e-SupplementCan primary care reduce inequalities in mental health?
Introduction
Mental health problems demonstrate social gradients in the same way as physical health problems, and represent a case of health inequality.1, 2, 3 However, although this has been known for many years, inequalities in mental health are only now beginning to be recognized in Scotland as a policy issue distinct from physical health inequalities. One reason for this might be that mental health problems in individuals and in the population are less easily defined and measured than physical health problems,4, 5 and are therefore more difficult to deal with in policies that depend on changes that can be measured through routinely collected data. Health and social policies in Scotland are moving much of the provision of frontline and follow-up services for patients with mental health problems towards primary and community care,6, 7 and at the same time, other health policies have started to include an aspiration to tackle health inequalities.8, 9 However, the extent to which primary care in Scotland is prepared to address inequalities in mental health is unknown.
Action to reduce health inequalities and inequalities in mental health is thought to require concerted effort on social circumstances as well as on biological conditions.10, 11, 12 Consideration should also be given to whether action is focused on addressing determinants of health or determinants of health inequalities,13 and whether the aim of the action is to improve the health of the most deprived, reduce the gap in health status between the rich and poor, or reduce the gradients in health throughout society.14 At the time of writing, policies generally expected that all public sector services should build action on health inequalities into their functions, but failed to offer explicit strategies or guidelines for practice that included a balance of biological and social interventions.
At the time of the study, community health partnerships (CHPs) were being established as the organizational structure for primary care and mental health in Scotland. An aim of CHPs was to develop relationships between primary care, community care and local planning structures for reducing health inequalities, but primary care performance measures continued to focus on biomedical and managerial outcomes. The study set out to explore in more depth the contributions that primary care could make to reducing and preventing inequalities in mental health.
Section snippets
Methods
The study used an interpretive policy analysis framework as described by Yanow.15 Yanow argued that stakeholder interpretations of policies were the drivers for change in practice rather than the policies alone. Stakeholders for any policy intervention could be described as belonging to three distinct communities of meaning: policy makers, implementers and service recipients, each with additional subcommunities. Four communities or levels of meaning were identified for this study:
- (1)
policy making
Policy makers' perspectives on inequalities
All nine policy documents included aims to tackle some aspects of health inequalities. The phrase ‘inequalities in mental health’ appeared in only two documents, neither of which provided any more than a mention. In general, the documents presented a disjointed picture of definitions for inequalities that lacked a clear overall interpretation of inequalities in health. They also proposed actions which often did not flow from the given definitions.
An example of a disjunction was where poverty,
Discussion
Exploration of all four levels of policy development and implementation for inequalities in mental health highlighted the potential for policies to be interpreted in very different ways within one organization. However, more detail on the drivers and barriers for primary care to tackle inequalities in mental health may have been identified if each of the levels could have been explored in more depth. For example, policy documents excluded from the document analysis included national reviews or
Conclusion
In conclusion, it appears that health and social policies are potentially moving towards adopting inequalities in health as a policy problem, but they are not yet at the stage of establishing primary care practice for reducing inequalities in mental health. Despite this, there were some examples within the CHP of ideas and practice that brought together action on social factors with frontline primary care mental health services. The majority of respondents in the study appeared to lack
References (18)
- et al.
Deprivation and health in Scotland
(1998) - et al.
Inequalities in mortality in Scotland 1981–2001. MRC Social and Public Health Sciences Unit Occasional Paper No.16
(2007) - et al.
The distribution of common mental disorders: social inequalities in Europe
Clin Pract Epidemol Ment Health
(2005) - et al.
Mental health and inequality
(2003) Beyond depression: a new approach to understanding and management
(2004)Framework for mental health services
(1997)Delivering for mental health
(2006)Towards a healthier Scotland – a white paper for health
(1999)Community health partnership statutory guidance
(2004)
Cited by (3)
The space of access to primary mental health care: A qualitative case study
2012, Health and PlaceCitation Excerpt :Finally, what are the immediate implications of this work, and how does it help us formulate recommendations for action? Our findings contribute to the call of the previous commentators for ‘wider strategies addressing the causes of inequality’ with ‘a focus on specific requirements of various underprivileged and less vocal groups’ (Fotaki, 2010, pp. 909–910; see also Craig et al., 2009). In terms of recommendations related specifically to health policy and research, there are several additional points we would like to make:
Simply spiffing
2009, Public Healthe-Supplement - 16th UKPHA Annual Forum 2008
2009, Public Health