By Hmellisa Mlo, MPH

The Shift Upstream

Health experts and healthcare systems are now beginning to focus on social determinants of health by increasingly adopting upstream rather than downstream approaches for prevention and care in matters of physical health. A similar approach is now needed for mental health.

Throughout recent decades, the attention in US healthcare has been turning towards social determinants of health (SDoH) factors that affect overall health and wellbeing. These include where someone lives, learns, plays, and works^[1] and their knowledge, attitudes, beliefs, and behaviors surrounding their health.^[2] Many healthcare interventions have already attempted to hone in on SDoH in order to improve health outcomes. Some of these interventions have been ‘downstream’, targeting individual behaviors and attitudes towards prevention and disease management. However, despite such efforts, health disparities and inequities are still present in the healthcare system. The COVID-19 pandemic has shined an even brighter light on these disparities.

A prominent and profound shift in public health to address SDoH using ‘upstream’ approaches is currently underway—approaches that focus on the macro level, namely government policies that can affect large populations. The field of mental health is ready for the same type of shift to upstream prevention.

How have upstream approaches affected health outcomes, and how can they be applied to mental health?

Downstream interventions that target individuals focus on providing care and services to mitigate poor health but fail to consider factors that can influence attitudes and behaviors. Thus, some communities and populations are left behind, sometimes due to factors beyond their control. Inevitably, the populations left behind tend to be our most vulnerable and underserved. Addressing SDoH means taking into consideration those influential factors. Applying upstream approaches means taking a look at those dimensions that are beyond an individual’s control which affect entire communities and populations.

The critical point: Social determinants of health matter. SDoH account for 20 percent of overall determinants of health. Lifestyle, which is affected by SDoH, accounts for another 50 percent. Also, early intervention that takes into account SDoH can have a significant impact on health in populations.

A downstream approach to addressing mother-infant health would be to offer health education classes, brochures, and pamphlets to pregnant women during prenatal care visits. Even though the information presented is evidence-based and classes are available, some women may be faced with a transportation barrier and have trouble getting to these classes or even attending prenatal care visits. We assume people have cars or someone to drive them to appointments. If they don’t have access to a car, we hope that public transportation is abundant, reliable, and work in their favor. What if the city or town they live in doesn’t have reliable public transportation or the location of the clinic or classes aren’t on the route? There may also be a financial barrier as some women who cannot afford to take time off work to attend these classes or go to prenatal visits may be at risk of losing their jobs if they take time off. These are all macro-level, socioeconomic factors that can have a detrimental effect on the health of these mothers and their infants if not addressed.

The Nurse-Family Partnership (NFP) is a prime example of how upstream approaches that address SDoH can not only improve health outcomes but also help make healthy living more sustainable, especially for vulnerable populations where sustainability is difficult. The NFP is a healthcare intervention program that began in the late 1970s to improve the health outcomes of mothers and infants.^[3] 

Instead of following the traditional route of prenatal care visits and classes, the NFP uses upstream methods by meeting women where they are—in their homes. Regular home visits by nurses occur during the course of the pregnancy and the first two years of children’s lives.^[4] During these home visits, nurses present specific, individualized ways to care for the children and educate expectant mothers about the potential harm to newborns from certain health behaviors such as cigarette, drug, and alcohol use during pregnancy. Essentially, the health of mom and baby are addressed holistically, and when services are directly delivered to them, the stress and impact of transportation and financial barriers are reduced. Early NFP research found that these home visits, compared to conventional prenatal and postnatal healthcare services, were associated with numerous improvements, not only in health but also in socioeconomic benefits, including an increase in maternal employment and a decrease in the number of months that mothers had to stay on welfare and food stamps.^[5] The NFP continues to be the gold standard for top-tier, evidence-based programs today.^[6]

Interventions that target SDoH, however, have tended to focus more on improving physical health outcomes, such as anti-tobacco interventions to reduce the risk of lung cancer or, in the case of the NFP program, lower rates of pregnancy-related hypertension. But, what about the social determinants of mental health?

Social Determinants of Mental Health

The statistics and costs associated with the mental health crisis are staggering. In their lifetime, half of US adults will experience mental health issues, and one in five adults are diagnosed with or seek help for mental health conditions and symptoms each year.^[7] Workplace stress contributes to $190 billion in US health costs^[8] and $1 trillion in global productivity loss each year.^[9] Despite the prevalence of mental health issues in the general population, 56 percent of the US population lacks access to mental health services.^[10]

Traditional mental health treatment and services are downstream approaches that focus on individuals, such as counseling, medication, and health education. Yet, 75 percent of those with mental health issues seek help on their own, without the assistance or guidance of professionals. Imagine if three-quarters of pregnant women attempted to seek prenatal care on their own or three-quarters of smokers attempted to quit smoking with unvalidated resources and tools. By allowing those at risk to help themselves while not addressing the social determinants that compound their challenges, poor health outcomes become more prevalent.

Upstream Intervention and Prevention in Mental Health

Thanks to the recent shift toward using upstream interventions to address SDoH and the impact of population health initiatives, the healthcare system is seeing better outcomes for physical health than ever before. It’s time to start considering mental health in this shift as well. Physical health and mental health are not mutually exclusive, and both contribute to health equity. A national survey on comorbidities found that more than 68 percent of adults with a mental health condition reported having at least one general medical condition, and 29 percent of those with a medical condition had a comorbid mental health condition.^[11] The social determinants that can affect physical health can also affect mental health and can even compound the prevalence of mental and physical health conditions.

People of low socioeconomic status (SES), for example, are 1.8 times more likely to report depression symptoms than those with higher SES.^[12] Neighborhood characteristics have been found to contribute to the risk of depression due to daily stress levels, exposure to negative events, and poor social support or disrupted social ties.^[13] Low SES and neighborhood characteristics have been attributed to high rates of obesity and diabetes due to barriers such as access to healthy food options.^[14]

Along with upstream interventions for mental health, there is a need to consider preventative interventions. The US healthcare system still primarily focuses more on treatment and disease management than prevention. When discussing SDoH, some risk factors that are considered include race/ethnicity, gender, neighborhood, income level, and education level. That’s because such factors are correlated with negative outcomes such as poverty and community violence, which can affect health. By thinking more positively and proactively about the social determinants of mental health, we see the possibility of improving on protective factors such as supportive relationships, community safety, resilience, and high self-esteem, which can all contribute to better mental health outcomes^[15].

What’s Next?

At CredibleMind, we want to meet people with mental health concerns where they are. We are committed to helping people thrive and flourish. Our platform is specifically designed for prevention, early intervention, and reducing the risk of future mental health conditions.

The statistics are staggering: Half of adults experience mental health issues in their lifetime (and one in five each year). As noted, about 75 percent of people who face mental health issues work on those issues by themselves, yet 95 percent of self-help resources have no scientific validity.

CredibleMind provides a solution. We offer evidence-based approaches and validated resources to improve on protective factors with topics and content rooted in emotional health, positive psychology, and spiritual well-being. We are also spearheading the upstream shift in mental health by engaging and empowering public health departments, hospitals, small businesses, and corporations to be advocates of early intervention. Individuals no longer have to be entirely self-reliant with the support of their workplace, health plan, and the larger community.

Together, with a better understanding of social determinants of mental health and the benefits of upstream approaches, we can work towards prevention and early intervention and pave the way for positive mental health outcomes for ourselves, our families, and our larger communities.

Other resources:

• Social Determinants of Mental Health by WHO and the Calouste Gulbenkian Foundation
• 3 Things to Know: Social Determinants of (Mental) Health by Josephine Gurch