Inequality can be tackled at an upstream (national), midstream (community) and downstream (individual and group) level, as shown in the diagram below. This will require actions across sector, but will lead to benefits in different areas as well, such as improved educational outcomes and reductions in crime.
Approaches to tackling inequalities in mental health. Source: Mental Health Foundation (2020)
Upstream approaches: Introducing a 50p minimum unit price (MUP) for alcohol at a local authority level has been predicted to have a significant impact on alcohol consumptions, especially for those who buy the most alcohol; and would reduce hospital admissions and crime rates[ii]. Evaluation of the introduction of MUP in Scotland and Wales suggest the impact is greatest on low-income households, hence this policy would also reduce health inequalities[iii].
Midstream approaches: Affordable housing should be a priority for promoting good mental health and wellbeing. Poor housing, including cold and damp housing, is associated with poor physical health and psychological distress[iv]. People who are unstably housed, and are live with family or friends, in hostels, or homeless, respond more poorly to treatment for depression compared to homeowners[v]. On the other hand, good living conditions can provide a stable and healthy environment for children to grow up in. Good insulation would not only tackle fuel poverty but also help to tackle the climate crisis.
Another midstream approach to tackling mental health inequalities is designing public services so that they are trauma-informed. This may be particularly important in tackling inequalities in women’s mental health. There is a strong link between traumatic experiences, particularly in childhood, and poor mental health[vi]. Women often have specific experiences of trauma, as traumatic experiences faced by women is more likely to have results from interpersonal violence and sexual abuse[vii]. Services should recognise the impact of trauma, build safe environments and empower all women by taking a holistic approach to service delivery[viii]. Such approaches have been delivered successfully in prisons, substance abuse services and homelessness support services.
Downstream approaches: One example of a downstream approach is designing services which are tailored towards the needs of marginalised groups. This is exemplified by ‘Shifting the Dial’, a project based in Birmingham that aimed to promote the mental year of young Black men aged 16 to 25. It was based on a partnerships which involved employment opportunities, peer mentoring and a programme run by a local theatre group; and provided young men with a place for belonging, self-expression and stress relief[ix].
References
[i] McDaid, S., & Kousoulis, A. (2020). Tackling social inequalities to reduce mental health problems: how everyone can flourish equally. London: Mental Health Foundation.
[ii] Brennan, A., Angus, C., Pryce, R., Buykx, P., Henney, M., Gillespie, D., … & Meier, P. S. (2021). Potential effects of minimum unit pricing at local authority level on alcohol-attributed harms in North West and North East England: a modelling study. Public Health Research, 9(4).
[iii] Anderson, P., O’Donnell, A., Kaner, E., Llopis, E. J., Manthey, J., & Rehm, J. (2021). Impact of minimum unit pricing on alcohol purchases in Scotland and Wales: controlled interrupted time series analyses. The Lancet Public Health, 6(8), e557-e565.
[iv] Harris, J., Hall, J., Meltzer, H., Jenkins, R., Oreszczyn, T., & McManus, S. (2010). Health, mental health and housing conditions in England. National Centre for Social Research: London.
[v] Buckman, J. E., Saunders, R., Stott, J., Cohen, Z. D., Arundell, L. L., Eley, T. C., … & Pilling, S. (2022). Socioeconomic indicators of treatment prognosis for adults with depression: a systematic review and individual patient data meta-analysis. JAMA psychiatry.
[vi] Merrick, M. T., Ports, K. A., Ford, D. C., Afifi, T. O., Gershoff, E. T., & Grogan-Kaylor, A. (2017). Unpacking the impact of adverse childhood experiences on adult mental health. Child abuse & neglect, 69, 10-19.
[vii] Scott, S., & McManus, S. (2016). Hidden hurt: violence, abuse and disadvantage in the lives of women. Agenda, London.
[viii] https://www.centreformentalhealth.org.uk/sites/default/files/2019-11/CentreforMH_ASenseOfSafety_0.pdf
[ix] https://www.centreformentalhealth.org.uk/sites/default/files/publication/download/CentreforMentalHealth_ShiftingTheDial_PDF.pdf