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Abstract

Mental health (MH) promotion campaigns play a vital role in improving awareness, access, and help-seeking behaviors. However, the concept of MH is not universally defined, and its meaning varies across cultural, historical, and ecological contexts. This paper argues against the universal applicability of a single model of MH promotion. Drawing on sociocultural theory, public health frameworks, and cross-cultural clinical experience, we highlight how cultural beliefs, idioms of distress, socio-ecological determinants, and locally grounded value systems shape perceptions of well-being and illness. Efforts to impose standardized, Western-centric campaigns risk undermining community trust and disregarding Indigenous frameworks of meaning and coping. Instead, MH promotion should be culturally sensitive, responsive to community needs, and developed through participatory, context-specific approaches. In a globalized world, such tailored strategies are essential for promoting sustainable and meaningful MH outcomes.

Keywords

mental health promotion cultural psychiatry idioms of distress global mental health public health campaigns health promotion strategies global health/globalization health promotion mental health

Introduction

The World Health Organization (WHO) defines mental health (MH) as ‘a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community (1)’. MH-related morbidities are a leading cause of disability and reduced quality of life globally.

Based on the Global Burden of Disease 2019 data, Wu and colleagues (2) predict a substantial increase in such problems over the next 30 years. Thus, it is necessary to focus on MH through the public health (PH) lens.

Mental health promotion campaigns (MHPCs) play a major role in improving the access to, and utilization of, MH services, and in destigmatizing MH-related help-seeking behaviors across societies (3). Aligned with the WHO’s view of MH as a state of well-being that requires us to define ‘health’ in positive terms and implicitly assume a benchmark for what is to be considered as normal, such campaigns presuppose a guiding consensus on the concept of ‘normality’ that is to be achieved as their overarching goal. However, defining the ‘normal’ in health is inherently complex (4), and the varied cultural, social, moral, ethical, and traditional factors at play make such attempts infinitely more intricate in the arena of MH. It becomes clear, therefore, that a MHPC, with an implied requirement to define the ‘normal’, will have to acknowledge these variations and wade through the resultant confusion.

This paper argues that the same MHPCs should not be expected to work in all settings, and highlights the need to adapt them to suit specific needs (5). In doing so, we conceptualize ‘settings’ (‘the time, place, and circumstances in which something occurs or develops’) (6) as the broader cultural-ecological context within which an individual’s MH is determined. The non-homogenous nature of MH and well-being concepts across societies, where cultures define expectations, requires a tailored approach to identifying factors that determine the appropriateness of a MHPC in a given population. The paper also provides a brief exposition of some of the features of a good campaign. Both authors have worked as psychiatrists across several states in India, and across different health services in Australia. This experience with fundamentally different cultures, administrative and value systems, with varying norms, practices, and mythologies to support their institutions, has sharpened our awareness of the need for different MHPCs rather than using a singular approach (7).

Method

This paper employed a conceptual review methodology drawing upon diverse scholarly sources across psychiatry, PH, sociology, anthropology, and health promotion. A purposive literature search was conducted in databases including PubMed, Scopus, PsycINFO, and Google Scholar using the following keywords and Boolean combinations: ‘mental health promotion’ AND ‘culture’ OR ‘cross-cultural psychiatry’ OR ‘health promotion campaign’ AND ‘setting’ OR ‘context’ OR ‘localization’ OR ‘idioms of distress’.

Relevant books, policy papers (e.g., WHO, Ottawa Charter), and classic texts were included through snowball sampling. Inclusion criteria were theoretical, empirical, or critical works discussing the cultural construction of MH or design of health promotion interventions. Thematic analysis was used to extract and organize content into conceptual categories aligned with four key arguments: diversity in MH conceptualization, cultural expression of distress, socio-ecological determinants, and technical considerations in promotion.

Results

The search yielded over 70 relevant sources, of which approximately 30 were used in the final synthesis. These included seminal works (e.g., Foucault (10), Szasz (9), Kakar (20)), contemporary PH models (McLeroy et al. (23), Compton and Shim (24)), and empirical studies of culturally specific syndromes (e.g., Dhat (21), spirit possession (19)). The exploration revealed four dominant themes:

MH is not a monolithic or universally defined concept;

cultures delineate their own existential aspirations and idioms of distress;

socio-ecological determinants shape MH outcomes;

effective MHPCs require rigorous, context-sensitive needs assessments (NAs) and participatory approaches.

The above dominant themes formed the basis of the arguments presented below.

Discussion

The first argument – mental health is not a monolithic concept

The essential role of the society in constructing the normal, ostracizing deviations, and creating illness labels have been highlighted by many authors over the past century. With gender as a central organizing tenet for the society, Brown and Charles (8) have traced the development of presumptions and prejudices in a male dominated world and the consequent shaping of the social discourses to disallow for women’s discontent and sanction them as mental patients. Thomas Szasz (9) criticized psychiatry for creating unnecessary labels for psychological distress and questioned the legitimacy of the specialty in toto. Foucault (10) explored the temporal evolution of the concept of madness through the Western civilization, and contrasted the exalted position of socially deviant madmen of the Middle Ages with the deplorable situation of those in the European mental asylums of the 20th century. These discourses highlight two facets of MH – the role of the society in creating, labeling, accommodating, and managing mental distresses, and thus determining ‘well-being’; and the natural evolution of these constructs with time and changes in the overall cultural values. On these lines, Phillips (11) invokes the concept of ‘social constructionism’ and elaborates on the need to adopt a critical approach to encourage multiple perspectives.

The conceptualization of MH has historically relied on the absence of mental illnesses, as defined currently by the two prevalent diagnostic systems – the International Classification of Diseases (12) and the Diagnostic and Statistical Manual (DSM) (13) – which assume their generalizability across human societies. This, however, is not true. For example, Kakar and Kakar (14) described how the Indian psyche differs substantially from the Freudian notion of human dispositions, and base this in the historical and sociological realities of Indian cultural development. Such variations in the psyche are personal, externally unobservable, and are interactive with their immediate non-physical ‘settings’. Consequently, the trajectory of the psyche’s evolution deviates unpredictably within a malleable scaffolding of the cultural milieu, thus making it almost impossible to define universally applicable psychological typologies (7). Ignoring such realities, the conceptual hegemonization by the Western worldview reinforces a uniform, individualistic perspective on well-being, leading to complex interactions between values, generating conflicts from the preferential pursuit of the individual’s interests (15), undermining deep-rooted collectivistic ethos in many societies, engendering stress, and limiting coping resources (16).

To illustrate this further, Chakraborty (17) wrote in her pioneering article that visual hallucinations were more commonly reported among Indian women and could be rooted in Eastern philosophy and collectivistic ritualized practices – perhaps more as a form of communication than as a purely pathological phenomenon. While the shift from focusing solely on objective symptoms to acknowledging subjective experiences is a welcome one, we must go a step further. The explanatory models that patients use to make sense of these subjective experiences can be highly diverse and culturally embedded. We need to remain open to these variations – without external bias or professional arrogance. This openness should also be reflected in our MH promotion strategies and PH messaging.

Similarly, Indigenous Australian women’s experiences highlight the culturally situated nature of MH. Colonization disrupted gender roles, eroded status, and imposed generations of trauma, including forced child removals, leading to disproportionate distress, illness, and suicide. Yet, Indigenous women also preserved strong leadership and community roles. In recent decades, their healing practices have been revitalized through self-determination movements, emphasizing social and emotional well-being as inseparable from cultural identity (18).

Therefore, MH and well-being depend on how a culture looks at life, its determinants, and the ecology that supports such societies within its own resources, limitations, and frameworks. The idiosyncratic nature of these precludes a single definition of the normal, a single way of managing distress, and therefore a unifocal pursuit of MH promotion.

The second argument – cultures delineate their own existential aspirations and idioms of distress

The mainstreaming of Western MH conceptualizations has also created a space for ‘othering’ of people belonging to non-Western societies. This is reflected in the DSM-5’s (13) definition of culture-bound syndromes (CBSs) as mental illnesses that are specific to particular cultures. In anthropological discourses, many of these CBSs have been discussed as metaphors, which have traditionally been used by numerous societies the world over to correct power imbalances and create space for the relief from oppressions (19). For example, the occurrence of spirit possession has been an ‘idiom of distress’ in collectivistic and traditional societies for millennia, primarily being used by their members to negotiate life’s exigencies within a framework of mutually agreed upon religious and cultural symbols, expressions, and mythological ecosystems (19,20). Reformulation of such spirit possession as pathological entities robs these societies of a valued metaphor, medicalizes a cultural mechanism, destroys the credibility of the shamans and the religious persons, and stigmatizes traditional expressions of distress (20).

In another example, the current MH system conceptualizes Dhat syndrome as a pathological entity and a CBS (21). The consequent dismissive approach to psychoeducation – asserting that ‘loss of semen’ is not a valid cause for concern – raises a critical question: is this actually helping to reduce the patient’s anxiety, or are we, in fact, undermining a culturally meaningful way of expressing distress, thereby increasing internalization and collective psychological discomfort further? If we put effort to normalize statements like ‘I am depressed’ in order to reduce societal stigma, then we must also acknowledge that in a different cultural context, finding solace in the label of Dhat syndrome or using somatic symptoms as a symbolic language of suffering may represent an alternative mode of expression. This, too, deserves respect and validation. As Hussein Rassool (22) points out, a believing Muslim would commit blasphemy if they went against their own Prophet (PBUH – peace be upon him) and disbelieved in the existence of the Jinns.

Therefore, if the culture decides what is acceptable and determines remedies for the unacceptable, then this paper argues that MHPCs should be perceptive of such nuances and encourage diverse perspectives. Incorporation of local beliefs, mythologies, language and values, respect for folk metaphors and recovery frameworks, and openness to organic solutions are essential for achieving sustainable MH promotion. A one-size-fits-all campaign will run the risk of decimating a society’s confidence in itself and deny them legitimate ways of relieving their existential stresses.

The third argument – socio-ecological determinants shape mental health outcomes

McLeroy et al. (23) introduced the ecological model of health promotion, conceptualized the various determinants at individual (e.g., knowledge and behavior), interpersonal (e.g., family, work colleagues), institutional, community, and policy levels that influence health behaviors, and identified a bidirectional interaction between these overlapping spheres. Compton and Shim (24) highlighted the importance of broader social and environmental factors in deciding a person’s MH by determining the availability of ‘money, power, and resources’ across the various sections of the society. From food security, economic stability, housing, built-environment, education, and social and employment status, to quality of interactions with nature (25), climate change, legislative and technological environments, war and strife, the authors showed how they all affect MH through their influences on stress, health choices, and differential elaboration of the individual’s risk status (24). Acknowledging such socio-ecological influences on the health outcomes of a population allows one to ‘understand and explore community engagement in community health initiatives’ and ‘develop multi-level solutions which cross multiply influential environments (26)’. Consequent interventions, then, consider the social, political, cultural, and resource-related realities of the population, including each individual stratum.

A very apt and optimistic contemporary example of culturally grounded health promotion is Bhutan’s COVID-19 vaccination campaign, where, to overcome vaccine hesitancy, His Majesty the King led by example, serving as a role model for the nation. The initiative was also embraced by monks and monasteries, integrating the vaccination effort with Bhutan’s core belief systems. In a setting where healthcare infrastructure is relatively limited, this culturally resonant approach led to one of the highest vaccination uptake rates in the world (27).

In line with modern approaches to PH policy, it is clear that the broad socio-geographical distribution of MH determinants shapes how MH problems are spread across populations (28). We reiterate that a flexible MHPC must recognize this reality. Even if a plan focuses on key determinants – such as improving housing or employment conditions – it must be adapted to the specific needs of each community within a complex web of interacting factors, rather than applied as a one-size-fits-all solution that ignores local realities (29,30).

The fourth argument – context-sensitive needs assessments and participatory approaches

The final argument against the universal applicability of a MHPC comes from the Ottawa Charter, which defines health promotion as ‘the process of enabling people to increase control over, and to improve their health (31)’. Inherent in this definition is an aspiration for people to become aware of their circumstance and manage their destinies, with an assumption of a commitment to change. Amongst various others, Bandura’s social cognitive theory (32) provides a fine conceptual framework for understanding how and why people change, highlighting nonlinear interactions among personal, socio-cultural, and environmental factors. Therefore, it is critical to understand these factors at play, as every health promotion program builds on several reiterations of such understandings (e.g., the PRECEDE-PROCEED planning model) (33).

Although a detailed exposition of these theories is beyond the scope of this essay, it is to be noted that NA is the cornerstone in designing any health promotion campaign (34). There are three considerations that are critical in conducting a NA. Firstly, assessments often emphasize normative and comparative needs, as per Bradshaw’s framework (35), while sidelining felt and expressed needs (5). This can make the process overly prescriptive and disconnected from ground realities. Secondly, needs change with temporal evolution of the parent culture (5), and hence NA requires adjustments to incorporate variations over time, even in the same society. Thirdly, defining the parameters to identify the relevant groups for NA has to be an exercise in diligence, because of the risk of artificially drawing boundaries and consequently corrupting the information (5).

We may prudently expect, then, that various cultures will have various combinations of needs and resources at any given point in time, which would also change with adjustments in the cultural realities. Hence, MHPCs, with NA as their starting point, cannot follow a universal template. This is also aligned with the third argument put forth in this essay.

A theoretical ideal for MH promotion campaigns

It is clear, therefore, that MH promotion should not be a monolithic exercise. The role of culture in framing, defining, elaborating, and healing mental distress needs to be considered during every MHPC planning process. Concepts such as ‘idioms of distress’ and ‘idioms of resilience’ highlight how communities express suffering and cope with adversity in locally meaningful ways. Recent studies from India (36), Somalia (37), Kenya (38), Haiti (39), Thailand (40), and France (41) have broadened this discourse by demonstrating that such idioms often guide help-seeking, aspiration, and healing. These insights are essential in an era shaped by displacement and migration, where standardized models may fail to resonate with lived experiences. Beyond psychiatric contexts, culturally shaped idioms have also been observed in somatic illnesses – such as hypertension in Afghanistan (42) and religiously framed distress in Sweden (43) – emphasizing the need for frameworks that validate both suffering and strength.

Understanding how displaced or marginalized populations interpret distress is central to designing appropriate interventions. Cohen (44) urges alignment between ‘mental health and psychosocial support’ (MHPSS) strategies and culturally rooted understandings of illness and recovery. Similarly, Cork et al. (45), in a systematic review, advocate integrating ‘idioms of distress’ and ‘culturally congruent concepts’ into clinical assessments and interventions to improve communication and outcomes. However, many global studies continue to use instruments developed in the Global North, often without adequate translation or validation. This perpetuates epistemic inequities. White et al. (46) emphasize the need for bottom-up, emic development of tools and approaches within the Global South to enable more equitable knowledge flows. As Shepherd (47) warns, neglecting local complexity risks ‘over-generalizing, simplistic and impractical’ strategies that can lead to unintended harm.

While there may be a few core principles applicable across settings – such as improving MH literacy and reducing stigma (3) – these should form only the basic kernel of MH promotion. Implementation must be shaped by contextual realities. Even in universal disciplines like mathematics, ethnomodeling and cognitive frameworks integrate both emic and etic perspectives (48). Ignoring this interplay, as Spivak et al. (49) caution, risks committing ‘epistemological violence’.

Thus, MHPCs must be contextually grounded and community-informed. They should begin with ethnographic mapping and participatory NAs. Campaigns that ignore culturally embedded beliefs may be rejected or resisted. For instance, in Islamic settings, failure to acknowledge beliefs about Jinns may render interventions ineffective unless these are respectfully integrated within medico-psychological frameworks (22,50). As Bhopal (5) argues, assessments must include preferred language forms, local values, and meaning systems. Community co-design, participatory message development, and iterative feedback loops are essential for ensuring cultural congruence. Tailored, culturally affirming strategies are not just preferable – they are necessary to achieve genuine empowerment and sustainable MH outcomes.

Conclusion

This paper reiterates that there could be no uniform model for MHPCs in the absence of a universal consensus on MH and well-being, and uniformity in the distribution of its determinants. With culturally safe health promotion practices being the need of the hour in a rapidly globalizing world, MHPCs should be customized to the needs, longings, and ethos of individual communities. Locally oriented holistic approaches, building on the core aspirations of reducing stigma and promoting healthy behavior, are likely to be more suitable in managing the burden of MH problems in the modern world than an ill-adapted, culturally confusing but universally applied campaign. At the same time, we are not being pessimistic or unduly critical. We recognize that policy implementation often requires a degree of simplification and homogenization, and many such policies have delivered significant positive outcomes. Our emphasis, however, is on continually reminding ourselves of the personalized needs that coexist alongside these broader frameworks.

Footnotes

Acknowledgements

We acknowledge the reviewer/s for their constructive and insightful comments that helped improve this manuscript.

Author contributions

SM – conceptualization; literature search; data extraction; synthesis of findings; writing – original draft; review and editing, validation. SSC – supervision; methodology; critical revision; review & editing; validation. Both authors approved the final manuscript.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Sayantanava Mitra

Seshadri Sekhar Chatterjee

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