Mental Health Inequalities

Mental Health Inequalities and the need for qualitative and quantitative evidence resources
Joanna Ptolomey

Introduction

An “evidence based” literature search in the field of mental health inequalities is an interesting and illuminating journey for an information professional. An understanding of health inequalities and the need for quantitative and qualitative evidence can have an effect on the successful outcome of your search.

This article represents my journey whilst working on a literature search for a Glasgow Community Health Partnership on Mental Health Inequalities. I have made reference to material I found particularly useful, but I have included supplementary references for further exploration.

Health inequalities: measurements and determinants.

There seems to be a body of literature to support the notion that the health of the nation is generally continuing to improve. However paradoxically it also reports that there are particular pockets of the population where their health status is continually poor (1). So how can it be possible that some health policies will work for some of the population, but not for others?

The answer lies in understanding inequalities. Historically the most used method of measuring inequalities between people has been through measures of occupation. This was originally developed to construct the census. Although it is considered to be an outdated measurement now it still captures basic information (1). For example, the higher your social class the more likely you are to have higher educational attainment and higher living standards.

However there are limitations to collecting measures of occupation. For example, do race, gender, sexuality, geography, age, disability, housing and social position have an effect on a person’s health (2)? And can you also experience many inequalities concurrently? Consider this; you are black gay women working as a bricklayer. In summary measuring inequalities can be problematic as there are many socio-economic determinants.

Health inequalities and mental health

One of the most socially excluded groups in society today is people who suffer from mental health problems (3) and it is a key health target for the national government. A 2004 report (3) stated that for many people who suffer mental ill health it is not merely an episodic disruption to participating in life, but a real “social and economic exclusion” throughout there lives. Generally this group will have the lowest employment rate of all the main disabled groups. Social isolation will be a major factor linking mental health and suicide. Depression, anxiety and phobias have the highest rates in deprived areas and have major financial implications on families. Mental health problems not only impact significantly on families emotionally and but also financially.

Mental Health Inequalities: A Social Model of Health Service Delivery

There are many social and cultural inequalities that are entwined in a person’s life, which can also create barriers to accessing suitable health services. In order to deliver realistic and appropriate services there needs to be a different model of health provision that brings together health and social care. At this moment in time the NHS in Scotland is radically changing. The Primary Sector no longer exists in its old format and Community Health Partnerships (CHP’s) are the new boys in town. It is hoped that CHP’s will deliver more effective community health strategies and services because they will be based on a social model of health that takes into account inequalities in the health of a population.

Mental Health Inequalities: A Glasgow Project

My recent work with a South West Glasgow CHP mental health project was about developing ways in which they could be more responsive in service delivery. This included the idea that experiencing inequalities has the most profound effects on mental well-being. The project team was formed to develop a proposal that aimed to explore these inequalities. There were two key areas for all team members to have a clear understanding of.

Policy and practice

• Understanding the impacts of inequalities on mental health.
• Identify the significance of experience of inequalities on the service users.
• Promote partnership and a coordinated approach in addressing inequalities.
• Implications for Greater Glasgow Primary Care mental health development and mental health services development in general.

Development of community based preventative work

• How to address inequalities.
• Identify ways of developing good mental health.

My role within the team was to deliver an “evidence based” synthesis on the literature surrounding their key project deliverables. The team members would then use these “knowledge portfolios” to support development of the service delivery model of mental health services. A complete methodology, fuller description of the project and the outcomes of the “Knowledge Portfolios” is published (4).

Qualitative versus Quantitative Evidence?

The CHP team make-up was a cross section of health and social professionals ranging from clinical to social science and arts backgrounds. Within the team there was also a mixture of research experience and methodologies. This led to a discussion on what types of evidence should we be looking for and where would it come from. I explained at length the “hierarchy of evidence” in clinical terms.

I also discussed the availability and quality of “qualitative evidence” from other sources. As information professionals we are always looking for and advising people on the best quality evidence. But what if the evidence you are looking for does not fall exactly into the clinical rigidly controlled scientific methodology. Where do we look when the clinical conditions has many determinants that are socially and culturally controlled?

Within the clinical setting there is a recognized “gold standard” of building an evidence base. The Cochrane Collaboration has set the standard on best practice for clinical interventions and is “tight” on scientific assumption, methodology, appraisal and synthesis. However Booth (5) has argued that the Cochrane Collaboration practices a “closed shop” for the inclusion of qualitative research to the detriment of adding to the evidence base. Dixon-Woods (6) argues that evidence-based healthcare so far has “lacked a critical perspective particularly with respect to social and educational interventions”. In fairness a BMJ (7) article has stated the importance on qualitative evidence inclusion into mainstream and proposes ways in which qualitative evidence can be assessed for quality. Some have already outlined a methodology for including qualitative research systematic reviews and call for further work to be done in this area (8). The Health Development Agency commissioned further work on this area and the report “Integrative approaches to qualitative and quantitative evidence” makes an interesting read (9).

To create some balance with the Cochrane Collaboration there has been the development of a breakaway group called the “Campbell Collaboration” (10). After all the discussions and arguments about quantitative versus qualitative evidence what’s the bottom line for us information professionals? The truth is there are already great volumes of good quality “qualitative evidence” out there now. So where do we look? There are broad areas that we should consider; government organisations, thinks tanks, academic centres of excellence, charity and voluntary sector, and professional organisations. Surprisingly there are also gems to be discovered on databases that we have access to on a daily basis through NHS Scotland e-library.

Guide to evidence in mental health inequalities

Databases

The coverage of the databases is clear to see, but don’t immediately discount the more clinical databases such as Medline. Over the years I have had some real finds in socio-economic type searches. One tip is not to rely on MESH searching for this area, as you will come across more blanks, workup your natural language searching. Here is my selection of useful databases available at NHS Scotland e-library. Medline

Embase

Cinahl

PsychINFO

AMED: complementary health

Cochrane Databases

AARP

AgeLine

HMIC

ASSIA: Social sciences including social services, psychology, race relations, education

Campbell Collaboration

ERIC: Educational resources and social

Social Work Abstracts: related topics homelessness, family welfare, and addictions

Planex: economic issues, social exclusion, housing

Social Science Citation Index

SocIndex

Sociological Collection

Consider also these databases, alas not available at NHS Scotland e-library.

Urbadoc: Acompline

CareData

Urbaline: Urbadisc

SIGLE: System for Information on Grey Literature in Europe

All other portals

Due to the restrictions in length of this article the following is a limited list of “other portals”. I have mainly excluded the charity and voluntary sector as it is very large, but I would be happy to be contacted.

UK Government Home Office Equality and Diversity http://www.homeoffice.gov.uk/equality-diversity/

Social Exclusion Unit http://www.socialexclusionunit.gov.uk/

Scottish Executive http://www.scotland.gov.uk/

Home Neighbourhood Renewal Unit http://www.neighbourhood.gov.uk/

Women and Equality Unit http://www.womenandequalityunit.gov.uk/

NHS National Institute for Mental Health England and BEM Programme http://nimhe.csip.org.uk/home

National Institute for Health and Clinical Evidence http://www.nice.org.uk/

National Electronic Library for Mental Health http://www.library.nhs.uk/mentalhealth/

Healthcare Commission http://www.healthcarecommission.org.uk/homepage.cfm

Kings Fund http://www.kingsfund.org.uk/

General Gateways BUBL http://bubl.ac.uk/

SOSIG : Sexual Orientation Special Interest Group and Mental Health http://www.sosig.ac.uk/

COPAC (UK Universities Unified Catalogue) http://copac.ac.uk/

BIOME (UK gateway sources in science and medicine) http://biome.ac.uk/

Think Tank, Academic Centres and Centres of Excellence Centre for Analysis Social Exclusion: London School of Economics http://sticerd.lse.ac.uk/case/

Centre for Economic and Social Inclusion http://www.cesi.org.uk/

Joseph Rowntree Foundation http://www.jrf.org.uk/

Centre for Research In Ethnic Relations, University of Warwick http://www.warwick.ac.uk/CRER/index.html

Centre for Evidence in Ethnicity, Health and Diversity, University Warwick http://www2.warwick.ac.uk/fac/med/clinsci/ethnicityhealth/

Sainsbury Centre for Mental Health http://www.scmh.org.uk/

Policy Studies Institute http://www.psi.org.uk/

UK Mental Health Research Network http://www.mhrn.info/dnn/ ROTA (formerly GLARE) http://www.rota.org.uk/pages/about/index.htm

Institute for Public Policy Research http://www.ippr.org.uk/

Townsend Centre for International Poverty Research, University of Bristol http://www.bris.ac.uk/poverty/

The School of Social Policy, Sociology and Social Research. University of Kent. http://www.kent.ac.uk/sspssr/

University of Durham. School of Applied Social Sciences. http://www.dur.ac.uk/sass/socialwork/

Social Perspectives Network http://www.spn.org.uk/

Democratic Health Network http://www.dhn.org.uk

EPPI-Centre Resources http://eppi.ioe.ac.uk/cms/

London School of Economic REGARD Database http://www.lse.ac.uk/collections/CARR/documents/regardDatabase.htm

Conclusions

A literature search in the mental health inequalities field is a mighty task. My main tip is to make sure that your client is familiar with “evidence based” searches. Furthermore, that they are educated in the availability and quality of quantitative and qualitative evidence sources. Information professionals are constantly defending their roles when we hear that “everything is free on the web”. To maintain and improve our professional standing we must strive to provide expertise in niche areas offering valued-added service as a matter of course.

References

1. NHS Health Development Agency. Health inequalities: concepts, frameworks and policy. London; 2004.

2. Wanless, D. Securing good health for the whole population: final report. London: HMSO; 2004.

3. Office of the Deputy Prime Minister. Mental Health and Social Exclusion. Social Exclusion Unit Report. 2004

4. Ptolomey, J. Creating Knowledge Portfolios for a Glasgow Community Health Partnership. Inequalities, Gender Sensitivity and Primary Care Mental Health Project. Information Scotland 2006; 4, 2.

5. Booth A. Cochrane or cock-eyes? How should we conduct systematic research reviews or qualitative research? Paper presented at the Qualitative Evidence –based Practice Conference, Taking a Critical Stance, Coventry University; May 14-16; 2001.

6. Dixon-Woods, M and Fitzpatrick, R. Qualitative research in systematic reviews. BMJ 2001; 323; 765-766.

7. Mays, N and Pope, C. Qualitative research in health care. Assessing quality in qualitative research. BMJ 320: 1 January 2000.

8. Dixon-Woods, M et al. Including qualitative research in systematic reviews: opportunities and problems. Journal of Evaluation in Clinical Practice, 7, 2, 125-133

9. Dixon-Woods et al. Integrative approaches to qualitative and qualitative evidence. Health Development Agency, 2004.

10. Campbell Collaboration. Available from URL http://www.campbellcollaboration.org/

Supplementary References

1. European Commission. The health status of the European Union. Narrowing the health gap. 2003.

2. Spencer L et al Quality in Qualitative Evaluation: A framework for assessing research evidence. London: Cabinet Office; 2003.

3. Hammersly, M. Systematic or Unsystematic, is that the questions? Some reflections on the science, art and politics or reviewing research evidence. Public Health Evidence Steering Group of the Health Development Agency; October 2002.

4. Oliver S et al. An emerging framework for integrating different types of evidence in systematic reviews for public policy.

Paper presented at the Methodologies Sub Group of the HAD Public Health Evidence Steering Group; 3 February 2003.

Joanna Ptolomey is a qualified librarian and works as a freelance information professional. She has held positions in the business sector and the NHS as a librarian. She can be contacted at joanna.ptolomey@ntlworld.com.