Thursday, 16 February 2017
Social determinants of mental health in low income countries
According to WHO, mental health is “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.”As is evident from the above, mental health disorders are also becoming an increasingly important public health problem in the low-income countries, thanks to the fall-outs from the very competitive globalized economy as well as the socio-politcal instability which is a spin off from the former. The magnitude of the problem is reflected in the Call by WHO (2014) for... ‘the promotion, protection and restoration’ of mental health so that we can ‘think, emote, interactwith each other, earn a living and enjoy life.’
Besides biological and psychological factors, various social,economic and environmental factors (‘conditions in which people are born, grow, live, work, and age’) also come into play to determine mental health status, together called the ‘social determinant of mental health’. These determinants act throughout the life-cycle starting from in-utero to old age. These determinants or risk factors for disorder(s) of mental health include poverty and exclusion, education, gender and violence, employment status, work and living environment, and social capital.
Poverty, exclusion, education and mental health
In low-(and middle-)income countries [henceforth, LAMICs], poverty and exclusion is intimately associated with common mental health disorders such as anxiety and depression. Poverty results in economic deprivation, income in-equalities, and poor level of education; and thus, low probability of gainful employment and high probability of indebtedness, ultimately leading to mental disorders. These two are related in a vicious circle: poverty perpetuates mental disorders and the latter interferes with engagement in productive activities and income-earning, therefore exacerbating poverty.
Unemployment and mental health
Unemployment is both a consequence and a cause of illness, including mental illness. Unemployment leads to deterioration of both physical and mental health, more of the latter including suicide,and long-term unemployment causes a higher burden of mental illnesses compared to short-term unemployment, the burden of illness increasing with the duration of unemployment. It has been found that unemployment leaves a long-term “scarring effect” on mental health of the individual. This deleterious effect of unemployment on mental health is especially prominent in countries with low level of economic development including absence of appropriate safety net for the unemployed.
Work environment and mental health
Work or engagement in gainful activities can be beneficial for an individual’s overall well-being including mental wellbeing, especially if the work environment is favourable and the supervision is good. It is also identified with providing one with sense of purpose and social identity, and opportunities for personal development, which again, is crucial for mental well-being. In organizational environment, issues such as ‘overwork, lack of clear instructions, unrealistic deadlines, lack of decision-making, job insecurity, isolated working conditions, surveillance, and inadequate child-care arrangements’ produce job stress, and consequent common mental disorders and reduced productivity, especially in low-income settings.
Living environment and mental health
A healthy environment and living arrangement is essential for better health including mental health. External environment may determine exposure to various physical, biological or chemical pollutants, producing health effects such as accidents/injury (direct)and bronchial asthma from air pollution (indirect). Housing or built environment has effects on mental health, either directly (e.g., increasing psychological distress) or indirectly (e.g., altering psychosocial processes with known mental health affects), through elevating the stress level and its consequences.
Gender, violence and mental health
Women’s experiences of social, economic and environmental factors are different from men including the level of stress of everyday life, and as such, they tend to have higher levels of common mental disorders (e.g., depression) compared to men, at every level of household income. Also, society’s negative attitude towards mental disorders e.g., stigma, is more dominant in case of women which interferes with their connectivity with the society at large.
Depression during pregnancy, both ante-partum and post-partum, is very common in women in low income countries and affects infant and child growth and nutritional status. Violence/intimate partner violence has been implicated for all forms of mental disorders (anxiety, depression, suicide attempts and post-traumatic stress syndrome) in low-income countries like Bangladesh Rwanda, Ghana, India.
Social capital and mental health
Social capital plays a significant role for people’s health and well-being in resource-poor settings, e.g., in LMICs. It works both as a source of health information in times of need and also, as a safety net in absence of formal financial resources. There is an inverse relationship between levels of social capital and occurrence of common mental disorders in times of peace, and disaster. Individual level of social capital (e.g., level of trust and harmony in the society) in women and men has been shown to be inversely associated with common mental disorders in diverse low-income settings such as Peru, Ethiopia, Vietnam, and Andhra Pradesh of India, Bangladesh, and Vietnam.
For people of low-income countries, poverty is all pervasive and affects physical as well as mental health in various ways. Any attempt to ameliorate mental illnesses calls for attention to these important social determinants and take appropriate measures to overcome adverse conditions.