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Social Determinants of Women´s M

Social Determinants of Women´s Mental Health - Ireland and India

Anna Datta*, Justin Frewen**

* Specialty Doctor in Psychiatry, East London Foundation NHS Trust, Masters Student of International Mental Health Policy and Planning with New University of Lisbon, ** UN Consultant

Abstract

This paper reviews the issue of negative social determinants of health and how they both incur economic costs as well as examining their impact upon creating health inequalities for women in Ireland and India The current policy approaches of the Irish government in tackling the economic problems faced by Ireland will adversely impact upon the social determinants of mental health of women in Ireland, with negative consequences in terms of the mental health equity of women. In India, socio-cultural issues impact adversely on women´s mental health. This is particularly true for women in economically disadvantaged circumstances. Urgent action needs to be taken to redress this situation by a) reversing these implicitly discriminatory policies and 2) introducing more gender-balanced policies that will not negative impact upon the social determinants of mental health of women.


Introduction:


The Social Determinants of Health

The social determinants of health refer to the social and environmental conditions in which people are born, live, work and age. The health system is an important part of these social determinants but there are several other critical components. The social determinants (SD) which impact upon the lives of people are shaped by the distribution of wealth, income, power and resources at the global, national and local levels. These factors are themselves influenced by policy choices. His unequal distribution of the social determinants of health plays a critical role in the production of health inequalities/ inequities, the unfair and avoidable differences in health status seen within and between countries’ Perhaps the most obvious SD is poverty or economic insecurity, which is associated with lower life expectancy, an increased prevalence of alcohol and drug abuse, depression, suicide, antisocial behavior and violence.2 The UK Black Report3 in 1980 argued that policies that tackled the material causes of health inequities could have the greatest benefit in improving general public health. However, focusing solely on economic inequalities across households can seriously distort our understanding of how inequality works and who actually bears much of its burdens. For instance, health gradients can be significantly different for men and women. Similarly, medical poverty may not trap women and men to the same extent or in the same way.4

The Importance of Social Determinants in Mental Health

In order to understand the importance of social determinants in influencing the mental health status of people it is worth looking at the following quote from Professor Marmot and Professor Wilkinson. “Combining economics, sociology and psychology with neurobiology with medicine, it looks as if much depends on understanding the interaction between material disadvantage and its social meanings. It is not simply that poor material circumstances are harmful to health; the social meaning of being poor, unemployed and socially excluded or otherwise stigmatized also matters. As social beings we need not only good material conditions but, from early childhood onwards, we need to feel valued and appreciated. We need friends, we need more sociable societies, we need to feel useful, and we need to exercise a significant degree of control over meaningful work. Without these we become more prone to depression, drug use, anxiety, hostility and feelings of hopelessness, which all rebound on physical health.”2 Whilst genetic factors undoubtedly play a role in determining dissimilar health prospects at the level of the individual, they fail to adequately explain larger scale variations between social groups. Furthermore, despite their potential importance in helping us understand and treat certain ailments, they are unable to adequately account for the rapid changes in the health prospects and healthy life expectancies of various social categories over relatively short timescales.6

Economic Cost Analysis of Mental Health

An International Labor Organization study in 2000 - Mental Health in the Workplace – estimated mental health could cost as much as 3 to 4% of the GNP of EU states.7 Close to two thirds of these costs - some 65% - are a direct result of a loss in productivity whether as a result of early retirement, premature mortality or sick leave. Healthcare costs comprised only a minority of these costs.8  A study by the Social Exclusion Unit in England noted that less than a quarter of people suffering from a mental health difficulty were employed. This was the lowest rate amongst the various main categories of disabled people.9 The value of nonmarket work was estimated using a calculation adopted by the Sainsbury Centre for Mental Health (SCMH) in a report for England that estimated unpaid work as being 60% of the total value of lost output in 2002-3.10 These reports clearly outline that the major costs associated with mental health problems are not those allocated to providing mental health services and treatment. Instead the costs of lost economic output far outweigh them.11

Taking 2002-3 as its base period, the SCMH study calculated that mental health problems had cost the English economy a total of £77.4 billion, a figure which dwarfed the cost of crime. As with the studies noted above, the delivery of health care services through the NHS accounted for only a fraction of this total. Expenditure on direct health care support amounted to £7.9 billion or just over 10% of this total. Even when the informal care costs of £3.9 billion were added to the £0.7 billion in other public sector costs and private expenditure, the total figure for the provision of healthcare rose to £12.5 billion or just 16.1% of total costs.10 Once again the lost output to the economy was significantly higher, being estimated at £23.1 billion, some 3 times the amount allocated to the NHS for mental health and close to twice that of overall health care costs.12 The remainder was made up of the human costs of mental illness which corresponded to the “adverse effects of mental illness on the health-related quality of life” of nonmarket work.11 In a follow up study covering the period of 2009-2010, SCMH calculated that mental health problems had an economic cost to the UK of £105.2 billion.13 Human and social costs comprised more than half these costs at £53.6 billion (51%), economic output losses £30.3 billion (28.8%) and health care costs £21.3 billion (20.2%).10

Negative social determinants and Women

Gender systems have a variety of different features, not all of which are the same across different societies. Women may have less land, wealth and property in almost all societies; yet have higher burdens of work in the economy of ‘care’ - ensuring the survival, reproduction and security of people, including young and old.12 Women are frequently regarded as little better than objects rather than subjects (or agents) in their own homes and communities, and this is reflected in norms. This discrimination is reflected in the behavior, codes of conduct, and laws that perpetuate their status as lower beings and second class citizens. A further demonstration of the subordinate status of women is clear in the manner in which men ‘exercise power’ over women. These factors are variable and tend to be more concentrated on those without a lot of money. However, the effect of these variables is intersected by age and lifecycle and social stratifiers such as economic class, race or caste. Together, gender systems, structural processes and their interplay constitute the gendered structural determinants of health.12

Three implications of globalisation are particularly significant when looking at gender relations. The first is how it has transformed the composition of workforces, and the implications for women’s health. The ‘Feminisation’ of the labour force has proceeded hand in hand with increased casualisation while, at the same time, the unequal division and burdens of unpaid work in the household has continued. This has serious implications for the health of women health, both in terms of their occupational health and the consequences of insufficient rest and leisure.12  Secondly, there has been an evolving narrowing of national policy space that has culminated in a reduction of funds for health and education with a consequent negative impact on access to these services for girls and womens.12 Thirdly, there has been an increase in violence that has been linked to the changing political economy of nation states in the international order. It is of course important to note that this gendered violence has also included violence not only against girls and women but also against boys and men, transgender and intersex persons and all those who fail to meet the dominant heterosexual norms.12

Negative social determinants and Irish women

According to the Irish Women’s Health Council in their 2005 study on Women’s Mental Health women are over represented in lower paid jobs.14 The increase in unemployment in Ireland as a result of the ongoing recession has further aggravated this situation, as women tend to dominate casual employment and are therefore frequently the first to be laid off. Furthermore, many unemployed women are not even on the register because of the ‘limitation rule’ and a significant proportion of jobs undertaken by women such as caring and domestic work are not even counted as labour market data.15

Women still earn substantially less than men. Even though as low wage earners they pay less income tax the proportion of tax paid indirectly is higher as they still have to pay tax levies and social insurance. Tax reliefs benefit the wealthy but few women fall into that category. The focus on reducing minimum wages has also impacted women as they comprise a predominant number of those employed at the lower end of the pay scale.16 Cutbacks in the public sector has affected women most as they tend to rely more on public services and also make up to two thirds of the public sector. Therefore, the reduction in the number of services and their accessibility has not only made many women redundant but has hit women hardest in depriving many of services they relied on to survive.16 Similarly the cuts in child welfare payments together with the exorbitant costs of child care in Ireland can eat up to 50% of income of single earner families (predominantly women) and 45% of dual earner families. These factors have resulted in restricting female participation in the workforce. Single parents, 98% of which are women, have been disproportionately impacted by such social welfare cuts. Disabled women, including those with a mental health problem, have lower incomes than nondisabled women and disabled men. Once again, the cuts being implemented in Ireland have had a serious impact upon their ability to lead a decent and secure existence.  For migrants and asylum seekers women, the situation is precarious. The Habitual Residence Condition (HRC) places burden on migrants and returned Irish immigrants, as the criteria are unclear and open to discretion. The situation of asylum seekers, particularly mothers caring for young children is particularly worrying; given the very meager support they receive to care for their young children.  The neglect of the Traveler community by the government and local authorities has led directly to the highly disadvantaged economic status of Traveler Women due to their extremely low educational levels, high long-term unemployment, poor health status & shorter life expectancy (12 Years less) than settled women. The cuts to services for women experiencing sexual and domestic violence and who are frequently in need of mental health support are also a matter of grave concern.16 In terms of mental health policy the fact that the current mental health strategy is gender blind and therefore fails to recognise gender differentials in presentation & treatment for mental illness needs to be urgently tackled.

Negative Social Determinants and Indian Women

Various authors have discussed the association of mental illness amongst Indian Women in the context of negative social determinants. Poverty, gender based discrimination, marital discord and domestic violence have been linked with various mental health illnesses. Women frequently present with genital, sexual or reproductive issues even though have underlying mental health problems.  For instance, Patel et al in 1998 describes how an analysis of 141 patients with common mental disorders in 2 PHC in India was associated with female gender, inability to buy food due to lack of money and being in debt.17 In a 2002 study, Patel et al found postnatal depression in 23% mothers. 78% of this study group had substantial clinical morbidity during antenatal period while over half remained ill at 6 months. He concluded that economic deprivation and poor marital relationships were risk factors for occurrence and the chronicity of depression.18

A 2006 study found that the prevalence of CMDs was 6.6% of which the commonest diagnosis was mixed anxiety depression (64.8%). Factors independently associated with the risk for CMD were those indicative of gender disadvantage. These included sexual violence at the hands of their husband; being widowed or separated; low autonomy in decision making and low levels of support from one's family; reproductive health factors, particularly gynaecological complaints such as vaginal discharge and dyspareunia; and factors indicative of severe economic difficulties, such as hunger. Patel et al concluded that the clinical assessment of CMD in women must include an exploration of violence and gender disadvantage. Gynaecological symptoms may be somatic equivalents of CMD in women in Asian cultures.19 Another study by Patel et al 2005 found that stress was the predominant causal attribution for the complaint of vaginal discharge.20 Shidhaye and Patel in 2010 studied the association of socio-economic, gender and health factors with common mental disorders (CMDs) in rural women. The prevalence of CMD was 10.7% in the women studied. The following factors were independently associated with the outcome of CMD in the final multivariable model: higher age, low education, low standard of living, recent intimate partner violence (IPV), husband’s unsatisfactory reaction to dowry, husband’s alcohol use and women’s own tobacco use.21

Patel et al 2008 studied the prevalence and risk of suicide in young people in India. He found that 3.9% had suicidal behaviour over last 3months. Suicidal behaviour was found to be associated with being female, not attending school or college, independent decision making, premarital sex, physical abuse at home, a life time experience of sexual abuse and probable common mental disorders. Gender segregated analysis found independent decision making, rural residence and premarital sex retained association with suicidal behaviour only among females. Women often give expression to their problems primarily through somatic complaints, typically a variety of body aches, autonomic symptoms, gynaecological symptoms and sleep problems. A 2007 study found that women often referred to an overall “weakness” and tiredness upon presentation. Economic difficulties and difficulties with interpersonal relationships (particularly related to marital relationships) were the most common causal models. However, women rarely considered biomedical concepts, for example, the notion that they may suffer from an illness or that their complaints were due to a biochemical disturbance in the brain. Despite the lack of a biomedical concept, most of the participants had sought medical help, typically for reproductive and somatic mplaints.21

Conclusion

Women in both Ireland and India are disproportionally affected by negative social determinants. These determinants can have an adverse impact upon their mental health and therefore contribute to mental health inequalities experienced by women compared to men. Therefore to reduce the unequal burden of mental illness in women it is important for policy makers and health officials to address the negative social determinants experienced by women worldwide through a gender specific approach, which includes reversing implicitly discriminatory policies and introducing more gender-balanced policies that will not negative impact upon the social determinants of mental health of women.

References

1.        WHO. Social Determinants of Health.

2.        Wilkinson, R., Marmot, M. The Solid Facts (2nd ed.). WHO: Denmark Regional Office. 2003

3.        DHSS. Black Report: Inequalities in Health: Report of a Research Working Group, London Department of Health and Social Security. 1980

4.        Sen, G., Piroska, Ö. Unequal, Unfair, Ineffective and Inefficient: Gender Inequity in Health (Final Report to the WHO Commission on Social Determinants of Health). WHO: Geneva. 2007.

5.        Datta, A., Frewen, J., The Socio-Economic Realities of Mental Health in Ireland. Thinktank for Action on Social Change: Dublin, Ireland. 2010.

6.        Gabriel, P., Liimatainen, R-M. (2000) Mental health in the workplace. International Labour Office: Geneva

7.        Sobocki, P., Jonsson, B., Angst, J. & Rehnberg, C. (2006) ‘The Cost of Depression in Europe’. Journal of Mental Health Policy Economics.’ 9(2): 87-98. 2006

8.        Social Exclusion Unit. (2004) Mental Health and Social Exclusion. The Office of the Deputy Prime Minister: London. 2004

9.        SCMH the economic and social costs of mental illness: Policy Paper 3. The Sainsbury Centre for Mental Health: England. 2003

10.      Datta, A., Frewen, J. The Socio-Economic Realities of Mental Health in Ireland. Thinktank for Action on Social Change: Dublin, Ireland. 2010.

11.     Sen, G., Piroska, Ö. Unequal, Unfair, Ineffective and Inefficient: Gender Inequity in Health (Final Report to the WHO Commission on Social Determinants of Health). WHO: Geneva. 2007.

12.     120 billion approx – 4 November 2010

13.     Women’s Health Council (Ireland). Women's Mental Health: Promoting a Gendered Approach to Policy and Service Provision. Women’s Health Council: Ireland. 2005

14.     National Women´s Council of Ireland. Submission to Budget 2011. 1-27

15.      Patel, V. et al. Poverty, psychological disorder and disability in primary care attenders in Goa, India. The British Journal of Psychiatry. 1998: 172; 533-536

16.      Patel, V. et al. Gender, Poverty, and Postnatal Depression: A Study of Mothers in Goa, India. American Journal of Psychiatry. 2002: 159; 43-47

17.     Patel et al. Gender Disadvantage and Reproductive Health Risk Factors for Common Mental Disorders in Women. Arch Gen Psychiatry. 2006: 63; 404-413

18.     Patel et al. Why do women complain of vaginal discharge? A population survey of  infectious and pyschosocial risk factors in a South Asian community. Int. J. Epidemiol. 2005: 34(4); 853-862

19.     Shidhaye, R., Patel, V. Association of socio-economic, gender and health factors with common mental disorders in women: a population-based study of 5703 married rural women in India. Int. J. Epidemiol. 2010: 39(6); 1510-1521

20.     Pillai, A., Andrews, T., Patel, V. Violence, psychological distress and the risk of suicidal behaviour in young people in India. Int. J. Epidemiol. 2009: 37(2); 459-469

21.     Per, B. et al. The explanatory models of depression in low income countries: Listening to women in India. Journal of Affective Disorders. 2007: 102; 209-218eira