1. The Social Determinants of
Urban Mental Health
Sarah Curtis
Professor of Health and Risk,
Durham University, UK.
20th September 2012
1

2. A ‘thought experiment’.......
Think of a ‘special’ place where
you feel....
- comfortable;
- happy;
- able to relax and ‘recuperate’ if
you are feeling tired or unwell;
- What kind of place is it?
-What are the features of the
landscape?
- Are there people there? Who?

3. ‘Places’ are more than ‘locations’ – they matter for health
(Model based on Wil Gesler’s ideas of a ‘therapeutic landscape’)
Symbolic
Physical Environments Environments
(e.g air, water, soil, plants (e.g.: civic pride;
animals, buildings, reputation; ‘sacred places’,
transport routes, weather, cultural venues;
‘material’ living conditions) ‘virtuous’ architecture )
Social
Environments
(e.g sense of community;
work place relationships)

4. Curtis, 2010, Space, Place and
...the setting we are in Mental Health, Ashgate
is important for mental
health and wellbeing....
....social processes in
communities (as well as
families) matter for
mental health….

5. Related theories to explain
‘salutogenic’ properties of
social environments include:
- ‘Social capital’ (participation,
reciprocity, trust and access to
resources in communities)
- ‘Social cohesion’ (social
inclusion and solidarity)
- ‘Density’ (concentration) of
people sharing similar socio-
cultural characteristics
- ‘Topophilia’ (emotional response
to landscapes with particular social
and cultural associations and
meanings) Antigone, Montpellier, France designed
by Ricardo Bofill, built 1980s
..also, Lack of these is detrimental

6. The concept of population mental health
- Includes ideas about good
health/wellbeing as well as illness;
- Considers patterns of health in whole
populations as well as individuals;
- Often draws on ideas about the wider
determinants of health…..

7. …Includes ideas about good
health/wellbeing as well as illness…
World Health Organization: definition of
health
“a state of complete physical, mental, and
social well-being and not merely the
absence of disease or infirmity”
(WHO: Preamble to the Constitution of the World Health Organization as
adopted by the International Health Conference, New York, 19-22 June,
1946;
7

8. …Considers patterns of health in whole populations as
well as individuals…
Population health vs. Individual Health
Individual approach: health is assessed in particular people
and considered in relation to their individual/family
characteristics.
Ecological approach: Health is assessed for populations
(aggregates of people) grouped by geographical,
demographic or social categories.
Some studies combine both , considering how individuals
relate to the wider social setting/community in which they live

9. …Often draws on ideas about the wider determinants of
health..
http://www.idea.gov.uk/idk/core/page.do?pageId=13380799
Dahlgren and Whitehead’s (1991) ‘Social Model’ of health (See Whitehead, 1995)

10. How to measure mental illness/wellbeing
at the population level?
Mortality:
Information on deaths from relevant causes
(e.g. suicide)
Disease/disorders:
Illnesses treated: (in hospital, in clinics and by
family doctors and psychiatric nurses)
Self reported illness/wellbeing:
population surveys

11. Ecological research is not necessarily a
....weaker substitute for individual studies and
not only individual factors cause disease.
(e.g. Schwartz, 1994)
So what do we learn from ecological
studies?....

12. We have known for a while about poor mental health in inner cities.....
Faris and Dunham, 1939: inner city concentrations mental disorders
Source: Geoffrey DeVerteuil http://www.umanitoba.ca/centres/mchp/concept/dict/intra_urban_areas/intra_urban_areas.html

13. A similar parttern still
evident in New York, 2000:
Mental Health Admissions...
&
Low income
(Almog, Curtis et al, 2004)

14. Suicide map for England:
male, age standardized mortality ratios due Low
to suicide (using statistical ‘smoothing’)
Middleton et al, 2007 Average
Remote rural and inner city high
populations have higher risk
of suicide

15. Curtis, Copeland et al, 2006:
London, UK: deprived
inner city areas have
higher psychiatric
hospitalisation rates
Index of multiple
Deprivation 2000
(dark=more deprived)
Standardized
Admission Ratios
for all psychiatric
causes; males 15-64
1996-1999
(red= high, blue=low)

16. Measuring area
social fragmentation/lack of social cohesion
Congdon (1996) used census data for small areas to create
Social Fragmentation score for areas
% living alone;
% adults not in married couples;
% moved in last year;
% in rented accommodation.

17. Geographies of deprivation and
fragmentation are not identical
social fragmentation
in London wards
Material deprivation
inLondon wards

18. Hospital admissions from small areas in London are
associated with social fragmentation as well as material
deprivation
Beta
coeff.
Curtis, Copeland et al, 2006 (table 3): psychiatric hospital admissions : result of a
multiple regression model including area deprivation and social fragmentation
(‘anomie’) in London. Significant beta coeffs in bold, marked *.

19. Moving beyond ecological studies.....
Why combine individual and population approaches?
Population health approach – the problem of the Ecological
fallacy
Individual approach – the problem of the Atomistic fallacy

20. Bringing area and individual data together...
Individuals aged 16-24 years in national Health
Survey for England.
mental distress (measured by General Health
Questionnaire) for individuals…..
social support survey information for individuals
Social fragmentation/ cohesion for areas of
residence...
Fagg, Curtis et al. (2007)

21. less area social
fragmentation,
1.4 better individual
health
1.2
Risk of mental distress
1
0.8
0.6
0.4
0.2
0
low medium high
Level of social fragmentation in neighbourhood (lack of social cohesion)
21

22. …so this national study suggests that,
for young adults:
In more ‘cohesive’ areas psychological
health is generally better.
This is independent of individual level
social support levels.

23. Reasons why social fragmentation in
communities may damage mental health:
lack of strong and reassuring role models and
social norms causing uncertainty and
undermining healthy lifestyles;
lack of ‘solidarity’ with others in one’s own group
reduces available emotional support and
practical help
crime and social disorder cause fear, insecurity
Evidence also comes from qualitative research...

24. Popay and Colleagues : qualitative accounts of material
degradation sense of relative poverty and fear of crime
in distressed areas
Source Popay et al, 2003: 65
Source: Popay et al, 2007: 973

25. Feelings of alienation – wanting to leave a
distressed community
Source Popay et al 2003: 62:

26. …So what social
environments make
mental health better?...

27. Examples of the evidence for
these theories that more
supportive social environment is
linked to better mental health...
27

28. Combining geographical data with accounts of
individual experience....
Eg Townley et al (2009) carried out research
with 40 people suffering from mental illness.
Participants drew maps of their community and
participated in walking interviews
28

29. Participants were asked people to explain the
maps they drew.
Source Townley et al (2009) p 253 29

30. Sample of an
informant’s mental
map of the
community
30

31. Using GIS Townley et al plotted all the places that were important
to individuals in different parts of the city – not limited to the
immediate area nearest home 31

32. Examples of comments emphasising social
cohesion and social integration
32

33. Pinfold’s 2000 study: ‘Safe Havens’
33
33

34. ‘ethnic density’ = concentration of
people from one’s own ethnic group.
Another measure of social
cohesion/solidarity: do other people in
your neighbourhood belong to your
social group?
Eg. For ethnic minority groups mental
health may be better when they have
more local contact with other people in
the same cultural/ethnic group.
34

35. Fagg, et al, 2006
Psychological distress among adolescents, and its
relationship to individual family and area characteristics
in East London.
Information on 2790 children in 28 schools in East
London, ages 11-4 years)
Mental health was measured using the ‘Strengths and
Difficulties Questionnaire’ (SDQ)
The study also collected information on factors
including: age, sex, individual social support, family
relationships, family poverty, illness or disability
35

36. Increasing % South Asians = higher ethnic density
lower risk
of distress
= better
health
In East London, East Asians have lower risk of distress (SDQ),
especially in areas of moderate ‘ethnic density’ (after allowing
for other individual characteristics )
(source: Fagg et al, 2006)

37. This study shows that being surrounded in their
residential area by more people from the same
ethnic group seemed beneficial for East Asian
school children,
......except in areas where East Asians were very
highly concentrated, with few other ethnic
groups in their neighbourhood
(see also:Becares, L., Nazroo, J., Stafford, M. (2009) The
buffering effects of ethnic density on experienced racism and
health Health and Place, 15,3, 2009, 700-708.)
37

38. evidence of the ethnic density effect also
comes from qualitative studies....
Whitely et al, 2006 : qualitative study of
people from minority groups in a London
ward with few residents from ethnic
minorities.
They reported
-lack of inclusion in social networks of
people in their group;
- lack of culturally specific services in their
area;
- racial abuse and sense of intimidation.
38

39. Key messages from this research:
Ecological research, quantitative analyses of individuals
and qualitative research suggest that ...
in communities with greater levels of social
cohesion, individuals have better mental health;
Socio-economic poverty and lack of social fragmentation
are both (‘independently’) associated
with worse mental health

40. ‘Social Capital’ is important for mental
health
-Trust
-Reciprocity
-Cohesion
-Solidarity/Support
-Access to resources
40

41. The practical implications of these
relationships…..

42. 1. wellbeing is higher in are
where residents can influen
decisions affecting their
neighbourhood
2. wellbeing is higher
amongst people who have
regular contact with
their neighbours
3. wellbeing is higher in are
where residents have the
confidence to exercise contr
over local circumstances.
Source: Young Foundation, 2008:
42
http://www.youngfoundation.org/fi

43. Improving mental health probably does not
depend only on interventions for individuals…
The wider social determinants of mental health
can be important for health differences
Action at the level of communities is likely to be
beneficial

44. make social environments more ‘therapeutic’
Adverse Therapeutic
anomie Social support
Social fragmentation Social cohesion
Social deprivation Social capital
- +
worse mental health better mental health
44

45. Reading around the subject...

46. References:
Curtis, S. (2010) Space, Place and Mental Health, Ashgate, Farnham. Especially Chapter 4 p 93 - 124
Berkman, L. F., Glass, T., Brissette, I., & Seeman, T. E. (2000). From social integration to health: Durkheim in the new
millennium. Social Science & Medicine, 51(6), 843-857.
Bernard, P., Charafeddine, R., Frohlich, K. L., Daniel, M., Kestens, Y., & Potvin, L. (2007). Health inequalities and
place: A theoretical conception of neighbourhood. Social Science & Medicine, 65, 1839-1852.
Dale , N et al (2008) ‘The RecedingTide’ Young Foundation
Source:http://www.youngfoundation.org/files/images/publications/The_Receding_Tide.pdf
Fagg, J., Curtis, S., Stansfield, S.A., Cattell, V., Tupuola, A-M. & Arephin, M. Area social fragmentation, social support
for individuals and psychosocial health in young adults: Evidence from a national survey in England. Social Science and
Medicine. 2007. (papers in press on line)
Fagg, J., Curtis, S.E., Stansfeld, S. & Congdon, P. Psychological distress among adolescents, and its relationship to
individual family and area characteristics in East London. Social Science and Medicine. 2006;63:636-648
Hothi et al (2008) ‘’Neighbourhood + empowerment = wellbeing’ Young Foundation Source: Young Foundation, 2008:
http://www.youngfoundation.org/files/images/N_E_W_web_v4.pdf
Kovess-Masfety, V., Murray, M., Gureje, O. (2004) Evolution of our Understanding of Positive Mental Health. In
Herrman, H., Saxena, S., Moodie, R. (Eds) Promoting Mental Health: Concepts, Emerging
Evidence, Practice, WHO, Geneva. Chapter 3, p 35- 45
http://www.who.int/mental_health/evidence/MH_Promotion_Book.pdf Online at:
http://www.who.int/topics/mental_health/en/ (accessed on 10/11/07)
Portes, A. (1998). Social capital: its origins and applications in modern sociology. Annual Review of Sociology, 24, 1-24.
Portes, A. (2000). The two meanings of social capital. Sociological Forum, 15(1), 1-12.
Putnam, R. (2000). Bowling Alone: The Collapse and Revival of American Community New York Simon & Schuster
Stafford, M., De Silva, M., Stansfeld, S., & Marmot, M. (2008). Neighbourhood social capital and common mental
disorder: Testing the link in a general population sample. Health & Place, 14(3), 394-405.
Townley, G., Kloos, B, Wright P. (2009) Understanding the experience of place: expanding methods to conceptualize
and measure community integration of persons with serious mental illness. Health and Place, 15, 520-531.
Cattell, V. (2001). Poor people, poor places, and poor health: the mediating role of social networks and social capital.
Social Science & Medicine, 52(10), 1501-1516.
Becares, L., Nazroo, J., Stafford, M. (2009) The buffering effects of ethnic density on experienced racism and health
Health and Place, 15,3, 2009, 700-708.
Whitley, R., Prince, M., McKenzie, K., & Stewart, R. (2006). Exploring the ethnic density effect: A qualitative study of a