Social cohesion, income deprivation and common mental disorder David Fone Department of Primary Care Public Health Ce

1. Social cohesion, income deprivation and common mental disorderDavid FoneDepartment of Primary Care & Public HealthCentre for Health Sciences ResearchCardiff University

2. Acknowledgements Frank Dunstan Daniel Farewell Keith Lloyd Gareth Williams John Watkins Stephen Palmer

3. Background ‘Place’ is an important factor in determining and sustaining inequalities in health outcome between individuals The social environment is an important aspect of place Social capital is one measure of the social environment

4. Social capital “Features of social organisation, such as trust, norms, and networks, that can improve the efficiency of society by facilitating coordinated actions”. Putnam RD. Making democracy work: civic traditions in modern Italy. Princeton, NJ: Princeton University Press, 1993, pp 167

5. Social cohesion Community-level characteristic measured by levels of trust, reciprocity and social bonds Debate on concepts, measurement, and whether a function of individuals or a collective attribute False dichotomy – need to investigate joint individual and group-level associations with health

6. Aim To investigate the hypothesis arising from qualitative research that levels of community social cohesion could influence associations between adverse community factors, such as deprivation, and the mental health of individuals

8. Methods: data sources The Caerphilly Health & Social Needs Study Population survey, sampling from 132 000 aged over 18 years 22 000 questionnaires posted, and 12 408 returned (= 63%) Questions on socio-demography, lifestyle, health, housing and perceptions of neighbourhood Respondents linked to one of 325 enumeration districts using the postcode

9. Data on survey respondents Age and gender Registrar General social class Gross household income Employment status employed seeking work Economically inactive Housing tenure Council Tax Valuation Bands

10. Mental health: the common mental disorders Levels of anxiety and depression are continuously distributed in the general population Around 15 to 30% of adults have CMD Evidence for reduced physical and social functioning, and mortality 20% of GP consultations £6 billion per year – mainly lost productivity Measured using instruments such as GHQ, SF-36

12. Mental Health Inventory (MHI-5) In the last four weeks: Have you been very nervous? Have you felt so down in the dumps that nothing could cheer you up? Have you felt calm and peaceful? Have you felt downhearted and depressed? Have you been happy?

13. Scoring the SF-36 mental health scale Five-point Likert Scale Aggregate score (possible range 5 to 25) transformed to values between zero and 100 Higher scores – better mental health

14. Social cohesion scale I visit my neighbours in their homes The friendships and associations I have with other people in my neighbourhood mean a lot to me If I need advice about something I could go to someone in my neighbourhood, I believe my neighbours would help in an emergency I borrow things and exchange favours with my neighbours I would be willing to work together with others on something to improve my neighbourhood I rarely have a neighbour over to my house to visit I regularly stop and talk with people in my neighbourhood

15. Measuring social cohesion Individual-level Five point Likert Scale –strong disagreement (score 1) to strong agreement (score 5) Sum of scores for the 8 scale items Range 8 – 40, mean 29.2 (SD 5.5) Categorised into three groups of low, medium and high cohesion Area-level Ecometric analysis Mean area scores, categorised in three groups of low, medium and high cohesion

16. Measuring area income deprivation Paycheck dataset % low income households (<£10K pa) Mean 31% (SD 13%), range 3% - 73%

19. Multilevel analysis 10,653 survey respondents aged 18 to 74 nested within 325 enumeration districts Modelling strategy Model 1 Null model Model 2 add compositional variables Model 3 add contextual variables as main effects and the interaction between them

20. Individual-level results

21. Mental health, age and gender

22. Mental health, age and employment 

23. Mental health, age and income

24. Model estimates

25. Predicted mental health and joint effect of small-area social cohesion and income deprivation 

26. Summary of results Mental health associated with both individual-level and community-level measures of income deprivation and social cohesion Association between mental health and community income deprivation is attenuated in communities with high social cohesion Cross-sectional evidence that both people and places are important to understanding the determinants of mental health Highlights the role that cohesive communities play in protecting health and adds force to the argument that social cohesion has an important role in tackling inequalities.

27. Why? Social cohesion may lead to better health through: influencing health-related behaviours by the adoption of health promoting activity and healthy norms, and exerting social control over deviant behaviour higher degrees of social organisation that enhances access to services that influence health

28. Why? Social cohesion may lead to better health through: psychosocial processes such as through the provision of affective support and enhancing self-esteem and mutual respect Being able to depend on neighbours for help may attenuate the adverse effects on mental well-being of living in socioeconomically deprived neighbourhoods

29. Strengths and limitations High sampling fraction and large sample size Non-response bias Same-source bias Health selection MHI-5 Administrative boundaries Measurement of social cohesion No causal interpretation

30. Further research 1. Neighbourhood, social deprivation and mental health: the mediating role of social cohesion Eva Elliott, Gareth Williams and David Fone Qualitative study to explore the meaning and significance of these findings and develop better explanations for the underlying processes The aim of the research is to investigate the processes through which social cohesion moderates the impact of deprivation on mental health and identify potential interventions to improve social cohesion and mental health Funded by Wales Office of Research & Development

31. Further research 2. Neighbourhood determinants of the common mental disorders: the Caerphilly Health and Social Needs Longitudinal Study David Fone, Frank Dunstan and Keith Lloyd Are socioeconomic and environmental characteristics of neighbourhoods associated with change in the mental health status of individuals? Submitted to the Welsh Assembly Government /Medical Research Council Health Research Partnership Award

32. References Fone DL, Farewell D, Dunstan FD. An ecometric analysis of neighbourhood cohesion. Population Health Metrics 2006; 4:17. Fone DL, Dunstan FD, Lloyd K, Williams G, Watkins J, Palmer SR. Does social cohesion modify the association between area income deprivation and mental health? A multilevel analysis. International Journal of Epidemiology 2007; 36:338-345.