Social Determinants of Urban Mental Health: Paving the Way Forward: Dr. Sarah Curtis
The Social Determinants of Urban Mental Health Sarah Curtis Professor of Health and Risk, Durham University, UK. 20th September 2012 1
A ‘thought experiment’.......Think of a ‘special’ place whereyou feel....- comfortable;- happy;- able to relax and ‘recuperate’ ifyou are feeling tired or unwell;- What kind of place is it?-What are the features of thelandscape?- Are there people there? Who?
‘Places’ are more than ‘locations’ – they matter for health(Model based on Wil Gesler’s ideas of a ‘therapeutic landscape’) Symbolic Physical Environments Environments (e.g air, water, soil, plants (e.g.: civic pride; animals, buildings, reputation; ‘sacred places’, transport routes, weather, cultural venues; ‘material’ living conditions) ‘virtuous’ architecture ) Social Environments (e.g sense of community; work place relationships)
Curtis, 2010, Space, Place and...the setting we are in Mental Health, Ashgateis important for mentalhealth and wellbeing........social processes incommunities (as well asfamilies) matter formental health….
Related theories to explain ‘salutogenic’ properties of social environments include:- ‘Social capital’ (participation,reciprocity, trust and access toresources in communities)- ‘Social cohesion’ (socialinclusion and solidarity)- ‘Density’ (concentration) ofpeople sharing similar socio-cultural characteristics- ‘Topophilia’ (emotional responseto landscapes with particular socialand cultural associations andmeanings) Antigone, Montpellier, France designed by Ricardo Bofill, built 1980s..also, Lack of these is detrimental
The concept of population mental health- Includes ideas about good health/wellbeing as well as illness;- Considers patterns of health in whole populations as well as individuals;- Often draws on ideas about the wider determinants of health…..
…Includes ideas about good health/wellbeing as well as illness… World Health Organization: definition of health“a state of complete physical, mental, andsocial well-being and not merely theabsence of disease or infirmity”(WHO: Preamble to the Constitution of the World Health Organization asadopted by the International Health Conference, New York, 19-22 June,1946; 7
…Considers patterns of health in whole populations aswell as individuals… Population health vs. Individual HealthIndividual approach: health is assessed in particular peopleand considered in relation to their individual/familycharacteristics.Ecological approach: Health is assessed for populations(aggregates of people) grouped by geographical,demographic or social categories.Some studies combine both , considering how individualsrelate to the wider social setting/community in which they live
…Often draws on ideas about the wider determinants ofhealth..http://www.idea.gov.uk/idk/core/page.do?pageId=13380799Dahlgren and Whitehead’s (1991) ‘Social Model’ of health (See Whitehead, 1995)
How to measure mental illness/wellbeingat the population level? Mortality: Information on deaths from relevant causes (e.g. suicide) Disease/disorders: Illnesses treated: (in hospital, in clinics and by family doctors and psychiatric nurses) Self reported illness/wellbeing: population surveys
Ecological research is not necessarily a....weaker substitute for individual studies and not only individual factors cause disease. (e.g. Schwartz, 1994) So what do we learn from ecological studies?....
We have known for a while about poor mental health in inner cities.....Faris and Dunham, 1939: inner city concentrations mental disordersSource: Geoffrey DeVerteuil http://www.umanitoba.ca/centres/mchp/concept/dict/intra_urban_areas/intra_urban_areas.html
A similar parttern stillevident in New York, 2000:Mental Health Admissions...&Low income(Almog, Curtis et al, 2004)
Suicide map for England:male, age standardized mortality ratios due Lowto suicide (using statistical ‘smoothing’)Middleton et al, 2007 AverageRemote rural and inner city highpopulations have higher riskof suicide
Curtis, Copeland et al, 2006: London, UK: deprived inner city areas have higher psychiatric hospitalisation rates Index of multiple Deprivation 2000 (dark=more deprived)StandardizedAdmission Ratiosfor all psychiatriccauses; males 15-641996-1999(red= high, blue=low)
Measuring area social fragmentation/lack of social cohesionCongdon (1996) used census data for small areas to create Social Fragmentation score for areas % living alone; % adults not in married couples; % moved in last year; % in rented accommodation.
Geographies of deprivation andfragmentation are not identicalsocial fragmentationin London wards Material deprivation inLondon wards
Hospital admissions from small areas in London areassociated with social fragmentation as well as materialdeprivation Beta coeff.Curtis, Copeland et al, 2006 (table 3): psychiatric hospital admissions : result of amultiple regression model including area deprivation and social fragmentation(‘anomie’) in London. Significant beta coeffs in bold, marked *.
Moving beyond ecological studies.....Why combine individual and population approaches?Population health approach – the problem of the EcologicalfallacyIndividual approach – the problem of the Atomistic fallacy
Bringing area and individual data together...Individuals aged 16-24 years in national HealthSurvey for England.mental distress (measured by General HealthQuestionnaire) for individuals…..social support survey information for individualsSocial fragmentation/ cohesion for areas ofresidence...Fagg, Curtis et al. (2007)
less area social fragmentation, 1.4 better individual health 1.2Risk of mental distress 1 0.8 0.6 0.4 0.2 0 low medium high Level of social fragmentation in neighbourhood (lack of social cohesion) 21
…so this national study suggests that,for young adults:In more ‘cohesive’ areas psychologicalhealth is generally better.This is independent of individual levelsocial support levels.
Reasons why social fragmentation incommunities may damage mental health:lack of strong and reassuring role models andsocial norms causing uncertainty andundermining healthy lifestyles;lack of ‘solidarity’ with others in one’s own groupreduces available emotional support andpractical helpcrime and social disorder cause fear, insecurityEvidence also comes from qualitative research...
Popay and Colleagues : qualitative accounts of materialdegradation sense of relative poverty and fear of crimein distressed areas Source Popay et al, 2003: 65 Source: Popay et al, 2007: 973
Feelings of alienation – wanting to leave adistressed community Source Popay et al 2003: 62:
…So what socialenvironments makemental health better?...
Examples of the evidence for these theories that moresupportive social environment is linked to better mental health... 27
Combining geographical data with accounts ofindividual experience....Eg Townley et al (2009) carried out researchwith 40 people suffering from mental illness.Participants drew maps of their community andparticipated in walking interviews 28
Participants were asked people to explain themaps they drew. Source Townley et al (2009) p 253 29
Sample of aninformant’s mentalmap of thecommunity 30
Using GIS Townley et al plotted all the places that were importantto individuals in different parts of the city – not limited to theimmediate area nearest home 31
Examples of comments emphasising socialcohesion and social integration 32
‘ethnic density’ = concentration ofpeople from one’s own ethnic group.Another measure of socialcohesion/solidarity: do other people inyour neighbourhood belong to yoursocial group?Eg. For ethnic minority groups mentalhealth may be better when they havemore local contact with other people inthe same cultural/ethnic group. 34
Fagg, et al, 2006Psychological distress among adolescents, and itsrelationship to individual family and area characteristicsin East London.Information on 2790 children in 28 schools in EastLondon, ages 11-4 years)Mental health was measured using the ‘Strengths andDifficulties Questionnaire’ (SDQ)The study also collected information on factorsincluding: age, sex, individual social support, familyrelationships, family poverty, illness or disability 35
Increasing % South Asians = higher ethnic densitylower riskof distress= betterhealth In East London, East Asians have lower risk of distress (SDQ), especially in areas of moderate ‘ethnic density’ (after allowing for other individual characteristics ) (source: Fagg et al, 2006)
This study shows that being surrounded in theirresidential area by more people from the sameethnic group seemed beneficial for East Asianschool children,......except in areas where East Asians were veryhighly concentrated, with few other ethnicgroups in their neighbourhood(see also:Becares, L., Nazroo, J., Stafford, M. (2009) Thebuffering effects of ethnic density on experienced racism andhealth Health and Place, 15,3, 2009, 700-708.) 37
evidence of the ethnic density effect alsocomes from qualitative studies....Whitely et al, 2006 : qualitative study ofpeople from minority groups in a Londonward with few residents from ethnicminorities.They reported-lack of inclusion in social networks ofpeople in their group;- lack of culturally specific services in theirarea;- racial abuse and sense of intimidation. 38
Key messages from this research:Ecological research, quantitative analyses of individuals and qualitative research suggest that ... in communities with greater levels of social cohesion, individuals have better mental health;Socio-economic poverty and lack of social fragmentation are both (‘independently’) associated with worse mental health
‘Social Capital’ is important for mental health -Trust -Reciprocity -Cohesion -Solidarity/Support -Access to resources 40
The practical implications of theserelationships…..
1. wellbeing is higher in arewhere residents can influendecisions affecting theirneighbourhood2. wellbeing is higheramongst people who haveregular contact withtheir neighbours3. wellbeing is higher in arewhere residents have theconfidence to exercise controver local circumstances.Source: Young Foundation, 2008: 42http://www.youngfoundation.org/fi
Improving mental health probably does notdepend only on interventions for individuals…The wider social determinants of mental healthcan be important for health differencesAction at the level of communities is likely to bebeneficial
make social environments more ‘therapeutic’ Adverse Therapeutic anomie Social support Social fragmentation Social cohesion Social deprivation Social capital - +worse mental health better mental health 44
References:Curtis, S. (2010) Space, Place and Mental Health, Ashgate, Farnham. Especially Chapter 4 p 93 - 124Berkman, L. F., Glass, T., Brissette, I., & Seeman, T. E. (2000). From social integration to health: Durkheim in the newmillennium. Social Science & Medicine, 51(6), 843-857.Bernard, P., Charafeddine, R., Frohlich, K. L., Daniel, M., Kestens, Y., & Potvin, L. (2007). Health inequalities andplace: A theoretical conception of neighbourhood. Social Science & Medicine, 65, 1839-1852.Dale , N et al (2008) ‘The RecedingTide’ Young FoundationSource:http://www.youngfoundation.org/files/images/publications/The_Receding_Tide.pdfFagg, J., Curtis, S., Stansfield, S.A., Cattell, V., Tupuola, A-M. & Arephin, M. Area social fragmentation, social supportfor individuals and psychosocial health in young adults: Evidence from a national survey in England. Social Science andMedicine. 2007. (papers in press on line)Fagg, J., Curtis, S.E., Stansfeld, S. & Congdon, P. Psychological distress among adolescents, and its relationship toindividual family and area characteristics in East London. Social Science and Medicine. 2006;63:636-648Hothi et al (2008) ‘’Neighbourhood + empowerment = wellbeing’ Young Foundation Source: Young Foundation, 2008:http://www.youngfoundation.org/files/images/N_E_W_web_v4.pdfKovess-Masfety, V., Murray, M., Gureje, O. (2004) Evolution of our Understanding of Positive Mental Health. InHerrman, H., Saxena, S., Moodie, R. (Eds) Promoting Mental Health: Concepts, EmergingEvidence, Practice, WHO, Geneva. Chapter 3, p 35- 45http://www.who.int/mental_health/evidence/MH_Promotion_Book.pdf Online at:http://www.who.int/topics/mental_health/en/ (accessed on 10/11/07)Portes, A. (1998). Social capital: its origins and applications in modern sociology. Annual Review of Sociology, 24, 1-24.Portes, A. (2000). The two meanings of social capital. Sociological Forum, 15(1), 1-12.Putnam, R. (2000). Bowling Alone: The Collapse and Revival of American Community New York Simon & SchusterStafford, M., De Silva, M., Stansfeld, S., & Marmot, M. (2008). Neighbourhood social capital and common mentaldisorder: Testing the link in a general population sample. Health & Place, 14(3), 394-405.Townley, G., Kloos, B, Wright P. (2009) Understanding the experience of place: expanding methods to conceptualizeand measure community integration of persons with serious mental illness. Health and Place, 15, 520-531.Cattell, V. (2001). Poor people, poor places, and poor health: the mediating role of social networks and social capital.Social Science & Medicine, 52(10), 1501-1516.Becares, L., Nazroo, J., Stafford, M. (2009) The buffering effects of ethnic density on experienced racism and healthHealth and Place, 15,3, 2009, 700-708.Whitley, R., Prince, M., McKenzie, K., & Stewart, R. (2006). Exploring the ethnic density effect: A qualitative study of a