Individual factors and perceived community characteristics in relation to mental health and mental well-being

The World Health Organization defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” [1]. A related concept, mental well-being, has been receiving increasing attention in recent years, is moving up the policy agenda [2, 3], and is becoming increasingly recognised as a key public health indicator [4]. There is no agreed definition of mental well-being, but it is generally seen as covering both the subjective experience of affect and life satisfaction, as well as psychological functioning, good relationships with others and self-realisation [5, 6]. Mental health and mental well-being can be seen to form two distinct, but correlated, continua in populations [7‐9]. Mental well-being (vs. mental illness) can be seen as the positive component of mental health [10]. However an absence of mental illness in an individual may not necessarily represent positive mental well-being, and vice versa, individuals with mental illness may also have positive mental well-being [11, 12]. Huppert has argued that the independence of mental illness and mental well-being suggests that their determinants may differ [13]. It is plausible that different individual and community level factors could affect mental health and mental well-being in different ways. Accordingly it is important to differentiate the individual and perceived social and environmental variables associated with both.

Features of the neighbourhood social environment, such as safety/violence, social connections or cohesion, and informal social norms have been associated with mental health outcomes, particularly depression [14, 15]. In a similar way, individual perceptions of neighbourhood social processes have been associated with depressive symptoms [16]. Furthermore, low individual social capital, which can be seen to refer to cognitive (support, reciprocity, sharing, and trust), and structural (the extent and intensity of associational links) aspects related to social relationships of individuals [17, 18], has been associated with common mental disorders [19]. Living in a deprived or socioeconomically disadvantaged neighbourhood is also associated with poor mental health, although the effect sizes have varied across studies and have generally been modest [14]. Emerging evidence also suggests that resilience of a locality, that is high levels of social capital, may help to explain why one poor neighbourhood has lower mortality than other equally deprived areas [20]. Some studies indicate that neighbourhood deprivation may affect mental health over and above individual-level socio-economic factors [21] and Jokela [22] has considered the causal relationship of neighbourhood deprivation and poorer health. Less is known, however, about mental well-being, Mason and Kearnes [23] explored mental well-being and physical activity in deprived neighbourhoods in Glasgow, UK and found the greatest potential benefits to mental well-being were for those from deprived neighbourhoods. These findings build further upon those of Bond et al. [6] who found that for people living in deprived areas, the perception of the housing and neighbourhoods were associated with mental well-being. Therefore the level of neighbourhood deprivation could also moderate the relationship between perceived social neighbourhood factors and mental health and well-being.

Most previous studies assessing the effects of neighbourhood social environment on mental health or mental well-being have used measures of mental illness (e.g., depression) rather than positive aspects of mental well-being [14]. In a recent review on social capital and mental well-being in older adults, all included studies showed positive association between social capital and some aspects of mental well-being, but the definitions and instruments to measure mental well-being varied widely [10]. This review further showed that there are no studies investigating the relationship between individual social capital and measures specifically designed to assess mental well-being such as the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS) [10]. However, in a recent study, people’s residential psychosocial environments were associated with higher mental well-being measured by WEMWBS [6].

In 2011 Giles articulated the ‘top ten’ research questions which should be priorities for social science. Among the most important of these was the question, how does the social become biological (and vice versa) [40]. This reflects the ethos behind the “No health without mental health” UK cross-government strategy for people of all ages [3]. The temptation is to think only of physical health, but to do so would ignore the importance of mental health and mental well-being which, though often less visible, are themselves strong explanatory variables of physical health and longevity [41].

Research literature, has for the main part been concerned with mental (ill) health and although there is widespread agreement that mental health is more than the absence of clinically defined mental illness, there is still ongoing debate as to the elements that constitute positive mental health or mental well-being. The WEMWBS considers both the hedonic and eudemonic dimensions of well-being, and has been validated for use in the United Kingdom [5]. Although a population level measure and not designed as a clinical tool, it does appear to be sensitive to changes in mental well-being at the individual level and allows for the investigation of the determinants of mental well-being [http://​www2.​warwick.​ac.​uk/​fac/​med/​research/​platform/​wemwbs/​].

The current study aimed to examine the extent to which individual factors and perceived neighbourhood social environment were associated with mental health and well-being, and compared these relationships across different levels of neighbourhood deprivation. The current study made use of measures specifically designed to assess mental health (SF8 MCS) and mental well-being (WEMWBS), making use of a representative sample of a population living in a specific municipality, including information on its neighbourhoods.

We found that a range of individual and perceived community characteristics accounted for a reasonably high proportion of variability in mental health and mental well-being (38 % and 30 % respectively), but the association power of these covariates differed among people living in deprived and more affluent neighbourhoods. For instance, for a 20 years increase in age, a participant would achieve a 1 point significant increase in their mental well-being score, whereas this increase was over two and a half fold greater at 2.6 points when participants from the most deprived strata were considered, but not a significant explanatory variable in any other of the deprivation strata. However, age was a significant explanatory variable of better mental health in both the total and stratified sample, of comparable magnitude regardless of the level of neighbourhood deprivation (1.6 to 2.2 point increase in mental health per 20 year increase in the age of the participant). In contrast, not being unemployed had a 3.7 point increase in mental well-being for the general sample, but when considering the neighbourhood deprivation strata, this increased almost two fold to 6.43 points for participants from the most affluent of areas. This improvement in mental well-being is almost one standard deviation of the population mean, which some have deemed as an adequate definition for the difference between low, average and high mental well-being [6]. Whereas for mental health, being educated to degree level only had a significant association for those living in the most deprived of areas, at the second largest magnitude of over 4 points, only improved upon further by an increase of one level in self-rated health EQ-5D-3 L or 17 % within the EQ-VAS. These differences may be important to those designing interventions to improve mental well-being if what works most effectively for one group or area is not what works for others, and it may be necessary to take account of such differences to avoid widening social inequalities. Our findings are in agreement with the conclusions of the 2009 WHO report on mental health, resilience and inequalities, “A greater understanding of inequalities is also crucial to recognizing the limits of what promoting positive mental health can achieve. Positive mental health does confer considerable protection and advantage, but it does so predominantly among those with equal levels of resources.” [20].

Some explanatory variables, such as self-rated health, are common to both mental health and mental well-being, were better perceived health is associated positively with both mental health and well-being, though an elevation to a higher level on the EQ-5D-3 L scale produced an increase of 6.19 points on the mental well-being scale (i.e., 0.71 of a SD, again almost a change from low to average or average to high mental well-being), but an increase of 13.09 points (greater than one (1.17) standard deviation of the population mean) would result for mental health. Others, including indicators of individual social capital, such as satisfaction with the local area and ‘social connections’, are more important for mental well-being than mental health when considered across neighbourhood deprivation strata. That is, greater local area satisfaction was found to be significant explanatory variable for better mental well-being for the total sample (+1.06 per category increase in local area satisfaction) and those from the more affluent neighbourhoods (+1.75 for NIMDM4, and +1.39 for NIMDM5); in contrast, it was found to be a significant indicator of better mental health only for the total sample (+0.75per increase in local area satisfaction category). In other words, if a participant from an area more affluent than average levels of neighbourhood deprivation (NIMDM4) where to alter their perception of their local area satisfaction from ‘very dissatisfied’ to‘ very satisfied’, the participant’s mental well-being score would increase by more than one standard deviation of the population average (5x1.75 = 8.75), sufficient to convert low or average mental well-being to average or high, if mental well-being were to be trichotomised as in Bond et al. [6]. Although social capital is a placed-based ecological concept, most directly conceived as related to one’s neighbourhood or to places where individuals interact socially [42], our data corroborate other studies that demonstrate its importance to individual health outcomes. But what we have yet to empirically discern is whether regeneration programmes aimed at neighbourhoods can shift average population mental well-being. If they do, it would still be important to know whether the number of people with mental illness would be changed and how such effects might be mediated.

Previous research has shown that mental health problems are more common in areas of material deprivation [15, 21]. By the same token poor mental well-being is consistently associated with unemployment, low education, low income and low material standard of living [11]. Although there is growing evidence on the role of social capital in improving mental well-being through promoting community cohesion, social interaction and social trust [43], of these covariates, in our study only social connections (through social networks and social support) and local area satisfaction were associated with mental well-being in fully adjusted models. Our findings are in accord with those of Gidlow et al., for whom other social capital indicators of trust and social participation did not emerge as explanatory variables of mental health or mental well-being [35]. In contrast, Propper et al. found that it was the characteristics of individuals and individual households that were more important (than place itself) in determining levels of common mental disorders [44].

Two recent studies have explored that relationship between housing, neighbourhoods and mental well-being (using WEMWBS) for residents of 15 deprived areas within Glasgow [6, 45]. The first found that perceived (poor) aesthetic quality of the neighbourhood was associated with lower well-being, while satisfaction with the local area was strongly associated with higher mental well-being [6]. Indeed, the perceived internal reputation of the neighbourhood, but not the external reputation was positively associated with mental well-being [45]. Our own results concerning satisfaction with the local area aspects of social capital accord with these findings. In contrast, Gale et al. found no association between area-level deprivation and mental well-being, assessed using the WEMWBS [46], but their study only examined the relationship in 69–78 year olds.

Mental health is not just the absence of mental illness [4, 20], while mental well-being, though a related concept, is a measure of the hedonic (positive feelings or positive affect such as subjective wellbeing, life satisfaction, happiness) and eudemonic (positive functioning such as engagement, fulfilment, sense of meaning, social wellbeing) dimensions [5, 20, 33]. As mental health and well-being move up the policy agenda as it has both social and health benefits:

“Mental health promotion does have a role in preventing mental health problems, notably anxiety, depression, drug and alcohol dependence and suicide. But mental health promotion also has a wider range of health and social benefits. These include improved physical health, increased emotional resilience, greater social inclusion and participation and higher productivity.” [4, pg28]

mechanisms by which to promote mental health through developing theoretical and empirically sound complex interventions are beginning to appear in the literature [47]. Nonetheless, as summarised in the 2009 WHO report ‘Mental health, resilience and inequalities’,

“While there is much that can be done to improve mental health, doing so will depend less on specific interventions, valuable as these may be, and more on a policy sea change, in which policy makers across all sectors think in terms of ‘mental health impact’.” [20, pg 4],

so it is a challenge to everyone, not just those involved with interventions, to make an impact on mental health.

By sampling a population across a range of neighbourhood deprivation levels in one city, and accounting for clustering within local areas, we have been able to compare the explanatory variables of both mental health and mental well-being. Although certain personal attributes, such as better self-perceived health, being of older age, and marital status of married or cohabiting were all associated with better health and well-being, when the total sample was considered, educated to degree level and not being unemployed where only associated with better mental well-being. Individual social capital explanatory variables of ‘local area satisfaction’ and ‘social connections’ emerge as explanatory variables of mental well-being across the total sample of all strata but were only associated with mental health in the affluent areas when considered by strata of neighbourhood deprivation. Although there are similarities in the explanatory variables of mental health and mental well-being, socio-ecological interventions designed to improve them may not have equivalent impacts in rich and poor neighbourhoods.