The social determinants of mental health
By Lynn Todman, PHD, Adler School of Professional Psychology, Chicago, IL
As a result of the important work undertaken by the World Health Organization and its Commission on the Social Determinants of Health, there is an increasing understanding of the ways in which social conditions — where we are “…born, grow, live, work and age…” — determine health outcomes. There is growing consensus that daily living conditions and the distribution of power, money and resources shape the incidence of physical health outcomes such as respiratory, cardiovascular and infectious diseases; cancers; obesity; and diabetes. By comparison, there is far less focus and collective agreement on the role of social conditions in shaping mental health outcomes. Mental health prevention and intervention efforts concentrate overwhelmingly on affecting individual, family and/or community change, while changing the broader social, political and economic conditions that impact mental health is often neglected.
To address the relative inattention to the ways in which the full range of social conditions determine mental health outcomes, the Institute on Social Exclusion (ISE) at the Adler School of Professional Psychology hosted a conference in June 2010 titled The Social Determinants of Mental Health: From Awareness to Action. The goal of the conference was to increase awareness among mental health care professionals about the many ways in which determinants such as housing quality, neighborhood safety and fair employment, as well as the distribution of political, civil, economic and other rights, impact mental health outcomes. The conference was also designed to increase awareness among “non-health” professionals of how their decisions and actions effect mental health. For instance, in my home discipline of urban planning, decisions are often made about housing, transportation, land use, and economic development that affect the mental health and well-being of people by impacting their ability to live in decent housing and safe neighborhoods with access to fresh air, nutritious food, safe places to recreate and quality jobs.
The same point can be said about professionals in education, employment, law enforcement, social welfare and other fields. Often, such “non-health” professionals are not familiar with how their work impacts the mental health of the people they serve. As a result, too often, their best intentioned decisions and actions undermine health outcomes, especially among the most vulnerable; and, in doing so, they create and exacerbate health disparities.
One of the strategies for taking action on the social determinants of health to promote population health is Health Impact Assessment (HIA). An emerging practice based on principles of democracy and equity, HIA is a combination of procedures, methods and tools undertaken to prospectively assess likely impacts of public proposals (e.g., legislation, policy, program and projects) on population health. HIA findings are used to inform evidence-based recommendations to help ensure that public decisions, including those put forth by “non-health” entities, narrow health disparities and foster health equity.
Similar to social determinants of health discourse, HIA practice focuses largely on physical health to the relative neglect of mental health. HIA practice has yielded considerable information on the physical health effects of public proposals, and that information is increasingly used to inform all types of public decision-making. HIA practice has focused far less attention on analysis of the impacts of public decisions on mental health.
To address this oversight and as an extension of the concepts presented at the June 2010 conference on the Social Determinants of Health, the ISE has launched an effort to integrate mental health considerations into HIA practice — what we call the Mental Health Impact Assessment (MHIA). The MHIA expands on established HIA practice (Read more about this in the article by Human Impact Partners) by more explicitly integrating mental health considerations. In addition to a more purposeful focus on mental health, our work will help to advance HIA practice in the following ways:
Expand beyond its traditional focus on planning, land use and built-environment proposals to proposals in areas such as labor, public safety, and other areas relevant to the needs of disadvantaged communities; and
Conduct a more rigorous evaluation and monitoring processes.
Our work will also advance the field of mental health by helping to develop the concept of population mental health.
More specifically, our MHIA work began in July 2010 with a pilot effort in which we assessed the mental health implications of a proposed amendment to the Vacant Buildings Ordinance of the city of Chicago. The proposal would hold banks more accounatble for the properties on which they foreclose. Our MHIA, which was based on a review of the literature and workshop during which stakeholder input was gathered, found that though there would be numerous challenges in associated with its implementation, the proposal could be expected to positively impact the collective mental health and well-being of communities that have been hard hit by the recent foreclosure crisis. The proposal was introduced to the Chicago City Council on July 6, 2011. A vote is expected sometime in the fall 2011 or winter 2012.
Subsequent to completion of the pilot, in January 2011, the ISE was awarded a $250,000 grant from the Robert Wood Johnson Foundation and a $150,000 grant from the W. K. Kellogg Foundation to conduct a more rigorous and ambitious MHIA. Working with the Englewood neighborhood, a low income African American community in Chicago, we are assessing the mental health implications associated with a proposed amendment to the Equal Opportunity Employment Commission (EEOC) Policy Guidance on the Consideration of Arrest Records in Employment Decisions. To date, our work has involved brief “framing” literature reviews and community-based focus groups for the purpose of guiding the research and analysis that will take place over the next few months, the results of which will be used to inform our findings and recommendations regarding the likely impact of the proposed amendment on population mental health.
MHIA is a useful practice for helping mental health professionals play a more active role in shaping the social conditions that impact population mental health. It is also useful for helping “non-health” professionals appreciate how their work impacts population mental health and for increasing their accountability and responsibility for population mental health.
As a prospective assessment process, the MHIA has the potential to become an important element of the mental health promotion and prevention toolkit. Its value is heightened in a context of spiralling healthcare costs and declining government funding for mental health services. Given these trends, it is essential, especially for our most vulnerable communities, that legislation, public policy and government programs and projects be “smarter” — that they actively work to narrow mental health disparities, promote mental health equity and support good population mental health. To this end, MHIA holds great promise. For more information on our work, please visit the Institute on Social Exclusion and the Mental Health Impact Assessment webpages.