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Chapter One Introduction and Background
Introduction
How does being a woman or a man, being young or old, or from an ethnic minority community affect mental health? How does poverty and deprivation affect well-being? What does having a mental health problem have on the chances of being discriminated against? These were the questions which formed the basis for the Equal Minds conference held by the Scottish Development Centre for Mental Health ( SDC) in Edinburgh in October 2003, around which this working paper has been developed.
The conference started from the belief that poverty, deprivation, discrimination and inequality are fundamentally unjust, detrimental to individual and community mental health and well-being, and can undermine the recovery of people who experience mental health problems. The conference provided a space in which to bring together some of the evidence for these claims and look at ways of breaking this vicious circle of social injustice.
The National Programme for Improving Mental Health and Well-Being (The National Programme), which financially supported the conference, subsequently commissioned the SDC to prepare this working paper with a view to developing the discussions held at the conference: bringing together further evidence of mental health inequality in Scotland and exploring the implications for policy and practice.
Although funded by the National Programme the views expressed are those of the authors.
Why Now?
The questions the conference raised are not new so why raise them now? First, the questions may have been asked, and the evidence collected, but the 'injuries' (Rogers and Pilgrim, 2003) to mental health and well-being arising from poverty, deprivation, discrimination and inequality, are still being sustained: addressing the hurt continues to be a challenge.
Secondly, the political and policy environment suggests an increased willingness to face up to this challenge. Under the umbrella policy of Social Justice 'A Scotland where everyone Matters' (Scottish Executive, 1999) the policy field of vision has focused increasingly on tackling the causes of social injustice, in addition to responding to
the effects. In health policy this is reflected in the increasing emphasis being given to measures for achieving improvements in health and reducing health inequalities (Scottish Executive, 2003a).
This widening policy field of vision is mirrored in the approaches being taken toward mental health. From a largely (though not exclusively) service orientation, embodied in the Framework for Mental Health Services (Scottish Office, 1997) increasing attention is being given to improving community and individual mental health and well-being through promotion and prevention. The key catalyst is the National Programme, launched in October 2001. The Programme's aims for the three years 2003-2006 are to: raise awareness and promote mental health and well-being; eliminate stigma and discrimination; prevent suicide; and promote support and recovery (Scottish Executive, 2003b). To improve mental health means, of necessity, having to look at, and tackle, the sources
of injustice and inequality which undermine individual and community mental health and well-being as well as the discrimination and disadvantage experienced by people who have mental health problems.
Thirdly, the legislative context underpins and reinforces the importance of the equalities and anti-discrimination message. This includes recent employment directives (relating to sexual orientation and religion/beliefs), amendments to the race relations legislation, proposed changes to the Disability Discrimination Act, together with the proposal to establish a UK-wide Commission for Equalities and Human Rights as well as a Scottish Commission for Human Rights. Specifically in relation to mental health, the principles behind the Mental Health (Care and Treatment) (Scotland) Act 2003, similarly reinforce the significance of ensuring equality and respecting diversity in responding to the needs of people with mental health problems.
What is meant by Mental Health Inequality?
The World Health Organization defines health inequality as 'differences in health status or in the distribution of health determinants between different population groups' ( http://www.who.int/hia/about/glos/en/index1.html). The focus is therefore on both the causes and the effects of differential health status. Adopting this formulation in the context of mental health means considering the unequal distribution of the factors
which are detrimental to mental health and well-being and/or promotive of positive mental health; and the distribution of mental illness/mental health problems between different population groups.
Drawing from Melzer, D. et al (2004, p. 9), inequality and inequity might occur in the distribution of:
Mental illness or mental health problems
Personal and social factors causing mental illness and mental health problems
Personal and social factors that increase resistance to mental illness and mental health problems
Personal and social factors that facilitate recovery
Personal and social factors that handicap individuals with mental illness and mental health problems
And/or access to services that help to prevent mental illness
And/or access to services that limit morbidity in duration or severity of mental illness and mental health problems
And/or access to services that diminish social disadvantage
Unequal distributions result not only from individual/genetic factors, or specific traumatic events, but the accumulation of 'insults' or 'injuries' (Rogers and Pilgrim, 2003) to mental health sustained through social, economic, ecological and environmental disadvantages. These disadvantages are not randomly distributed: some people and communities are exposed to greater risk than others. While epidemiological data suggest that 1 in 4 people may experience a mental health problem, it is not any 1 in 4. As Rogers and Pilgrim argue 'Mental health problems are not distributed in a non-random way in society. They reflect social divisions (of class, age, race and gender), and sometimes make a direct contribution to social inequalities (for example when patients suffer stigma and labour market disadvantage)' (2003, p.16).
This suggests there are three main social and economic influences on population mental health and well-being:
Class or socio-economic status. The experience of poverty and economic inequality are associated with poorer mental health and well-being.
Social identity. Social identities are those aspects of ourselves to which society attaches significance. This can include our gender, our ethnicity, our sexual orientation, our age, our religion or beliefs or whether we have a disability.
We all have a number of different 'social identities', e.g. as a white woman who is a lesbian or as an older black man. Some of these identities we ascribe to ourselves, others are ascribed to us.
Some aspects of social identity are viewed by ourselves and society as positive and, as such, can be protective or resilience factors in the face of difficulties. However, other aspects of our social identities can expose us to discrimination, stigma and prejudice in the form of, for example, racism, homophobia, sexism and ageism. The experience of discrimination, prejudice and stigma can undermine our mental health and well-being, both directly and indirectly through the experience of inequality, poverty and deprivation with which they are associated.
Experience of a mental health problem or mental illness. The discrimination, prejudice and stigma which someone may face because they have had or are experiencing a mental health problem or a mental illness may expose them to the risk of poverty, deprivation and inequality.
Mainstreaming Equality: Mainstreaming Mental Health
'Mainstreaming equality is essentially concerned with the integration of equal opportunities principles, strategies and practices into the every day work of Government and other public bodies from the outset … It is a long-term strategy to frame policies in terms of the realities of people's daily lives, and to change government organisational cultures and structures accordingly ... It entails re-thinking 'mainstream' policy making and service provision to accommodate gender, race, disability and other dimensions of discrimination and disadvantage, including class, sexuality and religion.' (MacKay and Bilton, 2003)
The Scottish Executive's Equalities Strategy (2000a) is based on a principle of 'mainstreaming'. This is seen as a long-term strategy for integrating and embedding an equalities perspective throughout the work of the Government and other public bodies. The aim is to ensure that 'policy-making is fully sensitive to the diverse needs and experiences of people'.
To begin to work through the policy and practice implications of the different sources of mental health inequality, the working paper both adopts and adapts the idea of mainstreaming. It is suggested that to achieve mentally healthy policy and practice there is a need to:
- Mainstream mental health improvement goals in policies and practices aimed at achieving social justice and closing the opportunity gap (and in ways that take into account the unequal distribution of mental health risk factors within and across different social groups).
And
- Mainstream social justice/equalities goals within mental health policies and services.
The Working Paper: Approach and Structure
Approach
The working paper draws on published and unpublished 'grey' literature, and includes policy statements as well as research studies. Material was identified through a combination of database and website searches and citations in the literature. It was not possible, however, within the scope of the project to cover all areas in extensive depth. Further, it was not intended to be a Cochrane-type review ranking different types of research evidence. Rather it was concerned to identify from a broad overview of the material key themes and issues. Attention is also drawn to areas where there appear to be gaps in research or where the available data is contradictory or ambiguous.
The presentations and discussions at the Equal Minds conference were drawn on both to contribute to the evidence base but also to inform the analysis. Early thoughts and ideas were further exchanged and developed in the course of a small 'roundtable' discussion with people with experience and knowledge in the fields of equalities, social inclusion and mental health.
Working paper structure
Chapter 2 provides a brief overview of the policy and legislative context. Facts and figures indicating the extent of poverty and deprivation in Scotland and the nature of health inequalities, including mental health inequalities are described in Chapter 3.
Having set the population and policy context, Chapter 4 presents evidence indicating how poverty, deprivation, inequality and discrimination can affect mental health, well-being and recovery and the factors that can protect people from 'injury'.
Chapters 5 to 8 begin to follow through in more detail the implications of this evidence for policy and practice in relation to: women and men, people from black and minority ethnic communities, lesbian, gay, bisexual and transgender people, and people with disabilities, including people with mental health problems. The implications for younger people and older people are discussed across each of these sections.
The final chapter sketches out some of the implications for policy and practice.
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