THE SOCIO-ECOLOGICAL FRAMEWORK OF MENTAL HEALTH

Abhijeet Singh¹, Arif Ali², Ibanlumlin Deingdoh³ & Nilesh Maruti Gujar⁴

^1,4 Ph.D. Scholar, Department of Psychiatric Social Work, Lokopriya Gopinath Bordoloi, Regional Institute of Mental Health, Tezpur (Assam). ² Assistant Professor, Department of Psychiatric Social Work, Lokopriya Gopinath Bordoloi, Regional Institute of Mental Health, Tezpur (Assam). ³M.Phil, Department of Psychiatric Social Work, Lokopriya Gopinath Bordoloi, Regional Institute of Mental Health, Tezpur (Assam).

Correspondence: Abhijeet Singh, e-mail- abhijeetsingh141089@gmail.com.

ABSTRACT

The social-ecological model of mental health and well-being reflects the multidirectional intricacy and dynamic ongoing interplay among factors operating within and across respective levels from macro (societal) through micro (individual). These factors affect people personally and corporately and can have singular as well collective impact on individual and society as a whole. The model emphasizes that intervention can be made at a variety of points to strengthen resilience and remove or reduce negative features associated with mental health at both micro and macro level. It also addresses interdisciplinary collaborative efforts to adequately address the diversity of issues that bear on the mental health and health of a community of people. It thus provides a matrix for determining and directing strategies that can together comprise a consistent, coherent response with cumulative force to effect positive change in the settings of concern.

Keywords: Society, individual, mental health.

INTRODUCTION

The Socio-ecological model of mental health is a theory-based framework for understanding the multifaceted and interactive effects of personal and environmental factors that determine behaviors, and for identifying behavioral and organizational influence points and intercessors for health promotion within organizations. Mental illness is one of the major concern now a days. Vulnerable sections of the society experiences more mental health burden. These sections may include children with problems of substance use, conflict with law, women with economically and socially deprived backgrounds, older persons with physical disability. Problems related to poor coping, depression, anxiety are common mental health problems. It was Ernst Haeckal, in 1866, who applied ecology in its philosophical sense. He defined ecology “as the total relations of the animal to both its organic and its inorganic environment”. This definition places ecology close to other disciplines like genetics, evolutionary physiology and psychology. It is Haeckel’s definition that is commonly abbreviated in ecology reference and textbooks as the study of the interrelations of plants and animals with their environments (Krebs Charles, 1978).

A more comprehensive view of ecology was given by Hedgpeth ( 1969), a psychiatrist, in which bio-psycho-social and historical dimensions were emphasized. He defined ecology “as that inter-intra confrontation of biological social and historical; factors that embrace one’s family, school, neighbourhood and the communities that teach values, defenses and offenses the meaning of oneself and one’s existence”. The relationship aspects of ecology were emphasized in different ways in this analysis. In the study of ecology, different schools of thoughts have been developed based on the emphasis on the analysis;

a. Cultural ecology (Lumsden and Wilson, 1981) – analysis of the influence of culture on human behaviour, with an emphasis on cultural determinism
b. Population and human ecology (Park, 1945) – analysis of population between multi species communities and its impact on environment based on system theory.
c. The study of human and natural ecosystems through understanding the interrelationships of culture and nature (Bookchin, 1986).
d. Social ecology is the study of the interaction of people with their environment. (Harvey, 2012)

Social ecology as a concept was introduced in 1965. Social ecology, has its role in suggesting, expounding, and giving an virtuous content to the natural core of society and humanity. (Bookchin, 1990a). Social ecology, rests on the awareness of the interdependence of the biophysical and socio-cultural domains (Guha Ramachandra, 1994). The basic categories of social ecology are; culture, polity, social structure, economy and ecological infrastructure. The power of social ecology lies in the association it establishes between society and ecology, the social conceived as fulfillment of the latest imension of freedom in nature, and the ecological conceived as the organizing principle of social development-in short, the guidelines for an ecological society (Bookchin, 1990b).

SOCIAL ECOLOGICAL SYSTEM

Within social-ecological systems theory, the overarching environmental context of which an individual develops is comprised of four primary levels: micro system, meso system, exo system, and the macro system (Härkönen, 2001).

a) The first system, the microsystem, is defined as “a pattern of activities, rules, and interpersonal relations experienced by developing person in a given face-to-face setting with distinctive characteristics of temperament, personality and systems of beliefs”. Essentially, this most inward layer encompassing the individual is comprised of the various characteristics of family, home, school, peer group, and workplace environment. b) The next layer, the meso system, is comprised of the “linkages and processes taking place between two or more settings containing the developing person”. For example, this is comprised of the relationships established with and interconnections between home and school, school and the workplace, etc. c) The third layer, the exo system, is comprised of settings “that do not involve the developing person as an active participant, but in which events occur that affect, or are affected by, impact of happens situation in the life of developing person”. For a developing child, examples of this environmental system may include the network and activities at a parent’s workplace, the rules established by the local school board, or a variety of other indirect environments potentially affecting a child. d) The most outward layer, the macro system, has been redefined as “the overarching pattern of micro system, meso system, and exo systems characteristic of a given culture, subculture, or other broader social context” highlights this system as a societal blueprint for an individual’s various levels of cultural and social environments. e) Urie Bronfenbrenner’s Ecological Systems Theory (1979) talked about relationship between the individual and the environment. f) Kenneth McLeroy’s Ecological Model of Health behaviors (1988) talked about situations influencing individual’sbehaviors. g) Daniel Stokols’s Social Ecology Model of Health Promotion (2003) identified the core assumptions which underpin the social ecological model.

SOCIO ECOLOGICAL PERSPECTIVE OF MENTAL HEALTH

Mental health problems may be associated to excessive stress due to a particular situation or chain of events. As other physical disorders, mental illnesses are often physical as well as emotional and psychological. Mental illnesses may be caused by a reaction to environmental stresses, genetic factors, biochemical imbalances, head injury or a combination of these. With proper care and treatment many individuals learn to muddle through or recuperate from a mental illness or emotional disorder. An socio-ecological perspective offers a way to simultaneously emphasize both individual and contextual systems and the interdependent relations between these two systems, and thus offers a variety of conceptual for organizing and evaluating health-promotion interventions (Stokols, 1996).

A meta-analysis study conducted in India reported that 12-month prevalence of common mental disorders was 5.52% – anxiety disorders (3.41%), mood disorders (1.44%), and substance use disorders (1.18%). Females had a relatively higher prevalence of anxiety and mood disorders, and lower prevalence of substance use disorders than males. The 12-month treatment for people with common mental disorders was 5.09% (range 1.66%–11.55% for individual disorders) (Sagar et al, 2017).According to the National Mental Health Survey Report (2017), the burden of mental health problems is of the tune of 2,443 per 100,000 population, suicide rate per 100,000 population is 21.1. The prevalence of schizophrenia and other psychoses were found to be 0.64%, mood disorders were 5.6% and neurotic or stress related disorders were 6.93%, this was nearly 2-3 times more in urban metros. The life time prevalence in the surveyed population was 13.7%.

Windley and Scheidt (1982) concluded that there is a relation that exist between the environmental and demographic predictors and mental health status. The model generally supports the position that older people most involved in community affairs are psychologically happier, healthier individuals.

Swearer and Hymel (2015) focus on how socio ecological diathesis-stress model can be effective in understanding the nature of bullying. It helped to understand the fluid and dynamic nature of bullying as a stressful life event for both children who bully and those who are victimized. It also paved the way for understanding history of bully, situation and circumstances where bully occurred, risk and protective factors in order to promote social and healthier life.

Cramer and Kapusta (2017) represent a valuable step in moving from a hyper-focus on individual-level suicide risk prediction toward a comprehensive socio-ecological perspective on suicide prevention.

Lakhan and Ekúndayò (2013) commented that socio-ecological model can contribute significantly in the treatment and prevention of depression both at secondary and tertiary level. It also can be used as an important framework for spreading awareness in the masses.This ecological approach may be a useful approach in treating and rehabilitating individuals with depression in the community. This may require some degree of community sensitization, empowerment and mental health advocacy.

Social ecology framework was applied to evaluate psychosocial well-being of soldiers in Nepal. At the individual level, traumatic exposures, especially torture, predicted poor outcomes, while education improved outcomes. At the family level, family conflicts, death, financial crisis, physical abuse predicted poor outcomes. At the community level, caste, and class system, predicted lack of reintegration supports. So, socio-ecological model is appropriate in finding and intervening psychosocial issues in primary, secondary and tertiary level (Kohrt et al, 2010).

Sexual assault involves multiple socio ecological factors like stigma, poor social connectedness, post assault, limited social support which leads to negative mental health. So, different levels of socio-ecological perspective need to be altered in the treatment of negative mental health due to sexual assault. Self-blame is also considered as a part of socio-ecological imbalance which occurs during victimization of sexual assault (Campbell, Dworkin, and Cabral, 2009).

SOCIAL AND ECOLOGICAL FACTORS INFLUENCING MENTAL HEALTH

There are various social and ecological factors that are associated with mental health:

Poverty: A systematic review of the epidemiological literature on common mental disorders and poverty in low and middle-income countries found that of the 115 studies reviewed over 70% reported positive associations between poverty and common mental disorders (Lund et al., 2010). Multiple studies in India concluded that poverty is an important as an important risk factor for common mental health disorders. Systematic reviews showed that around 79% of studies showed positive associations between poverty and common mental disorders (Patel et al., 2006; Brinda et al., 2016). Depression and emotional distress categorized as somatic symptoms are strongly associated with poverty (Mohindra, Haddad and Narayana , 2008; Raguram, Weiss, Channabasavanna, and Devins, 1996).Poverty and mental health is linked in an intricately negative vicious cycle. Persons with lower socioeconomic groups are more vulnerable to mental health problems because of inability to afford for mental health services and wellbeing services (National Mental Health Policy of India, 2014)

Economic Burden : In some studies a relationship between economic burden and mental health has been found. A population study in England, Wales, and Scotland found that the more debt people are more likely to develop some form of mental disorder, even after adjustment for income and other socio-demographic variables (Jenkins et al., 2008). Indian studies have shown that poor economic burden are independently associated with common mental disorders.(Shidhaye and Patel, 2010; Kuruvilla and Jacob, 2007).

Low socio-economic status : A systematic review of the literature found that the prevalence of depressed mood or anxiety was 2.5 times higher among young people aged 10 to 15 years with low socioeconomic status than among youths with high socioeconomic status (Lemstra et al., 2008). A longitudinal Indian study on 5703 individuals showed that poor socio economic conditions are associated independently with common mental disorders and also increases the chances of relapses (Shidhaye and Patel, 2010).

Poor social support : Study reported a high prevalence rate of depression and anxiety among women in the community as a whole (Lehtinen, Sohlman and Kovess-Masfety, 2005). A longitudinal global study on individuals of Australia and India revealed high level of depression, posttraumatic stress, suicidal ideation because of poor social support (Cheng et al., 2014). Study conducted in past showed that individual who perceived poor social support had worse outcomes in terms of symptoms, recovery and social functioning. The study also highlighted poor social support leads to poor prognosis in major mental disorders (Wang et al., 2018).

Stigma and discrimination: Stigma and discrimination related to mental health status also have effects on mental health outcomes and on disparities in health care, education, and employment outcomes (Hatzenbuehler, Phelan, & Link, 2013). Delay in accessing mental health care due to stigma and discrimination (Clement et al., 2014) or experiences of stigma and discrimination within the health care system may reduce the quality of care that individuals receive (Thornicroft, Rose, & Kassam, 2007).

Social Change: Researchers in India conducted a community based study in rural area, related to mental disorders in rural areas. 20 years after a similar study was conducted in the same areas and by comparing both the studies it was found that over all rates of mental disorders had changed. The rates of depression had increased from 4.9% to 7.3% (Nandi, 2000). World health organization commented that rapid social changes such as the experience of insecurity and hopelessness, the risks of violence and physical ill-health may make the poor vulnerable to common mental disorders (WHO, 2010).

Education: Studies have highlighted that Illiteracy or poor education is considered as a risk factor for common mental disorders. The relationship between low educational level and mental disorders may be a confused association so, it explained by a number of pathways: these include malnutrition, which impairs intellectual development, leading to poor educational performance and poor psychosocial development (Araya et al.,2001; Patel and Kleinman, 2003)

Climate change: Adverse climate change affect mental health through direct and indirect pathways, leading to serious mental health problems, possibly including increased suicide mortality. Mental health encompasses emotional, psychological, behavioral, and social wellbeing and associates with the normal stress of life and function within their community. Mental illness, on the other hand, adversely affects one’s thinking, feelings, and/or behaviors. As a result, it can lead to difficulties in functioning. Climate change can cause and intensify stress and anxiety, adversely affecting mental health. For example, frequent change in temperature can lead to depression, anger, and even violence. Targeted populations which are prone to develop mental health issues due to climate change are children, the elderly, and women (Berry, Bowen, 2010; Page and Howard, 2010).

PROMOTING POSITIVE MENTAL HEALTH THROUGH SOCIO-ECOLOGICAL APPROACH

In general, socio-ecological systems approach paves way for varying levels of Environmental influences that impact and interact with an individual’s feelings, behavior, and overall functioning. It justifies that to understand the individual and his problem his/her social context, environment, family factor and socio-ecological perspective must be taken in consideration. It also advocate that intervention should be made at every level in order to strengthen resilience and remove or reduce negative features associated with individual’s social functioning. The approach also highlights about the interdisciplinary collaborative approach in order to address diverse problems within the society. It thus provides a matrix for determining and directing strategies that can together comprise a consistent, coherent response with cumulative force to effect positive change in the settings of concern. Promotion of positive mental health in work place is also an integral part of socio-ecological model. Life skill training, awareness programme on common mental disorders (like – depression, anxiety, stress reduction, alcohol and tobacco use) can strengthen the individual and society.

Socio ecological approach also advocates creating opportunities for better care, employment, educational and income generation activities for persons with mental disorders. Legal, social and economic protection is also an important aspect of mental health. People should be aware about their rights, service delivery systems, right to information act, self-help groups for mentally ill person. Identifying of risk and protective factors of common mental disorders by the agencies can be a great initiative. Comprehensive understanding of the rehabilitation needs of the mentally ill at the district and state levels along with a longitudinal follow-up of affected individuals can be great initiatives. National agencies like ICMR, ICSSR, international agencies like WHO and other UN agencies should dedicate and enhance research funds for mental and substance use disorders. Other strategies in relation to promotion of mental health may include – Awareness progammes in community, School mental health programmes, Vocational Training Centres, Workshops on positive mental health.

CONCLUSION

Human behavior is difficult to change when the environment is not changing for the betterment of mental health of an individual. It is necessary to focus not only on the behavior choices of each individual but also on factors that influence those choices. The social ecological model help to find several factors influencing individual’s behavior by intervening the multiple levels of influences. The social-ecological model provides a framework that outlines the dynamic interplay of influences between people, and their environments. With a substantial proportion of the population likely to experience a mental or behavioral disorder at some point, the burdens of these disorders need to be addressed. Furthermore, the multiple and complex influences on mental health outcomes require a multi-level perspective that the social-ecological model offers. Moreover, this socio-ecological approach may be a useful approach in treating and rehabilitating individuals with depression in the community. This may require some degree of community sensitization, empowerment and mental health advocacy.

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