Mental health and poverty are inextricably linked and leave many young people trapped in a vicious cycle that can limit their chances of a better life, writes the University of Cape Town’s (UCT) Emily Garman.
Mental health is often misconstrued as the absence of mental illness, but it is much more complex than that. It is a state of emotional, psychological, and social wellbeing – a multidimensional concept that is intrinsically linked to an individual’s social and economic environment. The link between mental ill-health and poverty has received a lot of attention in the past two decades and it’s now well established that mental illness and poverty interact in a vicious cycle.
On the one hand, people living in poverty – who may be unemployed and lacking adequate housing and basic amenities – are more likely to be at risk of mental ill-health. This is known as the social causation pathway, and is thought to occur because of the heightened stress, social exclusion, decreased social capital, and increased violence and trauma that people living in adversity are likely to face. Research shows that these social determinants tend to lead to common mental disorders, such as depression and anxiety.
On the other hand, people who suffer from a mental illness are more likely to drift into or remain in poverty as a result of reduced productivity, loss of employment, and increased health expenditure. This is known as the social drift pathway.
So, poverty leads to poorer mental health – and vice versa – leading, in turn, to reduced opportunities for economic development and increasing the risk of lifelong poverty. Hence the vicious cycle.
This cycle affects not just adults, but adolescents too. Young adulthood is a time of key social, emotional and behavioural change; a time when individuals may have to transition from education to employment, and when relationships and social support are defining features of one’s identity. Young people living in poverty face additional disadvantages which are likely to affect their ability to complete education, find work, and achieve their goals, thus limiting their life chances and placing them at even greater risk of mental ill-health.
The intervention question
So, what can we do to break the vicious cycle? Cash transfers – direct cash payments provided to the poor and materially deprived – are one of the most popular forms of anti-poverty interventions designed to reduce inequalities in income, education and employment. Such interventions have been shown to enhance economic outcomes, but can they improve mental health and break the social causation pathway? Similarly, can mental health interventions, such as psychotherapy, rehabilitation programmes and medication, tackle the social drift pathway by improving economic opportunities, as well as mental health?
A study conducted nearly ten years ago reviewed all the research available on the subject, which at the time was quite limited. This is because most evaluations of anti-poverty interventions tend to focus on socioeconomic benefits, while most evaluations of mental health interventions focus on health-related outcomes, with very little overlap between the two fields of research. This study had a specific question in mind: given the vicious cycle, should we focus our efforts on anti-poverty interventions in the hope of improving the mental health of people living in poverty? Or should we focus on providing mental health interventions to alleviate the burden of mental illness and improve the lives and economic opportunities of people living with mental ill-health?
The answer is probably both. Improving mental health is likely to boost engagement in education and employment, and improve economic opportunities for people living in low resource settings. According to the study, the beneficial effect of mental health interventions on economic outcomes – such as income or months of employment – was quite clear among adults. Although given how socially determined mental health is, especially in low resource settings, these interventions alone are unlikely to reduce the burden of mental illness.
The impact of anti-poverty interventions on mental health was less clear cut. Some interventions involving unconditional cash transfers appeared to have no impact on adults’ or children’s mental health. Others were more promising: a study in Mexico, for example, found that children’s memory improved when their families received increased cash transfers on condition that they attend school and regular medical check-ups. In another study conducted in Uganda, AIDS-orphaned children had greater self-esteem after taking part in a family programme designed to promote financial assets.
More research is clearly needed, especially among young people, which is why we are currently involved in a new review that aims to identify recent evidence of the impact of anti-poverty interventions on the mental health of children and young adults in low and middle income countries.
The review is part of an international study called CHANCES-6, a novel collaboration among universities in the global south and north. These include the Alan J Flisher Centre for Public Mental Health at the University of Cape Town (South Africa), the University of Los Andes (Colombia), the Mackenzie Presbyterian University and Federal University of São Paulo (Brazil), and Kings College London and the London School of Economics (UK).
CHANCES-6 aims to get a better understanding of the impact of poverty reduction programmes on the mental health, life chances, and future risk of poverty of young people across six African and Latin American countries – Brazil, Colombia, Liberia, Malawi, Mexico, and South Africa. We aim to achieve this by using information already collected from cohort studies in each country – either as part of evaluations of anti-poverty programmes or national surveys that include information on the uptake of government anti-poverty initiatives. Interviews and focus groups with beneficiaries of anti-poverty programmes are also planned to better understand their experiences of accessing cash transfers and identify ways to improve their impact.
We hope our findings will help us estimate the potential impact of combined mental health and anti-poverty interventions on the future life chances of young people. Findings from this simulation bring us closer to turning the vicious cycle into a virtuous one.
The case in South Africa
In South Africa, a country marked by extreme inequalities in education, health, income and housing, our research for CHANCES-6 is focused on the child support grant – one of several social support grants introduced to reduce poverty among vulnerable groups.
Introduced in 1998, the child support grant has become the single biggest programme for reducing child poverty in South Africa, with over 12 million current beneficiaries. Initially aimed at children under the age of seven and set at US$20 a month, the grant amount, age eligibility and caregiver’s income threshold have since all increased gradually. Today, all children under the age of 18 are eligible, providing their caregiver earns less than $260 per month. There is good evidence that child support grants are spent on food, education and basic goods and services, and that they improve children’s nutritional status, health and educational attainment. Our role as part of CHANCES-6 is to make use of the regular changes in age eligibility over time to find out whether receiving the grant can also improve the mental health and life chances of young people in South Africa.
By continuously engaging with stakeholders and young people throughout the process, we hope to get a better understanding of people’s perceptions and beliefs about poverty, mental health, and the opportunities available to young people, thus ensuring that we can provide policymakers with recommendations that are relevant, usable, and appropriate.
Many young people living in adversity in South Africa are all too aware of the structured social and economic barriers that prevent them from achieving their life goals and taking up opportunities that would enable them to contribute to the country’s economic development. For them, being poor is closely linked with food insecurity, and associated with the loss of human dignity and feelings of shame – feelings that are likely to have long-term effects on their mental wellbeing and expectations of life.
It is, however, encouraging to see the resilience that some young South Africans exude, their willingness to get out of poverty, and determination to reject the status quo. As one young person in a CHANCES-6 focus group said:‘If you see poverty [as] your barrier in life, you will go nowhere. But if you see beyond poverty, you see your life as someone successful. When you are successful, it is not a must to be like Bill Gates and rich. When you are successful, you have achieved what you want in life; you are what you want in life.’
It is also clear that community and family structures are essential. Many young people tell us that they actively draw on support from their families and communities, both emotional and financial, as a way to get through schooling, find employment, and ‘stay out of trouble’: ‘My grandmother always pushes me to be the best, to do the best… That woman is really clever. It’s just that she didn’t get the opportunity to do what she wanted, and she wasn’t exposed to what I am exposed to right now. She tells me to make use of everything that you have in life. Opportunities you get, grab them. Everything you see could work for your life, follow it’.
As development agencies and governments begin to grasp the extent to which poor mental health can maintain poverty, we as researchers hope to take advantage of this recognition and continue to work with policymakers and youth advocates to evaluate and implement interventions which target this vicious cycle. Taking a life course approach to economic development – one which considers the critical stages, transitions, and settings in which a meaningful difference can be made to a person’s wellbeing – is the only way we will be able to improve the social, economic, and health circumstances of people living in adversity and break the vicious cycle of poverty and mental ill-health.
Dr Emily Garman is a Senior Researcher at the Alan J Flisher Centre for Public Mental Health – a joint initiative of the University of Cape Town and Stellenbosch University, South Africa. Dr Garman is based at the University of Cape Town.