06 GHM 202 - Social and Biological Risk (2021-2022) AC

GHM 202 – Session 6: Social and biological risk factors for MNS conditions
Aims
To explain how social inequalities and biological risk factors affect mental health outcomes.
Learning objectives
By the end of this session you should be able to:
 Define key terms related to social and biological risk factors for mental, neurological, and
substance use conditions.
 Explain how social and biological risk factors interact and affect mental health outcomes,
referring to established models.
 Identify interventions that address social and biological risk factors.
 Draw on the principle of proportionate universalism to critically assess priority-setting in
health policy and planning.
Essential readings
 Jayasinghe S (2015). Social determinants of health inequalities: Towards a theoretical
perspective using systems science. Int J Equity Health, 14, 71.
 Lund C, Stansfeld S & De Silva M (2014). Social determinants of mental health. In: Patel V,
Minas H, Cohen A & Prince M (eds.) Global mental health: Principles and practice. New York:
Oxford University Press. pp 116-136.
Recommended readings
 Allen J, Balfour R, Bell R & Marmot M (2014). Social determinants of mental health. Int Rev
Psychiatry, 26, 392-407.
 Cooper S, Lund C & Kakuma R (2012). The measurement of poverty in psychiatric
epidemiology in lmics: Critical review and recommendations. Soc Psychiatry Psychiatr
Epidemiol, 47, 1499-516.
 Fisher J, Mello MCD, Patel V, Rahman A, Tran T, Holton S & Holmes W (2012). Prevalence
and determinants of common perinatal mental disorders in women in low-and lower-middle-
income countries: A systematic review. Bull World Health Organ, 90, 139-149.
 Howard LM, Molyneaux E, Dennis C-L, Rochat T, Stein A & Milgrom J (2014). Non-psychotic
mental disorders in the perinatal period. Lancet, 384, 1775-1788.
 Lund C, Breen A, Flisher AJ, Kakuma R, Corrigall J, Joska JA, . . . Patel V (2010). Poverty and
common mental disorders in low and middle income countries: A systematic review. Soc Sci
Med, 71, 517-28.
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 Lund C, De Silva M, Plagerson S, Cooper S, Chisholm D, Das J, . . . Patel V (2011). Poverty

and mental disorders: Breaking the cycle in low-income and middle-income countries. Lancet,
378, 1502-1514.
 Muntaner C, Eaton WW & Diala CC (2000). Social inequalities in mental health: A review of
concepts and underlying assumptions. Health, 4, 89-113.
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Session outline
Aims....................................................................................................................................................1
Learning objectives.............................................................................................................................1
Essential readings..............................................................................................................................1
Recommended readings....................................................................................................................1
Session outline...................................................................................................................................3
Instructions.........................................................................................................................................4
1. Introduction.....................................................................................................................................4
2. Social inequalities and biological risk factors.................................................................................5
3. Models, mechanisms, and principles.............................................................................................7
4. Social risk factors.........................................................................................................................10
5. Biological risk factors....................................................................................................................15
6. High-risk populations....................................................................................................................18
7. Implications for policy and planning.............................................................................................20
8. Summary......................................................................................................................................21
9. Integrating activity.........................................................................................................................23
10. References.................................................................................................................................25
11. Answers to activities...................................................................................................................33
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Instructions
In this session you should first work through the different screens and spend time on the various
activities and exercises. This should take you about two hours. You will also be required to do any
required reading, as indicated. This should take you roughly an additional two hours.
You should then complete the integrating activity, referring to the readings as necessary. This
should take you about three hours.
Finally, you should spend a further two hours on self-study covering the supplementary reading
and any others from the references section as necessary.
1. Introduction
The Grand Challenges in Global Mental Health initiative has identified key areas of research that
must be undertaken in order to reduce the global burden of mental, neurological, and substance
use (MNS) conditions (Collins et al, 2011). These research priorities (ie prevention and
implementation of early interventions, improvement of treatments and increased access to care,
the identification of root causes, risk and protective factors) and the principles that undergird them
(ie use of life-course and system-wide approaches, consideration of environmental influences)
highlight the importance of understanding both social determinants of mental health and biological
risk factors for MNS conditions.
In this session, we will discuss the most prominent models, mechanisms and principles that shape
our understanding of risk factors for MNS conditions and how best to address them. We will then
examine a number of key social inequalities and biological risk factors in greater detail and discuss
how these risk factors might interact in high-risk groups. We will conclude with a brief overview of
the implications for policy and planning, which will be revisited in the session ‘Prevention of MNS
conditions and promotion of psychological wellbeing’.
There are two important points to keep in mind as we proceed.
First, it is important to remember that none of the risk factors we will examine in this session act in
isolation. For example, poverty is an important risk factor, but a woman living in poverty is at even
higher risk. Moreover, women are more likely to live in poverty, due partly to inequalities in terms
of educational opportunities. Fewer educational opportunities, in turn, increase the risk of
developing a MNS disorder (Fisher et al, 2014). These are just a few of the socioeconomic factors
that put women at risk, which we’ll explore further in this session.
Second, keep in mind how inequalities might also affect access to care. Access could be limited by
physical accessibility, help-seeking capacity, discrimination, or some combination of the three. For
example, it might be frowned upon for a woman to travel long distances unaccompanied, but she
may not have the financial resources to pay for a companion to join her or could be too ashamed
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to ask. The distance to health services is therefore compounded by discrimination and by the
woman’s help-seeking capacity.
Activity 1: Personal reflection

Not only is J.D. Vance’s TED talk on ‘America’s forgotten working class’ highly relevant to
current conditions in the United States, it also highlights the devastating effects of social
inequalities—which are as deeply entrenched in high-income countries (HICs) like the United
States as they are in low- and middle-income countries (LMICs).
Watch the video (http://www.ted.com/talks/j_d_vance_america_s_forgotten_working_class - t-
244906) and reflect on the ways in which the challenges that Vance describes might affect
physical and mental health in the community where he grew up. Write a short, reflective
paragraph (five to seven sentences) and post it to Moodle. Then look at the posts contributed
by your tutors and classmates. Did they come up with any new points that you hadn’t
considered before? Is there something missing from their posts that you think they should
consider? Comment on at least one post by a classmate or tutor.
2. Social inequalities and biological risk factors

The aetiology and onset of MNS conditions cannot be attributed to a single cause or risk factor.
Schwartz and Susser (2006) differentiated between a necessary cause (‘the disease will not occur
without it under any circumstances’), a risk factor (‘a factor that contributes to the risk of a disease,
but may be neither necessary nor sufficient to produce it’) and causal partners (‘when two or more
risk factors are involved in a causal pathway’). When it comes to MNS conditions, there are
several different categories of risk factors involved in various causal pathways—including genetic,
psychological, social, neurological, and environmental factors.
The relationship between causes and risk factors is complex. It varies both across disorders and
between individuals suffering from the same disorder. Currently, the most widely accepted model
of this relationship takes into account biological, genetic, psychological, and societal causes or risk
factors, which can affect mental health at the individual- or population-level (Figure 1).
Although in recent decades there have been significant advances in our understanding of the
various risk factors for MNS conditions, many of the mechanisms by which these risk factors
interact are still unknown. Greater understanding and recognition of the role of social inequalities
(eg violence and poverty) and biological risk factors (eg genetics) is necessary in order to
effectively address the burden of MNS conditions.
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Figure 1. Social determinants of mental health: A conceptual framework

Source: (Lund et al, 2014a)
2.1. Definitions
We have already introduced a number of challenging concepts in this session and will continue to
introduce more as we proceed. Some working definitions are included here for quick reference.
Inequities are the differences that result from unjust inequalities. For example, inequalities in risk
for depression are associated with the unfair lack of health and mental health resources available
to groups that live in poverty or who are members of a disadvantaged social group.
A life-course approach to public health aims to systematically mitigate risk factors and promote
protective factors at each phase of life (WHO & Calouste Gulbenkian Foundation, 2014). The life-
course can be divided into phases according to age group (neonatal, childhood, adolescence,
young adulthood, adulthood, old age) or other socially defined categories (parenthood, working
age).
Social capital is the quality and quantity of social relationships in a community; social capital is one
way of measuring the social environment at either an individual or collective level (Ehsan & De
Silva, 2015).
Social determinants of health are the conditions in which people live, work and age, which are
shaped by the economic, social, environmental and political context (Allen et al, 2014).
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The social gradient in health is the well-documented association between socioeconomic status
and health, observable in LMICs and HICs alike (WHO, 2008).
Social inequality is the unequal distribution of political power, prestige and resources among
different groups in society.
Activity 2: Check your understanding
We introduce a number of new concepts in Section 2. Below are short examples derived
from recent research on Alzheimer’s disease in the United States
(https://www.washingtonpost.com/local/social-issues/stress-of-poverty-and-racism-raise-risk-
of-alzheimers-for-african-americans-new-research-suggests/2017/07/15/4a16e918-68c9-
11e7-a1d7-9a32c91c6f40_story.html?utm_term=.158b6241aaf5). Read each example, then
select the concept that best fits from the multiple-choice list provided. When you're finished,
check the answers at the back of the session notes.
1. The stress of poverty and life in disadvantaged neighbourhoods raises the risk of
developing Alzheimer’s disease.
a. Social determinants
b. Social capital
c. Life-course approach
d. None of the above
2. In many parts of the United States, African Americans are more likely to experience
poverty and to live in disadvantaged neighbourhoods.
a. Social gradient
b. Social inequality
3. Studies from the United States find African Americans are one-and-a-half times more
likely to develop Alzheimer’s disease than whites.
a. Inequities
b. Social capital
3. Models, mechanisms, and principles

3.1. Stress-adversity
The stress-adversity model hypothesises that the degree to which environments present danger
and hardship to individuals is positively associated with risk for psychopathology (Cohen & Minas,
2008). In other words, there is a dose-response relationship between degree of hardship and risk.
For example, this type of association was found in a study examining the relationship between the
prevalence of psychiatric symptoms and experiences of torture among Vietnamese ex-political
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detainees. More exposure to torture was associated with higher rates of PTSD and depression
(Mollica et al, 1998).
3.2. Stress-diathesis
The stress-diathesis model is slightly more nuanced than the stress-adversity model. It portrays
risk of psychopathology as a product of environmental stressors and individual vulnerability
(Cohen & Minas, 2008). Vulnerability, in turn, is influenced by individual and social factors. The
individual’s reaction to stressors—shaped by the strength of their resilience and presence or
absence of risk and protective factors—determines whether he or she will ultimately develop a
mental disorder. Education and job security are examples of protective factors at the individual
level. Social capital, social inclusion and social cohesion are protective factors at the community
level.
Interventions informed by the stress-diathesis model aim to decrease stress, strengthen protective
resources, or increase resilience, by targeting social and/or environmental factors—a process
known as ‘buffering’.
3.3. Social inequalities at the individual and population level

Jayasinghe (2015) posits that the social determinants of health inequalities are the result of three
factors: context, structural mechanisms, and the socioeconomic position (SEP) of the individual
(see Figure 2). Context is a flexible concept that encompasses social, cultural and political
systems, and is strongly influenced by the decision-making of the state. Within these systems,
there are structural mechanisms that produce social and economic hierarchies, including gender,
race and ethnicity, wealth, and educational attainment. Subsequently, the socioeconomic positions
of individuals reflect the unequal distribution of power, prestige, and access to resources—hence,
producing social inequalities in health.1
Research related to the effects of social inequalities at both the societal and individual level
identifies different—and often complementary—opportunities to improve mental health outcomes.
Geoffrey Rose (1985) argued that the causes of disease are different for the individual and the
population, but risk factors driving incidence rates are likely to affect everyone—not only those
identified as high-risk. Rose makes the case for a population-centred approach to disease
prevention, maintaining that the health of individuals will be improved through population-level
interventions. However, Razak et al (2016) have questioned this assumption, suggesting that it is
better to focus prevention efforts on high-risk groups, rather than on an entire population. This
targeted approach to prevention requires a precise understanding of social determinants and the
unequal distribution of risk across populations. We will discuss these issues at length in the
session ‘Prevention of MNS conditions and promotion of psychological wellbeing’.
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For more detail, see Jayasinghe (2015). For a more detailed explanation of the above summary, focus on the section
entitled: ‘Current conceptualisation of SDHI’ (social determinants of health inequalities).
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Figure 2. The structural mechanisms of social inequalities 2
3.4. Life-course approach and proportionate universalism

A life-course approach means targeting the most pertinent social inequalities specific to each life
phase. For example, at the neonatal stage, this might mean targeting maternal nutrition; during
childhood, this could mean targeting education. The WHO promotes the adoption of a life-course
approach, with the caveat that ‘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’. This approach to tackling social inequalities in health
also suggests that interventions should follow the principle of proportionate universalism (WHO &
Calouste Gulbenkian Foundation, 2014). In other words, interventions should be made available
according to individuals and groups according to their level of need, instead of focusing solely on
those who are the most disadvantaged or at-risk.
2
Structural mechanisms in the diagram are not an exhaustive list.
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4. Social risk factors

4.1. Socioeconomic status
Socioeconomic status (SES) can be conceptualised in many different ways. Three fairly technical
ways of defining SES include absolute SES, neighbourhood SES, and relative socioeconomic
position (SEP), further discussed in this section.
4.1.1. Absolute SES
Absolute SES ideally refers to the wealth (assets minus debt) of an individual or household. This
type of measure was used in New Zealand in a study that examined the relationship between
wealth and mental health through a nationwide survey that collected information on levels of
psychological distress, occupation, family and household, income, and wealth. In brief, the study
found that individuals with relatively low levels of wealth were, compared to those with more
wealth, 1.45 times more likely to report high levels of psychological distress (Carter et al, 2009).
While this study demonstrated the association between psychological distress and adult SES,
there is also evidence that socioeconomic disadvantage in childhood has a similar effect.
Research suggests that children and adolescents who are socioeconomically disadvantaged are
between two and three times more likely to develop mental health problems than those who are
not (Reiss, 2013). Social disadvantage in childhood also appears to have long-term effects. For
example, low SES in childhood has been demonstrated to increase risk for major depression in
adulthood, even when controlling for adult SES (Gilman et al, 2002).
However, information about total value of assets and extent of debt is often not available, and
most studies rely on self-report of income. In most high-income countries, individuals (assuming
they are willing to divulge the information) can easily report annual income. This is not as possible
in LMICs, where informal economies and subsistence agriculture may be the prevailing methods
by which individuals make their livings. Thus, measures of income may not be reliable in LMICs,
and it becomes necessary to adopt a different approach to measuring socioeconomic status.
A wealth index is one proxy used to determine household wealth. For example, a study in Morocco
created an index based on: whether the household owned a particular item (eg television, car, or
refrigerator); characteristics of the house (eg modern roof or floor, number of persons per room);
and levels of education. Index scores were found to be negatively correlated with child mortality,
ie, families who scored high on the wealth index had relatively lower risk of infant and child
mortality (Garenne & Hohmann-Garenne, 2003). Other studies have used a simpler list of items in
households to determine SES. For example, a study in Nigeria used this approach and found that
incidence rates of dementia were relatively high among older residents of households with
relatively low SES (Gureje et al, 2011).
4.1.2. Neighbourhood SES
Neighbourhood SES is independent of individual socioeconomic status, accounting instead for the
collective SES of a defined neighbourhood.
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Activity 3: Critical thinking

A study in the UK found that individuals living in socioeconomically deprived neighbourhoods
were at elevated risk for depression, as well as persistent episodes of depression (Ostler et al,
2001). Other research suggests that the degree of neighbourhood deprivation is also
associated with risk of psychosis (Kirkbride et al, 2014; Omer et al, 2014).
On Moodle, list three reasons living in a deprived neighbourhood would elevate an individual’s
risk for depression. Then list three reasons living in a deprived neighbourhood would elevate
the risk for an episode of depression that persists, ie, last a long time or becomes chronic.
When you’re finished, check the model answers at the back of the session notes.
4.1.3. Relative SEP

Relative SEP compares the wealth of one entity (individual, community, region, country) to others
around it, encompassing both social class and socioeconomic position. A meta-analysis
demonstrated that higher income inequality is associated with poorer health, in general, and with
mental health, in particular (Pickett & Wilkinson, 2010). Research from South Africa suggests that
degree of income inequality is associated with risk of depression (Burns et al, 2017) and
schizophrenia (Burns & Esterhuizen, 2008).
The difference between absolute SES and relative SEP is that an individual may have a low
absolute SES (ie little wealth) but a high relative SEP (ie the people around him/her also have little
wealth). Michael Marmot clarifies with the following example: African-American men in black
communities in the US—men who are frequently experience police harassment and violence and
are deprived of work and educational opportunities—have shorter life expectancies than men in
Costa Rica even though African-American men have higher incomes relative to Costa Rican men
(Marmot, 2006). Relative community or regional SEP is quantified with the Gini coefficient, a
measure of the degree of income inequality in a geographic area. For example, research has
demonstrated that women are at increased risk for depression in US states that have relatively
high Gini coefficients (Pabayo et al, 2014), while research in São Paulo, Brazil, suggests that living
in neighbourhoods with relatively high levels of income inequality elevates the risk of depression
among adults (Chiavegatto Filho et al, 2013).
Box 1. Impact of poverty alleviation interventions on mental health
Given the increased risk of MNS conditions associated with poverty, one might expect that
poverty alleviation programmes lower that risk. However, the evidence is mixed. Costello et al
(2010) showed that lifting families out of poverty through employment reduced
psychopathology among children, adolescents, and young adults in the short- and long-term. In
contrast, Lund et al (2011) examined the evidence from three poverty alleviation programmes
(cash transfers and microcredit) in sub-Saharan Arica and found that one had beneficial effects
on mental health, one had negative effects, and one demonstrated no difference.
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4.2. Social capital

There are five types of social capital (Szreter & Woolcock, 2004):
 Cognitive: what people think (eg trust in someone)
 Structural: what people do (eg partaking in social activities)
 Bonding: links between people of similar social status (eg workplace relationships)
 Bridging: links between people of different social groups (eg relationships with neighbours)
 Linking: links between people and other individuals or institutions with more powerful
positions (eg relationships with community leaders)
There are both individual and ecological measures of social capital. Individual social capital
considers the actions and beliefs of individuals in a community. Ecological social capital
aggregates individual responses to determine, for example, what proportion of a community
believes that members of the community can be trusted.
A review of the relationship between social capital and mental health found that individual and
ecological cognitive social capital are both associated with a lower risk of common mental
disorders; however, evidence for ecological social capital is not as strong. No association was
found between common mental disorders and structural social capital—neither individual nor
ecological (Ehsan & De Silva, 2015).
Evidence is lacking about the possible association between social capital and risk of psychosis,
although the suggestion has been made that social capital may help to explain the association
between schizophrenia risk and urbanisation (Krabbendam & van Os, 2005). Few researchers
have designed interventions targeting social capital to improve the mental health of populations.
Figure 3 presents two examples and their results, but keep in mind that results of these sorts of
interventions are often mixed (Noya & Clarence, 2009; Semenza et al, 2007; Verduin et al, 2014).
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Sociotherapy-based Results: Significant positive effects on civic participation

intervention to improve and mental health, although these were not sustained
social capital and mental overtime.
Interpretation: These findings point out the potential
health in Rwanda. positive effects of increasing social capital on mental
(Verduin et al. 2014) health.
Intervention to promote
community participation in
Results: Significant positive effects on social capital, sense
the improvement of urban of community and mental health, although sustained
spaces and its effects on effects over time is uncertain.
social capital, sense of Interpretation: This study showed the benefits of
community and mental community empowerment and the engagement of
health in the US. multiple stakeholders (eg urban planners, politicians and
residents)
(Semenza, March and
Bontempo, 2007)
Figure 3. Social capital interventions

Source: (Noya & Clarence, 2009; Semenza et al, 2007; Verduin et al, 2014)
4.3. Education
Education and mental health have a bidirectional relationship. Higher educational attainment
protects against the development of MNS conditions, while lower educational attainment
constitutes a risk factor for common mental disorders (Lund et al, 2010). For example, a study in
Chile found a strong, inverse, and independent association between educational attainment and
common mental disorders. In other words, less education was associated with an increased
prevalence of common mental disorders (Araya et al, 2003). It appears that level of education also
has consequences for help-seeking behaviour. For example, a Canadian study found that for each
additional level of educational attainment, individuals were 15% more likely to see a psychiatrist
(Steele et al, 2007).
The evidence suggests that early-onset MNS conditions—especially bipolar, disruptive behaviour,
major depressive and anxiety disorders—are associated with early termination of education, and
that lower educational attainment is a risk factor for suicidal behaviour (Borges et al, 2010).
Education for mothers in Peru has been shown to have a double effect: it reduces the risk of MNS
conditions for the mothers and is associated with relatively better nutrition and cognitive
development for their children (Di Cesare et al, 2013). However, the benefits of education on
mental health may be limited—or even negative—in some countries if individuals cannot leverage
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higher education to find better-paid employment (Bracke et al, 2014). This could help to explain
why education is a strong predictor of mental health in some countries but not others (Araya et al,
2003).
4.4. Negative life events

Negative life events are those that cause emotional distress and/or threaten to disrupt routine
activities of individuals (Dohrenwend, 1973). Such events include family breakdown, bereavement,
experiencing or witnessing of violence, natural disasters, conflict and physical illness. Some
population groups may be more likely to experience negative life events, eg bereavement and
poor physical health are more likely to be experienced in old age (WHO & Calouste Gulbenkian
Foundation, 2014). In addition, the SES of an individual may influence the likelihood of
experiencing negative life events. During war, for example, a family with higher financial means
can afford to escape, possibly to another country, while poorer individuals must remain where they
are or move within the country. Two classic studies demonstrated that similar life events were
associated with increased risk of depression for women in London, UK (Brown & Harris, 1978),
and Harare, Zimbabwe (Broadhead & Abas, 1998).
Because of armed conflict, millions of people across the globe have experienced violence,
displacement, and separation from family. Social bonds are frayed, support systems are
fragmented, financial opportunities are lost, infrastructures are weakened, and rates of
communicable and non-communicable disease increase (Ratnayake et al, 2014; Tol & van
Ommeren, 2012). Although interventions that address emotional distress are necessary, the social
environment is a crucial target, too. For example, a group therapy intervention in Rwanda
promoted social interaction in order to restore and strengthen the social bonding that had been
destroyed by the genocide (Scholte et al, 2011). We will cover this topic more in depth in ‘Mental
health and humanitarian crises’.
4.5. Global forces

UNESCO compares globalisation to climate change: ‘If climate change is the key process in the
natural world impacting on sustainable development, then globalisation is the parallel process in
the human world, creating both opportunities for, and barriers to, sustainable development’
(UNESCO). Aspects of globalisation that undoubtedly impact mental health include urbanisation,
migration, rapid social change, spread of Western media and culture, and trade (Lund et al,
2014a). Globalisation can further exacerbate existing social and economic disparities, forcing
individuals to reshape their identities ‘to a new cultural environment’ (Bhavsar & Bhugra, 2008).
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Activity 4: Check your understanding

A recent news article about urbanisation starts with the following statement: ‘Urbanisation is
one of the defining processes of modern times, with more than half of the world’s population
now living in cities, and new mega-metropolises mushrooming in Asia, Latin America and
Africa’ (https://www.theguardian.com/cities/2016/jun/27/rise-fall-great-world-cities-5700-
years-urbanisation-mapped) A related article, ‘Sick cities: why urban living can be bad for
your mental health’, (https://www.theguardian.com/cities/2014/feb/25/city-stress-mental-
health-rural-kind) cites evidence about how living in cities puts individuals at risk for MNS
conditions. Based on the second article ('Sick cities'), complete the activity below. When
you're finished, check the model answers at the back of the session notes.
1. Name two features of urban living that may be associated with poor mental health. For
each feature, provide a one-sentence explanation of how it affects stress.
2. Provide two reasons why living in cities could actually be good for one's mental health.
4.5.1 Climate Change

Climate-related weather events and environmental changes are increasingly understood to
negatively impact mental health and wellbeing.
A range of undesirable climate-related exposures such as floods, rainfall, humidity, heat, droughts
and wildfires, have been found to be associated with psychological distress, diminished mental
health, increased psychiatric hospitalisations, heightened mortality in people with a pre-existing
mental health condition and higher levels of suicide rates (Charlson et al, 2021). Moreover, several
intense emotions have been linked to climate change, such as hopelessness, helplessness,
sadness, despair, fear, anger, stress; high rates of mood disorders, post-traumatic stress;
increased drug and alcohol use; increased suicide ideation, threats and disruptions to sense of
place; and loss of personal or cultural identity (Clayton et al, 2017; Cunsolo & Ellis, 2018).
Multiple pathways have been attributed to a decline in mental health as a result of climate change.
Mental health can be impacted through ‘direct’ changes to the climate such as extreme weather
events or natural disasters, or through ‘indirect’ long-term causes resulting from direct events,
such as food insecurity, damage to local infrastructure, and forced migration. (Comtesse et al,
2021). The term ‘ecological grief’ (also known as climate grief) has been commonly used to
describe climate-change related distress. Cunsolo and Ellis defined this concept as “the grief felt
in relation to experienced or anticipated ecological losses, including the loss of species,
ecosystems and meaningful landscapes due to acute or chronic environmental change” (p. 275,
Cunsolo & Ellis, 2018).
Ecological grief can be understood in relation to three levels (Cunsolo & Ellis, 2018):
1) Physical ecological losses (e.g., physical disappearance, degradation and/or death of
species, landscapes, and ecosystems).
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2) Loss of environmental knowledge and identity (e.g., when knowledge in relation to a land’s
physical features and uses by those whose lives and work are closely related to the natural
world, are no longer available due to unforeseeable changes to the weather and landscape)
3) Anticipated ecological losses that have not yet happened, associated with fear that people’s
way of life, livelihood, and culture will be lost as a result of climate change.
Closely related terms that may be regarded as sub-concepts of ecological grief include
‘Solastalgia’ which refers to a form of distress or pain caused from losing a comforting place due to
‘actual’ ecological loss of landscape; and ‘ecological-anxiety’, which has been referred to as an
adaptive emotional response, characterised by feelings of uncertainty, hopelessness and
helplessness in response to ‘future threats’ to the environment that may not have happened yet.
(Comtesse et al, 2021).
Box 2. Climate change and mental health

Illustrative examples of ecological-grief, and respective sub-concepts covered in section 4.5.1
can be found in the short film and online articles below.
 Attutauniujut Nunami / Lament for the Land. This short film tells the story of 24 Inuit
people from Nunatsiavut, Labrador on the mental, emotional and cultural impacts of rapid
climate change on one of Canada’s oldest and most enduring cultures.
https://www.youtube.com/watch?v=yi7QTyHERjY
 'Solastalgia': Arctic inhabitants overwhelmed by new form of climate grief. A Guardian
news article on the mental health and cultural impact of climate change on people living
in the arctic. https://www.theguardian.com/us-news/2020/oct/15/arctic-solastalgia-climate-
crisis-inuit-indigenous
 Climate grief: How we mourn a changing planet. A series of articles by BBC Future that
explore a wide range of emotions associated with climate change.
https://www.bbc.com/future/article/20200402-climate-grief-mourning-loss-due-to-climate-
change
5. Biological risk factors

5.1. Communicable diseases
5.1.1. HIV/AIDS
Major depression, dysthymia, anxiety, and substance use disorders are recognised comorbidities
of HIV/AIDS (Gaynes et al, 2015; Maj et al, 1994). The relationship between HIV/AIDS and
comorbid MNS conditions is bidirectional. The stigma associated with HIV/AIDS—in addition to the
physical and psychological consequences of having a life-threatening disease—increase risk of
developing a MNS condition. On the other hand, risky behaviours such as alcohol and drug use
16
elevate the risk of contracting HIV through unprotected sex and intravenous drug use (Chander et
al, 2006). The prevalence of HIV in people with severe mental disorders is between 1% and 24%
(De Hert et al, 2011). Treatment adherence and outcomes are also worse for people living with
HIV and a comorbid MNS condition (Ammassari et al, 2004; Ickovics et al, 2001).
Evidence of the effectiveness of psychological or psychopharmaceutical interventions for the
improvement of HIV-related health outcomes is mixed (Prince et al, 2007). The use of
antidepressants has been linked to increased adherence to antiretroviral treatment, but this has
not been confirmed by a randomised controlled trial. It is possible that the link between MNS
conditions and HIV/AIDS is mediated or confounded by factors that have not yet been
investigated.
5.1.2. Malaria
Although there has not been extensive research into the association between mental health and
malaria, a study in Ethiopia found common mental disorders to be present in around 25% of
patients with malaria. Suicidal ideation was present in 13% of the same patients (Tesfaye et al,
2014). A literature review also found strong evidence of the negative impact of malaria on
children’s cognitive functioning and development (Kihara et al, 2006). Recent evidence has shown
that cerebral malaria in infancy predicts MNS conditions in children (Idro et al, 2016). In addition,
certain antimalarial medications have psychiatric side effects including confusion, hallucinations,
mood change, and paranoia (Nevin & Croft, 2016).
Box 3. COVID-19 and mental health

In March 2019, the World Health Organization declared COVID-19, an infectious respiratory
disease, as an international public health emergency around the world (WHO, 2020). While
manifestations of the COVID-19 virus primarily affect the physical health of those infected, there
is mounting evidence to suggest that the pandemic has also had an unequivocal impact on the
mental health of the public, as well as COVID-19 patients.
The population at large have experienced heightened fear, worry and sadness in response to
the pandemic. Virus containment measures, such as physical distancing, shielding, restricted
physical contact with family, friends and co-workers has resulted in diminished social support
networks, that can lead to feelings of greater isolation and loneliness. Moreover, fear of
infection, bereavement, financial insecurity, and a reduction or loss of work may also negatively
impact mental health (Bernardini et al, 2021; OECD, 2021)
In the context of a newly emerging pandemic, some of these responses may be considered to
be functional. However, there is also evidence to suggest that rates of mental health symptoms
have increased. A study reviewing the impact of COVID-19 found comparatively higher rates of
symptoms of anxiety, depression, post-traumatic stress disorder, psychological distress, and
stress (Xiong et al., 2020). Moreover, a number of sub-populations have been identified to carry
17
a higher risk of poor mental health, including, non-infectious chronic disease patients,
quarantined persons, healthcare workers, and COVID-19 patients (Wu et al, 2021).
There is also evidence to suggest that a bi-directional association may exist between COVID-19
and psychiatric disorders. A retrospective cohort study in the US found that survivors of COVID-
19 with a psychiatric diagnosis in the previous year were more likely to have a higher incidence
of a COVID-19 diagnosis, especially for those with anxiety disorders, insomnia, and dementia.
However, while known physical health risk factors were accounted for, confounding by
socioeconomic factors cannot be ruled out. On the other hand, for patients with no previous
psychiatric history, a diagnosis of COVID-19 was associated with an increased incidence of a
first psychiatric diagnosis in the 14 to 90 days that followed after contracting the virus (Taquet et
al, 2021).
It is also important to note that COVID-19 infections are known to have neuroinvasive effects. A
study using data from real-time electronic medical records across international health care
systems found that 22% of people diagnosed with COVID-19 experienced neuropsychiatric
manifestations including headaches, sleep disorders (neurological manifestations), anxiety and
other related disorders, mood disorders and suicidal ideation (psychiatric manifestations)
(Nalleballe et al, 2020).
Emerging evidence has also found that psychiatric conditions were associated with increased
COVID-19–related mortality, when compared to patients without psychiatric conditions (Fond et
al., 2021). In particular, greater risk of COVID-19 mortality was associated with pre-existing
mental disorders such as psychotic and mood disorders, substance misuse disorders, and
intellectual disabilities and developmental disorders, after adjusting for age, sex and other
confounders (Vai et al, 2021).
While further research is required to determine the underlying mechanisms between what
appears to be a bi-directional association between COVID-19 and psychiatric conditions, these
findings highlight the need for targeted approaches to manage mental health and prevent
COVID-19 in groups within the population that are at risk (Vai et al., 2021).
5.2. Non-communicable diseases

5.2.1. Cardiovascular diseases
There is a significant association between common mental disorders and cardiovascular disease.
Angina (ie, chest pain, a possible symptom of coronary disease), as well as fatal and non-fatal
strokes have also been associated with anxiety and depression. At the same time, depression has
been identified as a risk factor for stroke, and comorbid depression has been found to predict
mortality from coronary heart disease (Albus, 2010; Prince et al, 2007). Comorbid depression
might also pose challenges to the adoption of healthier lifestyles for patients with cardiovascular
18
disease, thus leading to poorer outcomes. Although research into the effects of psychological
interventions on heart disease has found it possible to reduce the symptoms of common mental
disorders, research has not found that psychological interventions reduce mortality (Rees et al,
2004). With regard to treatment of depression in stroke patients, more research is needed to
determine whether the use of antidepressants significantly improves either neurological or
psychiatric symptoms (Hackett et al, 2005).
5.2.2. Diabetes
Estimates show that 11% of patients with diabetes have comorbid major depressive disorder and
around a third report symptoms of depression (Anderson et al, 2001). Research has also found
that depression is relatively common in adolescents with Type 1 diabetes (Kanner et al, 2003).
Depression in patients with diabetes has been associated with poor health outcomes such as low
adherence to glycaemic control guidelines, complications (eg retinopathy and nephropathy),
depression relapse, and a significant increase in mortality (de Groot et al, 2001; Katon et al, 2005;
Lustman et al, 2000). It is likely that depression poses a major barrier in terms of adherence to
healthier lifestyles.
Schizophrenia and diabetes are also strongly associated. Prevalence of diabetes in individuals
with schizophrenia is around 15% (Holt et al, 2005). In addition, poor health outcomes, such as
vascular complications, metabolic regulation, and mortality, are also common, and are likely
related to behavioural factors as well as the secondary effects of antipsychotic medications.
Evidence related to the effect of psychological interventions is mixed. Whereas meta-analyses
have found a positive effect in patients with Type 2 diabetes, a large trial conducted in primary
health clinics found no improvement in treatment adherence when using pharmacological
treatments and/or talking therapy (Ismail et al, 2004; Lin et al, 2006).
5.3. Genetics
The majority of human traits—including disease risk—are the result of a complex interplay
between our genes and our environment. Heritability is a statistic that measures the degree to
which variation in a certain trait in a population is due to their genetic variation (Wray & Visscher,
2008). Some traits, such as height, are largely determined by genetic factors and are said to have
a high degree of heritability. Other traits, notably behavioural traits, are largely determined by
environmental factors, and thus have a low degree of heritability. Whether understanding the
genetic basis of MNS conditions and their heritability will aid prevention of mental illness at the
population level remains an open question.
Genome-wide association studies (GWAS) have replaced more targeted approaches for
identifying genes associated with diseases. Before GWAS, it was thought that a small number of
genes controlled a single trait. What GWAS have demonstrated is that almost all human traits are
influenced by a large number of genes (Rutherford, 2016). Given the vast complexity of the human
brain, it is perhaps unsurprising that many genes are involved in MNS conditions.
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3.3.1.Genetic basis of schizophrenia

By tracking inheritance of schizophrenia in families and comparing coincidence of the disorder
between monozygotic (identical) and dizygotic (non-identical) twins, schizophrenia has been
shown to have a high (~80%) degree of heritability (Lichtenstein et al, 2006; Sullivan et al, 2003).
This suggests that genetic variants can dramatically increase an individual's risk of developing
schizophrenia.
At one time, the assumption was that the ability to compare whole genomes of people with
schizophrenia and those without would reveal the responsible genes. However, we now know that
the situation is more complex. The largest and most recent GWAS (involving 36,989 cases and
113,075 controls) identified 108 genetic loci associated with schizophrenia (Schizophrenia Working
Group of the Psychiatric Genomics Consortium, 2014). However, genes do not explain everything.
There is increasing evidence of the importance of epigenetics—changes in the expression of
genes due to environmental factors—in the aetiology of schizophrenia (Cariaga-Martinez et al,
2016). For example, a long-term follow-up study in Finland of adoptees at varying risk for
schizophrenia found that disruptive family environments were associated with the expression of
schizophrenia-spectrum disorders, but only for those adoptees at high genetic risk (Tienari et al,
2004).
3.3.2.Genetic basis of depression

Increased incidence of depression within families and between identical twins provides strong
evidence for a genetic contribution to depression, which is estimated to be around 40% (Kendler et
al, 2007; Sullivan et al, 2000). This is lower than for other MNS conditions, notably schizophrenia
and bipolar disorder. Nevertheless, the modest degree of heritability detected by these studies
suggests that, while depression is largely caused by environmental factors, there are also
significant genetic risk factors.
Several large GWAS have tried to identify genetic loci that are associated with depression. The
first meta-analysis, which looked at over 75,000 individuals, failed to find any loci that were
significantly associated with clinically diagnosed depression (Cross-Disorder Group of the
Psychiatric Genomics Consortium, 2013). Subsequent studies have tried to improve on this by
using a narrower definition of depression in a better-defined population, and have identified a
limited number of genetic loci that are associated with depression (Converge Consortium, 2015;
Wong et al, 2016). Another study that used self-report to identify cases and controls found 15
genetic loci associated with depression (Hyde et al, 2016). For the twenty-plus genes identified in
these three studies, two (TMEM161B and PHF21B) have been shown to play a role in mouse
models of depression and tolerance of stress, and two more (MEF2C and TRPM2) have been
associated with other neurological disorders (Le Meur et al, 2010; Paciorkowski et al, 2013; Wong
et al, 2016; Xu et al, 2009).
At this stage, all we can conclude is that depression is a complex condition and that there are
probably hundreds of genes contributing to its expression. As we approach the era of personalised
20
medicine, there may be some value for identifying genetic risk factors for depression and
developing these as drug targets. However, for the vast majority of people suffering with
depression, especially in LMICs, addressing the environmental risk factors is more relevant and
feasible.
Activity 5: Critical thinking
Breast cancer has been shown to be less heritable than depression (Lichtenstein et al, 2006).
Evans et al (2016) recently found there is a higher survival rate for patients receiving
intensive screening for breast cancer after testing positive for a genetic mutation. Given that
we have identified genes that increase risk of depression, would it be useful at this point to
develop genetic tests to help targeted prevention for at-risk individuals? List three possible
critiques of this approach to prevention, then check your responses with the model answers
provided at the end of the session notes.
6. High-risk populations
Population groups include social groups classified by gender, ethnicity, and sexual orientation,
among many others. In this section we will focus on two social identifiers: gender and ethnicity.
6.1. Gender
While there are biological differences between the sexes, social inequalities arguably play a more
important role in determining the mental health outcomes of men and women. For example,
prevalence data has consistently shown that women experience more mood disorders (ie
depression and anxiety) than men, while men experience more substance use disorders than
women (Seedat et al, 2009). It has been hypothesised that these differences are caused by
gender roles that normalise different coping strategies for men and women; as a result, women
tend to internalise emotional problems, while men externalise. This could also be a reason for the
higher rate of suicide among men compared to women—a phenomenon which we will discuss at
length in the session ‘Suicide’.
Cross-national research suggests that gender differences in the prevalence of major depressive
disorder and substance abuse are narrowing. One possible reason for this shift might be that
efforts to increase access to education and employment opportunities have decreased the
stressors to which women are exposed, and allowed them to access more ‘stress-buffering
resources’. In terms of substance use disorders, the increased prevalence among women could
be due to changes in attitudes about gender roles and substance use.
While the gap is narrowing, in most countries, substance use is still more prevalent in men than in
women. Data from the Global Burden of Disease Study suggested the burden of disease due to
alcohol, opioid, cocaine, amphetamine and other drug use disorders were between 12.3 and 303.9
times higher for men than women. The largest differences were in the burden of alcohol use
disorders (Whiteford et al, 2015).
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6.1.1. Maternal health

Maternal mental disorders offer an interesting case study of the interaction between biological and
social risk factors at a crucial stage in the life-course for both mothers and infants.
Extensive research has linked maternal mental disorders to negative outcomes in child physical
and emotional development. Due to its high prevalence, maternal depression (ie postpartum
depression, peripartum depression) has received special attention. It is estimated that 10% to 20%
of women experience depression during pregnancy or in the first 12 months postpartum (Shidhaye
& Giri, 2014), and rates have been found to be even higher in LMICs (Fisher et al, 2012). Relative
socioeconomic position, the relationship with the partner, and experience of violence are some of
the risk factors for maternal depression. Some of the effects on child outcomes that have been
found are low birthweight (Rahman et al, 2007), undernutrition and stunting (Rahman et al, 2004)
and cognitive and motor developmental delay (Deave et al, 2008; Galler et al, 2000). Some of
these child health impacts have been found to have a negative effect on health in later stages of
life; for example, harmful levels of glucose, blood pressure, and lipids in adults have been
associated with low birthweight and undernutrition during childhood (Victora et al, 2008).
Maternal depression has also been associated with children’s emotional problems—internalizing
(eg depression and anxiety), externalizing (eg aggression, conduct disorder, attention deficit
hyperactivity disorder) and general psychopathology (ie a combination of the previous two)—with
a greater effect in children who are exposed at a younger age and in families living in poverty
(Goodman et al, 2011). Potential explanations are that mental illness in mothers can contribute to
poor attachment behaviours and/or parenting practices, such as the use of physical punishment.
See Box 2 for examples of interventions targeting maternal and child wellbeing.
Box 4. Interventions targeting maternal and child mental health and wellbeing
Towards Parenthood is an intervention delivered through self-help printed materials, with the
support of specialists. The intervention is designed to help new parents strengthen their
relationship with their infant. Communication, coping skills, problem-solving and self-esteem
are some of the targeted areas. In a randomised controlled trial (RCT) conducted in Australia,
this intervention showed significant reductions in depression and anxiety (Milgrom et al, 2011).
Thinking Healthy Programme is an intervention that employs cognitive behavioural therapy
(CBT) delivered by lay health workers and which has been shown to reduce maternal
depression and improve child health outcomes in a large RCT in Pakistan (Rahman et al,
2008). The WHO also recommends this intervention to reduce maternal depression, and the
programme has been implemented in different regions around the world. For more information,
visit the Mental Health Innovation Network (http://www.mhinnovation.net/innovations/thinking-
healthy-programme?mode=default _2).
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6.2. Race and Ethnicity

It is important to remember that it is not necessarily race or ethnicity in isolation that results in
systematic differences in mental health, but rather the risk factors often associated with ethnicity;
for example, experiences of racism, social exclusion, economic disadvantage, and differential
treatment in—and access to—health and other services (Lund et al, 2014b).
A large household survey explored the relationship between ethnicity and depression among the
black American population in the US, and made comparisons to the white population (Williams et
al, 2007). The 12-month prevalence of major depressive disorder was similar across groups (see
also Breslau et al, 2005), but the lifetime prevalence was 17.9% for whites, 12.9% for Caribbean
blacks, and 10.4% for African Americans. The chronicity (ie, persistency, duration, and frequency
of recurrence), however, was higher for African Americans (56.5%) and Caribbean blacks (56.0%)
compared to whites (38.6%). Furthermore, just 45.0% of African Americans and 24.3% of
Caribbean blacks received any form of therapy for major depression (data on rates of treatment
among whites is not available). On average, these groups also rated their disorder as more
disabling and severe, compared to whites.
Consequently, addressing inequalities resulting from ethnicity are extremely complex, given the
potential biological factors, the accumulation of risk factors, and the implications of stigma from
within the community, towards the community, and from health professionals themselves.
7. Implications for policy and planning

As students of global health policy—not medicine—you might be wondering why it is necessary
that we explore the risk factors of MNS conditions in such detail. There are four specific situations
in which policymakers must pay special attention to social and biological risk factors. Two are
related to research and evaluation, and two are directly related to policymaking. These situations
are discussed briefly in this section.
More details about the policy planning process, its importance, and implications for the mental
health of populations are explored in the sessions ‘Policy and legislation’ and ‘Prevention of MNS
conditions and promotion of psychological wellbeing’.
7.1. Census and epidemiological data

Comprehensive data on social, economic, and health indicators is necessary for research as well
as policymaking. It is important to determine which social factors increase risk, identify vulnerable
groups, and examine associations between different disorders in order to develop and test
appropriate interventions.
7.2. Evaluation data

Often the impact of health and social programmes on mental health is not evaluated. Including
mental health indicators in the evaluation of programmes tackling social or biological risk factors
(eg welfare or HIV programmes) could help to inform policymaking across sectors.
23
7.3. Inter-sectoral policymaking

Inter-sectoral cooperation and support is essential to effective policymaking. Many structural
factors affecting mental health could be more efficiently approached through other sectors. One
example is advocating for regulations or policies that restrict the availability of pesticides or extend
the amount of maternity leave, both of which have had positive impacts on suicide rates and
depression, respectively, in some countries (Gunnell et al, 2007; Staehelin et al, 2007).
7.4. Priority-setting
The Independent Inquiry into Inequalities in Health has recommended that priority should be given
to policies that aim to tackle social inequalities. Special attention should be given to those that
reduce income inequalities and promote equitable access to health and education, given the
potential benefits to health overall (UK Department of Health, 1998). While aiming for universality,
policies should also take into account the social gradient in health; in other words, policies should
target whole populations but address needs proportionally.
8. Summary
This session has presented evidence of the complex interaction between social and biological risk
factors and MNS conditions. Two models (stress-adversity and stress-diathesis) offer similar
explanations of the relationship between environmental factors and mental health; however, the
former emphasises the role of the environment, while the latter also considers the role of individual
vulnerability and resilience.
There are different conceptualisations of the mechanisms by which social inequalities affect
mental health at the individual and the population level. The WHO recommends a life-course
approach and embraces the principle of proportionate universalism. This means prioritising
interventions that address everyone’s needs—regardless of severity—at all stages of life, but
especially during childhood.
In this session, we have examined a number of social risk factors. Poverty is arguably the most
important, as it impacts quality of life, access to health services and other resources, risk of
experiencing a negative life event, and the physical and social environment in which individuals
live. It is also bound up with a number of other risk factors, such as social capital and education.
These factors interact and are amplified in certain settings (eg during humanitarian crises) and
populations (eg among ethnic minorities), heightening risk.
In terms of biological risk factors, there have been recent advances in genetics that have furthered
our knowledge of the heritability of MNS conditions, especially schizophrenia and depression.
Gene expression—largely moderated by the environment—is a potential target for future
treatments, although the global applicability of this is not yet certain. Perhaps more immediately
relevant is the high level of comorbidity between MNS conditions and both communicable and
non-communicable diseases. The available evidence underscores the need to treat health as a
holistic concept, in which physical health and mental health are inseparable.
24
Lastly, in this session we explained why it is so important to consider biological risk factors and
social inequalities in the context of policy design and service planning. Essentially, this session
has sought to demonstrate that treating MNS conditions is necessary but not sufficient to improve
mental health. Effective interventions that improve the social and economic environment, access
to services, and freedom from discrimination are also urgently needed; we will discuss this further
in the session ‘Prevention of MNS conditions and promotion of psychological wellbeing’.
25
9. Integrating activity
Integrating activity
Although we have not discussed mental health in the workplace at length in this session, it is a
hot topic in global mental health and the theme of World Mental Health Day 2017. For this
activity, we will examine some of the data compiled by the Organisation for Economic Co-
operation and Development (OECD) relevant to the well-being of the workforce and think about
implications for mental health in OECD countries.
For example, OECD measures job quality by rating various aspects like earnings, labour
market security, and quality of the work environment: http://www.oecd.org/statistics/job-
quality.htm.
Start by looking up the OECD data on job quality from 2013-2015 in this report:
http://www.oecd.org/sdd/labour-stats/Job-quality-OECD.pdf.Then, answer the questions in Part
A below, before checking the model answers at the end of the session notes.
In Part B, you will be asked to provide a more fine-grained interpretation of the 2015 OECD
data on job quality, examining key indicators disaggregated by sex:
http://stats.oecd.org/Index.aspx?DataSetCode=JOBQ#. As in part A, you can check the model
answers at the end of the session notes when you have written your response.
Part A: Short answer questions
1. Which two EU countries have the highest incidence of job strain?
2. Compare the data on incidence of job strain with the data on labour market insecurity,
for these two countries. What do you observe?
3. Analyse the relationship between job strain and labour market insecurity in three to four
sentences. How might high levels of insecurity in the labour market also place additional
strain on workers?
4. Compare the data on earnings quality from the countries you identified in response to
the first two questions. In three to four sentences, discuss the implications of this data, in
terms of both the relative socioeconomic position of the poorest citizens of these
countries and their absolute socioeconomic status.
Part B: Short answer questions

1. For the countries identified in Part A, refer to the job quality statistics disaggregated by
sex on the OECD statistics database. What trends do you observe for each of the
indicators of job quality? Give a one- to two-sentence description for each of the
indicators listed.
a. Job strain
b. Labour market insecurity
26
c. Earnings quality
2. Focusing on the one country where disaggregation by sex was possible for all three
indicators of job quality listed in Question 1 of Part B, what does this data suggest in
terms of the economic stressors affecting men and women, respectively? How might this
affect the relative risk for MNS conditions in men versus women? Explain, briefly, in
three to four sentences.
3. Drawing on the elements of social determinants theory, as illustrated in Figures 1 and 2,

how do you think job quality might relate to mental health? Give a two- to three-sentence
explanation for each of the four elements below, using gender as a lens to examine
inequalities in the countries we have been discussing.
a. Occupation
b. Socioeconomic position
c. Income and wealth
d. Educational achievements and access
27
10. References
10.1. Additional resources
OECD/Noya A, Clarence E. Community capacity building: fostering economic and social
resilience. Project outline and proposed methodology, 26-27 November 2009, working document,
CFE/LEED, OECD, www.oecd.org/dataoecd/54/10/44681969.pdf?contentId=44681970
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11. Answers to activities

11.1. Activity 2
1. The stress of poverty and life in disadvantaged neighbourhoods raises the risk of developing
Alzheimer’s disease.
35
a. Social determinants
b. Social capital
2. In many parts of the United States, African Americans are more likely to experience poverty
and to live in disadvantaged neighbourhoods.
a. Social gradient
b. Social inequality
3. Studies from the United States find African Americans are one-and-a-half times more likely to
develop Alzheimer’s disease than whites.
a. Inequities
b. Social capital
11.2. Activity 3
List three reasons living in a deprived neighbourhood would elevate an individual’s risk for
depression.
 Elevated risk of being victim of violence
 Poor housing conditions
 Lack of health services
List three reasons living in a deprived neighbourhood would elevate the risk for an episode of
depression that persists, ie, last a long time or becomes chronic.
 Elevated risk of being victim of violence
 Poor housing conditions
 Lack of health services
36
11.3. Activity 4
1. Name two features of urban living that may be associated with poor mental health, and
provide a one-sentence explanation of why each of these features of urban living might lead
to increased levels of stress.
Population density: High levels of population density can pose challenges to mental
health because of lack of privacy, noise and pollution.
Lack of social support: Migrants seeking employment in cities have often left their
families behind and have little in the way of social networks.
3. Provide two reasons why living in cities could actually be good for one's mental health.
More employment and career opportunities
Greater availability of most goods and services
11.4. Activity 5
List three possible critiques of this approach to prevention.
 There are probably hundreds of genes contributing to the expression of
depression, and other social and biological risk factors play an important role,
as well. At the moment, it is difficult to imagine a genetic test could be
developed that would have enough specificity to really ‘target’ prevention.
 Genetic testing would likely be quite expensive. As the cost of intensive
screening for breast cancer is very high, perhaps genetic testing is actually
cost-saving; this is not the case for depression, which can also be detected
with simple, self-reported screening tools.
 Following the principle of proportionate universalism, it might be more sensible
to use the limited resources available for prevention to focus on interventions
that reduce the population risk as a whole, not just the risk of targeted
individuals.
11.5. Integrating activity

Part A: Short answer questions
1. Which two EU countries have the highest incidence of job strain?
Greece and Spain have the highest incidence of job strain.
2. Compare the data on incidence of job strain with the data on labour market insecurity, for
these two countries. What do you observe?
Greece and Spain also have the highest labour market insecurity.
3. Analyse the relationship between job strain and labour market insecurity in three to four
sentences. How might high levels of insecurity in the labour market also place additional
37
strain on workers?
In a context of high unemployment risk and a weak safety net for those who are
unemployed, there is a strong disincentive for employees to challenge
excessive demands in the workplace. At the same time, as resources dwindle
and more people become unemployed, the demands placed on the remaining
employees increases. Therefore, it is perhaps unsurprising that both Greece
and Spain—two countries that have experienced crippling financial crises in
recent years—have both the highest incidence of job strain and the highest
labour market insecurity.
4. Compare the data on earnings quality from the countries you identified in response to the
first two questions. In three to four sentences, discuss the implications of this data, in
terms of both the relative socioeconomic position of the poorest citizens of these
countries and their absolute socioeconomic status.
Average earnings in both Greece and Spain are not the lowest of any OECD
country, though they are substantially lower in Greece than in Spain. Earnings
inequality is also middling, and similar in both countries. This suggests that
the relative socioeconomic position of the poorest citizens in Greece and Spain
is perhaps not as significant an issue as it might be in the United States, for
example. However, overall socioeconomic status is lower, particularly in
Greece.
Part B: Short answer questions
1. For the countries identified in Part A, refer to the job quality statistics disaggregated by
sex on the OECD statistics database. What trends do you observe for each of the
indicators of job quality? Give a one- to two-sentence description for each of the
indicators listed.
a. Job strain: In both Greece and Spain, job strain is higher for men than
women. In Greece, there is a higher level of demand and fewer resources for
men; however, in Spain, there is a higher level of demand and more
resources for men.
b. Labour market insecurity: In both Greece and Spain, labour market insecurity
is higher for women than men. In Greece, both unemployment risk and
unemployment insurance are higher for women; in Spain, however, the
unemployment risk is higher for women, but unemployment insurance is
lower.
c. Earnings quality: Disaggregated data is not available for Greece; however, in
Spain, earnings quality is lower for women than men. While the earnings
inequality index used for both men and women is the same, the difference in
average earnings accounts for the gap in earnings quality.
2. Focusing on the one country where disaggregation by sex was possible for all three
indicators of job quality listed in Question 1 of Part B, what does this data suggest in
terms of the economic stressors affecting men and women, respectively? How might this
affect the relative risk for MNS conditions in men versus women? Explain, briefly, in three
to four sentences.
38
In Spain, men experience greater job strain, but they are also more likely to
have a job in the first place, and their jobs are higher-paid. The consequences
of unemployment are also harsher for women, who are less likely to have
unemployment insurance. So, while we might expect stress related to job
strain to be higher among men, for women, stress related to income inequality
—whether a result of lower-paying jobs or inequitable access to unemployment
insurance—might be higher.
3. Drawing on the elements of social determinants theory, as illustrated in Figures 1 and 2,
how do you think job quality might relate to mental health? Give a two- to three-sentence
explanation for each of the four elements below, using gender as a lens to examine
inequalities in the countries we have been discussing.
a. Occupation: Job strain, labour market insecurity and earnings quality all vary
by occupation, and options are limited by education. Some would also argue
that gender discrimination is observable in terms of the kinds of
occupations deemed appropriate for men and women, respectively. While
there is no direct measure included in this dataset, we can perhaps infer
from the higher rates of unemployment and lower salaries of women, that
occupation differs by sex—perhaps exposing men and women to different
stressors.
b. Socioeconomic position: Earnings inequality is an indicator of relative
socioeconomic position, which both impacts and is impacted by mental
health. The same estimate of earnings inequality was used for both men and
women, so it is difficult to infer the relative socioeconomic position of men
and women in this dataset. However, socioeconomic status can be inferred
from average earnings, as discussed further under ‘Income and wealth’.
c. Income and wealth: Income and wealth are indicators of socioeconomic
status, and are both risk factors and consequences of poor mental health.
Data on the average earnings of men and women show stark differences,
with men making higher salaries than women.
d. Educational achievements and access: There is no direct measure of
educational achievement or access in this dataset; however, average
earnings could perhaps serve as a proxy measure. It is clear that women
make less money in Spain. Poorer educational attainment is a risk factor as
well as a consequence of poor mental health.
39

06 GHM 202 - Social and Biological Risk (2021-2022) AC

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GHM 202 – Session 6: Social and biological risk factors for MNS conditions

 Lund C, De Silva M, Plagerson S, Cooper S, Chisholm D, Das J, . . . Patel V (2011). Poverty

Activity 1: Personal reflection

2. Social inequalities and biological risk factors

Figure 1. Social determinants of mental health: A conceptual framework

3. Models, mechanisms, and principles

3.3. Social inequalities at the individual and population level

Figure 2. The structural mechanisms of social inequalities 2

3.4. Life-course approach and proportionate universalism

4. Social risk factors

Activity 3: Critical thinking

4.1.3. Relative SEP

4.2. Social capital

Sociotherapy-based Results: Significant positive effects on civic participation

Figure 3. Social capital interventions

4.4. Negative life events

4.5. Global forces

Activity 4: Check your understanding

4.5.1 Climate Change

Box 2. Climate change and mental health

5. Biological risk factors

Box 3. COVID-19 and mental health

5.2. Non-communicable diseases

3.3.1.Genetic basis of schizophrenia

3.3.2.Genetic basis of depression

6.1.1. Maternal health

6.2. Race and Ethnicity

7. Implications for policy and planning

7.1. Census and epidemiological data

7.2. Evaluation data

7.3. Inter-sectoral policymaking

Part B: Short answer questions

3. Drawing on the elements of social determinants theory, as illustrated in Figures 1 and 2,

10.2. Cited references and sources

Le Meur N, Holder-Espinasse M, Jaillard S, Goldenberg A, Joriot S, Amati-Bonneau P, . . . Bonneau D

Marmot MG (2006). Status syndrome: A challenge to medicine. JAMA, 295, 1304-7.

WHO. 2008. RE: Social determinants of health: Key concepts.

11. Answers to activities

11.5. Integrating activity

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