title: How well are we tackling the social determinants of mental health? An assessment of the quality of implementation studies and the examination of mental health care.
Creators: name: Vaughan, Matthew
Publisher: name: University of Liverpool Repository
Year: 2024

description: Over recent decades, the context in which people live and work has become accepted as the fundamental factor driving health inequalities including factors such as the quality and security of people’s housing, employment, and education (Alegría et al., 2018; Pickett &amp; Wilkinson, 2010; WHO Health Commission, 2008). Ultimately, these social inequities translate into people dying earlier than they should and spending more years of their shorter lives in poorer health. While impacting the most deprived communities, social inequalities follow a gradient, and negatively impact the health of all but the most affluent (Marmot &amp; Bell, 2009). 
These factors are known as the social determinants of health (SDOH), defined as “the conditions in which people are born, grow, live, work, age” (WHO Health Commission, 2008, p. 26).
More recently the literature has expanded beyond physical health to specifically explore the social determinants of mental health (SDMH). Research has implicated SDMH as a key driver influencing the development, severity and chronicity across a range of mental health diagnostic categories (Alegría et al., 2018; Shim &amp; Compton, 2018). Allen et al. (2014) conducted a seminal review of SDMH, confirming that the higher the inequality, the higher the risk of various mental health diagnoses. Furthermore, these factors have been identified as key barriers to both, people accessing support (Comino et al., 2012; Ford et al., 2016; Goddard, 2008), and benefitting from it (Falconnier, 2009; Finegan et al., 2018).
The United Nations special rapporteur and human rights expert Daniel Pūras (2017), has argued for an urgent need for mental healthcare to prioritise targeting the SDMH. Additionally, there are mounting calls from organisations such as the World Health Organization (WHO) for mental health to be conceptualised firmly within the context of adverse social experiences, in contrast to “a growing over-emphasis on individual pathology” (Friedli &amp; Organization, 2009, p. 7) through the dominant, bio-medical model, which many argue to be either limited or flawed (Division of Clinical Psychology, 2013; Johnstone &amp; Boyle, 2018; Kinderman, 2021; World Health Organization, 2021).
Considering how the SDOH affect mental health, and how services respond to them is especially timely within the context of current social and economic challenges. Before the onset of the COVID-19 pandemic, health inequalities within the United Kingdom (UK) had increased following a decade of austerity policies (House of Commons, 2019; Marmot, 2020; Wickham et al., 2016). It was in this context that the COVID-19 pandemic presented itself, with a prominent review by Marmot et al. (2021) emphasising that the pre-existing inequalities will have been further exacerbated by the pandemic. The lingering effects of these two significant events and related policies are then compounded by the cost of living crisis (Harari et al., 2022; Levell &amp; Karjalainen, 2021). Consumer prices are 21% higher in February 2024 than in 2021 (Harari, 2024), and it is important to note that even if high inflation rates are reduced, this is only a measure of how quickly prices increase – with prices expected to remain high for the foreseeable future (Cominetti et al., 2024). Consequently, any reductions in inflation rates bring little respite to 3.1 million low-income families with children forced to make sacrifices on essentials such as food and toiletries (Joseph Rowntree Foundation, 2023).
This thesis presents two papers exploring how mental health services can effectively respond to SDOH. A growing intervention to respond to such factors is the intervention of social prescribing (SP). However, the differential impact of social prescribing on different populations is unclear. Chapter one is a systematic review exploring the quality of reporting demographic characteristics and reporting rates in social prescribing studies to aid in answering this question. Beyond social prescribing as a bespoke intervention, there remains the question of how mental health services more broadly respond to such factors. Chapter two is an empirical qualitative study, exploring how mental health professionals become aware of SDOH present within the lives of service users, and how they respond to these factors once aware. Together, these two chapters aid reflections on how mental health services currently respond to the factors driving poor mental health and associated limitations. The conclusions from these chapters have ramifications for the structure of mental health services, and how they can meet the increasing demand.