Fast and awkward urbanization is taking place in a context of other global challenges: financial crises (1,2), high unemployment, increasing elderly population (3) and changes in family structure, among others. In countries with different levels of infrastructure and health system preparedness, these social problems pose significant development challenges (4). Urban planning and design, and social conditions can be good or bad for human health and health equity depending on how they are set up (5): different forms of governance can shape agendas, policies and programmes in inclusive and health-promoting ways, or perpetuate social exclusion, inequitable distribution of resources and health inequities. The urbanization model adopted in many cities in the world needs to be reconsidered (5). This will involve paying attention to the social and environmental determinants of urban health inequity as referred in the literature (6-13). As Snyder and colleagues (5) argue, social vulnerability in health is not a “natural” condition but results from the unequal social context surrounding the daily life of the disadvantaged and of the often socially excluded groups (4,12).
The Commission on Social Determinants of Health stated that communities ensuring access to basic goods and social cohesion, are essential for health equity (4). There is a growing interest in documenting the role of context (defined as neighbourhoods, workplaces, regions) in producing health inequalities. Empiric evidence suggests that certain characteristics of the environment may influence mental health beyond individual characteristics, e.g. the neighbourhood/place effect (8,10). Multilevel analyses have made possible to separate the individual effect from the neighbourhood effect on health (6,9,8,11,13).
Mental health is an essential component of health, as there can be no health without mental health (14,15). Mental disorders are, nowadays, one of the chief causes of disability and of increased mortality rates (16).
Financial crises can promote an unequal distribution of power, status, and resources impacting people’s freedom to participate in decisions that affect their lives (17,2). Empowerment is therefore fundamental to build health (5) and mental health equity. The social determinants of health related to empowerment are political, economic and social drivers and norms that distribute power, income, goods and services and the consequent conditions of daily living. A social determinants approach suggests that improving living conditions in such areas as income, housing, transport, employment, education, social support and health services is central to improving mental health of the populations (7,11,13,18-20). The extent to which economic changes impact on health, argue Stuckler et al (2), depends on the extent to which people are protected from harm, with three relevant issues: exposure to risk factors; social cohesion (informal welfare); and social protection (formal welfare).
Employment and income are clearly interrelated determinants of mental health (21) and both impact on social status, which is also a key determinant of wellness (22). Economic changes can be powerful determinants of health, and economic crises are associated with an increase in mental disorders and mortality (1,2,17,23,24) due to the fact that long-term unemployed individuals are more likely to suffer from depression than those with a satisfying job, because of relative poverty, lack of purpose in life, and hopelessness (22,2). Poverty itself (whether or not due to unemployment) is associated with poor housing, limited mobility, reduced life chances (12), and increased stress, all likely to impact on health and wellbeing (22).
Mental disorders are unequally distributed i.e., people who live in socially and economically disadvantaged situations suffer from a disproportionate burden of disease and subsequent adverse consequences (15) The National Psychiatric Survey-2009 (25), has revealed that Portugal is one of the European countries with a higher prevalence rate of mental disorders (25). Mental disorders have multiple causes. Risk is determined by a combination and interaction of biological, psychological and social determinants (26,15), meaning that socio-environmental factors (13) such as "context" and others, play an important role in determining individual and collective mental health and wellbeing (6,8,10,11,19,27).
Neighbourhoods may function as stressors or buffers of mental health vulnerability (27,28). Adverse characteristics of the residence areas, work or education, expressed in terms of low social capital and social cohesion (e.g. the absence of social support) contribute to the development of emotional problems (7,2,19), the lack of identity and community integration, and the weakening of social bonds (18). This process has consequences on behaviour negatively impacting general as well as mental health (29,19,27).
Social capital, in the form of social affiliation and social cohesion within communities, may help reduce the risk of morbidity and maladaptive functioning (30). Informal social control, maintenance of healthy norms, and access to various forms of social support can contribute to both healthier lifestyles and positive wellbeing.
Further studies on the effect of urbanization on physical and mental health equity are mandatory. However, current knowledge stresses the need to invest in healthy societies to prevent mental illness and promote mental health (5). Thus, collaboration between the health system and other social and economic authorities is urgent to reduce the socioeconomic inequality in mental health, particularly in crisis periods (27,31).
Stuckler et al (2), reflecting on the ability to learn from the mistakes of the past, concluded: “Crises have the potential to save many lives or cause more deaths; what happens will ultimately depend on how governments and policymakers choose to respond.”
|(1)||Ruhm C (2005): Healthy living in hard times. Journal of Health Economics 24 (2005) 341–363.|
|(2)||Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M (2009): The public health eﬀect of economic crises and alternative policy responses in Europe: an empirical analysis. The Lancet 2009; 37(4): 315–23.|
|(3)||WHO Commission on Social Determinants of Health (WHO CSDH) (2008): Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Final report of the Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization.|
|(4)||Snyder VNS, Friel S, Fotso JC, Khadr Z, Meresman S, Monge P, Patil-Deshmukh A (2011): Social Conditions and Urban Health Inequities: Realities, Challenges and Opportunities to Transform the Urban Landscape through Research and Action. Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 88, No. 6.|
|(5)||Macintyre S, Ellaway A (2000): Ecological Approaches: Rediscovering the Role of the Physical and Social Environment. In: Social Epidemiology chap., pp. 332–348. Oxford University Press.|
|(6)||Evans GW (2003); The built environment and mental health. Journal of Urban Health; 80(4):536-55.|
|(7)||Mair C, Diez Roux AV, Galea S (2008): Are neighbourhood characteristics associated with depressive symptoms? A review of evidence. J Epidemiol Community Health; 62(11): 940-6.|
|(8)||Paczkowski MM, Galea S (2010): Sociodemographic characteristics of the neighbourhood and depressive symptoms. Curr Opin Psychiatry; 23(4): 337-41.|
|(9)||Fone DL, Dunstan F (2006): Mental health, places and people: A multilevel analysis of economic inactivity and social deprivation. Health & Place; 12(3):332–344.|
|(10)||Sundquist K, Ahlen H (2006): Neighbourhood income and mental health: A multilevel follow-up study of psychiatric hospital admissions among 4.5 million women and men. Health & Place; 12(4): 594–602.|
|(11)||Friedli L (2009): Mental health, resilience and inequalities. Denmark: WHO Regional Office for Europe.|
|(12)||Patel V, Lund C, Hatherill S, Plagerson S, Corrigall J, Funk M, Flisher AJ (2010): Mental disorders: equity and social determinants. In Equity, Social Determinants and Public Health Programs. Edited by Blas A, Kurup AS. Geneva: WHO Press:115–134.|
|(13)||WHO (2005): Global health promotion scaling up for 2015 - A brief review of major impacts and developments over the past 20 years and challenges for 2015, Unedited working paper, WHO.|
|(14)||Veenhoven R, Haganaars A (eds)(1989): Did the Crisis really hurt? Effects of the 1980 - 1982 economic recession on satisfaction, mental health and mortality. Universitaire Pers Rotterdam, The Netherlands.|
|(15)||Almedom AM (2005): Social capital and mental health: An interdisciplinary review of primary evidence. Social Science and Medicine; 61(5): 943–964.|
|(16)||Miles R, Coutts C, Mohamadi A (2011): Neighborhood Urban Form, Social Environment, and Depression. Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 89, No. 1: 1-18.|
|(17)||Johns L, Aiello A, Cheng C, Galea S, Koenen KC, Uddin M (2012): Neighborhood social cohesion and posttraumatic stress disorder in a community-based sample: findings from the Detroit Neighborhood Health Study. Soc Psychiatry Psychiatr Epidemiol, DOI 10.1007/s00127-012-0506-9.|
|(18)||Artazcoz L, Benach J, Borrell C, Cortès I: Unemployment and mental health: understanding the interactions among gender, family roles, and social class. Am J Public Health 2004, 94:82–88.|
|(19)||Marmot, M., 2004. The Status Syndrome: How Social Standing Affects our Health and Longevity. Times Books, London.|
|(20)||WHO (2011): Impact of economic crises on mental health. Copenhagen: Whorld Health Organization.|
|(21)||Cooper B (2011): Economic Recession and Mental Health: an Overview. Neuropsychiatrie, Band 25, Nr. 3/2011, S. 113–117.|
|(22)||Silver E, Mulvey EP, Swanson JW. (2002) Neighbourhood structural characteristics and mental disorder: Faris and Dunham revisited. Social Science and Medicine; 55:1457–1470.|
|(23)||Khedmati E, Forouzan A, Majdzadeh R, Asadi-Lari M, Noorbala A, Hosseinpoor A (2012): Understanding determinants of socioeconomic inequality in mental health in Iran's capital, Tehran: a concentration index decomposition approach. International Journal for Equity in Health 2012, 11:18.|
|(24)||Stockdale SE, Wells KB, Tang L, Belin TR, Zhang L, Sherbourne CD (2007): The importance of social context: neighborhood stressors, stress-buffering mechanisms, and alcohol, drug, and mental health disorders. Soc Sci Med; 65(9): 1867-81.|
|(25)||Rohrer JE. Jr J.R.P, Blackburn C (2005): Lifestyle and mental health. Preventive Medicine; 40: 438–443.|
|(26)||Kawachi I (1999): Social capital and community effects on population and individual health. Ann N Y Acad Sci.; 896: 120-30.|
|(27)||Saman D, Walsh S, Borowki A, Odoi A (2012): Does place of residence affect risk of suicide? A spatial epidemiologic investigation in Kentucky from 1999 to 2008. BMC Public Health; 12:108.|
|(28)||Veit, C, Ware, Jnr J (1983): The structure of psychological distress and well-being in general populations. Journal of Consulting and Clinical Psychology, 51, 730-742.|
|(29)||Johnson S, Kuhlmann R, EPCAT Group (2000): European Psychiatric Assessment Team. The European Service Mapping Schedule (ESMS): development of an instrument for the description and classification of mental health services. Acta Psychiatr Scand Suppl. 2000;405:14-23.|
|(30)||Kuldorff M (1997): A spatial scan statistic. Communic. Statist. Theory Meth., 26: 1481–96.|