Written by Scott Fitzpatrick – Centre for Mental Health Research, The Australian National University

The recent round of funding opportunities for research on the social determinants of mental health is long–overdue.  Whether they signal a change in the way mental health and suicide are responded to in national and state policy agendas, however, remains unclear. Public health researchers and organisations have long argued for policy to address the social determinants of health to eliminate health inequalities. However, this is proving a considerable and ongoing challenge.

The social determinants of health provide a conceptual framework for understanding the political, socioeconomic and cultural factors that impact patterns of health and disease at a population level (Collins et al., 2007). The term health inequalities is closely linked to the social determinants of health and refers to the systematic differences in health status between and within social groups (Exworthy et al., 2003). The causes of health inequalities are complex and involve working and living conditions, health-related behaviours and accessibility to health care (Schmidt et al., 2010). However, different ways of framing these issues convey different ways of understanding the problem. Inequalities may be seen to be the result of the behaviours of certain groups. Alternatively, they may be seen to result from factors beyond people’s immediate control such as material–structural factors (eg, income, working conditions, housing and unemployment) (Baker et al., 2018; Oliver & Nutbeam, 2003).

The mental health and suicide prevention communities are certainly engaged with addressing the social determinants of health. In most cases, however, this involves a focus on specific disadvantaged groups or communities with interventions typically taking the form of health promotion or education programs aimed at improving community awareness of mental health risks, symptoms, prevention and treatment.

To many public health experts, the sources of health inequalities are primarily material–structural in origin (Raphael, 2015). Research shows that household income, unemployment, low educational attainment, social isolation, along with gender and Indigeneity are associated with poor mental health outcomes (Allen et al., 2014; Silva et al., 2016). There is also a strong association between socioeconomic status and suicide (AIHW, 2023). In this view, health inequalities are inequities driven by the unfair distribution of power, money, resources and opportunities and require some form of political intervention to reduce them (Oliver & Nutbeam, 2003). This raises difficult ethical questions and inevitable clashes between competing priorities and values.

Although important, increased funding for research on the effects of the social determinants on mental health and suicide suggests that research evidence alone dictates policy decisions. However, theoretical perspectives of policy making as a rational, linear process in which evidence is transferred directly into policy has been shown to be out of step with how policy making occurs in practice (Baum et al., 2013; Crammond & Carey, 2016). While policy is supported by evidence, it is also driven by the values and interests of key actors (Baum et al., 2013; Exworthy, 2008).

A ‘crowded’ health policy agenda and the constant pressure on acute care services mean that policy action on the social determinants of health is invariably pushed to the margins (Baum et al., 2013; Hauck & Smith, 2015). The role of the medical profession in capturing public, media and government attention and influencing the policy agenda toward clinical interventions should also not be overlooked (Baker et al., 2018). The politicised use of research evidence by prominent researcher/policy advocates has been shown to be a factor in recent Australian mental health reform (Whiteford et al., 2016).

The feasibility of policy solutions has also been questioned. The complex, multifaceted pathways linking the social determinants with adverse mental health and suicide outcomes are misaligned with the preferences of government for clearly defined, conceptually simple policy solutions (Baker et al., 2018). Policy action on the social determinants of health often fall outside of the health sector. As such, they require coordinated responses across the whole of government to develop and implement health promoting policies in non–health sectors such as education, housing and welfare (Baker et al., 2018; Crammond & Carey, 2016).

This raises challenging questions about the role and responsibilities of government. Ideology, which can be defined as an overarching paradigm of principles, beliefs and assumptions that provides bureaucrats, policy experts and politicians with ways to frame solutions and shape public opinion is frequently cited as a barrier to political action on the social determinants of health (Baker et al., 2018; Béland, 2005). For those who believe the responsibilities of government are to provide services to the community, manage public spending, encourage economic growth, and support innovation and private industry there is likely to be strong resistance to redistributive policies targeting health inequities.

To this end, some have argued that strategies that can be implemented within existing policy objectives may have a better chance of succeeding than those that directly challenge them (Schmidt et al., 2010). Katherine Smith’s (2015) work is insightful here. Interviewing researchers, public servants and politicians who had undertaken work on health inequalities, she found that interpretations of current political contexts were communicated by public servants to researchers in ways that consciously shaped their decisions about which research projects to pursue or how best to present results in order to be viewed as ‘credible’ by policy audiences, most notably ministers and their advisors.

Smith’s (2015) work shows how complex networks of actors and organisations play an important role in perpetuating (or resisting) dominant political and economic ideas. Rather than viewing ‘government’, ‘political context’ or ‘political ideology’ as an overarching social force that people are relatively powerless to challenge, she asks us to consider the ways that we, as researchers, advocates, organisations and media may be inculcated into certain ways of thinking and working that perpetuate the status quo; ways of thinking and working that need to be challenged if health inequalities are to be reduced.

Because health inequity is an ethical concept that describes empirical phenomena in moral terms, researchers would do well to connect policy issues with ethical and political analysis (Embrett & Randall, 2014; Gamble & Stone, 2006). To date, there seems to be a general neglect of policy analysis in mental health and suicide prevention fields that considers the ethical and political bases for decisions relating to, for example, the prioritisation of problems, the weighing of values (such as fairness and efficiency), and the allocation of resources, not to mention the impacts of current government policies on mental health in areas such as welfare, housing and immigration. To generate policy change that addresses the social determinants of health inequalities there is a clear need to make these decisions explicit and subject to critical scrutiny. Evidence alone is not enough.

References

Allen, J., Balfour, R., Bell, R., & Marmot, M. (2014). Social determinants of mental health. International Review of Psychiatry 26(4): 392-407.

Australian Institute of Health and Welfare. (2023). Deaths by suicide, by socioeconomic areas. Available at https://www.aihw.gov.au/suicide-self-harm-monitoring/data/behaviours-risk-factors/suicide-by-socioeconomic-areas

Baker, P., Friel, S., Kay, A., Baum, F., Strazdins, L., & Mackean, T. (2018). What enables and constrains the inclusion of the social determinants of health inequities in government policy agendas? A narrative review. International Journal of Health Policy and Management 7(2): 101-111.

Baum, F.E., Laris, P., Fisher, M., Newman, L., & MacDougall, C. (2013). “Never mind the logic, give me the numbers”: Former Australian health ministers’ perspectives on the social determinants of health. Social Science & Medicine 87: 138-146.

Béland, D. (2005). Ideas and social policy: An institutionalist perspective. Social Policy & Administration 39(1): 1-18.

Collins, P.A., Abelson, J. & Eyles, J.D. (2007). Knowledge into action?: Understanding ideological barriers to addressing health inequalities at the local level. Health Policy 80(1): 158-171.

Crammond, B.R., & Carey, G. (2016). Policy change for the social determinants of health: The strange irrelevance of social epidemiology. Evidence and Policy 1-9.

Embrett, M.G., & Randall, G.E. (2014). Social determinants of health and health equity policy research: Exploring the use, misuse, and nonuse of policy analysis theory. Social Science & Medicine 108: 147-155.

Exworthy, M. (2008). Policy to tackle the social determinants of health: Using conceptual models to understand the policy process. Health Policy and Planning 23(5): 318-327.

Exworthy, M., Blane, D., & Marmot, M. (2003). Tackling health inequalities in the United Kingdom: The progress and pitfalls of policy. HSR: Health Services Research 38(6): 1905-1921.

Gamble, V.N., & Stone, D. (2006). U.S. policy on health inequities: The interplay of politics and research. Journal of Health Politics, Policy and Law 31(1): 93-126.

Hauck, K., and Smith, P.C. (2015). The politics of priority setting in health: A political economy perspective. Center for Global Development Working Paper No. 414. Available at SSRN: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2671571

Oliver, A., & Nutbeam, D. (2003). Addressing health inequalities in the United Kingdom: A case study. Journal of Public Health Medicine 25(4): 281-287.

Raphael, D. (2015). The political economy of health: A research agenda for addressing health inequalities in Canada. Canadian Public Policy November S21-S25.

Schmidt, M., Joosen, I., Kunst, A.E., Klazinga, N.S., & Stronks, K. (2010). Generating political priority to tackle health disparities: A case study in the Dutch city of The Hague. American Journal of Public Health 100(S1): S210-S215.

Silva, M., Loureiro, A., & Cardoso, G. (2016). Social determinants of mental health: A review of the evidence. European Journal of Psychiatry 30(4): 259-292.

Smith, K.E. (2015). Understanding responses to the political context of health inequalities in research and policy: Can post-structural theories of power help? Social Theory & Health 13(3): 355-376.

Whiteford, H.A., Meurk, C., Carstensen, G., Hall, W., Hill, P., & Head, B.W. (2016). How did youth mental health make it onto Australia’s 2011 federal policy agenda. SAGE Open 1-12.

About the Writer

Scott Fitzpatrick – Centre for Mental Health Research, The Australian National University

Scott is a Research Fellow in the Lived Experience Research Unit at the Centre for Mental Health Research, The Australian National University. Scott is an interdisciplinary scholar whose work is grounded in the sociology of health and illness, public health, and applied ethics. His research interests are suicide, the social and political determinants of health, and lived experience. Scott is especially interested in broadening contemporary ethical discussion of suicide and its prevention within the fields of research, clinical, and public health practice and policy by examining the intersection between knowledge, practice, ethics, and politics.

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