Psychology, public health and the soil of social circumstances

My first encounter with health inequities and prevention was during a master's in Health and Clinical Psychology. I learned about the seminal Whitehall studies (Marmot et al., 1978), which identified the correlation between socioeconomic status and health outcomes, paving the way for a substantial body of work around the 'social determinants of health' (SDOH), defined by the World Health Organisation as 'the conditions in which people are born, grow, live, work and age' (World Health Organisation, 2024). They're building blocks, supporting and allowing us to develop good health. 

Whilst the SDOH concept may feel theoretical, their impact is anything but. Think of the tragic death of two-year-old Awaab Ishak from prolonged mould exposure. The social determinants of health are the earth from which health outcomes grow, good and bad – the harsher the soil of social circumstances, the worse the health outcomes.

Despite many conversations on poor health outcomes focusing on acute services, social factors have a far greater impact on health outcomes – with around 80 per cent of health outcomes being determined by non-medical factors (Hood et al., 2016). Despite this, only 15 per cent of NHS spending in 2021 was on preventative care (Office for National Statistics, 2021). For mental health specifically, SDOH has been found to influence the development, severity and chronicity of mental distress (Shim & Compton, 2018).

Literature around the SDOH has continued to grow over the past several decades (Braveman & Gottlieb, 2014; Marmot & Bell, 2009; Pickett & Wilkinson, 2010). I recall an article in The Psychologist quoting a researcher: 'Kids from lower socioeconomic levels show brain physiology patterns similar to someone who actually had had damage in the frontal lobe as an adult'. Way back in 2011, Braveman and colleagues wrote that the question of whether social factors influence health has been answered – the question now is how do we intervene?

Responsibilities as mental health professionals

There is a striking paradox within mental health services. Whilst the literature identifies the fundamental, aetiological role of social factors in mental distress, many mental health professions and training programmes emphasise individual interventions (Hall et al., 2015). Many mental health professionals are unequipped with the tools to comprehend or respond to what has long been the elephant in the room. Likely reflecting the history of Psychology as a profession focusing on individuals, approaches to exploring and responding to SDOH within mental health services are not standardised, roles and responsibilities are not clearly demarcated, and training is not well established (Handerer et al., 2021; Vaughan et al., 2024).

As I say, relatively early in my Psychology journey I was influenced by epidemiologist Michael Marmot. In his book The Health Gap, Marmot describes the work of firefighters in Liverpool. Hearing concerns about living conditions when installing fire alarms, they would speak to the council. They would speak to people about smoking in bed, before starting to help people stop smoking. They gave pensioners free access to their gym, and worked with Liverpool Football Club to get children and young people into playing sport, and growing vegetables in the fire station to keep them off the streets. 'This is what the firefighters are doing to improve health in deprived communities,' Marmot said: 'What are you doing?'

Marmot also questioned the effectiveness of individual interventions without changing the social context – 'Why treat people and send them back to the conditions that make them sick?'

If firefighters can tackle SDOH, surely mental health professionals, trained in formulating and considering key factors contributing to an individual's distress, should? As stated by Desmond Tutu and illustrated by Dr Juliet Young (also known as Creative Clinical Psychologist) above, 'There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they're falling in.'

This is the realm of public health.

Public Health Placement

Through chance, I became friends with a determined trainee who also had an interest in the broader context influencing services and wellbeing. This trainee sought and fought for a placement in Public Health, and I was able to follow in their footsteps. The recent expansion of Clinical Psychology programmes presents challenges in sourcing placements, but it also offers an opportunity for a diversification of placements for trainees obtain a broader range of experiences applying their skills in new settings. Otherwise, they will remain for the lucky or particularly resolute.

During my placement, with Trafford Public Health Team, I worked on three larger project areas. The first involved the writing of a housing strategy chapter on inequalities and contributing to recommendations for the local area. Through the second, I led the writing of a report on the challenges facing those with co-occurring addiction and mental health needs accessing services. Lastly, I conducted a scoping exercise on local social prescribing roles and challenges, aligning with the focus of my systematic review on social prescribing.

Through the development of the inequality housing strategy chapter, I liaised with and consolidated various perspectives from public health colleagues, and reviewed research and policy documents to understand the needs of the local area and the evidence base. Alongside this, I needed to develop a communication style fit for influence and policy. Whilst before the placement I had often had a sense of policy documents as dry, dusty things that often aren't reviewed, I also saw how they can be important strategic levers when the timing is right. In this case, the recommendations of this chapter aided discussions of further collaboration between health and housing services.

My work on co-occurring conditions was contributing towards a 'Joint Strategic Needs Assessment' which reviewed the current and future needs and challenges of the local area regarding drugs and alcohol. I contacted a wide variety of practitioners at varying levels of seniority to ascertain an accurate summation of the current quality of care for those with co-occurring conditions, along with the strengths and challenges facing the area. 

Whilst I already had some awareness of the interconnected nature of services, the placement allowed me to peek behind the curtain. I became acutely aware of how services exist within a complex ecosystem and saw specific examples of how the changes or challenges of one can have significant impacts on other services around them. Added to this was the need to synthesise a range of perspectives on various contentious topics with often limited quantitative data. This required the interpersonal skills of Clinical Psychology training, alongside using limited and incomplete data pragmatically – integrating both to assess need and construct a meaningful narrative.

The review had practical implications for how services run, linking into higher-level meetings regarding reviewing and learning from drug-related deaths, suicide prevention, and plans to improve how services work effectively together. Through this work, I felt the parallels of working within teams holding varying perspectives facing different challenges and needing to understand the individual experiences of each person (or service in this case). Particularly, I recall the clear applicability of systemic principles, the dynamics among and between various services, the feedback loops that could manifest (circularity), and how systems become stuck in homeostasis even when this perpetuates challenges. 

To assess the landscape of Social Prescribing roles and the challenges facing them, this required a flexibility of working and creativity of thinking which felt distinct from prior placements. I had to use my initiative to connect with various social prescribing practitioners and related roles. This project made me aware of the significant (and often under-appreciated) role of VCFSE sector organisations to fit the gaps between and outside of services. A report summarising the work was completed and presented to NHS, public health, social care and children's services representatives. From this, a steering group was established to focus on resolving some of the challenges identified along with a further task-and-finish group regarding future funding decisions relating to social prescribing roles. This project strengthened my confidence in networking, chairing meetings, considering key elements of change (such as timing, leverage and relationships) and providing invaluable experience in project management.

Throughout these projects, I have seen the ready applications of Psychologists' skills in forming relationships and understanding various perspectives across services and systems. Such placements can be a fruitful opportunity for trainees already well-versed in one-to-one relationships, to apply what they know to service-to-service relationships. 

In stepping outside of an NHS service, I feel that I have been able to take an 'observing eye' over mental health services, gaining the confidence to question the status quo. I've gained a broader perspective on how Clinical Psychologists can alleviate distress, seen the value of collaborating with external services beyond the NHS, and thought more about the 'stuckness' which can afflict some services in the challenges they face.

Challenges

This is not to suggest that the placement did not pose challenges. Particularly, I noticed how public health professionals spoke the language of 'influencing'. Conversations in meetings would often discuss the framing of messaging and priorities and subtle discussions of roles and responsibilities. This language felt like a distinct change from the psychobabble of psychology, and it took me a while to comprehend. The greater flexibility I had in my role was a blessing and a curse too: the freedom to test things out could at times feel uncontained, certainly more so than traditional trainee placements focused on one-to-one sessions. 

These challenges were meaningful – I have been stretched, learned, and grown in confidence. Since then, in my first qualified post, I've sat more comfortably with responsibility and using my own initiative. 

The next generation

The recent draft British Psychological Society standards for the accreditation of doctoral programmes highlight the importance of placements in areas such as public health, recommending 'Developing an understanding of prevention and public health in clinical psychology, focusing on improving and protecting community health and wellbeing, with an emphasis on prevention at community and population level'. By moving beyond traditional clinical roles, trainees are likely able to obtain insights into the interplay of services, the nature of such inequalities, and the potential of collaborative efforts to push for meaningful change. 

Ultimately, this experience has given me a broader appreciation of the role, capabilities, and responsibilities of Psychologists in the face of prominent and increasing inequalities and systemic problems. If firefighters, with no skills in the formulation of distress, can recognise the impact and importance of addressing health inequalities, then we must seek to ensure that the next generation of Psychologists are primed to do the same. 

Image, above: Dr Juliet Young (also known as Creative Clinical Psychologist)

References

Braveman, P., Egerter, S., & Williams, D. R. (2011). The social determinants of health: coming of age. Annual review of public health, 32(1), 381-398. 

Braveman, P., & Gottlieb, L. (2014). The social determinants of health: it's time to consider the causes of the causes. Public health reports, 129(1_suppl2), 19-31. 

eClinicalMedicine. (2022). Awaab Ishak and the politics of mould in the UK. eClinicalMedicine, 54. 

Hall, J., Pilgrim, D., & Turpin, G. (2015). Clinical psychology in Britain: Historical perspectives. Clinical Psychology, 273, 52. 

Handerer, F., Kinderman, P., & Tai, S. (2021). The need for improved coding to document the social determinants of health. The Lancet Psychiatry, 8(8), 653. 

Hood, C. M., Gennuso, K. P., Swain, G. R., & Catlin, B. B. (2016). County health rankings: relationships between determinant factors and health outcomes. American journal of preventive medicine, 50(2), 129-135. 

Kishiyama, M. M., Boyce, W. T., Jimenez, A. M., Perry, L. M., & Knight, R. T. (2009). Socioeconomic disparities affect prefrontal function in children. Journal of cognitive neuroscience, 21(6), 1106-1115. 

Marmot, M. (2015). The Health Gap: The Challenge of an Unequal World. Bloomsbury Publishing. 

Marmot, M., & Bell, R. (2009). Fair society, healthy lives. 

Marmot, M. G., Rose, G., Shipley, M., & Hamilton, P. J. (1978). Employment grade and coronary heart disease in British civil servants. Journal of Epidemiology & Community Health, 32(4), 244-249. 

Office for National Statistics. (2021). Healthcare expenditure, UK Health Accounts: 2021. 

Pickett, K., & Wilkinson, R. (2010). The spirit level: Why equality is better for everyone. Penguin UK. 

Shim, R. S., & Compton, M. T. (2018). Addressing the social determinants of mental health: if not now, when? If not us, who? Psychiatric Services, 69(8), 844-846. 

Vaughan, M., Bryant, A., Boland, A., Abba, K., Anderson de Cuevas, R., Kinderman, P., Barr, B., & Corcoran, R. (2024). How we ask, how we act: A qualitative study exploring how mental health professionals discuss and respond to the social determinants of health with service users (Pre-print). 

World Health Organisation. (2024). Social determinants of health. 

Young, E. (2020). It is hard to be poor, harder than we thought. The Psychologist, 33, 16-18.