Places, people and mental health: A multilevel analysis of economic inactivity

Abstract

This paper investigates multilevel associations between the common mental disorders of anxiety, depression and economic inactivity measured at the level of the individual and the UK 2001 census ward. The data set comes from the Caerphilly Health & Social Needs study, in which a representative survey of adults aged 18–74 years was carried out to collect a wide range of information which included mental health status (using the Mental Health Inventory (MHI-5) scale of the Short Form-36 health status questionnaire), and socio-economic status (including employment status, social class, household income, housing tenure and property value). Ward level economic inactivity was measured using non-means tested benefits data from the Department of Work and Pensions (DWP) on long-term Incapacity Benefit and Severe Disablement Allowance.

Estimates from multilevel linear regression models of 10,653 individuals nested within 36 census wards showed that individual mental health status was significantly associated with ward-level economic inactivity, after adjusting for individual-level variables, with a moderate effect size of −0.668 (standard error=0.258). There was a significant cross-level interaction between ward-level and individual economic inactivity from permanent sickness or disability, such that the effect of permanent sickness or disability on mental health was significantly greater for people living in wards with high levels of economic inactivity. This supports the hypothesis that living in a deprived neighbourhood has the most negative health effects on poorer individuals and is further evidence for a substantive effect of the place where you live on mental health.

Introduction

Mental health is an important indicator of individual and population health status. The most common symptoms of poor mental health in the general population are anxiety and depression, which make up the bulk of the so-called ‘common mental disorders’ (Goldberg & Huxley, 1992). The common mental disorders have a population prevalence of 15–30%, depending on the case definition used (Weich, 1997). They constitute a major public health burden of reduced physical and social functioning (Lloyd, Jenkins, & Mann 1996), higher mortality (Huppert & Whittington, 1995), and lost productivity, as the common mental disorders account for up to one-third of sickness absence from work (Croft-Jefferys & Wilkinson, 1989).

In view of the wide geographical variation in the prevalence of the common mental disorders (Singleton, Bumpstead, O’Brien, Lee, & Meltzer, 2002), understanding the determinants of poor mental health status is essential to plan effective strategies to reduce their impact on the population and reduce health inequality. Individual risk factors for poor mental health status have been well described and include female gender, low socio-economic status, and unemployment (see for example, Weich, 1997). The key question, however, is whether this observed geographical variation simply reflects variation in levels of individual risk factors for poor mental health or whether there are area-level, or contextual, effects on mental health that operate directly or indirectly through social, psychological and biological mechanisms related to factors in the social and physical environment such as housing, transport, leisure facilities, the labour market, social networks and cohesion, neighbourhood disorder such as graffiti and vandalism, and environmental hazards such as noise (Macintyre, & Ellaway, 2003; Macintyre, Ellaway, & Cummins, 2002).

In spite of emerging evidence that the places where people live influence health status (Pickett & Pearl, 2001), and general theoretical arguments for developing more sophisticated and fine-grained analyses of the importance of context in the determinants of health (Williams, 2003), the evidence from research investigating contextual explanations for the variation in population mental health status remains inconclusive. Some UK studies have suggested an association between area deprivation at the level of the census ward or local authority and poor mental health (Fone & Dunstan, 2006; McCulloch, 2001; Skapinakis, Lewis, Araya, Jones, & Williams, 2005; Wainwright & Surtees, 2004; Weich, Twigg, Holt, Lewis, & Jones, 2003), but other studies have not shown that small area-level deprivation is of importance to mental health (Propper et al., 2005; Weich, Twigg, Lewis, & Jones, 2005).

Given the public health importance of the common mental disorders it is surprising that few studies have investigated the effect of economic inactivity at both individual and area level on mental health. One study has shown that the contextual association between area deprivation and mental health was stronger in an analysis of survey respondents who reported economic inactivity (Weich et al., 2003). In previous work we confirmed these findings and also found that the slope of the association between poor mental health status and economic inactivity at individual level varied significantly between electoral wards, such that the gradient of association was significantly steeper in more deprived wards (Fone & Dunstan, 2006). However, neither study was able to model a contextual measure of economic inactivity and so whether economic inactivity at the area level exerts an independent effect on mental health, and how that relation might vary by population subgroup, is not known.

In order to investigate the joint compositional and contextual effects of economic inactivity on mental health a contextual measure of economic inactivity is required. There has been an interest in using benefits claimant data from the Department of Work and Pensions (DWP) at ward level for use in studies of inequalities in population health and social needs (Fone et al., 2002; O’Reilly & Stevenson, 2004). Data are available on the non-means tested benefits of long-term Incapacity Benefit and Severe Disablement Allowance, payable to people of working age who are economically inactive from being unable to work through permanent sickness or disability. The numbers of claimants have risen steadily in recent years to 6.5% of the working age population of Great Britain and 10.9% in Wales by February 2002 (Department for Work and Pensions, 2002a). The most common reason for claiming Incapacity Benefit falls in the diagnostic category of Mental and Behavioural Disorders (ICD-10, F00-F99), representing 34% of all claims, 31% for males and 38% for females. Despite this potentially useful and interesting source of data, no published papers have used these data to investigate places, people and mental health, and economic inactivity.

In this paper we investigate the associations between individual mental health status and contextual economic inactivity measured using these benefits data, with a focus on the population subgroups that are economically inactive, that is people who are retired, students, carers or looking after the home, or unable to work due to permanent sickness or disability. We have gathered in-depth and representative survey data geographically referenced to small area level on the mental health status, employment status and a range of socio-economic data from over 12,000 adult residents of Caerphilly county borough, Wales, UK, in the Caerphilly Health and Social Needs Study, a collaborative study of health and social inequality (Fone, 2005; Fone et al. (2002), Fone (2005))). Caerphilly county borough is located in the valleys of south Wales. It is one of the 22 local government areas in Wales, with a declining and ageing population of 169,519 (2001 Census). Employment in Caerphilly borough was previously dominated by the coal and steel industries. Throughout the period of industrial decline, the borough, and indeed much of south-east Wales, suffered major changes in its social and economic structure with associated high levels of unemployment.

The aim of this paper was to investigate the hypotheses that: (1) the mental health status of individuals is associated with electoral ward contextual measures of economic inactivity from permanent sickness or disability after adjusting for compositional measures of employment status and other socio-economic markers; and (2) the association between mental health and area economic inactivity is stronger in participants reporting economic inactivity from permanent sickness or disability, compared to being economically inactive for other reasons or being economically active.