventative models for older persons used a multidimensional approach [32]. Promotion of mental well-being and prevention of mental disorders in older persons were less common in the MINDMAP cities. There was a predominance of single-dimensional programmes, for example, physical training courses (32 programmes, domain 11). However, not all cities seemed to actually connect such programmes by using a multidimensional approach to outdoor spaces and infrastructure plans (16 programmes, domain 4), to courses of cognitive training (14 programmes, domain 10), awareness programmes (11 programmes, domain 1) or courses on nutrition (8 programmes, domain 12).

There were education or training programmes for healthcare professionals (domain 15) in 10 of the 12 cities. Screening instruments might be applied in such programmes to concentrate on appropriate older population subgroups, and for raising awareness of multifactorial interrelationships. As an example, the guide “Safe and sound” was developed for independent community-dwelling older people. Meanwhile, it is used in the context of an education programme in Hamburg to support professionals, e.g. GP practices, physiotherapist practices, sports clubs, social services, and community care information centers (Pflegestützpunkt) to screen for the risk of falling and to provide advice dedicated to improve stability and maintenance of mobility [33].

The value of existing policies/strategies and programmes offered is likely to be underestimated because indicators to evaluate effects of programmes offered to defined target groups were almost unavailable although 10 of the 12 MINDMAP cities might have access to multidimensional data from longitudinal cohort studies (Fig. 1). Thus, supplementary indices could have been used from screening or assessment in order to get information on programme acceptance and effects. For example, the “Municipal Masterplan 2015–2030 – Vision: Quality of life and growth” in the MINDMAP partner region Nord-Trøndelag does include predefined indicators for the strategies’ performance review:

Data from the HUNT cohort (HUNT4) are used for this purpose (http://​www.​levanger.​kommune.​no/​Global/​dokumenter/​kommuneplan_​samfunn_​english.​pdf, access: 05.06.2017). Another example is the application of the LUCAS functional ability index [20] as screening and as indicator to measure effects of a programme of transsectoral healthcare coordination for older independent community-dwelling people (programme in domain 6) (https://​www.​albertinen.​de/​krankenhaeuser/​geriatrischeklin​ik/​leistungsspektru​m/​netzwerkgesundak​tiv; access: 05.06.2017).

The spectrum of policies, strategies and programmes collated in this European MINDMAP city survey will be a rich source for a better understanding of the diversity within and between the longitudinal cohorts of the MINDMAP project (harmonised metadata platform). Further research is planned in the MINDMAP project (2016–2020) to develop recommendations for policies and plans by using evidence-based practice feedback from the European MINDMAP cities with longitudinal ageing cohorts.

The information retrieved from the survey may be limited as only one (maximum 2) local expert, even a person with best available background knowledge in the field of public health was interviewed. Consequently, only those policies, strategies and programmes were taken into account which were reported by the local MINDMAP interviewees. However, all MINDMAP consortium partners carefully searched in their cities for experts and explained the survey details in the mother tongue. The consortium had decided that all interviews should be performed in English. However, there might still be an information bias. Therefore, a written outline of the interview topics was sent in advance to prepare the information, and feedback from the interviewee based on a written summarising interview synopsis was obtained. It should also be noticed that policies, strategies and programmes on national and city levels cannot be compared in total, and recommendations cannot be simply transferred from one to another city/metropole region, also because of different healthcare systems in Europe.

A strength of this survey is the complete data collection from each of the 12 European MINDMAP cities. Furthermore, the development, performance and analyses of this survey were carried out in a way that was as structured as possible (review of existing databases/reports, development of interview questions based on different adequate models, structured identification and preparation of the interviewee by provision of written outline in advance, semi-structured interview, transcription of each interview, structured analysis using predefined summarizing tables, and feedback based on a written summarising interview synopsis).

Further research is clearly needed bringing together national and city level policies and the translation and implementation into linking programmes relevant to practice. Also, appropriate indicators for outcome measurement should be developed and applied.