Social determinants and mental health in pandemics: new challenges.

Social determinants of health (SDH) are the “conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life” these conditions can produce health inequity and inequality, segmenting the population and creating groups that are vulnerable or at risk of poor physical, psychological, or social health. Thus, factors such as belonging to different population groups/ethnicities, socio-economic status, sex/gender, life cycle, illness or disability create greater health vulnerability.

There is historical and contemporary evidence that health inequalities have resulted in increased risk of illness and mortality in times of pandemics. Thus, the so-called "Spanish flu" of 1918 or "avian flu" of 2009, as well as the current "Covid-19" pandemic, have affected countries and social groups with low incomes, lower educational levels, immigrants, households that are overcrowded or lacking in basic services, and even rural areas to a greater extent. The Covid-19 pandemic has impacted these groups creating situations that affect health in the short, medium and long term, such as instability and insecurity in the home, in employment or in migratory status, risk of stress, conflict and violence, or unhealthy lifestyles (sedentary, poor diet, substance abuse), limited social support, isolation and loneliness that affect physical and mental health, restricted access to social, health and community resources, among others.2, 3, 4

Bambra et al. cite the concept of a syndemic, coined by Merrill Singuer, to refer to “risk factors or comorbidities are intertwined, interactive and cumulative—adversely exacerbating the disease burden and additively increasing its negative effects”. This synergy places vulnerable groups affected by SDH at greater risk of chronic disease, and affects Covid-19 comorbidity and mortality. The syndemic theory specifically applies to global mental health, as health inequalities are a risk factor for mental illness.

People with mental health disorders are more vulnerable to the consequences of Covid-19. Their psychological symptoms have increased during the pandemic, which translates as greater psychological stress, anxiety, depression, post-traumatic stress disorder, alcohol and other substance abuse, with particularly high suicide rates during the pandemic.2, 5, 6, 7 These situations have especially affected the most vulnerable groups such as children and adolescents (associated, among other issues, with school closures), health workers, people in prisons, institutionalised people with disabilities, and women victims of gender-based violence; the mental health care gap has also increased.2, 5, 8

Fortunately, thanks to the World Health Organisation-sponsored surveillance of SDH, there are several opportunities to combat the effect of health inequities in times of pandemic. We should highlight two fundamental strategies: the systematic collection, analysis, and evaluation of data on the impact of SDH, and the incorporation of health in all policies, with an emphasis on the creation and evaluation of policies and programmes to promote social inclusion and combat SDH, with strategies based on scientific evidence.9, 10

With respect to evaluation, Martín-Moreno et al., proposed principles, methodologies and dimensions to evaluate to improve the response to Covid-19 in Spain, to make our society more resilient to future pandemics, with five evaluation objectives: 1) the characterisation of and compliance with government and administrative provisions; 2) the planning, programming and articulation of government actions; 3) the impact on health and social services with attention to vulnerable groups; 4) the level of collaboration with European institutions and the WHO; and 5) the formulation of bases for short-term action and public health preparedness for future emergency situations. Regarding social aspects in particular, they propose examining the level of equity and how social inequalities have contributed to the transmission and exacerbation of Covid-19.

In relation to responses in terms of health programmes and policies, in the field of mental health, there have been responses at various levels, notably the "whole-of-society" report by the United Nations, the report by the Reference Group on Mental Health and Psychosocial Support in Emergencies, the European Union's Mental Health Strategy, as well as other national responses. The key themes for the development of policies and services to cushion the impact of the pandemic on mental health are highlighted as addressing SDH and health inequity with an emphasis on human rights, innovation, good practice, and new service models that emphasise community empowerment, the reduction of stigma, and the promotion of psychosocial interventions. Finally, the development of robust and responsive health systems is proposed, highlighting actions in digital health.8, 12

In conclusion, the conditions in which people are born, work, live and age pose a challenge in times of pandemic as they interact with the risk of illness and death, as well as with other chronic physical and mental illnesses, aggravating the consequences on physical, mental, or social health. These situations particularly affect mental health. In this context, countries need to prepare themselves by analysing tools to combat SDH, establishing adequate surveillance and monitoring mechanisms, and developing and evaluating evidence-based policies and programmes, taking good health models and practices as examples.