Social determents to mental health



Mental health and many common mental disorders are shaped to a great extent by the social, economic, and physical enviro nments in which people live. • Social inequalities are associated with increased risk of many common mental disorders. • Taking action to improve the conditions of daily life from before birth, during early childhood, at school age, during family building and working ages, and at older ages provides opportunities both to improve population mental health and to reduce the risk of those mental disorders that are associated with social inequalities. •

While comprehensive action across the life course is needed, scientific consensus is considerable that giving every child the best possible start will generate the greatest societal and mental health benefits. • Action needs to be universal: across the whole of society, and proportionate to need in order to level the social gradient in health outcomes.

• This paper highlights effective actions to reduce risk of mental disorders throughout the life course, at the community level and at the country level. It includes environmental, structural, and local interventions. Such actions to prevent mental disorders are likely to promote mental health in the population. The prevalence and social distribution of mental disorders has been well documented in high-income countries. While there is growing recognition of the problem in low- and middle-income countries, a significant gap still exists in research to measure the problem, and in strategies, policies and programmes to prevent mental disorders. There is a considerable need to raise the priority given to the prevention of mental disorders and to the promotion of mental health through action on the social determinants of health. Building on analyses completed by the WHO Commission of Social Determinants of Health, the Marmot Review in England, the WHO Review of Social Determinants of Health and the Health Divide, and recent, well-researched resources by experts in mental health, researchers at the Institute of Health Equity examined two key issues: 1) the social determinants of common mental disorders; and 2) action on social determinants that can prevent mental health disorders and/or improve population mental health. The work was undertaken in collaboration with staff members of WHO’s Department of Mental Health and Substance Abuse and an international panel of experts.



EXECUTIVE SUMMARY 09 SOCIAL DETERMINANTS OF MENTAL HEALTH Certain population subgroups are at higher risk of mental disorders because of greater exposure and vulnerability to unfavourable social, economic, and environmental circumstances, interrelated with gender. Disadvantage starts before birth and accumulates throughout life. A significant body of work now exists that emphasizes the need for a life course approach to understanding and tackling mental and physical health inequalities. This approach takes into account the differential experience and impact of social determinants throughout life. A life course approach proposes actions to improve the conditions in which people are born, grow, live, work, and age. Actions that prevent mental disorders and promote mental health are an essential part of efforts to improve the health of the world’s population and to reduce health inequities. There is firm consensus on known protective and risk factors for mental disorders. In addition, a growing body of evidence exists, not only from high-income countries but growing in low- and middle-income countries, that shows effective actions can be successfully implemented in countries at all stages of development. A key principle to be taken forward from this paper is proportionate universalism, policies should be universal yet proportionate to need.

Focusing solely on the most disadvantaged people will fail to achieve the required reduction in health inequalities necessary to reduce the steepness of the social gradient in health. Therefore, it is important that actions be universal yet calibrated proportionately to the level of disadvantage. Risk and protective factors act at several different levels, including the individual, the family, the community, the structural, and the population levels. A social determinants of health approach requires action across multiple sectors and levels. Taking a life course perspective recognizes that the influences that operate at each stage of life can affect mental health. Social arrangements and institutions, such as education, social care, and work have a huge impact on the opportunities that empower people to choose their own course in life. Experience of these social arrangements and institutions differs enormously and their structures and impacts are, to a greater or lesser extent, influenced or mitigated by national and transnational policies. Good mental health is integral to human health and well being.


A person’s mental health and many common mental disorders are shaped by various social, economic, and physical environments operating at different stages of life. Risk factors for many common mental disorders are heavily associated with social inequalities, whereby the greater the inequality the higher the inequality in risk. It is of major importance that action is taken to improve the conditions of everyday life, beginning before birth and progressing into early childhood, older childhood and adolescence, during family building and working ages, and through to older age. Action throughout these life stages would provide opportunities for both improving population mental health, and for reducing risk of those mental disorders that are associated with social inequalities.

PRINCIPLES AND ACTIONS CONCLUSION MAIN FINDINGS EXECUTIVE SUMMARY 10 SOCIAL DETERMINANTS OF MENTAL HEALTH While comprehensive action across the life course is needed, there is a considerable evidence base and scientific consensus that action to give every child the best possible start in life will generate the greatest societal and mental health benefits. In order to achieve this, action needs to be universal, across the whole of the social distribution, and it should be proportionate to disadvantage in order to level the social gradient and successfully reduce inequalities in mental disorders. A life course approach to tackling inequalities in health, adapted from WHO European Review of Social Determinants of Health and the Health Divide

EXECUTIVE SUMMARY 12 SOCIAL DETERMINANTS OF MENTAL HEALTH BACKGROUND AND CONTEXT This report brings together evidence that strategic action on the social, economic, environmental, and political determinants of the distribution of mental disorders and effective interventions at different stages of the life-course have considerable potential to promote mental health and to prevent and alleviate mental disorders in countries at all stages of economic development. Much is already happening, as the report’s case studies illustrate. Much more needs to happen. The report aims to stimulate such action. Considerable and growing evidence shows that mental health and many common mental disorders are shaped to a great extent by social, economic and environmental factors. A review of global evidence by Vikram Patel and colleagues for the WHO Commission on Social Determinants of Health reported convincing evidence that low socioeconomic position is systematically associated with increased rates of depression1 . Gender is also important, mental disorders are more common in women, they frequently experience social, economic and environmental factors in different ways to men. Taking action to improve the conditions of daily life from before birth, during early childhood, at school age, during family building and working ages, and at older ages provides opportunities both to improve population mental health and reduce the risk of those mental disorders that are associated with social inequalities. While comprehensive action across the life course is needed, scientific consensus is considerable that giving every child the best possible start will generate the greatest societal and mental health benefits. The prevalence and social distribution of mental disorders has been reasonably well documented in high-income countries. While there is growing recognition of the problem in low- and middle-income countries, a significant gap still exists in research to measure and describe the problem, and in strategies, policies and programmes to prevent mental disorders. There is a considerable need to raise the political, and strategic priority given to the prevention of mental disorders and to the promotion of mental health through action on the social determinants of health.

MAJOR CONCEPTS AND DEFINITIONS MENTAL HEALTH AND MENTAL DISORDERS Mental health and mental disorders are not opposites, and mental health is “not just the absence of mental disorder”2 . BACKGROUND AND CONTEXT MENTAL HEALTH The World Health Organization defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”2 . In this, the absence of mental disorder does not necessarily mean the presence of good mental health3 4. Looked at in another way, people living with mental disorder can also achieve good levels of well being – living a satisfying, meaningful, contributing life within the constraints of painful, distressing, or debilitating symptoms. 13

SOCIAL DETERMINANTS OF MENTAL HEALTH MENTAL DISORDERS Mental disorders include anxiety, depression, schizophrenia, and alcohol and drug dependency. Common mental disorders can result from stressful experiences 5 , but also occur in the absence of such experiences; stressful experiences do not always lead to mental disorders. Many people experience sub-threshold mental disorders, which means poor mental health that does not reach the threshold for diagnosis as a mental disorder. Mental disorders and sub-threshold mental disorders affect a large proportion of populations6 . The less commonly-used term, mental illness, refers to depression and anxiety (also referred to as common mental disorders) as well as schizophrenia and bipolar disorder (also referred to as severe mental illness)7 . In countries around the world, a shift of emphasis is needed towards preventing common mental disorders such as anxiety and depression by action on the social determinants of health, as well as improving treatment of existing conditions. Action is needed as many of the causes and triggers of mental disorder lie in social, economic, and political spheres – in the conditions of daily life. Box 1 Mental health and well being There has been growing interest in well-being in recent years among researchers and in public policy. Amartya Sen’s capability approach8 has been influential in opening up debate around a set of capabilities that enable individuals to do and to be that which they have reasons to value. According to Sen, the range of things which people value doing or being may vary from “elementary ones (such) as being adequately nourished and being free from avoidable disease to very complex activities or personal states, such as being able to take part in the life of the community and having self-respect”9 . The political theorist Martha Nussbaum has elaborated the concept of capabilities across ten domains including: “not dying prematurely”, “being able to have good health”, having “bodily integrity”, “being able to use the senses, to imagine, think, and reason”, having freedom of emotional expression, practical reasoning enabling “planning of one’s life”, “affiliation” with others in conditions that engender “self-respect” and “non-discrimination”, having concern for “other species”, “being able to laugh, to play, to enjoy recreational activities”, “being able to participate effectively in political choices that govern one’s life” and having control over one’s material environment10. Mental health is integral to this conceptualization of wellbeing, because it enables people to do and be things they have reason to value. Conversely, being and doing things one has reason to value contributes to mental health. Capabilities to do and to be are shaped by social, economic, and environmental conditions. To illustrate, a woman’s capabilities are severely restricted if she is unable to complete secondary education, is subjected to domestic violence, works for low pay in the informal labour

BACKGROUND AND CONTEXT 14 SOCIAL DETERMINANTS OF MENTAL HEALTH market, and faces difficulties in being able to feed and clothe her children. Such a woman is at higher risk for low mood, and feelings of hopelessness and helplessness associated with depression, than a woman who is not exposed to these social determinants. Capabilities and well-being relate to the socioeconomic gradient through social determinants. BACKGROUND AND CONTEXT 15 SOCIAL DETERMINANTS OF MENTAL HEALTH METHODS Building on analyses completed by the WHO Commission of Social Determinants of Health, the Marmot Review in England, the WHO Review of Social Determinants of Health and the Health Divide, as well as pioneering WHO reports on mental health promotion and prevention of mental health11 12 and a number of recent, well- researched resources by experts in mental health, researchers at the Institute of Health Equity examined two key issues: 1) the social determinants of common mental disorders; and 2) action on social determinants that can prevent mental health disorders and/or improve population mental health. The work was undertaken in collaboration with staff members of the WHO’s Department of Mental Health and Substance Abuse and with advice from an international panel of experts.

METHODS 16 SOCIAL DETERMINANTS OF MENTAL HEALTH MAIN FINDINGS AND DISCUSSION Tackling societal determinants of common mental disorders and sub-threshold common mental disorders is the major focus of this paper. Comprehensive strategies at the population level to address these societal determinants are likely to improve mental health in the population and reduce inequities, because such strategies focus on improving the conditions in which people are born, grow live, work, and age. Systematic inequalities between social groups that are judged to be avoidable are inequitable and unfair, so systematic differences in mental health by gender, age, ethnicity, income, education, or geographic area of residence are inequitable and can be reduced by action on the social determinants. There is good evidence, for example, that common mental disorders (depression and anxiety) are distributed according to a gradient of economic disadvantage across society13 and that the poor and disadvantaged suffer disproportionately from common mental disorders and their adverse consequences1 14 15. A systematic review of the epidemiological literature on common mental disorders and poverty in lowand middle-income countries found that of the 115 studies reviewed over 70% reported positive associations between a variety of poverty measures and common mental disorders. The strength of the association varied depending on the type of poverty measure used16. The association between low income and mental disorders is accounted for by debt in some studies. A population study in England, Wales, and Scotland found that the more debt people had, the more likely they were to have some form of mental disorder, even after adjustment for income and other sociodemographic variables17. A review of population surveys in European countries found that higher frequencies of common mental disorders (depression and anxiety) are associated with low educational attainment, material disadvantage and unemployment18, and for older people, social isolation. The pattern of social distribution of common mental disorders is observed as a social class gradient, more marked in women than in men (Figure 1)19. Epidemiological studies on the distribution of positive mental health in Europe have also been undertaken. Results from the Eurobarometer survey in 2002 showed significant variation in population mental health between countries, and between men and women within countries20. Poorer mental health was found in women, poorer groups, and among those who reported weak social support20. A two-way relationship exists between mental disorders and socioeconomic status: mental disorders lead to reduced income and employment, which entrenches poverty and in turn increases the risk of mental disorder. Patterns of inequity in social distribution emerge before adulthood. A systematic review of the literature found that the prevalence of depressed mood or anxiety was 2.5 times higher among young people aged 10 to 15 years with low socioeconomic status than among youths with high socioeconomic status21. Among children as young as three and five years of age, socioemotional and behavioural difficulties have been shown to be inversely distributed by household wealth as a measure of socioeconomic position22. A dominant hypothesis linking social status and mental disorders focuses on the level, frequency, and duration of stressful experiences and the extent to which they are buffered by social supports in the

SOCIAL DETERMINANTS, SOCIAL INEQUALITIES, AND COMMON MENTAL DISORDERS MAIN FINDINGS AND DISCUSSION 17 SOCIAL DETERMINANTS OF MENTAL HEALTH Key: Pale bars: women; dark bars: men. Figure 1: Prevalence of any common mental disorder by household income, England 2007 (19) Re-used with the permission of the Health and Social Care Information Centre. All rights reserved form of emotional, informational, or instrumental resources provided by or shared with others, and by individual capabilities and ways of coping. Those lower on the social hierarchy are more likely to experience less favourable economic, social, and environmental conditions throughout life and have access to fewer buffers and supports. These disadvantages start before birth and tend to accumulate throughout life, although not all individuals with similar exposures have the same vulnerabilities; some are more resilient or have access to buffers and supports to mitigate the potential mental health effects of disadvantage and poverty. A multilevel framework for understanding social determinants of mental disorders can be applied to strategies and interventions to reduce mental disorders and promote mental well being. Important areas are listed below23. These areas are important for two reasons: they influence the risk of mental disorders; and they present opportunities for intervening to reduce risk. Life-course: Prenatal, Pregnancy and perinatal periods, early childhood, adolescence, working and family building years, older ages all related also to gender; Parents, families, and households: parenting behaviours/attitudes; material conditions (income, access to resources, food/nutrition, water, sanitation, housing, employment), employment conditions and unemployment, parental physical and mental health, pregnancy and maternal care, social support; Community: neighbourhood trust and safety, community based participation, violence/crime, attributes of the natural and built environment, neighbourhood deprivation; Local services: early years care and education provision, schools, youth/adolescent services, health care, social services, clean water and sanitation; Country level factors: poverty reduction, inequality, discrimination, governance, human rights, armed conflict, national policies to promote access to education, employment, health care, housing and services proportionate to need, social protection policies that are universal and proportionate to need. MAIN FINDINGS AND


The experience and impact of social determinants varies across life, and influence people at different ages, gender and stages of life in particular ways. The Commission on the Social Determinants of Health, Marmot Review, WHO European Review, and others emphasize the need for a life-course approach to understanding and tackling mental and physical health inequalities that accounts for the differential experience and impact of social determinants throughout life24 25. A life-course approach LIFE-COURSE proposes actions to tackle health inequality appropriate for different stages of life (Figure 2). Strong evidence shows that many mental and physical health conditions emerge in later life but originate in early life27 28. Stressors experienced in sensitive development periods during early childhood affect biological stress regulatory systems, neural mechanisms by which stress responses are regulated in the brain, and the expression of genes related to stress responses29. The effects of stressors on these systems are buffered by social support provided by loving, responsive and stable relationships with a caring adult29 30. Such relationships build secure attachment between child and caregiver, which is essential for healthy social and emotional development. Secure attachment to the primary caregiver in the early years is of fundamental importance for the individual in buffering against anxiety and coping with stressors31. Cumulative exposure to stressors over time causes alterations in stress responses that have physiological effects on the immune system, cardiovascular function, respiratory system, and other systems, including the brain, that affect physical functioning in ways that are damaging to health27 30. Beyond MAIN

FINDINGS AND DISCUSSION 19 SOCIAL DETERMINANTS OF MENTAL HEALTH early childhood, both social supports in the family and wider community, and positive beliefs related to optimism, self-esteem, and sense of control buffer the effects of stressors29. Stress-related behavioural responses include alcohol and drug abuse, which are classified as mental disorders when then lead to alcohol or drug dependency. Analysis of exposure over the life-course to advantage and disadvantage shows that these negative and positive factors and processes accumulate over time, influencing epigenetical, psychosocial, physiological, and behavioural attributes among individuals as well as social conditions in families, communities, and social groups including gender. This accumulation of advantage and disadvantage leads to social and economic inequities and consequently to inequitable mental and physical health outcomes. These processes are dynamic, in the sense that the accumulation of positive and negative influences takes place throughout life. These processes of accumulation leads to the factors that most immediately affect mental health, and indicates the need for action at every stage of life. Taking a life-course perspective recognizes that the influences that operate at each stage of life can change the vulnerability and exposure to harmful processes, or stressors. Social arrangements and institutions, like preschool, school, the labour market and pension systems have a significant impact on the opportunities that empower people to choose their own course in life. These social arrangements and institutions differ enormously and their structures and impacts are, to greater or lesser extent, influenced or mitigated by national and transnational policies. PRE-NATAL EXPERIENCE AND MENTAL HEALTH The prenatal period has a significant impact on physical, mental, and cognitive outcomes in early life and throughout life. A mother’s maternal health is particularly important and poor environmental conditions, poor health and nutrition, smoking, alcohol and drug misuse, stress, and highly demanding physical labour can all have a negative effect on the development of the foetus and later life outcomes7 . Children with poor mothers are more likely to be disadvantaged even before birth, for example, with an increased likelihood of poor nutrition during pregnancy and low birth weight and exposure to stress, poor working conditions, and demanding physical labour26. A systematic review and meta-analysis of 17 studies on maternal depression or depressive symptoms and early childhood growth in developing countries showed that children of depressed mothers were a greater risk of being underweight and stunted, low birth weight is itself an increased risk factor for depression in later life32. Analysis of data from four longitudinal studies showed that among children of depressed mothers the risk of underweight and stunting was approximately doubled32. The scale of the problem of perinatal depression among mothers in developing countries is substantial.

A systematic review of studies in low- and middle-income countries estimated prevalence of common perinatal mental disorders among women to be 16% before birth and 20% postnatally33. Risk factors for common perinatal disorders include socioeconomic disadvantage; unintended pregnancy; being younger; being unmarried; lacking intimate partner empathy and support; having hostile in-laws; experiencing intimate partner violence; having insufficient emotional and practical support; in some settings, giving birth to a female, and having a history of mental health problems. Protective factors include having more education; having a permanent job; being of the ethnic majority and having a kind, trustworthy intimate partner33. Rahman and colleagues estimated that reducing maternal depression in Pakistan by 25%, 50%, or 75% would result in reductions in child underweight by 7%, 26%, and 36% MAIN FINDINGS AND DISCUSSION 20 SOCIAL

DETERMINANTS OF MENTAL HEALTH respectively34. A large body of research has emphasized the importance of maternal education for a wide range of outcomes for children, with lower maternal education relating to increased infant mortality, stunting and malnutrition, overweight children, lower scores on vocabulary tests, conduct problems, emotional problems, lower cognitive scores, mental health problems and infections35-38.

THE EARLY YEARS Adverse conditions in early life are associated with higher risk of mental disorders. Family conditions and quality of parenting have a significant impact on risk of mental and physical health. The Institute of Health Equity conducted a recent review of literature on factors influencing early childhood and found that “lack of secure attachment, neglect, lack of quality stimulation, and conflict, negatively impact on future social behaviour, educational outcomes, employment status and mental and physical health”23. Children’s exposure to neglect, direct physical and psychological abuse, and growing up in families with domestic violence was particularly damaging28. Parental mental health plays a key role in outcomes for children. For example, children of mothers with mental ill-health are five times more likely to have mental disorders39. Poverty, and particularly debt, can increase maternal stress. Moreover, conflict between parents also carries risks for children. Exposure to multiple risks is particularly damaging as effects accumulate26 40. Children in lower socioeconomic groups are less likely to experience conditions to allow optimal development38. Social gradients in social and emotional difficulties have been shown among children as young as three years. Analysis from the United Kingdom showed that family income was inversely related to socioemotional difficulties in children at ages 3 and 522. However, impact can be offset by protective parenting activities, such as good social and emotional interactions22. These inequalities in early years’ development are potentially remediable through family and parenting support, maternal care, and child care and education. Wider family and strong communities can also act as buffers and sources of support to ameliorate impact (see Annex 1)26. Actions to support mental health in the early years A systematic review of interventions to address common perinatal mental disorders (CPMDs) in low- and middle- income countries found that with the correct training and supervision of primary and community health-care workers, while ensuring that interventions were culturally adjusted, interventions implemented within this setting can improve the mental health of mothers41. Other reports suggest interventions also benefit mothers by creating better employment opportunities for women and higher levels of income42 43. Effective interventions have been implemented in South Africa reducing depression in mothers and improving child attachment and interaction over certain time periods44. A homeMAIN

FINDINGS AND DISCUSSION 21 SOCIAL DETERMINANTS OF MENTAL HEALTH based intervention to test the effectiveness of early stimulation on maternal depression was implemented in several Parishes in Jamaica. The intervention aimed to improve child development through educating mothers about better child rearing practices and improving their parental self-esteem. The intervention involved community health workers from government health centres visiting homes on a weekly basis for half an hour to demonstrate activities – usually play activities – which involve the child, mother and other caregivers. The home visits also presented an opportunity to discuss parenting issues, including important nurturing skills, child nutrition and how to promote good play and learning environments, between health worker and mother. Analysis of the intervention suggests the home visits from community health workers significantly reduced maternal depression42. The Triple P-Positive Parenting Programme is a behavioural family intervention that aims to improve child behaviour and development by altering the family environment to one that enables the child to realize its potential; thus, increasing the child’s life chances and reducing the risks associated with poor mental health45. The programme takes a population approach to implementation and was developed and first implemented in Australia. The programme has been successfully replicated in a number of different countries, including China (Hong Kong), the Islamic Republic of Iran, Japan, and Switzerland46-49. In the USA, a considerable evidence base has been established, including studies examining the effectiveness of preschool interventions on young children living in low-income and poverty stricken settings over long periods of time. The High/Scope Perry Preschool Project, the Nurse-Family Partnership and the Incredible Years series are three examples of programmes that have contributed significantly to the evidence base. These programmes improve pregnancy outcomes and children’s readiness for school, educational achievement, economic success, and mental and physical health outcomes50-52. Additionally, the Incredible Years programmes have been implemented in 20 countries and territories, including, Denmark, Finland, the occupied Palestinian territory, and the Russian Federation53. The Mother2Mothers programme is an early years intervention implemented in the Kwa-Zulu-Natal region of South Africa that helps communities develop peer support groups to provide education and psychosocial support to pregnant women and new mothers with HIV/ AIDS, particularly with support in accessing existing health-care services. An evaluation of the intervention showed that participants had greater psychosocial well-being, made greater use of the services available to them, and experienced better outcomes as a result, compared with non-participants. Additionally, the evaluation found that new mothers experienced more positive changes than pregnant participants as a result of more contact time with the programme54.

MAIN FINDINGS AND DISCUSSION 22 SOCIAL DETERMINANTS OF MENTAL HEALTH LATER CHILDHOOD While the early years of brain development are highly significant for later life outcomes, continued and appropriate forms of support are needed throughout childhood and adolescence. Education is important in building emotional resilience and affecting a range of later life outcomes that raise the risks of mental disorders – such as employment, income, and community participation. Schools are also important as institutions capable of delivering upstream, preventive programmes to young people. As with infancy and early childhood, children and adolescents from poorer backgrounds are likely to have greater exposure and experience of poor environments and stressful family contexts, there is therefore a need for a proportionately greater focus on those most at risk. Poverty makes it more difficult to provide home environments conducive to learning, for instance overcrowding and unhealthy conditions55. Parents’ access to employment not only reduces poverty, but also improves family routines, and ensures children grow up understanding the role of employment in adult lives. Schools can play a key role in working directly with children; they can also work with other services to provide parents with support and advice on parenting strategies and potentially support them with readiness for work or skills training. As children grow into adolescents, they become more interested in taking risks, including substance misuse56 57. It is important to ensure that adolescents have the knowledge to make informed decisions, and that they have protective factors including social and emotional support and positive interactions with peers, family, and the wider community. Depressive symptoms among adolescents are associated with their history of adverse childhood experiences as well as their current experiences23 58. Actions to support mental health among children and adolescents Actions to support mental health in children and adolescents tend to be implemented in school settings, which offer a good and efficient opportunity for action, which should reach the whole population59. Additionally, schools play an integral role in nurturing development in terms of social, emotional, academic, and cognitive ability; the effects of which can influence children’s short- and long-term mental health60. Actions to support mental health and address mental disorders in children and adolescents within school settings have been implemented in countries across the world61-63. This includes a number of school level interventions in low- and middle-income countries afflicted by war and violence, where the risks of developing mental health problems are particularly high102 103. Systematic reviews of school-based interventions indicate that the vast majority of interventions have taken a universal (whole-school) approach to supporting mental health to achieve optimal impact. These approaches usually include changes to the school ethos, liaising with parents, special teacher training, educating parents, comMAIN

FINDINGS AND DISCUSSION 23 SOCIAL DETERMINANTS OF MENTAL HEALTH munity involvement and collaboration with external agencies64. The Social and Emotional Learning programme, implemented in a number of States across the USA, is a good example of a school-based intervention. The programme promotes supportive relationships that make learning challenging, engaging, and meaningful, whilst developing children’s social and emotional skills; in order to reduce risky behaviours65. A report summarizing the results from three large-scale reviews of the Social and Emotional Learning programme, which included 317 studies and covering 324 303 children, found that the programmes were effective and produced a number of benefits in each of the three reviews, including social-emotional skills, attitudes about self and others, school engagement, positive social behaviour, academic attainment, social conduct and emotional distress66. In Sri Lanka, after the end of the civil war in 2009, a school-based intervention was introduced in randomly selected schools. The intervention was based on similar models from other war-afflicted countries, such as Indonesia67. It consisted of 15 sessions over a 5-week period using non-specialized personnel who were trained in implementing the intervention. The structure included specific topics for the different sessions, such as information on safety, stabilisation, awareness and self-esteem, trauma, coping skills, reconnecting with the social context, and planning for the future. Results showed improvements in some participants’ mental health and conduct behaviour, including improvements in the ability to settle disputes in a non-violent way68. WORKING AGE The Global Burden of Disease project indicates there are significant and increasing levels of mental disorders among the global adult population. Among women, major depression is the leading cause of years lived with disability, while anxiety ranks 6th in this list. Among men, major depression ranks 2nd, drug use disorders rank 7th, alcohol use disorders rank 8th and anxiety ranks 11th6 . An estimated one in four or five young people (aged 12-24) will suffer from a mental disorder in any one year, notwithstanding substantial variations in prevalence between regions69. Many mental disorders are undiagnosed and untreated globally70 71. In England, one in four people experience a mental disorder during their lifetime and 17.6% of adults experience at least one common mental disorder. Seventeen percent of adults have a subthreshold common mental disorder, while 5% of adults experience subthreshold psychosis and 24% of adults drink more than the safe upper limit of alcohol72. MAIN FINDINGS AND DISCUSSION 24 SOCIAL DETERMINANTS OF MENTAL HEALTH Policies to reduce alcohol consumption In many countries across the world, alcohol consumption is negatively associated with population mental health increasing the likelihood of alcoholism, depression and suicide, as well as other harmful outcomes, such as poor physical health, accidental injury and domestic violence73. There has been growing political debate and policy movement in a number of countries, including England, Australia, Malawi, Zambia and Scotland, that has focused on measures to reduce the consumption of alcohol74-77. In the Canadian province of British Columbia, minimum alcohol pricing has been implemented for the past 20 years adjusting the price of alcohol incrementally over time in an attempt to reduce consumption. A longitudinal study analyzing data from 1989 to 2010 estimates that a 10% increase in the minimum price of an alcoholic drink reduced consumption relative to other drinks by 16.1%, with consumption of all alcoholic drinks reduced by 3.4%78. As previous sections have described, adult mental disorders have impacts beyond the individuals concerned: they also influence children, partners and wider family, communities, economic development, and subsequent generations. Unemployment and poor quality employment are particularly strong risk factors for mental disorders and are a particularly significant cause of inequalities in mental disorders, as risk of unemployment and poor quality employment closely relates to social class and skill levels. A recent report from the Institute of Health Equity on health impacts of economic downturns, describes evidence suggesting close associations between job loss and symptoms (though not clinical diagnoses) of depression and anxiety79 80, and demonstrates that these impacts are particularly clear for the long-term unemployed. Strategies to reduce long-term unemployment will be particularly important in reducing risk of mental disorder in adults24. Poor quality employment, such as employment with no or short-term contracts, and jobs with low reward and control at work, have significant harmful impacts on mental health. Conversely, job security and a sense of control at work are protective of good mental health81 82. Employers therefore have a significant role in potentially reducing or exacerbating mental disorders among working age populations and should institute better employment practices to ensure that a higher reward and control balance at work, better working conditions. As described in previous sections, income, levels of debt and relative poverty have clear associations with risk of mental disorders. Strategies and ambitions to provide sufficient income for healthy living are important – both through social protection and minimum wage policies.

MAIN FINDINGS AND DISCUSSION 25 SOCIAL DETERMINANTS OF MENTAL HEALTH Actions to support mental health among adults The implementation of accessible financial services are essential to tackling poverty, empowering people (particularly women) and communities, and reducing poor physical and mental health among the most disadvantaged83. Microfinance programmes help the poorest earn a living, improve their businesses and provide a means for entire communities to work their way out of poverty84. A review of microfinance services in relation to health described microfinance programmes as an underutilized resource that has the potential to deliver health-related services to large and hard to reach populations85. Nonetheless, and despite a great deal of support for microfinance programmes and the implementation of them across many countries, only limited research has examined the effects of these programmes on mental health. A study examining the effectiveness of poverty alleviation tools looked at the relationship between small individual loans and mental health among adults in South Africa. Its findings indicate that methods to reduce financial stress on poor and vulnerable adults are effective in reducing depressive symptoms among men, but are less effective among women86. Although there were no reductions in depressive symptoms among female participants in this study, other studies suggest that microfinance interventions can improve the lives of women, including their mental health. An evaluation of the Intervention with Microfinance for Aids and Gender Equity (IMAGE), which combined group-based microfinance with a gender and HIV/AIDS training programme, suggested that levels of interpersonal violence were reduced significantly within villages taking part in the intervention. This has a direct benefit to physical health, interpersonal, familial, and wider social relations, as well as being likely to reduce downstream effects of violence, including anxiety and depression87. Another study in Kolkata, India, involving a partnership with a large microfinance organization called Village Financial Society (VFS), examined the effect of small changes in the structure of loan repayments on the stress levels of clients. The study wanted to establish whether increasing the flexibility of loan repayments would improve clients’ experiences of microfinance services. The results indicated that clients who were on a monthly repayment scheme were 51% less likely to experience feelings of anxiety about repayment than clients on a weekly repayment scheme. Additionally, the monthly clients reported improvements in income and business investment, said to be a result of increased flexibility which encouraged clients to invest their loans more profitably and allowed for clients to better manage short-term shocks to income; ultimately reducing financial stress88. MAIN FINDINGS AND DISCUSSION 26

SOCIAL DETERMINANTS OF MENTAL HEALTH Actions in the Workplace One of the largest retail companies in China, Credibility Retail Enterprise, sought the expertise of academic researchers at Peking University to help promote mental health among its workforce. Nine firms were selected from within the enterprise, and 300 employees from each firm were selected to participate in the study. The university research team developed and implemented a Health Promotion Enterprise programme 93, which applied the Ottawa Charter 198694 approach for health promotion and improved organizational care. It also developed interventions at two levels: the organizational level – aimed at managers and leaders to equip them with the skills and training to promote mental health, create a good working environment, and develop an organizational health policy; and the employee level – which helped the enterprise identify employee needs and priorities to create an environment that promoted mental health. At the organizational level, managers attended interactive sessions over a three-year period to learn and enhance their skills, including skills in communication, stress management, problem solving, conflict management, and self-awareness. The employee level intervention required employees to attend discussion sessions over a three-year period, during which they discussed work activities, developed a better working environment, and helped address employees’ specific needs. Pre- and post-intervention surveys showed that the programme was effective in reducing depression and anxiety among the workforce, improving work performance, and reducing absenteeism. It also provided employees with the ability to manage work demands more effectively. Furthermore, research examining the economic case for mental health promotion and prevention suggested that every £1 spent on workplace mental health promotion would generate a £10 million return in economic returns95. The workplace is increasingly regarded as a key intervention setting where both mental and physical health can be improved and promoted among adult populations89. Systematic reviews suggest that employers that promote actions such as greater job control, task-restructuring and decreased demand90 91, can positively influence mental health through reducing stress, anxiety and depression, and increasing self-esteem, job satisfaction and productivity92. Employers also can improve people’s health by paying a minimum wage for healthy living, which would guard against poverty — a major risk factor for poor mental health24.

MAIN FINDINGS AND DISCUSSION 27 SOCIAL DETERMINANTS OF MENTAL HEALTH Case study box The Sure Start initiative in England is a good example of a scaled-up approach to early years intervention. Implemented by the government, the initiative seeks to engage with parents, pregnant mothers, infants and pre-school age children to reduce the rates of low birth weight, cognitive delay and promote child development, as well as work with parents and families to improve relationships, child attachment and reduce social disadvantage while ensuring that these services are available and easily accessible to the most disadvantaged and deprived96 97. FAMILY BUILDING Family building and parenting influences children’s mental and physical health and a range of other outcomes throughout their lives; in addition adult mental health can be profoundly affected during family building. This risk during adulthood partly relates to socioeconomic factors. For example, incidence of postnatal depression in England shows a clear social class gradient, in 2003-4 just over 20% of those in the lowest quintile for socio economic status had experienced post-natal depression, compared with 7% in the highest socio-economic quintile24. Good, accessible maternal services, information and advice about parenting strategies, and helping manage transitions to parenthood are protective of adult and child mental health24. Support should be maintained throughout childhood and into adolescence. In addition, support must be appropriate to parental circumstances and to that of the child’s developmental stage. Efforts to support maternal and postnatal mental health will benefit parent and child and help disrupt the intergenerational transfer of inequities. Support for parents to improve employment prospects, income, and housing conditions also influence successful parenting and reduce mental disorders. OLDER PEOPLE Older people’s mental health relates both to earlier life experiences and also to particular experiences, conditions, and contexts specific to ageing and the post-retirement period. Experiences of mental and physical health differ throughout the older age period. Evidence from England, for example, shows risks of depression increasing markedly beyond 80 years of age. In this paper we do not include dementia in the analysis. Much of the rather limited evidence relating to incidence and distributions of mental health disorders and mental health for older people is from high-income countries. However, the available evidence that exists points to inequalities in older people’s mental health related to socio-economic status, educational status, gender, ethnicity, age, levels of physical health (itself related to cultural, social, and

MAIN FINDINGS AND DISCUSSION 28 SOCIAL DETERMINANTS OF MENTAL HEALTH economic factors)98 99. Experiences also vary by country, related to their social, political, and economic arrangements and particular levels of social protection100. Some evidence from analysis of studies across Europe shows that for men, depressive mood relates to chronic ill-health and somewhat to exercise; for women, the differences are more closely related to social factors, such as levels of isolation, contact with family, and belonging to faith or other community groups100. Many studies show worse outcomes for older women than men across a range of mental disorders. Evidence from England points to increasing risks and incidence of depression for men older than 75 years and for women older than 65 years99. Some of the life events that can trigger depression are likely to be experienced in older age – bereavement, perceived loss of status and identity, poor physical health, loss of contact with family and friends, lack of exercise, and living alone. As with the rest of the life-course, evidence shows a social gradient in mental disorder for older people: higher levels of education appear to be protective against mental disorders, particularly for women101. An analysis of data from the Survey of Health, Ageing and Retirement in Europe (SHARE) found that after adjustment for demographic characteristics, there were differences between countries in both late life depression and well-being100. The Scandinavian countries seem to have lowest levels, followed by Western European countries, while older people in Italy, Greece and Spain have the highest levels of mental disorders. The variable rates across Europe partly relate to the levels of provision of state support and services, with more provision of services related to better mental health100. In contrast to many other countries where ageing is associated with increasing risk of depression and other common mental disorders, Japan has lower rates of depression among those aged more than 65 years, compared with younger age groups102. Social isolation among older people is particularly significant (especially for women) in raising the risk of mental disorders. Surveys of ageing in England show that at least 10% of older people are socially isolated; these rates are even more pronounced for those older than 75 years. A review of literature shows links between loneliness in older people and depressive symptoms, poor mental health and cognition, alcoholism, suicidal ideation, and mortality. Actions to support mental health among older people Systematic reviews indicate that interventions which prolong and/or improve older people’s social activities, life satisfaction, and quality of life can significantly reduce depressive symptoms and protect against risk factors, such as social isolation103. Research suggests that effective interventions exist, including psychosocial interventions, interventions to reduce social isolation, exercise and physical activity programmes, and programmes promoting lifelong learning; in addition to actions aimed at

MAIN FINDINGS AND DISCUSSION 29 SOCIAL DETERMINANTS OF MENTAL HEALTH reducing poverty and improving physical health104. Furthermore, interventions that improve heating in the home105 106, help older people make new friends107, and provide opportunities for older to people to volunteer108, have been found to be effective in improving and protecting mental health. The Meeting of the Minds programme in Auckland, New Zealand, was formed in 2001 to promote positive ageing for older people through a coordinated cognitive activity programme, through collaboration between Auckland’s community libraries, Auckland City Council, Age Concern and the Mental Health Foundation. Twelve community libraries agreed to participate in the programme and were selected based on their location and ease of access – with good transport systems and parking facilities. The programme was advertised in local newspapers and radio stations. The programme consists of hour-long sessions held once a month in each of the libraries. During the first six months, 1085 people attended the programme. It enabled people to engage in a number different social activities including: sharing family, local and cultural histories; life-long learning, such as computer skills, arts and crafts, travel, and current affairs; and library-based events, such as book clubs and talks from invited authors. Thirty-eight per cent of participants lived alone and the programme provided an opportunity for participants to meet new people and develop social relationships109. The Upstream Healthy Living Centre, based in England, was introduced as an innovative approach to identifying and engaging with older people in rural areas who may experience significant isolation. The Centre uses mentors to deliver specially-tailored activities and support, to improve social networks and get people involved in creative activities. An evaluation indicated that participants benefited from attending the centre, reporting improved psychological well-being and reduced depression110. While there is a body of evidence from high-income countries that points to effective interventions in maintaining mental health and preventing poor mental health in old age, there appears to be a serious lack of evidence and literature supporting interventions targeted at older people in low- and middle-income countries. INTERGENERATIONAL TRANSFER OF DISADVANTAGE Social and economic inequities, perpetuated across generations, result in the entrenchment of mental health inequities over time13. Taking a social determinants approach across the life-course means also addressing the intergenerational transfer of inequity. The concept of intergenerational transfer of risk, which has been developed and developed by climate change mitigation approaches, has relevance to analysis of transmission of social and economic factors between generations and in developing policy

MAIN FINDINGS AND DISCUSSION 30 SOCIAL DETERMINANTS OF MENTAL HEALTH The past four decades have seen a number of mental health self-help groups introduced by nongovernmental organizations in the northern regions of Ghana. The BasicNeeds Mental Health and Development programme is one example of an intervention in this area where no psychiatric facilities exist. The programme is designed to facilitate access to the psychological services offered by the Ghanaian Health Service. Self-help groups meet once a month and provide a number of supports to members, such as assisting with care responsibilities, collecting wood and water, and even visiting homes to cook for people. Additionally, the programme provides access to credit for those affected by mental health problems as a way of assisting them to be productive members of the community. Evaluation of the programme concluded that self-help groups were useful, particularly in their provision of a wide range of support services, including social and financial support. Self-help groups also made better use of the services available to them (including the Ghana Health Services) and were more likely to complete treatment programmes with better outcomes113. The BasicNeeds programme has also been implemented in rural Kenya. An evaluation Action to support mental health at the community level provides a platform to develop and improve social norms, values and practices, while encouraging community empowerment and participation. Central to a number of community-based approaches is the realization that change within a community is best achieved through engaging people of the community92. This change is brought about by efforts to improve key determinants of mental health, including a social inclusive community, freedom from discrimination and violence, and access to economic resources111. In many low- and middle-income countries, adequate human resources to deliver essential mental health care and interventions are lacking112. However, a number of community-based interventions have been implemented to address this issue and compensate for the lack of health workers.

COMMUNITY LEVEL CONTEXT responses to tackling these. A basic principle of sustainable development is that the present generation should not compromise the environment of subsequent generations. This principle should also be applied to the social determinants of mental and physical health. Intergenerational transfers of inequity occur directly, for instance, prenatally and throughout life from parents to children, as discussed above. Intergenerational transfers of inequity are also at community level and nationally.


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