National and global health disparities emanate from an interaction of structural, social, environmental, psychological and biological factors – Discuss. 

Health inequalities are unfair and systematic differences in the health of people, who through no fault of their own hold unequal positions in society (Mc Cartney, et al, 2013).  Factors such as Ethnicity, Gender, Social Class and geographical location can unfairly impact a person’s health outcomes.  Where a person is born, the socio-economic background they are born into and their race can affect their access to safe/regulated healthcare and can negatively impact life expectancy.  The black report 1980, identified four main theories in an effort to better understand health inequalities namely,  “artefact theory”, “social selection theory”, “behavioral & Cultural theory” and “structural theory” (Mc Cartney, et al, 2013).  This essay will discuss these and conclude that structural theory is the best-placed perspective to explain these inequalities.

To explore health inequalities, we will look at the elusive definition of health itself and the difficult task of narrowing down the term “health” as can mean different things to different people.   It will also summarize the Biomedical Model, The Social Model and The Bio-psychosocial Model adopted by medical professionals in the treatment of health & wellness and explore their advantages and limitations.  Finally, it will lay out the Sustainable Development Goals (SDG) which were drafted by the WHO in 2015 with the aim of reducing global health inequalities through reformation of the financial, economic and political systems of the EU member states (Biermann, et al, 2017).

Health can be viewed as a relative term which may mean different things to different people e.g., being physically fit to an Athlete or mobile to an elderly person.  There has been ample discourse and discussion regarding its definition (Boyd, 2000). The W.H.O.’s definition, (1948) has been criticised as being broad, complex and ambiguous (Song, Kong, 2015).   The definition can be described as a more idealistic view, which incorporates the absence of ill health and also physical, social and mental well-being.  It can be argued that this definition is an ideal to strive towards, but it also implies if a person does not achieve total physical, social and mental well-being, they are in ill health.   Health has been defined as the absence of disease (Boorse, 1997), but this medicalized view has been challenged due to its singular focus, that does not account for mental health issues or include well-being for instance.

The Biomedical model approach aligns with Boorse, 1997,  that the absence of disease denotes health.  This approach focuses on medicinal treatments of disease and ill health as deviant from normal, including mental health.  It does not take into account the social or economic factors that impact an individual’s health outcomes.   This model can be criticised for its sole focus of a  medicalised approach to treatment and its failure to acknowledge the role of social factors on the causes of health problems, which are caused by the unequal distribution of power and wealth. (Marmot, 2015) The term clinical gaze was introduced by Michel Foucault, who argued that the emergence of the medicalisation of health resulted in the Doctor becoming more important than the views of the patient.  The clinical gaze is a useful concept when reviewing the emergence of the patient safety movement over the previous 20 years.  The lack of progress in this area may be linked to the continuance of a medical ethos and hierarchical structure, which undermines this new way of thinking. The Clinical gaze changed the physician-patient dynamic by emphasising the Doctor over the patient.    The patient did benefit from the outcomes and changes in how disease/health were viewed, but it has also led to less patient-centered care and overall medicalisation of health.  (1973, Foucault cited in Lachman, 2013, 1.)

The Social Model of health has a broad spectrum that consists of multiple perspectives, i.e., the social determinants of health, unhealthy lifestyles and the social construction of health and illness.  The social determinants of health are features that can determine health outcomes, they are non-medical and range from social, economic, political and geographical factors.  Where an individual is born, works and lives will have an impact on their health (WHO, 2020).  These determinants which are beyond the individual’s control, are a result of the unequal distribution of power and wealth, which occurs nationally and globally.   Marxism proposes that class relations can be characterised by an uneven distribution of power, by Modern western/capitalist societies consisting of people who own the means of production and those who sell their work/labour for their living.  It is a classic and unequal division of classes, with the labour being systematically exploited and oppressed.  Through  capitalism, social divisions began based on the ownership or non-ownership of property and that the economic inequalities that stemmed from this, were the starting point for understanding why there are inequalities in health between the middle and the working classes (Barry, 2012).  While social determinants are beyond an individual’s control, unhealthy lifestyles are the opposite and consist of individual choice.  A person’s diet, alcohol/drug intake and exercise will have a bearing on health e.g., if a person smokes, they are more likely to develop cancer.  The final element of the social model is the social construction of health and illness.  This encompasses the way in which we as a society understand phenomena/problem, the labels we use to describe them and the theories we use to define them, will have a direct impact on the individual who directly experiences the phenomena/problem and the way’s others in society will respond (Conrad, Barker, 2010).

The final Bio-psycho-social model is a comprehensive model which considers biological, psychological, and social factors in order to comprehend and address health issues (Skewes & Gonzalez, 2013).  It understands that while there are biological factors such as being genetically predisposed to disease, there are other factors which also play a part, such as social, family, partner, peer influences and also psychological factors, a readiness to change, self-belief and outcome experiences (Borell-Carrio et al, 2004).

Theories of health inequalities seek to identify and understand the problem of health inequality so an appropriate response such as policy creation can be affected to alleviate and solve the issue.  The four main theories that were used to understand health inequalities originated in (The Black Report, 1980), they were artefact theory; social selection theory; and behavioural & cultural theory; structural theory.  The artefact theory, posits that health inequalities are a result of measurement process.  This theory has been widely disregarded in recent times.  The Social selection theory has a reverse view of health inequalities, meaning  health inequalities will determine social class.  A Person with ill health will “slide down” the social ladder.  Behavioural and cultural theory views the opposite of the social selection in that class is seen to determine health inequalities.  This view suggests that lifestyle choices adopted by the lower social groups negatively impact health equality.  People from these groups tend to take part in risky and damaging behaviour like drugs and alcohol.  (Mc Cartney, et al, 2013).  Structural theory is the final and best-placed theory to explain health inequalities.  This theory suggests that variances in socio-economic factors (wealth, environment, income, power) will impact an individual over their life span, from cradle to the grave and will result in differences in health outcomes.  The other theories are viewed as subordinate as while they may provide some insight, they do not recognise the cause of the “causes” of health inequalities, which is directly related to the unfair distribution of wealth & power and the actions of those in power.  (Mc Cartney, et al, 2013).

Health inequalities are caused by social, economic, structural and environmental variances that result in disparities in health outcomes.  Where a person is born, the availability of and access to; education & housing, their, diet, gender, ethnicity and work will influence their health.  For instance, males who live in the most affluent areas in Ireland will live 4.3 years longer than males residing the most deprived areas.  This gap widens further in the case of mortality rates for Traveller men, which is 3.7 times higher than non-traveller males (IMO, 2012).  Ireland also has gender-based differences in life expectancy, while women are likely to live longer than males, they will have fewer years of good health.  Gender roles such as caring, domestic duties and career development can adversely impact women’s health & well-being.  As does the gender pay gap experienced from working life through to pension (Eurohealthnet, 2017).  On a global scale, life expectancy is linked to inequality in the top rich and unequal countries such as, USA and UK.  There is a direct correlation between an unequal country experiencing a higher number of social problems and the more equal countries experiencing less (Pickett, Wilkinson, 2010).   Globalisation is also an influencing factor; it has contributed to rising obesity and diabetes statistics, resulting from the spread of fast-food franchising.  It has also aided in the spread of communicable diseases due to increased air travel with longer journeys (Pang & Guindon, 2004).  These structural and environmental factors are beyond the individuals control and are a direct result of the unequal distribution of wealth and power, nationally and globally (Mc Cartney et al, 2013).

The sustainable development goals (SDG) were drafted by the United Nations as part of the 2030 agenda for sustainable development which was launched in 2015.  The SDG were created with the universal goals of eliminating poverty, attaining peace, prosperity, equal opportunities for all in a healthy and sustainable planet by the year 2030 (WHO, 2020).  The plan required an immense commitment and action from all the 193 U.N. member states in order to reform the financial, economic and political systems and to harmonize the three interconnected core elements of economic growth, social inclusion, and environmental protection which are vital for the health of individuals and societies.  The individual countries have been tasked to achieve these goals through their own sustainable development policies, plans and programs,  in alignment with the other UN members.  The U.N. are seeking fair, inclusive and sustainable globalisation for all through the 2030 agenda for sustainable development and implementation of the SGD goals (Biermann, et al, 2017).

National and global health disparities emanate from an interaction of structural, social, environmental, psychological and biological factors.  Health inequalities are unfair and systematic differences in the health of people who through no fault of their own hold unequal positions in society (Mc Cartney, et al, 2013).  Ethnicity, Gender, Social Class and geographical location can unfairly impact a person’s health outcomes.  These inequalities occur both nationally and globally, with globalisation and capitalism exasperating these disparities and are a direct result of the unequal distribution of power and wealth.  Of the four main theories identified in the Black Report, 1980; artefact theory, social selection theory, behavioral & Cultural theory and structural theory, structural theory is the best-placed perspective to explain/understand these inequalities (Mc Cartney, et al, 2013).  There has been much discussion regarding the definition of health, which still remains elusive.   The medicalized view of the Biomedical Model fails to address the social factors, i.e., root causes of causes of ill health (Marmot, 2015), while the Bio-psycho-social model is a more comprehensive model which considers biological, psychological, and social factors to comprehend and address health issues (Skewes & Gonzalez, 2013). The Sustainable Development Goals were drafted by the WHO in 2015 with the aim of reducing global health inequalities through reformation of the financial, economic and political systems of the EU member states (Biermann, et al, 2017).

References

Barry, A-M. (2012) ‘Sociological theory: explaining and theorising’, Understanding the sociology of health, 3, London: Sage Publications Ltd, pp. 3-19.

Biermann, F., Kanie, N., Rakhyun E Kim, R.E. (2017) ‘Global governance by goal-setting: the novel approach of the UN Sustainable Development Goals’, Current Opinion in Environmental Sustainability, 26–27, pp. 26-31.  Available from: https://doi.org/10.1016/j.cosust.2017.01.010 [Accessed 01 Dec 2020]

Boorse, C. (1997) ‘A Rebuttal on Health’. In: Humber J.M., Almeder R.F. (eds) What Is Disease? Biomedical Ethics Reviews. Humana Press, Totowa, NJ.  Available from:  https://doi.org/10.1007/978-1-59259-451-1_1 [Accessed 01 Dec 2020]

Borrell-Carrió, F., Suchman. A.L. & Epstein RM. (2004) ‘The biopsychosocial model 25 years later: principles, practice, and scientific inquiry’, Ann Fam Med. 2004 Nov-Dec;2(6):576-82.  Available from: doi: 10.1370/afm.245. PMID: 15576544; PMCID: PMC1466742.

Boyd, K. (2000) ‘Disease, illness, sickness, health, healing and wholeness: exploring some elusive concepts’, Med Ethics: Medical Humanities, 26, pp. 9–17.  Available from: http://dx.doi.org/10.1136/mh.26.1.9 [Accessed 01 Dec 2020]

Conrad, P. & Barker, K. K. (2010) ‘The Social Construction of Illness: Key Insights and Policy Implications’, Journal of Health and Social Behavior, 51(1_suppl), pp. S67–S79.  doi:  Available from: 10.1177/0022146510383495 [Accessed 30 Nov 2020]

Eurohealthnet (2017) Making the link: Gender Equality and Health, Policy Precis, published online, Available from: https://eurohealthnet.eu/sites/eurohealthnet.eu/files/publications/PP_Gender_Digital%20Version.pdf [Accessed 02 Dec 2020]

IMO. (2012) Position Paper on Health Inequalities, Irish Medical Organisation, Available from: https://www.imo.ie/policy-international-affair/documents/imo-position-papers/ [Accessed 30 Nov 2020]

Lachman, P. (2013) ‘Redefining the clinical gaze’, BMJ Quality & Safety. Available from: doi: 10.1136/bmjqs-2013-002322 [Accessed 01 Dec 2020]

Marmot, M. (2015) The health gap: the challenge of an unequal world [ebook]. Bloomsbury. 2015. 9781408857984 [Accessed 30 Nov 2020]

McCartney, M., Collins C. & Mackenzie, M. (2013) ‘What (or who) causes health inequalities: Theories, evidence and implications?’, Health Policy, 113, (2013) pp. 221–227. Available from: 10.1016/j.healthpol.2013.05.021 [Accessed 30 Nov 2020]

Pang, T. & Guindon, G.E. (2004) Globalization and risks to health. EMBO reports, 5 Spec No(Suppl 1), S11–S16.  Available from: https://doi.org/10.1038/sj.embor.7400226 [Accessed 02 Dec 2020]

Pickett, K. & Wilkinson, R. (2010) The Spirit Level: Why Equality is Better for Everyone [ebook]. Penguin UK, 2010, 0141921153, 9780141921150.

Skewes, M.C. &  Gonzalez, V.M. (2013) The Biopsychosocial Model of Addiction, Miller, P.M. Principles of Addiction: Comprehensive Addictive Behaviors and Disorders, Volume 1, Academic Press, pp. 61-70.

Song, M. & Kong, E-H., (2015) ‘Older adults’ definitions of health: A metasynthesis’, International Journal of Nursing Studies, Volume 52, Issue 6, 2015, pp. 1097-1106,

ISSN 0020-7489. Available from: https://doi.org/10.1016/j.ijnurstu.2015.02.001 [Accessed 02 Dec 2020]

W.H.O. (2020) Sustainable Development Goals (SDGs). Available from: https://www.who.int/health-topics/sustainable-development-goals#tab=tab_1 [Accessed 2 Dec 2020]

World Health Organisation. (2020) Social determinants of health. Available from: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1 [Accessed 30 Nov 2020]

The objective of this essay is to explore how interaction between individuals and external social structures can impact on mental health, trauma and suicidality. It will view these social influences through the lens of social construction theory, structural functionalism theory and symbolic interaction while also applying the psychological theories of psychoanalysis and cognitive behavioural approaches. It will also explore advocacy for sex workers through the approach of three different feminist perspectives. This essay will maintain that supports and advocacy cannot come solely from a biomedical approach, which seeks to treat illness without recognising any social influences. A more effective method would be the biopsychosocial approach, which acknowledges the impact social factors can have on an individual, treating not just an illness but its causes. A comparison of the themes of nature versus nurture and agency versus structure will also feature throughout this essay, while comparing the role these themes play in many social and psychological theories on mental illness, as well as advocacy work. This essay seeks to argue that the perceived significance and potential of an individual can often by determined by their connection to social structures, and how understanding these connections can provide a greater opportunity towards treatments, supports and advocacy for equality and unbiased social structures. 

From the psychodynamic perspective, Freud believed the mind comprised of three parts, the unconscious (id), the subconscious (ego) and the conscious (superego), with the ego maintaining balance between the instinct driven id and the morality driven superego (Boyd and Bee, 2019). According to Freud, the ‘self’ was shaped and influenced in youth by external social forces and that unconscious thought controls behaviour (Daly, 1971). If the ‘self’ was faced with a traumatic event that it believed it was unable to resolve, the ‘self’ shattered and split, using the coping mechanism of forgetting the event and repressing it in the unconscious mind. However, the event did happen and, according to Freud, the repressed memory sometimes presented itself as psychosis. Increased reliance on the stress-diathesis model, which emphasises that mental disorders can be ascertained through interactions of predisposition and environmental stresses, have paved the way for recognition of psychological therapies in treating mental disorders. Though many of Freud’s theories have been discounted by modern psychologists, Alessi & Kahn, (2017) believe that interventions which are rooted in psychoanalytic theory can provide practitioners the necessary skill set to intervene with clients. The repressed memory would be uncovered by a therapist, who would then take receipt of the individual’s unwanted feelings and recreate them in a more acceptable, less overwhelming form, counteracting any sense of dehumanization experienced following the traumatic event. 

According to Quist-Adade (2019), symbolic interactionism (SI) defines how individuals interact through use of symbols (including language), creating their social world and identities, under the influence of cultural interpretation. Through the continued process of interaction, it is possible for these identities to be redefined through the process of reflexivity. In SI, language is particularly important in shaping self-awareness as the sense of self is obtained through the perceived appraisals of others and changes through social experiences. This is particularly poignant in the case of women experiencing trauma following domestic abuse or battering relationships. In such cases, men can exert control over a woman by isolating her, removing her from her social identities, leaving only the identity of wife, which she will own with a low sense of self-worth (Anderson & Rouse, 1988). The social stigma attached to being a battered wife or rape victim can become a barrier to the victim seeking help and support to overcome the trauma (Muldoon, 2020). To counteract the damage done by the trauma, a clinician or counselor will endeavor to impress on the victim that the violence done to her was inherently wrong and the blame falls solely on the abuser, not the victim. A counselor would then seek to help positively rebuild the woman’s sense of self, helping her to remember her identity before the abusive relationship and recapture or reconnect with her social identity outside of her marriage while using her competencies to rebuild self-esteem, allowing her to become an individual in society again and not just a ‘victim’. (Anderson & Rouse, 1988).  

Muldoon, Haslam, Haslam, Cruwys, Kearns & Jetten (2020), state that traumatic events are associated with actual or threatened risk to life, serious injury or sexual violence. Though both SI and psychodynamic practice different approaches and therapies towards trauma, both recognize that the impact of trauma on the ‘self’, whether through the shattering or splitting of self, and both are united in prioritizing the restoration of ‘self’ at the core of successful therapy. Though Muldoon (2020) observed that positive restructuring of the ‘self’ as a therapeutic intervention, in line with the SI approach, challenging the medical approach to trauma treatment, research shows that alongside therapeutic approaches, there is evidence that bio-medical interventions also have positive outcomes for symptom relief of adults experiencing post-traumatic stress disorders (van der Kolk, Spinozzola, Blaustein, Hopper, Hopper, Korn & Simpson, 2007, Sonis & Cook. (2019). Exploring these different approaches to trauma treatments lends support to the understanding that trauma interventions should always be approached on an individual basis while keeping the impact of external social factors at the heart of any treatment.  

Dukheim’s Structural Functionalism theory suggested that people’s mental health can fare better when they are aware of their place within society and the system of interactive bonds which sustains it, i.e., their social facts. Durkheim viewed individualism as detrimental to mental health, observing the influence of external social structure on individuals (Tan, 2011). According to Durkheim, modern society is shaped by capitalism’s drive to promote individualism, while maintaining the power structure, thus weakening the structured bonds of obligation. Cain (2018) believes that neoliberalist societies have a direct impact on psychological distress and mental illness while promoting dependence on the biomedical model. Durkheim (1897) viewed anomie as being adrift, due to the loss of norms and structures that uphold a individual’s ‘social facts’, having a negative impact on mental health, possibly resulting in suicide. An open letter to the Irish Government by the Psychologists for Social Change Ireland, (PSC Ireland)(2020), advocating for those living in direct provision illustrates the detrimental effects on the mental health of people trapped within a system with considerable uncertainty about when their situation will change. PSC Ireland state that “suicide can occur in the context of hopelessness, when the present is unbearable with no end in sight”.  Durkheim believed that higher suicide rates were influenced by integration and regulation of society.  PSC Ireland believe that detention in direct provision centres was a “primary cause” of this mental health crisis.  

Where Durkheim believed social facts shaped individuals, social construction theory posits that individuals have agency, and social actors give meaning to their world through social interactions (Tan, 2011). As speech or language are the primary source of social interaction, it follows that, as individual ideas and perceptions change, so too does interactive discourse that surrounds these ideas, such as the changing attitudes towards mental health and suicide (Tew, 2005). Anthony Giddens’s Theory of Structuration postulates that individuals are shaped within social structures, but, social structures are, in turn, shaped and reshaped by individuals. Tew (2005) believed that it was damaging to socially exclude mental health sufferers, segregating them under the label of ‘other’ or ‘ill’ and providing medical based treatments only. This belief is supported by Rosenhan’s (1973) study On Being Sane in Insane Places, relating how eight volunteers faked mental illness and were admitted into psychiatric facilities, indicating that mental health specialists were unable to accurately diagnose mental health illnesses. There is a real and lasting damage to the shame and stigma that surround mental health and suicide (Tyler, 2020). In recent years, there has been a positive change in attitude and discourse towards poor mental health and suicide. ‘Death by suicide’ is gradually replacing ‘committed suicide’, removing suicide from the association of criminality. Inviting further open and accepting discourse within society, regarding mental health and suicide, may result in further positive changes in attitudes towards those who are still ‘othered’ by society’s perceptions. 

According to Scott (2007), research suggests that the biomedical model as a sole treatment of bipolar disorder has been unsuccessful. A growing recognition of the stress-diathesis model in exploring mental disorders has acknowledged the importance of therapies, such as cognitive therapy, in conjunction with the biomedical model of treatment. Beck’s theory of cognitive therapy posited that unhelpful thought patterns were linked to depression and anxiety. He suggested that a depressed person’s negative outlook on themselves, their future and their world was a negative cognitive triad. He also suggested that mania was the mirror image of depression, with overly positive thought patterns creating a positive cognitive triad, and that a person experiencing these two triads was bipolar. According to Scott (2007), while cognitive triggers are better understood in the case of depressive relapse rather than manic relapse, there is very little evidence to support Beck’s cognitive theory to explain the onset of mania. Scott (2007) believed that adding cognitive therapy to the biomedical treatment approach may improve prognosis to bipolar sufferers. According to Swartz & Swanson (2014), there is little evidence to show that cognitive therapy provides more positive results than other bipolar disorder specific therapies. Scott and Swartz both agree that further research is warranted in this area of bipolar treatment. 

Social functionalism views the increase of mental illnesses as the result of the deterioration of supportive social structures, while social construction considers mental health illness through the interpretations of individuals, during social interaction and discourse, within respective societies and cultures. Beck’s cognitive theory views mental health illnesses as the result of negative thought patterns that can be triggered by external factors. Though each theory views mental illness through a different lens there are some similarities. Each theory suggests society has an impact on mental health, either through lack of social supports, societal opinions and views or external triggering factors and recommends that mental health illness should be addressed using a biopsychosocial approach. According to PSC Ireland (2020) hopelessness and uncertainty, arising from imposed social structures, can have a detrimental effect on mental health. Structural functionalism suggests that ongoing, changing perceptions towards mental health in society, proposing that mental illness should be removed from the sole lens of psychiatry (Rosenhan, 1973). Beck’s cognitive theory, however, has not withstood the test of time with cognitive therapy being more useful in treating mental illness than cognitive theory is at explaining the onset of mental illness (Scott, 2007). There is growing awareness that the imposition of social structures that result in hopelessness and uncertainty to individuals can have long-term detrimental effects on mental health (PSC Ireland, 2020, Cain, 2018).  Continuing advocacy and dialogue can challenge society’s ideas and harmful perceptions of mental health illness to promote equality and acceptance. 

According to Beegan & Moran (2017), the approach to advocacy for sex workers is a contentious topic which has splintered feminist groups for decades. Radical feminists view sex workers as universally suppressed, coerced and exploited by a patriarchal society, while liberal feminists view sex work as a choice where suppression arises from a lack of social freedom, placing them in the role of ‘other’. Post-modernist feminists view that suppression occurs when an individual’s choice to partake in sex work is criminalised. (Beegan & Moran, 2017). Radical feminists favour legislation based on ‘The Nordic Model’, on which Irish legislation of prostitution is based. This model criminalises the purchasers of sex rather than the sellers. (Beegan & Moran, 2017). Liberal and post-feminists agree that business transactions between consenting adults should not be criminalised as criminalisation can do more harm than good to the sex worker. Post-modern feminists further believe that sex workers should have the same equal rights and recognition as any other worker. Platt et. al. (2018), research shows that criminalisation of sex work can be detrimental to the health and safety of sex workers, increasing their exposure to violence and unsafe sex while disrupting peer support groups and services. However, Beegan & Moran (2017) state that the decriminalisation of sex work in New Zealand has not decreased the violence or stigma aimed at women engaging in sex work. Therefore, negative attitudes towards sex workers mainly arise from society’s perceptions towards them. Advocacy for sex workers should address not only the legal position that promotes negative attitudes towards sex workers, but society’s attitudes that attribute stigma and shame to sex workers, making them easier targets for violence while denying them the rights and dignity afforded to other workers.  

This essay has sought to explore some of the complex social interactions and structures that influence different therapeutic approaches to mental health and, also, three different feminist advocacy approaches to sex work. The holistic, biopsychosocial model is the favoured approach to treating mental health illness, especially in the case of cognitive therapy. Different therapeutic approaches can have long-term, positive outcomes if the effects of contributing, external social factors are acknowledged, explored and considered in every case. Advocacy, whether in the case of mental health, direct provision, sex work or other social issues, for the promotion of equality and dignity of all, must also raise awareness to the stigma and dehumanisation that arises from political, legal and social structures, which can further contribute to difficult circumstances. Adjunct to advocacy, open and honest discourse could change social perceptions, giving every individual, regardless of their mental health, employment choice or social standing, the support and opportunity to become a valued and respected member of an equal, inclusive society. 

References

Alessi, E.J. & Kahn, S. (2017). Using psychodynamic interventions to engage in traumatic-informed practice. Journal of Social Work Practice. DOI:10.1080/02650533.2017.1700959. Available at: http://www.researchgate.net/publication/321655980_Using_psychodynamic_interventions_to_engage_in_trauma-informed_practice [Accessed on 20 April 2021] 

Boyd, D. & Bee, H. (2019). Lifespan Development, Global Edition, Pearson Education Limited. 

Beegan, R. & Moran, J. (2017) Prostution and Sex Work: Situating Irelands New Lawa on Prostitution in the Radical and Liberal Feminist Paradigms. Irish Journal of Applied Social Studies. Vol. 17: Iss. 1, Article 6. Available at: https://arrow.tudublin.ie/cgi/viewcontent.cgi?article=1305&context=ijass [Accessed 27 April 2021]. 

Cain, R. (2018). How neoliberalism is damaging your mental health. https://theconversation.com/how-neoliberalism-is-damaging-your-mental-health-90565 [Accessed on 23 April 2021] 

Daly, J. (1971) Freud and Determinism. The Southern Journal of Philosophy, 9(2), pp. 179-188 

Goforth, A.N., Pham, A.V. & Carlson, J. S. (eds. Goldstein, S. & Naglieri, J.A.) (2011). Diathesis-Stress Model. Encyclopedia of Child Behaviour and Development. Springer, Boston, MA. Available at https://link.springer.com/referenceworkentry/10.1007%2F978-0-387-79061-9_845 [Accessed on 20 April 2001] 

Muldoon, O.T., Haslam, S.A., Haslam, C., Cruwys, T., Kearns, M. & Jetten, J. (2020). The social psychology response to trauma, social identity, pathway associated with divergent traumatic responses. European Review of Social Psychology. 30:1,311-348, Available at: 

https://www.tandfonline.com/doi/full/10.1080/10463283.2020.1711628 [Accessed 20 April 2020] 

Platt, L., Grenfell, P., &Meiksin, R., Elmes, J., Sherman, S., Sanders, T., Mwange, P & Crago, A. (2018) Associations between sex work laws and sex workers’ health: A systematic review and meta-analysis of quantitative and qualitative studies. PLOS Medicine, 15(12), p.e1002680. 

Psychologists for Social Change Ireland (13 August, 2020). Open letter to Taoiseach Michael Martin and Minister for Children, Disability, Equality and Integration, Roderick O’Gorman. Available at: http://www.psychchange.org/blog/open-letter-from-psc-ireland-calling-to-end-direct-provision [Accessed on 23 April 2021]. 

Rosenhan. D.L. (1973). On Bing Sane in Insane Places. Science, New Series, Vol 179, No. 4070: 250-258. 

Scott, J. (2007). Cognitive Theory and Therapy of Bipolar Disorders. Available at psykologtidsskriftet.no/2007/05/cognitive-theory-and-therapy-bipolar-disorders#:~:text=Beck’s%20original%20cognitive%20model%20(1967,called%20the%20negative%20cognitive%20triad). [Accessed on 23 April 2021]. 

Sonis, J. & Cook, J.M. (2019). Medication versus trauma focused psychotherapy for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Available at: https://pubmed.ncbi.nlm.nih.gov/31690461/ [Accessed on 20 April 2021] 

Swartz, H.A. & Swanson, J. (2014). Psychotherapy for Bipolar Disorder in Adults: A Review of the Evidence. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4536930/ [Accessed on 23 April 2021] 

Tan, S. (2011). Understanding the “Structure” and “Agency” debate in the Social Sciences. Habitus. Available at: https://www.academia.edu/576759/Understanding_the_Structure_and_ Agency_debate_in_the_Social_Sciences. [Accessed on 23 April 2021]. 

Tew, J. (2005). Social Perspectives in Mental Health: Developing Socials Models to Understand and Work with Mental Distress. London. Jessica Kingsley Publishers Limited. 

Tyler, I. (2020). Stigma: the machinery of inequality. Zed Books. London. 

van der Kolk, B.A., Spinazolla, J., Blaustein, M.E., Hopper, J.W., Hopper, E.K., Korn, D. L. & Simpson, W.B. (2007). A Randomized Clinical Trial of Eye Movement Desensitization and Reprocessing (EMDR), Fluoxetine, and Pill Placebo in the Treatment of Posttraumatic Stress Disorder: Treatments Effects and Long-Term Maintenance.  J Clin Psychiatry. 68:0. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.476.4096&rep=rep1&type=pdf [Accessed on 20 April 2021] 

The effects of Covid 19 on youth mental health in Ireland and the barriers to accessing mental health services 

This research project attempts to identify issues affecting young people’s mental health and barriers to access supports available. Data collected through secondary sources were used in this research project. The sources included transcript interviews conducted through the youth services Spunout. The report concludes that many young people in Ireland are experiencing mental health issue due to the Global pandemic – Covid 19. Urbanisation, and lack of services for young people suffering, making it impossible to receive help. Although mental health is an issue, some people present with hope for the future, post Covid-19. 

 Aims and Questions 

Explore the attributes of mental health deterioration in a society where young people are more connected than ever before. 

1. What is the average age young people in Ireland are gaining access to social media platforms? 

1. What impact does social media have on young people’s mental health in today’s society? 

Explore the existence of suicide ideation amongst young people 

1. Is suicide ideation a trend linked to social media influence? 

1. Why are mental illnesses being flaunted by influencers? 

Explore the stigma associated with young people speaking about their personal issues. 

1. What is the social image associated with speaking about negative thoughts and self-image? 

Identify how COVID-19 has caused many young people to feel isolated, afraid, and with little feeling of hope. 

1. What impact has COVID-19 isolation had on young people in Irish society? 

1. How has the isolation of COVID-19 helped young people to understand their feelings and made them aware of the emotional connection between the outside world and the thoughts in their heads? 

Literature review 

 Youth Mental health in Ireland is a significant concern, as the rates of suicide are increasing, and young people are presenting more often to mental health units. The following literature explores some of the issues surrounding mental health amongst youth’s and its contributing factors. Research areas include the attributes of mental health deterioration in a society where young people are more connected than ever before. This research will: 

• Explore suicide ideation amongst young people.  
• Explore the stigma associated with young people speaking about their issues.  

• Identify how COVID-19 has caused many young people to feel isolated, afraid, and with little feeling of hope.  

Smartphones and access to social media aid with the rise in mental health issues, depression, suicide ideology and anxiety, particularly among young girls and women (Abi-Jaoude et al, 2020). It appears the length young females spend on social media is much higher than their male opposites (Abi-Jaoude et al, 2020). Young women and men are using social media platforms as systems of approval amongst peers developed in the forms of likes, comments and emojis, which many young people consider a form of personal validity (Hughes 2020). Young people in the past would arrange to meet up for connection in places such as café’s, restaurants and public areas, yet now these occupancies are meeting points to scroll through social media with little human interaction (Hughes, 2020). 

 Mental illness and its stigma can create barriers for young people to openly speak about their issues (Fortune et al, 2008). Young men find it difficult to talk to their peers about personal issues, creating a weak personal image (Garcia, 2013). Mental health is a topic regularly mentioned in modern societies, yet young people still lack awareness and information about its definition and resources available in the community (Collingwood, 2009). Ireland has developed a prestigious policy surrounding the high level of suicides in Ireland, Connecting for Life (Dept of Health, 2020). The plan implemented initially for a five-year strategic plan in 2015 has been extended for a further four years to 2024 due to its success in mental health (Dept of Health, 2020). Connecting for Life has been developed to help young people suffering and give them a voice; strategic planning and implementation throughout the services and community has aided its success (Dept of Health, 2020). Research has established that primary care is essential in early intervention; rural Ireland lacks these services, affecting youth mental health (Leahy et al, 2013). 

The effects of COVID-19 are ongoing concerning youth, with a significant rise in the number of young people presenting to the emergency department experiencing mental health issues (Leeb et al, 2020). Social factors such as school are essential for young people in their developing years, and with the closure of schools early in the pandemic, many young people feel isolated, depressed, and anxious (Leeb et al, 2020). These findings are firmly in line with the constructionist theory, which states that our realities compile by the human mind is subjective to the learner’s perspective (Clarke, 2001). A study completed in the US, which has had a similar response as the UK to COVID-19, uses age groups (0–4, 5–11, and 12– 17 years) and gender variables in the study (Leeb et al, 2020). 

Connections between the length of time young people spend on their social media have long-term mental health issues. The social areas that people once used to occupy for deep meaning connections now occupy socially disengaged activities. The idea that peers thinking a person is weak for acknowledging and talking about their feelings is still apparent amongst young male groups. COVID-19 1had a clear link to mental health in youths, with ongoing research obstructed. The literature above has found many of these trends apparent with youth is in Ireland and their diminishing mental health. 

Methodology 

Constructivism is the belief that knowledge is socially constructed (Hammersley, 2012). When put into practice, the researcher constructs the research based on their subject’s reality (Hammersley, 2012). Different perspectives and realities help compile the ideas for the researcher (Hammersley, 2012). Constructionist researchers question scientists’ ability to understand other people or even themselves (Hammersley, 2012). Researchers question whether a set of already learned belief and behaviour can influence a person’s behaviour or independently create their existence sporadically (Hammersley, 2012). 

The ontological position for the qualitative research on youth presenting with mental health is constructivism. The research constructed is by the lived experiences of young people who have been subject to impaired mental health in Ireland. Information for the qualitative research project gathered using opened-ended questions implemented to the subject, giving the researcher a more appropriate idea of the participant’s views of mental health among youths (Hammersley, 2012). The constructivist approach will explore the effects of Covid 19 on young people in Ireland. 

The epistemological position for the qualitative research on youth mental health is Interpretivism, which explores the researcher’s information based on the participants’ view of their situation. Interpretivism is essential as it looks at the subjects from a humanistic view, connecting through emotion, culture and lived experiences (Hammersley, 2012). Through this connection, the researcher gets a better understanding of human beings (Hammersley, 2012). Expansion into the participants lives is essential to give a well-informed deep view on mental health in youths (Hammersley, 2012). The researcher will obtain knowledge from the young people experiencing mental health issues on a deeper precise level.  

The data used in this qualitative research study is of secondary sources involving interviews of young people writing to Spunout explaining their experiences through COVID-19. Research is a powerful tool adaptable to many aspects of the world through the researcher’s interpretation (O’Leary, 2004). Much of the research conducted in this qualitative research was obtained through interviews online from the Spunout website, which helps protect the participants’ anonymity (O’Leary, 2004). The benefits of this type of research are a multitude of information is widely accessible throughout the internet, cost-effective when sourcing and accessible promptly.  

Many of the research participants in the research aged between 16 and 23 years of age; their anonymity maintained securely by using their first names and the county where they originated (Spunout, 2020). For the study, the participants gave detailed accounts of the effects COVID 19 is having on their mental health, which the researcher gathered the responses to interpret (Spunout, 2020). The interviews are available online through the spun-out website available to the public.  

The fundamental principles developed by ESRC were incorporated information to establish research. Integrity, transparency and quality must be maintained when carrying out the process (ESRC, 2015). Participants must have limited information on using the research to implement unbiased opinions; respondent’s anonymity must remain dignified during the process (O’Leary, 2004). In the research carried out, many participants were under 18 years of age, which concealed their anonymity, data collected through interviews prescribed through Spun-out.  

The research implemented secondary data collection to collaborate the data. All data obtained is gathered into files for thematic coding due to the data’s sensitive nature, secured on a password encrypted laptop (O’Leary, 2004). As the data collected is secondary data, approval to use the data in a sensitive and caring manner identified by the researcher (O’Leary, 2004). Themes discovered through the text interviews provided, while codes developed for the themes (O’Leary, 2004). All the codes and themes were produced into mind maps to identify patterns in the codes and themes (O’Leary, 2004). 

Findings 

 This research aims to understand the lived experiences with mental health in young people in Ireland. The research findings and analysis, thematic coding established links in the transcripts provided, based on secondary data (Braun, Clarke, 2012). Several interviews were transcribed from Spunout to give an in-depth account of young people’s lived experiences with mental health issues (Spunout, 2021). The interviews used for this research project are available on the Spun out website. The interviews transcribed were used to establish themes and coding of the data while remaining relevant to the aims and the contents of the research (Braun, Clarke, 2012).  

 From the analysis of the research, the emerging themes are: 

• The psychological effect Covid-19 is having on young people in Ireland. 
• The impact of the lack of social inclusion in communities. 
• Although there is a worldwide pandemic young people are optimistic and are having a positive outlook. 
• Continuity of support networks for young people throughout Covid-19. 

 Many of the interviews presented numerous young people speak of the adverse psychological distress affecting their mental health, making everyday tasks a struggle.  

This theme identifies “The psychological effects of Covid-19 on young people in Ireland”.  

 Maisie, from Mayo, speaks of the mental distress in her interview. 

“My experience with Covid-19 over the past few weeks have been quite challenging. I have got the added pressure of the Leaving Certificate, which has taken a toll on my mental health”.  

 Young people recognise that their mental health may not have been excellent before the pandemic, but now it has affected their mental health. 

“I feel like lockdown made my anxiety and depression far worse. Even with a lot of exercises and doing things I enjoy, life feels hard at the moment”- Jamie, Kildare. 

 Young people thrive within their peer groups; they develop essential skills to help them cope with life’s challenges. When there is no social inclusion, young people experience negative thoughts and find each day excrescently difficult. Majorly young people spoke about the mental effects in their interviews as their freedom has been taken away from them. 

“Usually, I’m a really outgoing person who’s never really sat in the house, but when it came to lockdown, my freedom just crumbled around me” – Emma, Donegal.  

 Separation from friends and family is causing great distress. Young people struggle with not seeing their family members. 

“The effect on my mental health is amplified by the separation I’m feeling from my friends and family”. 

 Although this is a terrifying time for many young and older adults in Ireland, optimism still shines through. Many of the young people interviewed did show some hope when it came to the future.   

“I’m very lucky, however, that over the past couple of years, I have developed efficient coping skills and I have built up a network of outstandingly supportive friends through Spunout. ie’s Action Panels” – Maisie, Mayo. 

 The support networks designed to help people during Covid-19 availed throughout the whole experiences of young people in Ireland. As the pandemic is worldwide, it has created a sense of unity among communities. 

“I’m lucky to have such good people I can count on when this whole nightmare is over”- Emma, Donegal. 

“Having open discussions can form a sense of clarity and unity with others, which is a special bond to share during this time of universal crisis”- Jessica, Dublin. 

 Discussion 

 From the findings, even though people connect through social media and other connected forms, mental health is diminishing. The feeling of isolation is evident among communities in need of more and better mental health services. There is some alleviation of isolation from group check-ins organised by Spunout. Negative thoughts while slight social inclusion is causing young people to be in their head more frequent, causing negative thoughts and isolation (Spunout, 2020). There is still a stigma of talking about the personal issue as people do not want to burden their family members or worry. Young people are still keeping their worries to themselves. The effects of Covid-19 are ongoing concerning youth, with a significant rise in the number of young people presenting to the emergency department experiencing mental health issues (Leeb et al, 2020). Social media platforms create easy access for social connections, resulting in people making little effort to connect in person; this is now evidence suggesting that suicide ideation among young people links to their social media consumption (Abi-Jaoude et al, 2020). Young men find it difficult to talk to their peers about personal issues, creating a weak personal image (Garcia, 2013). 

 As the Covid-19 pandemic is ongoing, the long-term effects on youth mental health in Ireland is unpredictable. The finding’s sample size is small as people are still finding it difficult to reach out to use mental health services. Suicide is still rising among young men in Ireland, while the stigma around speaking about personal issues still reside (Garcia, 2013). The limitation associated with this study is that there is still not enough research conducted in these areas.  

 Limitations 

This research’s limitations are the small sample size; nine interviews used for this research’s findings. The interviews are all conducted n the basis of secondary data, which the researcher has to aid as believing to be entirely accurate. There can only be a presumption that guideline influenced by ESRC throughout. As the Covid-19 pandemic is ongoing, there is little previous research to base the findings. 

 Suggestions 

 I suggest an entire subject module on Mental Health in primary and secondary schools in Ireland, which will enable young people to nurture and strengthen their mental health. Ideally, empower people with knowledge around their negative thoughts while introducing strategies to combat these feelings. This empowerment movement will influence peer involvement also.  

 Conclusion 

 As to conclude the qualitative research report, the main aims of this report were to explore the attributes of mental health deterioration in a society where young people are more connected than ever before. Explore whether suicide ideation is common amongst young people. Explore the stigma associated with young people speaking about their issues. Identify how COVID-19 has caused many young people to feel isolated, afraid, and with little feeling of hope. 

Although social media platforms keep people connected, the research project has shown that their mental health is diminishing (Spunout). There are still significant stigmas associated with people talking about their issues, especially in young men (Garcia, 2013). The ongoing issues surrounding the Covid-19 pandemic has seen some harrowing admissions from young people suffering from their mental health while also holding little regards for the future (Spunout, 2020). The data used in the research is secondary data, all sources from the Spunout website. The interviews are real-life lived experiences of young people in Ireland (Spunout). 

 One of the themes established through this report is that young people are encouraged to reach out to different agencies but feel a stigma of judgement from peers. Through social media, young people are beginning to use their voices as a sense of unity brings connection through the pandemic. A second theme recognised in the research is the importance of community involvement to regulate and social inclusion combatting mental health issues.  

It is evident that Government policies and procedures are evolving while remaining relevant to the youth population. The roll-out of the “Connecting for Life” Government policy surrounding suicide has been an enormous success. It has been restructured and implemented until 2024. Mental health services and outreach programmes are making significant progress in eliminating the stigma associated with mental. Only through education and zero-tolerance will their efforts be recognised, so it is up to the Government to implement funding and policy influence. Communities can begin to educate themselves on how everybody can relish mental health functioning. Normalising talking about how people feel, especially among men, will see a considerable shift in the stigmas (Garcia, 2020). Mental health is hard to see, but if everybody pays special attention to their loved ones while checking in with them regularly, this will have a hugely positive outcome. While checking in with them regularly, this will have a hugely positive outcome. 

 The research identifies gaps in the needs of the service of communities. It is a good indication of the need for services funding and implementation. The Government official should take heed and understand that there is a need to support young people suffering from mental health distress. However, other factors may implement the policies’ effectiveness, such as economic, political, urban areas, and funding access. 

References

Abi-Jaude, E, Naylor, K,T, Pignatiello, A., (2020) ‘Smartphones, social media use and youth mental health’, Canadian Medical Association Journal, 2(6), pp. 136-141 [Online]. Available at: http://eds.a.ebscohost.com/eds/detail/detail?vid=1&sid=6beff4ae-7f95-4201-b616-954f6ee75972%40sdc-v-sessmgr02&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=141684891&db=edb 

 [Accessed: 22nd February 2021]. 

Clarke, J., (2001) ‘Social Problems, Sociological Perspectives’, in May, M, Page, R, Brunsdon, E., (ed.) Understanding Social Problems: Issues in Social Policy: Wiley-Blackwell, pp. 6-8. [Accessed 23rd February 2021]. 

Collingwood, F., (2009) ‘Critical, Social, Thinking; Policy and Practice ‘, Exploring young people’s attitudes to mental helath: challenges and supports in rural West Cork, 1(), pp. 40-53 [Online]. Available at: University College Cork [Accessed: 22nd February 2021]. 

Department of Health (2020) Connecting for Life: Ireland’s National Strategy to Reduce Suicide 2015 – 2024, Available at: https://www.gov.ie/en/publication/7dfe4c-connecting-for-life-irelands-national-strategy-to-reduce-suicide-201/ [Accessed: 07th April 2021]. 

Fortune, S, Sinclair, J, Hawton, K., (2008) ‘Adolescents’ views on preventing self-harm’, Social Psychiatry & Psychiatric Epidemiology , 43(2), pp. 96-104 [Online]. Available at: http://eds.a.ebscohost.com/eds/detail/detail?vid=12&sid=6beff4ae-7f95-4201-b616-954f6ee75972%40sdc-v-sessmgr02&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=28564457&db=edb [Accessed: 22nd  February 2021]. 

Hammersley, M, Campbell, L, J., (2012) ‘Methodological Philosophies’, in Hammersley, M, Campbell, L, J., (ed.) What is Qualitative Reserch. London: Bloomsbury Publishing, [Accessed 05th March 2021] 

Hughes, S., (2018) ‘The Effects of Social Media on Depression, Anxiety and Stress’, Dept of Psychology, Dublin Business School. [Online]. Available at:e-journal [Accessed: 22nd  February 2021]. 

Leahy, D, Schaffalitzky, E, Armstrong, C, Bury, G, Cussen-Murphy, P, Davis, R, Dooley, B, Gavin, B, Keane, R, Keenan, E,Lathaam, L, Meagher, D, McGorry, P, McNicholas, F, O’Connor, R, O’Dea, E, O’Keane, V, O’Toole, P, T, Reilly, E, Ryan, P, Sanci, L, Smyth, P, B, Cullen, W, (2013) ‘Primary care and youth mental health in Ireland: qualitative study in deprived urban areas’, BMC Family Practice, 4(1), pp. [Accessed 07th April 2021]. 

Leeb, T, R, Bitsko, H, R, Radhakrishnan, L, Martinez, P, Njai, R, Holland, M, K., (2020) ‘Mental Health-Related Emergency Department Visits Among Children Aged <18 During the Covid 19 Pandemic’, Morbidity and Mortality Weekly Report , 1(69(45)), pp. 1675-1680 [Online]. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660659/ 

[Accessed: 23rd  February 2021]. 

Untangling Drug Effects from Placebo Effects in the Treatment of Depression: A Study of Biomedical Hegemony

Abstract

Modern medicine has done an excellent job in curing certain illnesses, where the disease cause is well understood and where objective examination of the physiology can take place. However, treating the discomfort and psychological trauma associated with multiple diseases such as depression, chronic pain and anxiety has proven difficult (Wager and Atlas, 2015). This dissertation focuses on research on how the placebo effect has been traditionally regarded as deceptive and misunderstood (Newman, 2017) despite evidence that suggests it is extraordinarily effective. It explored whether placebo effects are clinically useful in the treatment of depression, with the aim of critically evaluating whether current literature supports the evidence that placebo effects might be partially accounting for antidepressant effects in depression. The study thoroughly evaluated the findings of previous studies to answer the research question. The researcher adopted a constructivist approach to analyze the results in relation to arguments that the bio-medical method of treatment has gained cultural control over many of the healthcare systems. The research findings indicate that the latest generation of antidepressants produced just minimally better outcomes than the older ones that were below the current prescribed criterion for clinical relevance (Kirsch, 2002). Further, research reflects how important studies have been hidden from the public by drug companies and the impact of this on individuals’ health (Turner and colleagues, 2008). By researching the relationship between the placebo effect and depression the researcher discovered that the challenge of determining the placebo effect is always a controversial one (Freisen, 2019). A better understanding of the physiological, neurobiological, and genetic effects on the placebo effect is important for assessing medical treatments and can allow health providers to customize and personalize therapies in clinical environments in order to improve treatment outcomes (Kirsch, 2009) 

Please contact the programme leader aine@chevrontraining.ie if you would like a copy of Shannen’s dissertation to read.

Female Genital Mutilation (FGM) is defined by the World Health Organisation (WHO) as a procedure whereby external female genitalia are partially or fully removed for cultural purposes (WHO, 2001). The severity of the procedure and the age at which it’s performed is dependent on a number of factors including a female’s ethnicity and their socio-economic background (EndFGM, n.d.). For many, it is seen as an initiation process, allowing females to transition from childhood to adulthood, in preparation for marriage. While often viewed as a religious obligation, neither the bible nor the Koran mention female circumcision. Furthermore, the practice is seen as a socio-cultural practice in many countries in Africa and the Middle East, however, it is also a symbol of gender discrimination and can have grave implications, both physically and psychologically.  

FGM violates both constitutional rights, and International human rights as outlined by the Universal Declaration of Human Rights (UDHR) (UN General Assembly, 1948), namely Article 5 which states that “No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment”. Through the continuation of this practice, those involved are contributing to the subordination of women in patriarchal societies further strengthening the gender divide. This is in direct violation with numerous articles within the International Covenant on Economic, Social and Cultural Rights (ICESCR) which aim to promote equal rights among men and women.  

Organizations including the United Nations (UN), United Nations Children’s Fund (UNICEF), and the WHO have devised initiatives to help eradicate the global practice of FGM. However, authors such as Newland (2006) argue that eradication, namely in the form of zero-tolerance policies, serves as cultural imperialism. Others favour the criminalization and/or the medicalization of the practice (28TooMany 2020, Galeotti 2007). Monahan (2007) discusses the nuances, yet one can clearly see how education, intra-cultural resistance, cultural sensitivity, and gender transformation are key to a rights-based approach.   

28 Too Many is an organization which seeks to create global change surrounding the practice of FGM. They released a report in 2020 in collaboration with TrustLaw and a number of international law forms which sought to act as a guideline for policymakers in criminalizing FGM. The report, the FGM Law Model, claims that criminalizing the practice is demonstrative of commitment to eradicate (28TooMany, 2020). This Report identified as the minimum standards for anti-FGM legislation to be effective these include:  

1. Provide a clear definition of FGM;  

1. Criminalise the performance of FGM;  

1. Criminalise procuring, arranging and/or assisting acts of FGM;  

1. Criminalise the failure to report incidents of FGM;  

1. Criminalise the participation of medical professionals in acts of FGM;  

1. Criminalise the practice of cross-border FGM (28TooMany, 2020, p11).  

These benchmarks are controversial because Treaty Monitoring Bodies (TMBs) highlight that reactions by nation states that primarily rely on legislation and prosecution potentially discourage those who are in greatest need of education, awareness-raising, social and legal support, along with health services (Khosla et al., 2017). Khosla and colleagues (2017) outlined that Treaty Monitoring Bodies have raised concerns that the criminalization of FGM may place girls and women at greater risk of state violence. They highlighted that victims of FGM will fear being exposed and may only utilize health services in situations of emergency. This places more danger on themselves and increases the complexity and urgency of treatment for healthcare providers. Khosla and Colleagues (2017) detail that Treaty Monitoring Bodies have highlighted that attempts to withstand and abandon FGM demand multi-sectoral approaches that encompass both gender and culturally sensitive responses and that works across sectors, communities, and generations.  

Berer (2015) argues that criminalizing FGM has a social cost and has led to extreme measures in some countries. While attempting to arrest two men in relation to FGM in Uganda, police officers were attacked and apprehended by members of the tribe. After the criminalization of the practice in Tanzania in 1967, members of the population claimed that female genital mutilation was the only cure for ‘lawalawa’ (ailments including urinary tract infections) and thus, FGM was re-invented. It’s crucial to take into consideration the vast differences in the way FGM is both practiced and criminalised across countries. Where you are in the world has different implications for the severity of the circumcision, the beliefs surrounding the practice, and whether or not the act is punishable by law. Burkina Faso’s FGM Law 1996 states that the penalty in the event of death as a result of FGM, is 5 to 10 years imprisonment. Whereas under Edo State FGM Law, the perpetrator is sentenced to 6 months imprisonment for the same crime. Such lenient measures do nothing to discourage the abandonment of FGM and as such, the adequacy of such laws is in doubt (Yerima, 2016). 

Furthermore, studies have shown that criminalization alone will not lead to the eradication of FGM and may lead to driving genital cutting further underground and to decreases in the age for marriage (Pells & Robinson, 2014). In an attempt to reduce the harms, some states have turned away from criminalization and towards medicalization to transfer the practice from traditional practitioners to healthcare professionals. 

 Anna Elisabetta Galeotti is an Italian University Professor whose controversial 2007 journal article caused heated discussions around the subject of FGM. Galeotti proposes the theory of toleration and a harm reduction approach to the practice of FGM, proposing the idea of symbolic circumcision as a compromise to mutilation. Her stance on the issue caused public outrage as it is seen as perpetuating the subordination of women in patriarchal cultures. She suggests that this negative response to the proposed alternative stems from “an aggressive post-9/11 attitude towards Muslims and immigrant practices” (Galeotti, 2007). While there’s no doubt that the 9/11 attacks in the US have had a profound impact on the way Muslims are viewed around the world, this can be seen as exploiting the oppression of minority cultures to gain support. Postcolonial scholar Ratna Kapur (2002) discusses a tragedy of victimization as a symptom of post-coloniality whereby women, particularly in the Global South, are displaced and portrayed as being victimized by their culture. She posits that the International human rights movement reinforces the victimization of women through their focus on violence, and as a result, this strengthens gender and cultural essentialism.  

Ruderman (2013) argues that while total abandonment of FGM is an ideal goal, it is also unrealistic, certainly for the near future. In agreement with Galeotti, she argues that criminalizing FGM fuels the clandestine practice of it, thus increasing the risk of harm for those involved. As such, they argue that symbolic circumcision is a relatively safe and short-term solution. However, while this may be seen as a less harmful approach, such a ritual still legitimizes the subordination of women. Furthermore, while her theory proposes agency, some would argue this is not agency but false consciousness and a form of patriarchal bargaining.  

Galeotti questions the universalistic approach to FGM, suggesting that individuals have the right to culture and to freedom of choice, and goes as far as suggesting that the symbolic circumcision does not infringe on any rights. What can be perceived as Galeotti’s complete lack of moral conscience has caused quite a reaction. Laegaard (2008) is vehemently opposed to her theory of toleration, arguing that it ignores the fact that the practice of female genital mutilation, regardless of a harm-reduction approach, is a direct violation of human rights and not simply a difference of cultures. Furthermore, Galeotti proposes the idea of harm as instrumental to future good. While she argues that her approach is culturally sensitive, there are many other proposals which do not result in the physical harm of females. By supporting a harm reductionist approach there is also an acknowledgement that harm is still being done, just on a reduced level and as such can still be viewed as a human rights abuse.  

Leye and colleagues (2019) argue that medicalizing FGM can result in legitimizing the practice and undermines International efforts to end it. The International Covenant on Civil and Political Rights (ICCPR) and the Committee on Economic, Social and Cultural Rights (CESCR) have both raised concerns over this and Treaty Monitoring Bodies (TMBs) have called for States to confiscate medical licenses should the practice be carried out in medical establishments (Khosla et al., 2019).  

Laegaard (2008) critiques Galeotti’s universalist liberalist approach arguing that her perspective is symbolic of the problems within liberalism and does not rightfully acknowledge the importance of transforming societal standards. This is why many are so strongly opposed to medicalization because it will ultimately lead to the reinforcement of the cultural and gender-based norms and attitudes that research has revealed are at the root of the practice.  

 The United Nations Population Fund (UNFPA), and the United Nations Children’s Fund (UNICEF) (2014), are working in unison toward the eradication of female genital mutilation. Their joint programme, launched in 2008 in 17 countries and works to remodel pre-existing social norms from within. The programme aims to work in partnership with governments to transform their individual legal frameworks, promote awareness and support broader accountability surrounding the practice of FGM (UNFPA–UNICEF, 2014).  

While the policy brief seeks to advocate for the eradication of female genital mutilation on the basis that the practice is a human rights abuse, many argue that it’s a move toward cultural imperialism. International development around the world has seen Western governments, UNICEF, and the WHO among others, oppose the practice on the basis that they see FGM as a major violation of human rights. Cornwall and Brock (2005) argue that this human rights approach to international development is actually a covertly strategic approach rooted in neoliberalism, concealing the real aim of neo-colonialism that’s still exploiting countries in the Global South and trying to impose Western values and economic approaches into these countries. Neo-liberalist strategies such as the Structural Adjustment Programme and the MDGs failed in their quest toward development and sustainability in Africa as the programmes place developing countries at the mercy of the West (Durokifa and Ijeoma, 2018). It’s been argued that the SDGs will follow in these footsteps, whereby colonial agendas are hidden under the guise of international development, perpetuating the hypocrisy of the Western International Development movement. Target 5.3 of SDG 5 on gender equality seeks to eliminate FGM by 2030 in all countries and highlights that addressing the issue of gender inequality is crucial to abandoning FGM. 

Korieh (2005) claims that Western ideas around FGM are reflective of Eurocentric ideas of individualism and sex valued in Western societies, with little attempt to understand women in the Global South. Thus, this arrogance has caused the continuance of the practice as an act of defiance. Western feminists have become increasingly concerned with female genital mutilation and the idea that it reinforces patriarchal dominance through controlling women’s sexuality (Knox, 2021). Walby (1990) defines patriarchy as a system of social structures, and practices in which women are dominated, oppressed, and exploited by men. However, Western feminist views have created tension with feminists from the Global South. Nnaemeka (2005) purports that Western feminists make assumptions about women in the developing world, ensuring the West has ultimate authority over cultural values. Mohanty (2003) argues that ideologies from Walby for example, must be understood in the context of global hegemony.  

In their study, Pells and Robinson (2014) highlight important considerations from separate studies carried out by Oxford University and World Vision. Both suggest that criminalization and advocacy are insufficient and may lead to driving genital cutting further underground and to decreases in the age for marriage. While enforcing legal ramifications may be effective in the short term, the reality is that criminalizing FGM results in clandestine practice and may invoke greater risk for those involved. In Somaliland, a reduction in the severity of the type of FGM carried out led to an increase in the number of child marriages. This is due to the belief that females who are not infibulated are more promiscuous and so females enter into marriage at an earlier age for social protection. In Kenya, females are given the opportunity to create an alternative rite of passage, unique to them, to replace FGM minimising the risk of perceived Western imperialism (Pells and Robinson, 2014). In places such as the UK and Europe, it can be much more difficult to tackle these complex social and gender norms as female genital mutilation being a deeply rooted socio-cultural tradition may serve as a connection to a family’s native country (Williams and Robinson, 2014).Thus, interventions need to be culturally sensitive because the attitudes underlying the practice vary by culture. 

 Non-Governmental Organisation Sahiyo, renowned internationally for its community-based approach, seeks to find a solution to end FGM through research, campaigns, and advocacy initiatives (Sahiyo, 2018). They recently held a webinar to discuss the role of male allies in this process, giving viewers a powerful outline of the practice from a male perspective. One suggestion made was to focus first on ending FGM within a patriarchal system and then focus on ending the patriarchal system (Sahiyo, 2021). However, this patriarchal hierarchy executes control, and many argue that it needs to be dismantled in the first instance to effectively eradicate FGM. 

A study carried out by Strid and Axelsson (2020) explores the role of men in the practice of FGM by applying Connells theoretical lens on masculinity. They purport that FGM is symbolic of honour-based violence within a gender order (Connell, 1995). They take a social norms approach to understanding Connell’s (1995) concept of complicit masculinity whereby failing to challenge gender order, men can reap the benefits of a patriarchal society. Sahiyo (n.d.) urge men to use this patriarchal power positively as men are important agents of change.  

Judith Butler (1990, cited in Morgenroth and Ryan, 2018) argues that gender is an idea encapsulated by societal norms and should an individual not act as their gender suggests, they will face consequences. Therefore, men who challenge the gender order may be perceived as failing in their ‘performance’ of their role as men. However, deconstructing gender norms may be difficult as they’ve been internalized early on in life. For example, many men and women (patriachial bargaining (Kandiyoti,1988)) would rather have the females in their family undergo female genital mutilation than experience the social sanctions that refusal of the practice would bring (Monagan, 2010). Ultimately, their views on social norms outweigh the physical and psychological impacts of the procedure.  

UNICEF (2020) highlights the importance of intersectionality in their publication on Gender Transformative Approaches. They propose an Intersectoral Approach within a gender transformative framework which seeks to go beyond increasing awareness and tackle the power structures that uphold the practice. In Nigeria, the MenEngage Alliance was set up in to address the systemic gender inequality in the fight for social change, through male peer to peer advocacy (UNICEF, 2020). In Kenya, the Maasai community are challenging the tradition of FGM by focusing on the intersection of gender, culture, ethnicity, and place. Many argue that awareness of these intersections is key to changing social norms around FGM (Van Bavel, 2019). 

 Female genital mutilation is described as a manifestation of gender inequality and constitutes an extreme form of discrimination against women. Yet for many, it is a deep-rooted socio-cultural tradition and attempts to eradicate the practice can be seen as cultural imperialism. It’s been argued that to push universality, especially forces from the West pushing assimilation in the Global South, is a form of global hegemony and suggests that there is a more sinister reason behind International development. Feminists from the Global South posit that eradication of the practice would lead to re-westernisation and a new form of colonial power. However, FGM goes against fundamental human rights and freedoms, perpetuates the gender divide, and promotes violence against women.  

Approaches to eradicate the practice include the medicalization and the criminalization of FGM however, these do not address the patriarchal system that upholds the practice. It’s been argued that while having a comprehensive legal framework is essential, it is not sufficient in tackling the practice on its own, explaining that legislation may help with prosecution but in terms of prevention it is lacking.  

Furthermore, globalisation has resulted in more awareness being brought to FGM and the production of global policy responses. Due to such policies and awareness, there has been a decrease in FGM over than last three decades. However, there is no quick or easy solution and local, national, and global actors are required to address the issue successfully. 

Engagement is needed at community level in order to address the social norms and consequences underpinning the practice. A gender transformative approach is needed to eliminate FGM, by dismantling power structures that support patriarchy across the world. In order to successfully abandon FGM, countries must first tackle gender and social norms promoting a move beyond awareness towards action to diminish gender inequalities relating to FGM. 

References

Barry, A-M. (2012) ‘Sociological theory: explaining and theorising’, Understanding the sociology of health, 3, London: Sage Publications Ltd, pp. 3-19.

Biermann, F., Kanie, N., Rakhyun E Kim, R.E. (2017) ‘Global governance by goal-setting: the novel approach of the UN Sustainable Development Goals’, Current Opinion in Environmental Sustainability, 26–27, pp. 26-31.  Available from: https://doi.org/10.1016/j.cosust.2017.01.010 [Accessed 01 Dec 2020]

Boorse, C. (1997) ‘A Rebuttal on Health’. In: Humber J.M., Almeder R.F. (eds) What Is Disease? Biomedical Ethics Reviews. Humana Press, Totowa, NJ.  Available from:  https://doi.org/10.1007/978-1-59259-451-1_1 [Accessed 01 Dec 2020]

Borrell-Carrió, F., Suchman. A.L. & Epstein RM. (2004) ‘The biopsychosocial model 25 years later: principles, practice, and scientific inquiry’, Ann Fam Med. 2004 Nov-Dec;2(6):576-82.  Available from: doi: 10.1370/afm.245. PMID: 15576544; PMCID: PMC1466742.

Boyd, K. (2000) ‘Disease, illness, sickness, health, healing and wholeness: exploring some elusive concepts’, Med Ethics: Medical Humanities, 26, pp. 9–17.  Available from: http://dx.doi.org/10.1136/mh.26.1.9 [Accessed 01 Dec 2020]

Conrad, P. & Barker, K. K. (2010) ‘The Social Construction of Illness: Key Insights and Policy Implications’, Journal of Health and Social Behavior, 51(1_suppl), pp. S67–S79.  doi:  Available from: 10.1177/0022146510383495 [Accessed 30 Nov 2020]

Eurohealthnet (2017) Making the link: Gender Equality and Health, Policy Precis, published online, Available from: https://eurohealthnet.eu/sites/eurohealthnet.eu/files/publications/PP_Gender_Digital%20Version.pdf [Accessed 02 Dec 2020]

IMO. (2012) Position Paper on Health Inequalities, Irish Medical Organisation, Available from: https://www.imo.ie/policy-international-affair/documents/imo-position-papers/ [Accessed 30 Nov 2020]

Lachman, P. (2013) ‘Redefining the clinical gaze’, BMJ Quality & Safety. Available from: doi: 10.1136/bmjqs-2013-002322 [Accessed 01 Dec 2020]

Marmot, M. (2015) The health gap: the challenge of an unequal world [ebook]. Bloomsbury. 2015. 9781408857984 [Accessed 30 Nov 2020]

McCartney, M., Collins C. & Mackenzie, M. (2013) ‘What (or who) causes health inequalities: Theories, evidence and implications?’, Health Policy, 113, (2013) pp. 221–227. Available from: 10.1016/j.healthpol.2013.05.021 [Accessed 30 Nov 2020]

Pang, T. & Guindon, G.E. (2004) Globalization and risks to health. EMBO reports, 5 Spec No(Suppl 1), S11–S16.  Available from: https://doi.org/10.1038/sj.embor.7400226 [Accessed 02 Dec 2020]

Pickett, K. & Wilkinson, R. (2010) The Spirit Level: Why Equality is Better for Everyone [ebook]. Penguin UK, 2010, 0141921153, 9780141921150.

Skewes, M.C. &  Gonzalez, V.M. (2013) The Biopsychosocial Model of Addiction, Miller, P.M. Principles of Addiction: Comprehensive Addictive Behaviors and Disorders, Volume 1, Academic Press, pp. 61-70.

Song, M. & Kong, E-H., (2015) ‘Older adults’ definitions of health: A metasynthesis’, International Journal of Nursing Studies, Volume 52, Issue 6, 2015, pp. 1097-1106,

ISSN 0020-7489. Available from: https://doi.org/10.1016/j.ijnurstu.2015.02.001 [Accessed 02 Dec 2020]

W.H.O. (2020) Sustainable Development Goals (SDGs). Available from: https://www.who.int/health-topics/sustainable-development-goals#tab=tab_1 [Accessed 2 Dec 2020]

World Health Organisation. (2020) Social determinants of health. Available from: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1 [Accessed 30 Nov 2020]

A Tsunami of Adolescence Anxiety: An impact of today’s modern world

This assignment will critically examine research evidence that investigated a rise in the prevalence of mental health disorders amongst adolescents and in particular the rise of anxiety disorders among young girls in Western capitalist countries such as Europe and North America (Dooley at al., 2019; Kessler,2007; WHO, 2000).  Biopsychosocial factors that affect the development of a cohort of adolescents will be explored using a life course approach (Jacob, Baird, Barker, Cooper & Hanson, 2015; Mazza, 2017). Longitudinal studies will be analysed to demonstrate the relationship between poverty and the development of mental health disorders through pathway and cumulative risk models, in which structural inequalities predict outcomes that impact later life health outcomes.    Hall’s (1908) Theory of ‘Storm and Stress’ will be compared to the research findings conducted by Margaret Mead (1928) suggesting that psychological disorders in the teenage years mainly manifest in Western individualistic societies. Arnett’s (1999) adapted translation of ‘storm and stress ‘states that young people can make more choices and act out of agency due to modern individualistic societies. Marcia (1966) concluded that increased individualism has given an increased choice which makes commitment more difficult to identify. Through Meta-analytic studies this assignment will confirm that anxiety is higher in individualistic societies than in collectivist societies. Psychological perspectives such as attachment theory, learning theories, and Bronfenbrenner’s bioecological system theory will explain the findings of the increase of anxiety and mental health issues in adolescents. It will be argued that there is over medicalizing of anxiety in young people and this obscures that the roots of ‘the epidemic’ stem from economic inequalities, and the epistemological fallacy that young people living in a modern individualistic world have more personal agency than they actually have (Beck,1992).   Interventions to support mental health should be in line with sustainable development goals which address the causes of the causes of psychological distress which are structural inequalities in the distribution of power within societies. 

  A life-course approach to health explains how crucial stages for an individual’s life are relevant for health and it can explain illnesses in later life which can lead to an increased risk of mental health and a risk of early mortality. It investigates the social perspective of cultural, social, and economic circumstances experienced by an individual, and their cohort (Jacob, Baird, Barker, Cooper & Hanson, 2015).  The Life-course perspective explains three models that are interconnected. Hertzman ( as cited in Maggie, 2005) describes how bios-psychosocial factors interact influence outcomes for later life. The critical period model is where an environmental exposure to an individual in a limited time window affects the body’s organs and structures at that specific time of development with a result of permanent damage. This exposure will influence the health of an individual in later life. This model includes risks from biological and social exposures. No other exposure in later life will alter that effect on the individual.  An example of this is the Dutch Hunger Winter study which showed that members of the cohort who were exposed to poor nutrition following conception had higher risks of developing schizophrenia and obesity in later life (Roseboom et al., 2011).  

    The cumulative effect model refers to the series of risks and poor social determinants of health an individual is exposed to which build-up to affect the individual during their life course. Structural inequalities shape the individual at risk, and the ability to deal psychologically with risks. Bronfenbrenner’s (1993) Ecological systems model explores how risks such as maltreatment, neglect, poverty, discrimination in an individual’s microsystem, and macrosystem influence their mental health outcomes. Exposure to toxic stress hinders the development of an individual to self-regulate. Trauma impacts negatively on brain development which impacts behavior, learning, and health throughout the lifespan (Harvard.edu, 2020). Recent studies in epigenetics suggest that environmental hardships and risk in the first five years of childhood produce risky behaviors and increase the risk of unpredictability in adolescence and later years (Machluf & Bjorklund, 2015).  The Adverse Childhood Experience study (Anda & et al., 2010) has concluded that children living with abuse, neglect, and poor family circumstances are at risk of poor health outcomes. Patalay and Fitzsimons (2018) described how poor socioeconomic status is associated with poor mental health in girls aged 11-14 but not in males of the same age. This emphasizes how the sex-specific vulnerability of deprivation is linked with poor mental health in female adolescents. Economic and social policy should focus on interventions to reduce the inequalities limited by the social determinants of health due to an unfair resource distribution through society (Marmot et al, 2008). Governments need to set targets that are in line with the Sustainable Development Goals which will address the inequalities in society (United Nations, 2020). Multi-level interventions aimed at reducing social determinants of health such as poor education, unemployment, and substandard housing. Interventions need to focus on improving the self-esteem and well-being of an individual by improving family and working life. Housing policies  need to address the causes of homelessness. Various countries have recognized that accessibility to primary health care is essential to reduce mental health inequalities. There needs to be increased awareness of suicidal tendencies through prevention programs, and media coverage which may lower suicidal ideation (Wahlbeck et al., 2017). 

   The pathway model refers to linked exposures or events where stress inducing exposures or experiences lead to another risk and the links are continuous.  It can combine both social and biological risks.  It suggests that risks can send an individual on a definite trajectory. Negative events and stressors in the life course can be a cause of social anxiety disorder.  Events such as family conflict as in the case of parents’ marital breakup, sexual and physical abuse have a long-lasting effect on an individual (Kessler, Davis & Kendler, 1997). Brumariu (2010) applied the pathway model for the development of anxiety. The study found that temperament and poor early attachment predicted early anxiety. This study also suggested that experiences with peers and emotion regulation are accountable for explaining interactions between some attachment patterns or temperament and anxiety in later life.  Bowlby’s Attachment Theory maintains that a baby’s first connection with an adult is the most important as this is how it connects to others (Hart, 2008). A meta-Analysis by Lawrence and colleagues (2019) concluded that anxiety disorders are 7 times higher in children of parents with anxiety disorders contrasted to parents that have negligible  mental health symptoms . Studies such as the MWS-1(2012) to MWS-2(2019) have shown a marked increase of young people in the moderate, severe, or very severe range for depression and anxiety (Dooley et al., 2019). 

    There are no identifiable genes that create a susceptibility to Anxiety disorders, but children of socially anxious parents are more likely to be diagnosed with a mental health disorder and this suggests familial links. Recent studies suggest a complex link and interaction between cognition, emotional, and biological responses. Research, where identical twins were studied, showed a rate of 21.5% for both twins having anxiety, compared to a 13.5% rate for dizygotic twins having anxiety. These findings indicate a genetic predisposition but because the rate is very low it indicates that psychosocial and environmental factors also play an important part in the development of anxiety disorders (Andrews et al., 1990). The child’s temperament style of social inhibition of the child has been linked to the development of an anxiety disorder (Clauss & Blackford, 2012: Hudson & Dodd, 2012). Banduras (1977) Observational Learning Theory can explain how a child can learn and mimic a parent’s anxiety behaviour (Doherty & Hughes, 2009).   

    Every individual has a certain amount of choice to take care of their mental health. Rational Choice Theory gives that responsibility to an individual, but some adolescents make choices to take risks.  Individual agency is inhibited by structural forces such as environment, classism, racism, and ableism while at the same time structural dynamics generate the identities of individuals and their culture proposing they are interrelated. (Giddens, 1984).   The modern life course introduces a more structural opportunity for individuals to change in socio-economic standings. This pathway is influenced by structural advantage and psychological development (Hitlin & Kirkpatrick Johnson, 2015). Structural inequalities create an important role in affecting who is at risk, and the capability to cope with such risk (Merchant, 2013). Individuals with better socioeconomic status have more agency. Individuals are progressively accountable for their life courses within western societies, partly because of disappearing class networks (Honneth, 2004). The importance of agency versus structure has been disputed with many academics suggesting agency is an illusion while others maintain that western concepts of agency emphases positive ideas of an individual, thus observing noticeably anti-social self-determining actions. Beck (1992) argues that modern life is indicated by individualists and there is a move from structural agency. He suggests that identity is based on the individual rather than the community. 

     The life course incorporates that individuals born throughout time are born into different worlds, with different constraints and choices (Johnston et al., 2011). The era in which someone was born into shapes their development and outcomes. Valsiner & Lawrence (1997) suggests that the life stage known as adolescence is predominantly an invention of the 18th to 20th Western culture. Literature throughout time has depicted young people and the idea of adolescence is not new (Shute & Slee, 2015). To have adult status in preindustrial times, biological maturity was the main benchmark. Girls were expected to marry once they reached menarche. The post-industrial revolution brought technologies with a demand for education increasing. Recognition of adult status was delayed, and the transition of adolescence began. In traditional cultures that celebrate age grades with distinct ceremonies such as the Jewish Bar Mitzvah, the process of psychosexual development appears easier to deal with as they have less to learn since the pace is slower.  

    Mental illness throughout history has been chronicled from the earliest record in the old testament of the Ancient Hebrews right up to the works of Foucault.  The work of Foucault suggests that psychiatrists construct society through ideas and conceptualizations of mental health discourses. Medicalisation describes the process by which non-medical problems are discovered, recognized and treated as a medical disorder (Conrad, 2007). Several experts have suggested that the development of medical control is one of the most potent changes in the West in the last fifty years (Clarke et al.,2003). Beck (1992) argues that increased anxiety is due to living in a risk society. However, the biomedical approach to understanding and treating anxiety has led to labelling and medicalizing of anxiety even though the risk has been associated with social structures. 

    Due to the extended transition into adulthood, some groups of adolescents are restricted in their life choices due to structural constraints, young people are continuing in education longer and marrying in their thirties which leads to delayed adulthood, living with parents, and relying on them financially (Johnson et., 2011).  The youth are now living under the false assumption of epistemology fallacy that essentially raises their obligation to transition and make the right decisions or live with self-blame as a failure (Furlong & Carmel as cited in Merchant, 2013), this itself is giving rise to high mental disorders amongst disadvantaged youth. Changes associated with the economy and consumerism have generated greater levels of risk. Modern youth now have an increasing sense of autonomy, self-control due to the high demand for a multidimensional set of interdependencies. With the ability to make choices comes an increase of different risks in their life course. A European study of two German-speaking countries concluded that there is a higher quantity of anxiety and neuroticism which was predicted by age of marriage and unemployment (Schurmann & Margraf, 2018).  Meta-analyses in America of children and college students show increased rates of anxiety and neuroticism (Twenge, 2000). The National Institute of America concluded that one in three 13 to 18-year olds will experience an anxiety disorder (Mc Carthy, 2019). These findings show that the differences in anxiety and neuroticism rates between Europe and North America are connected to social factors such as the economy and very high divorce rates. Studies in Japan have concluded that adolescents have a moderate level of anxiety in comparison to western countries. This is explained due to culture and strict education demands (Shin-Ichi et al., 2008). In Western capitalist societies, government policies should be established in line with the sustainable development goals to focus on the lack of agency and to decrease the risk to lower socio-economic groups in society. For example, Goal 10. 2 by 2030, includes empowerment and promotion of social, economic, and political equality for all (United Nations, 2020).  

   The categorization of Stanley Hall’s Storm and Stress Psychological theory remains an open discussion. Repeated negative effects during this period have been assumed to explain the increased rates of affective disorders, suicide, and accidental death during this time of life. Reports that the onset of many mental health symptoms rise significantly from infancy to puberty (Kessler et al., 2005). However, some teenagers emerge from adolescence with minimal chaos.  The theory suggests when a Universal child reaches puberty there is a stage of Storm and Stress which involves mood disruption, conflicts with parents, and taking part in risky anti-social behaviours (Hall, 1904). Storm and stress suggest that there is a discontinuity, a sudden change in adolescent development due to biological causes in the brain, and hormones. He believed that the youth are very receptive to stimuli causing increased stress (Arnett, 1999). In Western societies there is evidence there is a gap in the life course but there is also continuity due to gradual cumulative change. Evidence is not as consistent for non-western societies (Johnson et al.,2011).   

   Modern research has explored brain development and evidence suggests that biological factors as suggested by Hall (1904) in ‘Storm and Stress’ can increase emotions and sensitivity. Increase hormones such as testosterone can lead to increased aggression. Adolescence involves a period of the lengthy structural brain development of grey and white matter tracts (Dumontheil, 2016). This development change in white enables higher cognitive functions such as cognitive control and social cognition. The difference in white matter development implicates emotion processing and regulation in individuals diagnosed with an affective disorder. (Ladouceur et al., 2012). Grey matter development in individuals with a high IQ have a greater window of sensitivity to the environment (Dumontheil, 2016: Ladouceur et al., 2012).  The difference in the growth between pubertal maturation and subcortical regions support processes concerning rewards and emotions. Parietal frontal and temporal cortex development aids self-regulation and social understanding. Adolescents react specifically to emotion and rewards but also, they have reduced self-control which indicates an increase in taking risks and mortality compared to children. Adolescents become more sensitive to peer rejection and risky behaviors increase in the company of their peers (Dumontheil, 2016). The events individuals experience can mould neural pathways with synaptic pruning altering the brain itself into a more efficient neurological structure in adulthood. Studies have established that individuals with Social Anxiety Disorder have a greater cortisol response when performing in front of onlookers. Social Anxiety disorders are linked with hypersensitive postsynaptic 5HT receptors. People with general anxiety show a low dopamine activity (Beidel & Turner, 2007). 

     However, Margaret Mead challenged Hall’s theory of Storm and Stress. Through her anthropological research Mead in 1925 contradicted the assertion that storms and stress in adolescence are worldwide. She maintained that culture could have an impact rather than biological influences that cause adolescents to suffer emotional and psychological stress.  Through her studies of Samoan girls, she established that Samoan youth were relaxed and well balanced due to their cultural and societal norms (Delaney, 1995). Also, Jeffrey Arnett (1999) modified Hall’s theory of storm and stress where an amended version of the theory is more accurate in today’s modern world. It is predominantly linked to western individualistic, neoliberalist societies such as North America and Europe where there is individual variability, with agency the youth becoming more independent, and with the ever-changing environment which can lead to risky behaviour. But not all young people suffer from it as each person is individual and it is not cross global or cross cultures. He concluded in more traditional cultures adolescents do not expect to become independent from the family so there is less conflict. However, conflict can occur in traditional families where an adolescent is challenged due to economic changes and integration with the modern global society (Arnett, 1999).  

   Biological factors are embedded in an evolutionary approach where there are family conflicts, peer influence, and risk-taking.  Conflict during socialization of the child should be viewed as a struggle concerning the biology of a child with the biology of the parents but also the biology of the child in conflict with the culture of the parent (Badcock, 2012). Bandura disagrees with the evolutionary approach suggesting that media contributes to portraying youth as stormy. He believes that parents that are in good relationships with their adolescents often wait for the stress and stormy phase to start which leads Bandura to suggests that this can become a self-fulfilling prophecy. He believes any problem in adolescence develops from early childhood struggles and hardships (Vilelli, 2013).   

   Marcia (1966) argued that the increase in anxiety is due to the large creation of choices young people have and these choices increase identity moratorium. Psychodynamic approaches suggest that identity matures because of inner conflict. This approach formed statuses: achievement (commitment after exploration), foreclosure (commitment with no exploration), moratorium (continuing exploration), and diffusion (no commitment and exploration). Marcia’s research has concluded that most adolescents are in identity achievement or identity foreclosure. That is, a high level of positive improvements and a secure identity is considered. Whereas people with a moratorium and an identity status are considered to have a high level of unsafe problematic behaviour and irregular identity crisis (Hatano, Sugima & Crocetti, 2015). As adolescents develop through their teenage years they think more about their identity and they may reassess values that they already accepted. This can lead to an identity crisis, but most can solve it before they reach adulthood. Our culture growing up also influences the way we perceive ideas such as self and identity. Living in an individualistic culture a person gains a sense of identity as an autonomous individual who has clear distinctive boundaries separating from other people. But if a person grew up in a traditional based culture the conception of self would be with the family members and friends. 

        To improve the wellbeing of young people interventions that remove the existence of stigma, manage mental health symptoms need to be established. Policymakers need to tackle problems in accessing services that can make it a difficult transition to adulthood. Universal healthcare should be made available to reduce mental health inequalities by increasing awareness of the risk of suicide through precaution programs that reduce suicidal ideation (Wahlbeck et al.,2017). There is a large amount of money invested in early years education to support the cognitive development of children from disadvantaged areas. Due to brain restructuring in the ages 9- 14, it is a good stage for prevention interventions. 

Conclusion: 

   The life course approach incorporates a bio-psycho-social understanding of health during a lifespan and it focuses on the adolescent period as important for health outcomes such as low educational attainment and disorder. The transition between adolescence and adult life is a central period that provides an opportunity to impact adult, physical wellbeing. An individual’s mental health can influence how a person navigates norms and social structures which can affect educational accomplishment and employment capability.  Individuals that are uninvolved with education participate in risky lifestyles and are more likely to experience poor life experiences. It is at this life stage that due to poor social determinants of health they are more at risk to experience an abrupt than a gradual transition to adulthood (Sapiro & Ward, 2019). Psychological development is constrained by genetics and environmental influences. All an individual undergoes and understands is partly determined by nature (brain and genes) and partly by nurture (the environment as a child, poverty, risk of neglect, physical abuse, sexual abuse, food inequality). These factors are continuously interacting in a complex way. It is not our social situations that determine how we develop but our social circumstances impact how good we are at adjusting to the changes that take place during our life span. (Elder, 1998). Studies suggest Anxiety among youth is increasing, this due to the over medicalizing of young people and not considering the stress  associated with the responsibility of self -failure in an individualistic society.  The mixture of attachment styles, biological, negative life events, and stressors such as making risky choices with an increased abundance of life options and have a causal role in the development of social anxiety disorder for most affected individuals. Eastern cultures have less prevalence of Social anxiety disorder than Western cultures due to having a positive constructive attitude towards anxiety. The existence of stigma, management of mental health indicators, and problems in accessing services can make it difficult to transition to adulthood. Policymakers and health care professionals have a duty to provide adequate interventions and healthcare.  

References

Ando, F., Porter, L., Brown, D. (2010) Inside the Adverse Childhood Experience Score; Strengths, Limitations, and Misapplications. American Journal of Preventative Medicine[online][ accessed 30 November ] Available at https://www.ajpmonline.org/article/S0749-3797(20)30058-1/fulltext 

Andrew, G. Stewart, G. Allen, R. Henderson, A.S. (1990) The genetics of six neurotic disorders: a twin study. Journal of Affected Disorders. 19(1)23-29.  

Arnett, J. (1999) Adolescent Storm, and Stress Reconsidered. American Psychologist.  University of Maryland10.1037110003-66  

Badcock, C. (2012) [accessed 4/11/2020]. Parent-offspring conflict. A time to listen to the Argument. Psychology Today. Available at: https://www.psychologytoday.com/us/blog/the-imprinted-brain/201207/parent-offspring-conflict-time-listen-the-argument 

Bandura, A. (1977) Self -efficacy: toward a unifying theory of behavioural change. Psychological Review.84(2):191-215. 

Beck, U. (1992) Risk Society Towards a New Modernity. Sage Publication. University Library. London. 

Beidel, D.C. Turner, S.M. (2007) Etiology of Social Anxiety Disorder. In shy children, phobic adults: Nature and treatment of social anxiety disorder. American Psychological Association 10.1037/11533-004. 

Bronfenbrenner, U. (1998) The ecology of development process. Handbook of child psychology. Theoretical models of human development. 5th edn, Vol.1. New York: Wiley, 993-1,027. 

Clauss, J. & Blackford, J. (2012) Behavioural inhibition and risk for developing social anxiety disorder: a meta-analytical study. J Am Accad Child Adolescent Psychiatry. 51:1066-1075 

Clarke, A., Shim, J. Mamo, L. (2003) Biomedicalization: Technology Transformation of Health, Illness, and U.S. Biomedicine. American Sociological Review 68:161-94 

Conrad, P. (2007) the Medicalisation of Society. On the Transformation of Human Conditions into treatable disorder. The John Hopkins University Press. USA. 

Dooley, B., O Connor, C., Fitzgerald, A., O’Reilly, A. (2019) My World Survey 2. The National Study of Youth Mental Health in Ireland. UCD, School of Psychology and Jigsaw. 

Delaney, C. (1995) Rites of Passage in Adolescence, Academic Journal Article. Vol 30, 120 

Doherty, J., Hughes, M. (2009) Child Development. Theory and Practice 0-11. Pearson Longman. England. 

Dumotheil, I. (2016) Adolescent brain development. Current Opinion in Behavioral Sciences.10.10.1016/j.cobena,2016.04,012 

 Elder, G. H. (1998) The life course and human development in R.M. Lerner (Eds). Handbook of child psychology Vol1. Theoretical models of human development. 5th ed. New York. 

Giddens, A. (1984). The Constitution of Society. Introduction of the theory of Structuration. Berkeley University. California Press.  

Hall, G. (1904) Adolescence: Its psychology and its relation to physiology, anthropology, sociology, sex, crime, religion, and education. (Vols.1& 2). Englewood Cliffs, Nj: Prentice-Hall. 

Hatano, K., Sugimura, K. Crocetti, E. (2015) Looking at the dark side and bright side of identity formation: New Insights from adolescents and emerging adults in Japan. Journal of Adolescence. The University of Japan. 47(2016)156-168. 

Hitlin, S. & Kirkpatrick Johnson, M. (2015). Reconceptualizing Agency within the life course: The Power of Looking Ahead. American Journal of Sociology. 1429-1472 

Honneth, A. (2004). Organized Self – Realisation. Some Paradoxes of individualization. European Journal of Social Theory. 962-1023. 

Hudson, J. Dodd H. (2012). Informing early intervention: preschool predictors of anxiety disorders in middle childhood. PLoS One 7: e42359. 

Jacob, C. Baird, J. Barker, M. Cooper, T. & Hanson, M. (2015) The importance of a life course approach to health chronic disease risk from preconceptions through adolescence and adulthood. Southampton: University of Southampton. Furlong’s legacy for youth studies. Journal of youth studies 23:1:1-11 

Johnson, M., Crosnoe, R. & Elder, G (2011) Insights on Adolescence from A life Course Perspective. National Institute of Health. 10.1111/j.1532-7795.2010. 00728.x 

Kessler, R. C., Davis, C. G., & Kendler, K. S. (1997). Childhood adversity and adult psychiatric disorder in the US National Comorbidity Survey. Psychological Medicine, 27(5), 1101–1119. https://doi.org/10.1017/S0033291797005588 

Kessler, R. C., Angermeyer, M., Anthony, J. C., DE Graaf, R., Demyttenaere, K., Gasquet, I., DE Girolamo, Guzman, S., Gureje, O., Haro, J. M., Kawakami, N., Karam, A., Levinson, D., Medina Mora, M. E., Oakley Browne, M. A., Posada-Villa, J., Stein, D. J., AdleyTsang, C. H., Aguilar-Gaxiola, S., Alonso, J., Ustün, T. B. (2007). Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World psychiatry: official journal of the World Psychiatric Association (WPA),6(3), 168–176 

Ladouceur, C.D., Peper, J.S., Crone, E.A. & Dahl, R.E. (2012) Identity Status and Anxiety: A Meta-Analysis Identity: An International Journal of Theory and Research.13.214-227.10.1086/15283488.2013/799432. 

Larkin, Mary. (2009) Vulnerable groups in Health and Social Care. Sage Publications. United Kingdom.  

Lawrence, P., Murayama, K., Creswell, C. (2019) Systematic Review and Meta-Analysis: Anxiety and Depressive Disorders in Offspring of Parents with Anxiety Disorders. J Am Acad Child Adolescent Psychiatry 58(10):46-60. 

 Liebenberg, L. & Ungar, M. & Ikeda, J. (2013).  Neo-Liberalism and Responsibilities in the Discourse of Social Service Workers. British Journal of Social Work. 45. 10.1093/bjsw/bct172 

Marcia, J. (1966) Development and validation of ego -identity status. Journal of Personality and Social Psychology. 3.551-558 

Marmot, M., Friel, s., Bell, R., Houweling, T., Taylor, S. (2008) Closing the gap in a generation: health equity through action through action on the social determinants of health. The Lancet. Vol372. Issue 9650. [online] accessed 1 December 2020. Available from https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61690-6/fulltext 

Maggi, S., Irwin, L., Siddi, A., Poureslami, I., Hertzman, E. Hertzman, C.(2005) Knowledge Network for Early Child Development. Analytic and strategic Review Paper:  International Perspectives on Early Child Development. Human Early Learning Partnership. World Health Organisation. 

Machluf, K., Bjorklund, D. (2015) Understanding risk-taking behaviour: Insights from Evolutionary Psychology. Emerging trends in behaviour science[online] [Accessed 7 November 2020] Available at https://nature.berkeley.edu/garbelottoat/wp-content/uploads/machluf-and-bjorklund.pdf 

Mazza, J., Lambert, J., Zunzunegui, M., Tremblay, R., Boivin, M., & Côté, S. (2017).  Early adolescence behavior problems and timing of poverty during childhood: A comparison of life course models. Social Science & Medicine,177, 35-42.  

Merchant, J. (2013) Constructing risky identities in policy and practice. ProQuest eBook 

Mc Carthy, C. (2019). Anxiety in teens is rising: What is going on? Healthy Children.org [online] [Accessed29 November2020] available at https://www.Healthychildren.org/English/health-issues/conditions/emotional-problems/pages/anxiety-disorders.aspx. 

Mc Robbie, A., Garber, J (1975) Girls, and subculture. Resistance through Rituals. Youths Subcultures in Post War Britain. Hutchinson. London. 

 Patalay, P., Fitsimmons, E. (2018) Development and predictors of mental health and Wellbeing from childhood to adolescence. Social Psychology and Psychiatric Epidemiology. 53(1201311-1323. 

Pearson, G, (1983). Hooligan, A History of Respectable Fears. McMillan. London. 

Read, J. Sanders, P. (2011) The Causes of Mental Health Problems. PCCS Book Ltd. UK. 

 Roseboom T J., Painter, R., Van ABeelen, A., Vierendeel, V., De Rooij, S. (2011). Hungry in the womb: What are the consequences? Lessons from the Dutch famine. Maturities 2011; 70 141- 145.  

Sapiro, B., Ward, A. (2020) Marginalized youth, Mental Health, and Connection with Others: A View of the literature Child and Adolescent Social World Journal 37:343-357. 

Schurmann, J., Margraf, J. (2018) Age of Anxiety and depression revisited. A meta-analysis of  

2 European community samples (1964-2015). International Journal of clinical and health psychology:1jchp,18(2),102-112.  

 Shin-ichi, I., Sato, H., Sasagawa, S. (2008). Anxiety Disorder Symptoms in Japanese children and Adolescents. Journal of Anxiety vol 23.1[online][accessed 30 November] Available at https://www.sciencedirect.com/science/article/pii/S0887618508000984 

Shute, R. & Slee, T. (2015) Child Development Theories and Critical Perspectives. Routledge. London  

Twenge, J.M. (2000) The age of anxiety? Birth cohort change in anxiety and neuroticism,1952-1993. Journal of Personality and Social Psychology. 79: 1007-1021. 

United Nations (2020) United Nations Sustainable Development Goals[online][accessed 20 November] Available at https://www.un.org/sustainabledevelopment/ 

Valsiner, J. Lawrence, J. (1997) Human development in culture across the life span. Handbook of cross-cultural psychology(vol2). Boston: Allyn & Bacon. US. 

 Vilelli, R. (2013) Storming into Adulthood. Are Adolescence emotional volcanoes waiting to explode? Psychology Today. 

Wahlbeck, K. Cresswell – Smith, J. Haaramo, P. Parkkonen, J. (2017) Intervention to mitigate the effects of poverty and inequality on mental health. Social Psychiatry and Psychiatric Epidemiology. 52(5)505-14, 10.1007/.00127-017-1370-4.  

World Health Organisation (2014) Social Determinants of Health. Switzerland. [online][accessed 15 November 2020] Available at   https://www.who.int/mental_health/publications/gulbenkian_paper_social_determinants_of_mental_health/en/at: 

World Health Organisation (2000) The world Health Report 2000- Health systems: improving performance. [online] [accessed 1December 2020] available at https://www.who.int/whr/2000/en/ 

Childhood Adversity and Mental Health Outcomes 

Abstract 

Introduction. It is only in recent years, that childhood adversities are being seen as predictors of mental ill health. A review of literature focussing on physical abuse and neglect and PTSD and depression was undertaken. Based on previous research significant associations between experiences of childhood physical abuse and neglect and diagnoses in adulthood of depression and PTSD were predicted Method For this analysis, a random sample of 25% of cases were generated from Wave 1 and Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) data (n = 8675). Crosstabulations and Chi Square Tests of Independence were run in RStudio to test the hypotheses. Findings There were significant associations found between childhood physical neglect and PTSD (X2 = 344.88, df=1, p<.05) and depression (X2 = 159.57, df=1, p<.05) and childhood physical abuse and PTSD (X2 = 372.086, df=1, p<.05) and Depression (X2 = 171.041, df=1, p<.05). Conclusion This research highlights that national policies need to address structural inequalities which cause childhood poverty which is associated with childhood neglect. It also highlights that practitioners who work with individuals with PTSD and depression should be aware that adverse childhood experiences may be at least part of the reason for such diagnosis.  

LITERATURE REVIEW 

It is only in recent years, that childhood adversities are being seen as predictors of mental ill health. These adversities are not exclusively focussed on neglect and abuse but also take into consideration other factors such as maternal mental health or loss of a parent (Read and Bentall, 2018). As mentioned in the introduction, Bowlbys Attachment Theory posits that an individuals experiences of relationships (through their caregiver) in childhood affect their development and their ability to form relationships in adulthood (Holmes, 2014). Developmental trauma is the term used to describe childhood trauma such as chronic abuse and neglect. If the caregiver is unable to ease the toxic stress caused by developmental trauma or if the caregiver is the cause of the toxic stress, it can lead to physical and mental ill health in adulthood. (Van der Kolk, 2005). 

A review of literature focussing on physical abuse and neglect and PTSD and depression was undertaken. A study conducted by Sullivan and colleagues (2006), found that PTSD symptoms were correlated with forms of childhood abuse and neglect. The study showed that emotional abuse had a high association with PTSD and that sexual and physical neglect had a moderate association with PTSD.A further study carried out by Grasi-Oliveira and Stein (2008) found that childhood abuse and neglect predicted a high chance of PTSD and depression in later life. The study, which was carried out on patients in a public hospital seeking treatment, found that there was a history of physical abuse and neglect in childhood and because of these experiences, individuals were more vulnerable to PTSD and depression in adulthood. Other studies, such as one carried out by Widom (1999) agree that sexual and physical abuse are risk factors to PTSD in later life, however it did give not much attention to the impact physical neglect has.  

Sexually abused women who also experienced physical abuse had a higher risk of developing PTSD. This was based on a study conducted by Roth and colleagues in 1997 who used an evaluation on participants in the DSM-IV PTSD Feld Trial.Further studies, such as one by Nothling and colleagues (2016) found that although trauma had an association with PTSD and depression, other factors such as community violence and demographics needed to be considered. Of the sample they surveyed they found that over half had symptoms of PTSD or depression but those who had experienced physical abuse alone made up just 5.3%. It found that the type of trauma experienced, rather than the trauma load predicted PTSD and depression. Other studies looking at depression and adverse childhood experiences, such as a study by Paterniti and colleagues (2017), found that physical neglect in childhood was a key predictor for depression in adulthood, and the effect of childhood physical neglect on the course of an individuals depression was independent of demographic variables. Studies in Taiwan by Cheng-Fang and colleagues, in 2008, found that 22% of those surveyed who had depression, had experienced childhood physical abuse and led the researchers to conclude that childhood physical abuse increased the risk of depression. 

This research aims to answer the following research questions and to test their associated hypotheses. 

Are those who experience physical neglect in childhood more likely to suffer PTSD in later life, than those who do not experience physical neglect? 

Ho there is no association between childhood physical neglect and PTSD. 

H1 there is an association between childhood physical neglect and PTSD in later life. 

Are those who experience physical abuse in childhood more likely to suffer PTSD in later life, than those who do not experience physical abuse? 

Ho there is no association between childhood physical abuse and PTSD in later life. 

H1 there is an association between childhood physical abuse and PTSD in later life. 

Are those who experience physical neglect in childhood more likely to suffer depression in later life, than those who do not experience physical neglect? 

Ho there is no association between childhood physical neglect and depression in later life. 

H1 there is an association between childhood physical neglect and depression in later life. 

Are those who experience physical abuse in childhood more likely to suffer depression in later life, than those who do not experience physical abuse? 

Ho there is no association between childhood physical abuse and depression in later life. 

H1 there is an association between childhood physical abuse and depression in later life. 

METHODOLOGY 

This quantitative research took a post positivist approach. Karl Popper, a philosopher best known for his post positivist approaches, suggested that theories should be tested against data with the intention of falsifying hypotheses. (Fox, 2008). For the purpose of this research the Hypothetico-Deductive Method was used. This method identifies a broad problem, defines a statement about this problem, conducts literature review, defines research questions, and hypotheses, collects and analyses data and discusses the findings from the data. By deducting the observations, the hypotheses will be seen as true or false (Neuman, 2013).The ontological (philosophical framework) position of the research is critical realism. Critical realism is acknowledging the world is real, but acknowledging that its true workings may be beyond us. The epistemological (philosophical framework) position of the research is modified objectivism. Modified objectivism sees the world and researchers as separate but not independent.  

METHOD 

Sampling 

The data is based on the 2001-2002 Wave 1 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and Wave 2 NESARC (2004-2005). It was conducted under the National Institute on Alcohol Abuse and Alcoholism (NIAAA)’s direction (NIAAA, 2010). 

It should be noted, given the complex survey design, variance estimation procedures that assume a simple random sample are not appropriate. Given the clusters in the sample section, the variance estimates do not account appropriately for sample design effects and make non -significant differences appear significant. Taking this into consideration, all standard errors of estimate were generated using SUDAAN (Research Triangle Institute2008), a computer program that uses statistical techniques to adjust for sample design effects. 

The sampling design and methodology of the NESARC can be found in “Source and Accuracy Statement for Wave 1 of the 2001 – 2002 National Epidemiologic Survey on Alcohol and Related Conditions” (Grant et al., 2003) and “Source and Accuracy Statement for the 2004 – 2005 Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions” (Grant and Kaplan, 2005). 

Participants 

The sample set for Wave 1 was 43,093 individuals who were aged 18 and over from all fifty states and the District of Columbia, and included civilians, non-institutionalised adults and military personnel. The sample set for Wave 2 re-interviewed 34,653 of the original Wave 1 participants. Of the remaining 8,440, 3,134 were not eligible due to being institutionalised, on active duty, deceased, deported or mentally/physically impaired. The remaining 5,036 either refused or were unable to be located. 

Response rates for Wave 1 was 81 percent and Wave 2 was 86.7 percent, yielding an overall response rate of 70.2 percent (NIAAA, 2010). 

Variables 

Age 

Anyone over the age of 90 years of age was classed as 90 years of age (NESARC Codebook, 2008). 

Sex 

The code used was 1 for males and 2 for females. There were 42% males and 58% female. (NESARC Codebook, 2008). 

Ethnicity 

Ethnicity was measured with the codes 1 for White,non-Hispanic, 2 for Black,non-Hispanic, 3 for American Indian/Alaska Native, non-Hispanic, 4 for Asian/Native Hawaiian/Other Pacific Islander, non-Hispanic and 5 for Hispanic, any race. Participants were made up of 58.0% white, 19% black, 2% native, 3% Asian and 18% Hispanic (NESARC Codebook, 2008) 

Perception of Current Health Status 

Participants were asked to measure how the perceived their current health, the following options were given for this variable 1 as excellent, 2 as very good, 3 as good, 4 as fair, 5 as poor and 9 as missing data (NESARC Codebook, 2008). 

Measures of Childhood Adversity 

    Physical Abuse 

Participants were asked if they had experienced physical abuse before the age of 18 years old (NIAAA, 2010). 

    Physical Neglect 

Participants were asked if they had experienced physical neglect before the age of 18 years old (NIAAA, 2010). 

    Measures of Mental Health in Adulthood 

    PTSD 

Participants were asked if they had ever been diagnosed with PTSD by a health professional (NIAAA, 2010). 

   Depression 

Participants were asked if they had ever been diagnosed with depression by a health professional. (NIAAA, 2010). 

Analysis 

For this analysis, a random sample of 25% of cases were generated. The initial dataset contained 8745 cases. Cases with missing data were omitted from the dataset in R Studio using na.omit function. This new dataset with cases with missing data point omitted contained 8675 cases. The minimum age was 20 and the maximum age was 90, 57% were female, 58% were white, 18.7% were black, 1.8% were native, 2.8% were Asian, and 18.6% were Hispanic. (RStudio, 2020). 

FINDINGS 

The age range for the sample was 20 to 90 years of age, with a mean of 49.2 (SD=17.25). The summary statistics for age are illustrated in Table 1. 

Table 1.    Descriptive Statistics for Age 

The distribution for age is illustrated below in figure 1. 

Figure 1. 

From Table 1 and Figure 1, shows that the distribution of age is positively skewed. When skewness was run in R Studio it was found to be 0.38, so although positively skewed it was within the normal range, so therefore the skewness would not be considered significantly skewed. The kurtosis at -0.68, although negative, would be considered mesokurtic (Hair et.al., 2017)  

 Boxplot for Age 

                                                       Figure 2.                             

From Figure 2, the boxplot is comparatively short. The median age was 47 and corresponds to the thicker vertical line. The box shows the lower and upper quartiles of age (36-61) , while the whiskers show the ages below the 1st Quartile (20-36) and above the 3rd Quartile (61-90). 

Table 2.                      Crosstabulation for Physical Neglect and PTSD (n=8675) 

Table 3.                   Chi Square Test of Independence for Physical Neglect and PTSD 

The results from the Chi Square suggest that the H0 can be rejected. These results indicate that those who experience childhood physical neglect are more likely to have a PTSD diagnosis than those who do not. Specifically, the results indicate that 43% of those who experienced childhood physical neglect, in contrast to 10% who did not experience childhood physical neglect met the threshold for PTSD. 

Table 4.                   Crosstabulation for Physical Abuse and PTSD (n=8675) 

Table 5.                       Chi Square Test of Independence for Physical Abuse and PTSD 

The results from the Chi Square suggest that the H0 can be rejected. These results indicate that those who experience childhood physical abuse are more likely to have a PTSD diagnosis than those who do not. The results show that 43% of those who experienced childhood physical abuse, in contrast to 9% who did not experience childhood physical neglect met the threshold for PTSD. 

Table 6.                     Crosstabulation for Physical Neglect and Depression (n=8675)              

Table 7.                 Chi Square Test of Independence for Physical Neglect and Depression 

The results from the Chi Square suggest that the H0 can be rejected. These results indicate that those who experience childhood physical neglect are more likely to have a diagnosis of depression than those who do not experience childhood physical neglect. The results indicate that only 2% of those who experienced childhood physical neglect did not experience depression, whereas 98% of those who had not experienced childhood physical neglect did not experience depression. 

Table 8.             Crosstabulation for Physical Abuse and Depression (n=8675)              

Table 9.                 Chi Square Test of Independence for Physical Neglect and Depression 

The results from the Chi Square suggest that the H0 can be rejected. These results indicate that those who experience childhood physical neglect are more likely to have a diagnosis of depression than those who do not experience childhood physical neglect. The results show that the expected amount for those with experience of childhood physical abuse is 81, however the observed results are over twice that at 182, showing an association between childhood physical abuse and depression. 

DISCUSSION 

The findings from the crosstabulations run can reject all four null hypotheses. The findings would agree with that of previous research, that show there is an association between childhood neglect and abuse and PTSD and depression in adulthood. The findings would suggest the need for interventions in childhood for those who have experienced physical abuse and neglect, as these adverse childhood experiences are key predictors of PTSD and depression. The findings in this research and other research would support this. 

The limitations of the study are it was secondary data so questions specific to the research questions were not asked (frequency of exposure). The sample set was only 25% of the original data. The study was conducted in the US, so can only be generalized to the US population. 

CONCLUSION 

The findings concluded that physical abuse and neglect in childhood have an association with PTSD and depression in later life. These findings were conducted by running crosstabulations and chi square calculations on R Studio. The sample set was 25% of the original dataset and missing data was adjusted using na.omit in R Studio. Previous research was reviewed and the findings conducted for this research agreed with previous research that there is an association between the variables. This highlights that interventions need to take place for children as childhood neglect and abuse are predictors of PTSD and depression in later life. It also highlights the need for national policies to take into consideration such inequalities as poverty, as childhood neglect can often be the socio -economic environment a child lives in. It also highlights that practitioners who work with individuals with PTSD and depression should be aware that adverse childhood experiences may be at least part of the reason for such diagnosis. Therapy to address these issues should be considered along with medication to treat the symptoms of such diagnosis. 

References

CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study. (1995 to 1997). [online], Available:  https://www.cdc.gov/violenceprevention/aces/about.html [Accessed:  01 January 2021] 

Cheng-Fang, Y., Mei-Sang, Y., Cheng-Chih, C., Ming-Jen, Y., Ching, S., Mei-Hua, W., and Chu-Mei, L. (2008). Effects of childhood physical abuse on depression, problem drinking and perceived poor health status in adolescents living in rural Taiwan. Psychiatry and Clinical Neurosciences, 62 (5), pp.575-583. [online], Available: https://doi.org/10.1111/j.1440-1819.2008.01836.x [Accessed 7 January 2021]. 

Fox, N.J. (2008). Post-positivism. The sage encyclopaedia of qualitative research methods. London:Sage. 

Grant, B.F.; Kaplan, K.D.; Shepard, J.; and Moore, T. (2003) Source and Accuracy Statement for Wave 1 of the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. 

Grant, B.F., and Kaplan, K.D. (2005). Source and Accuracy Statement for the 2004–2005 Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. 

Grassi-Oliveira, R. and Stein, L.M. (2008). Childhood maltreatment associated with PTSD and emotional distress in low-income adults. The burden of neglect. Elsevier. 

Hair, J.F., Hult, G.T.M., Ringle, C.M., and Sarstedt, M. (2017). A Primer on Partial Least Squares Structural Equation Modelling. Sage.  

Holmes, J. (2014). John Bowlby and Attachment Theory. United Kingdom: Taylor and Francis Ltd. 

National Epidemiologic Survey on Alcohol and Related Conditions. Wave 2,2004-2005. Codebook. (2008).  

Neuman, W.L. (2013). Social Research Methods. Pearson Education Limited. 

NIAAA, (2010). Alcohol use and alcohol use disorders in the United States, a three year follow up: Main findings from the 2004-2005 wave 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). US Alcohol Epidemiologic Data Reference Manual, 8 (2). [Online], Available: https://pubs.niaaa.nih.gov/publications/NESARC_DRM2/NESARC2DRM.htm#TOC15  [Accessed 18 October 2020] 

Nothling, J., Sulliman, S., Martin, L., Simmons, C., and Serdat, S. (2016). Differences in abuse, neglect and exposure to community violence in adolescents with and without PTSD and depression. Journal of Interpersonal Violence.[online] https://doi.org/10.1177/0886260516674944 Accessed 06 January 2021 [Accessed 2 January 2021] 

Paterniti, S., Sterner, I., Caldwell, C., and Bisserbe, J.C. (2017). Childhood neglect predicts the course of major depression in a tertiary care sample: a follow up study. BMC Psychiatry, 17 (113). [online], Available: https://doi.10.1186/s/2888-017-1270-x  [Accessed 8 January 2021]. 

Read, J., and Bentall, R.P. (2018). Negative childhood experiences and mental health: theoretical, clinical and primary prevention implications. The British Journal of Psychiatry. 200 (2), pp.89-91. Cambridge University Press. [online], Available: https://doi.org/10.1192/bjp.bp.111.096727 [Accessed 2 January 2021] 

RStudio Team (2020). RStudio: Integrated Development Environment for R. RStudio, PBC, Boston, MA URL http://www.rstudio.com/. 

Roth, S., Newman, E., Pelcovitz, D., Van der Kolk, B., and Madel, F.S. (1997). Complex PTSD in victims exposed to sexual and physical abuse: results from the DSM-IV Field Trial for Posttraumatic stress disorder. Journal of Traumatic Stress. 10, pp.539-555. [online], Available: https://doi.org/10.1023/A:1024837617768 [Accessed 8 January 2021]. 

Sullivan, T.P., Fehon, D.C., Andres-Hyman, R.C., Lipschitz, D.S., Grilo, C.M. (2006). Differential Relationships of Childhood Abuse and Neglect subtypes to PTSD symptoms clusters among adolescent inpatients. Journal of Traumatic Stress 19 (2) pp. 229-239. [online], Available:  https://doi.org/10.1002/jts.20092  [Accessed: 30 December 2020] 

Van der Kolk, B.A. (2005). Developmental Trauma Disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals. 35 (5) 

Widom, C.S. (1999). Posttraumatic stress disorder in abused and neglected children grown up. The American Journal of Psychiatry. 156 pp.1223-1229. 

Question: To what extent has Globalisation been the cause of global health problems? 

Introduction 

Globalization is widespread and is often inconclusive and open to many interpretations. It can be described as the interdependence and relationship of people and countries. Alternatively, global health focuses on many countries’ challenges and concerns, and emphasizes transnational issues like climate change and urbanization. World Systems Theory, Solid Modernity, and Liquid Modernity are theories that attempt to explain Globalization. To evaluate the extent of Globalization on a global health issue, case studies will be used. For example, global rates of obesity and associated non-communicable diseases have been rising for the last four decades (Raine, 2012). Obesity rates have been related to globalization processes that encourage obesity by overwhelming low-income country economies with cheap, obesity – promoting products and disseminating Western-style fast food restaurants (dependency/world system’s theory) (Fox, Feng and Asal, 2019).  Domestic factors such as increased excessive calorie consumption in addition to income and increased female labour force participation as economies grow (the “modernization” theory) are potential hypotheses (Fox, Feng, and Asal, 2019). Globalization, or the unrestricted flow of information, technology, culture, and capital between countries, has been both a beneficial and detrimental force, especially in the realm of health. Globalization has aided in the emancipation of thousands of people from severe poverty, reduced hunger and infectious disease, and improved people’s overall quality of life. The problem is that the same social and economic changes that raised individuals’ prosperity have expanded their waist sizes, leading to the worldwide epidemic of obesity. The concept of “globalization” is also widespread in contemporary academia and is often inconclusive and open to many interpretations, which will be seen throughout the different case studies.  

  Define what Globalisation and global health are. 

The concept of “globalization” has become widespread in contemporary academia and is often inconclusive and open to many interpretations (Mir, Majeed, Qadri, & Hassan, 2014; Upali, 2017). As stated by the WHO, Globalization can be characterised as the growing interrelation and corelation of nations and individuals, which are two interconnected components. Globalization, according to Anthony Giddens, is the strengthening of global social links that bind distant locales in such a way that events in one country impact events in another country, even if they are miles away (IInfed (2017) and Upali (2017). This requires a paradigm change in our thinking regarding geography and our perception of the locality. Along with opportunities, it often involves significant threats, among which are those associated with technological development. The enhanced interrelationship and interdependence of peoples and countries (Economics Online, 2020) and changes in structures and policies that foster or facilitate such flows. Globalization refers to developing various economic, social, cultural, and technological processes that increase inter-connectivity between societies and people worldwide (IInfed.org, no date).  Michael Mann, for example, has recently stated: 

“… what is generally called globalization involves the extension of distinct relations of ideological, economic, military, and political power across the world.” (IInfed, 2017). 

However, other views, including transformationalists and postmodernists, except that globalists have exaggerated globalization’s influence. They argue that dismissing the idea outright is foolish. Globalization, according to this theoretical perspective, would have to be regarded as a intricate network of interrelated associations in which authority is often implemented indirectly. They argue Globalization can be slowed or stopped, mainly where it is harmful or at least regulated (Thompson, 2015). Global optimists conclude Globalization is taking place and that local identities are eroding due to multinational capitalism’s growth and the rise of a homogeneous global society. They perceive Globalization as an optimistic phenomenon, marked by increased development, economic growth, and the spread of democracy (Thompson, 2015). Globalization, according to pessimist globalists, is a process of Western American imperialism. They argue Globalization serves as a mechanism for enforcing Western institutions and values on the rest of the world. 

With the globalization of ideas, goods, and resources, the term is often used in industry to refer to an interconnected economy categorised by free trade and unrestricted capital flows, while using external labour trades to boost income (Lutkevich, 2021). As diverse nations become more politically, culturally, and economically linked, the world becomes more globalized. Technological advancements, especially in transportation and telecommunications, enable and accelerate these cross-border interactions and dependencies (Lutkevich, 2021). As a result, globalization can be classified into three distinct phases. Economic globalization is the process of integrating and integrating international financial markets and multinational corporations with significant market influence. Political globalization is a concept that refers to policies that facilitate international trade and commerce. Additionally, it includes the organisations that carry out these strategies, including national governments and foreign organizations such as the International Monetary Fund (IMF) and the World Trade Organization (Economics Online, 2020). Globalization of culture focuses on the social forces that allow societies to mix, such as increased communication and transportation facilitated by technology. It is critical to keep in mind that each form has an impact on the others (Lutkevich, 2021). For instance, certain liberal trade policies, collectively referred to as political Globalization, promote economic Globalization. Cultural globalization is driven by policies implemented as part of political and economic globalization, such as trade and imports. Technological innovation is the unifying theme that runs across all three strands of Globalization. As discussed previously, technology plays a role in the acceleration of each form. 

Each form of globalization has implications that can be seen locally and globally and can be established in interactions at all levels of society, from the individual to society. Each country or region considers the effect of foreign influence on its ordinary people. At the community level, the effects on local or regional organisations, markets, and economies are included. Although the ramifications of globalization are obvious, assessing the net effect of globalization is a difficult job, as some globalization results are often regarded as positive by proponents and as negative by critics. Sometimes, a relationship that benefits one party can hurt another, and the debate continues about whether Globalization benefits the world. 

Global health (GH) has replaced international public health, and in different ways, both concepts are equally applicable. International public health centres themselves on applying public health principles to health problems and issues affecting LMICs, and the diverse set of global and local determinants that form them. GH focuses on many countries’ challenges and concerns and emphasizes transnational issues like climate change and urbanization (Merson, Black, and Mills, 2018). 

GH considers health issues deemed global relevance and magnitude, attracting interest funding and cooperation from the public sector and private sector actors. This would also include corporations, foundations, and NGOs. Determining whether a particular health issue is recognized as a global or international issue, and how the response is constructed or governed, is strongly influenced by the shifts in political and financial power distribution (Tarontala, Ferguson & Gruskin, 2012).  

GH recognizes that malnutrition, infectious diseases, environmental destruction, and global warming all pose threats to the planet. It acknowledges how pervasive inequality misrepresents the inequalities between the global North and South in terms of wellness, medical advances, and economic development (Benatar, 2009). Global North institutions, particularly those in North America and Europe, receive significantly more funding than those in the global South. However, having information to positively impact global health problems also encourages scholars to migrate from the global South’s less developed nations. This results in ‘brain drain,’ in which indigenous wisdom is diluted in order to strengthen the global North (Hunt, 2019).  This disparity in the number of professionals demands a shift in the number of individuals emigrating from less-developed countries. This enables countries that have lost competent people to wealthy nations to participate on an equal footing in resource sharing (Hunt, 2019), resulting in a truly global approach to health. 

Health is not merely the absence of illness or the absence of symptoms. A state of complete physical, emotional, and social well-being is described as health. Health is not only physical; it is also psychological and social. Our social relationships can have a profound effect on an individual’s health and the health of a family, a group, or a society. GH is concerned with international health concerns. In other words, it is not only concerned with health problems within a specific country, but also with global issues. Numerous infectious diseases, for example, do not require passports. They fly easily between countries. 

Covid 19 is a recent example of this. Additionally, many health problems that would be classified as NCDs affect a substantial percentage of the world’s population. Thus, the definition of GH is synonymous with collaboration and trade. In other words, as a global phenomenon, GH can only be strengthened by cooperation and knowledge exchange between not only societies and communities within countries, but also between countries. Additionally, this partnership and trade must be global in scope. 

Increasingly in GH over the last few decades, both developed and developing countries can provide valuable lessons and guidance about how to manage health issues. The principle of GH is a combination of two distinct principles. The first is the philosophy of public health, which emphasizes population-based interventions and solutions that could be most effective for a given situation. At other times, offering individual treatment may be just as necessary, if not more so. Taking both and using them as required is one of GH’s defining characteristics, as it strives to be adaptable in addressing and resolving health issues. Now, numerous functions within GH tend to perform, or attempt to perform. One is to track and assess the global health status and health conditions. By collecting data, we hope to educate, inform, and empower nations, societies, and individuals. To establish mechanisms conducive to improved health and to concentrate on establishing and mobilizing partnerships. Both with governments or non-governmental organisations, human rights and the right to health care are well-established in the majority of countries (Tarontala, Ferguson & Gruskin, 2012). 

GH is a significant security hazard. Unhealthy populations, where illness can ravage groups, can breed political instability (Fox, Feng, and Asal, 2019; Shanmugam, 2020). Globalization is also dependent on GH. We are increasingly living in a globalized world. Where people cross borders easily, economics is now changing between countries. Certain countries prosper, while others do not. All becomes global, including health and disease. 

Additionally, as the world becomes more globalized, it is important for countries to view health as a global phenomenon, rather than a national one. A population with significant illness cannot grow economically as rapidly as other populations. As is frequently the case, improving one’s health will aid in growth. 

 Evaluate the theories of Globalisation, which help explain its impact. 

The term “globalization” has been misused and overused, according to Lee and Collin (2010). Lee and Collin (2010) describe globalization as three distinct forms of changes that have occurred at a rapid pace over the last few decades. They suggest explaining globalization. There are three dimensions of global change – spatial change, temporal changes, and cognitive changes. Globalization influences how physical or territorial space is perceived or experienced by spatial changes. It is how time is experienced or perceived with temporal changes, while cognitive changes are how people regard themselves and the world (Lee, 2004). 

Since there are various ideas and arguments on Globalization, three main theoretical perspectives from prominent scholars will be discussed that contribute to globalization literature. These include World Systems Theory, Solid Modernity, and Liquid Modernity. According to Wallerstein, the world-systems theory is characterized by an international division of labour comprised of a hierarchical set of relationships between three distinct types of capitalist zones (Thompson, 2015a). The core or developing countries have a monopoly on the supply of consumer products and regulate global wages. Countries like South Africa and Brazil are in the semi-peripheral region, which has urban centres that resemble the core, but still has rural poverty that resembles the peripheral countries. These are the countries that will receive the core contracts. Countries at the bottom of the food chain, for example, Africa, provide raw materials such as cash crops to the centre and semi-periphery. Additionally, the developing markets are where the core intends to sell their manufactured goods. 

 The Modern World-System is intricate, with core countries constantly devising new ways to profit from developed countries and regions. Wallerstein may also be chastised because underdevelopment is caused by various factors other than capitalism. Cultural influences, corruption, and ethnic strife are other examples. Wallerstein places much too much focus on economics and capitalism’s supremacy. People may also be abused and oppressed in other ways, including by tyrannical religious regimes. Some regions remain outside of the World System, including some indigenous groups in South America, who are relatively untouched by global capitalism. Finally, Wallerstein’s conceptions of the Core, Semi-Periphery, and Periphery are ambiguous, making it difficult to assess his theory in practice (Thompson, 2015b). 

The emergence of two main factors characterizes a social imaginary: mass migration and electronic mediation. Appadurai explains that global interactions between culture, economy, and politics have led to certain profound disjunctions between culture, economy, and policy. He describes how modernity impacts daily life and the significance of innovating as a social practice. Ethnoscapes, mediascapes, technoscapes, finanscapes, and ideoscapes comprise a unique group of five global flows of cultural imagination. To better understand this global concept, Ethnoscape considers it through culture and borders. Technoscapes also incorporate new exchanges and experiences that result from technological advances. Finance is connected to the economy and to the competitive nature of the economy, which is highly unpredictable. Mediacircumstance and informationscape relate to the development and distribution of information through the internet and media sources. 

The works of Ulrik Beck are considered the beginning of “risk society.” He discusses the political, economic, and social causes and effects of Globalization. This conceptual framework incorporates three interrelated elements: risk, individualization, and reflexive modernization. Beck identifies a process propelled by an increase in risks and science’s capacity to detect increasingly minute risks. He would suggest this contributes to a shift in social roles in society and a change in risk’s cultural definitions. The key argument is that the distribution of wealth results in the amount of risk. Social factors produce societal risks that threaten humankind’s survival. Leading institutions, including economic, political, legal, and administrative, generate certain risks and determine the resulting risks non-existent in society’s eyes (Beck, 1992). Beck speculated that those who stray from tradition face danger as a result of modern life’s globalization, such as those who move from rural to urban areas. Unpredictable results become the primary catalyst of social change in this danger society. Global economic growth would entice the poor to more affluent urban areas, despite the possibility of negative consequences (Beck, 1992). India faces challenges in combating poor public health among those who live in and migrate to megacities from rural areas, owing to the country’s dense and high population density. They live in filthy conditions in Mumbai, which is home to nearly half of the population. Families who bathe, brush their teeth, and wash their clothes in excrement-filled rivers are at the epi-centre of these unsanitary conditions, which provide an ideal environment for the spread of cholera (Hamner et al., 2006). These deplorable living conditions, as well as the risk of contracting cholera, are significant risks associated with slum living. 

Critique the theories of Globalisation that you use. 

The Network Society is the name given to the critical theory of Globalization that Manuel Castell has advanced. Globalization refers to a transition from a post-industrial society to an information society. Globalization, he explained, is the new basis of modern production and social organization through knowledge. Manuel Castell’s rise of the network society demonstrates how Globalization takes a technological approach. Although his theory employs a similar approach to analysing the capitalist system and its dynamics in the world-system and global capitalism, it is the logic of technological revolution, rather than capitalist growth, that is shown to enforce fundamental causal determination on the plethora of data obtained through Globalization. 

Multinational corporations are a clear example of Globalization. The word “multinational corporation” essentially refers to a company that operates in many countries. McDonald’s, for example, is a global fast-food company. McDonald’s’ global presence is understandable as a global brand, operating in over 100 countries and serving nearly 70 million customers daily. It employs over 2 million people and produced more than $22 billion in revenue yearly (Racoma, 2019). Owing to their widespread presence and effect on social and economic development in the countries in which they operate, multinational corporations such as McDonald’s are representation of Globalization’s contradictions. 

On the one side, multinational corporations would invest in indigenous people and facilities in order to create jobs, skills, and stability in the communities where they work. However, multinational companies, comparatively, can kill small industries, exploit cheap labour in developing countries, and disrupt cultural diversity. Although they provide benefits to the communities in which they work, they are often unsustainable. The corporation’s sole allegiance is to its bottom line, not the community through which it has incorporated itself. 

Offer specific case studies of globalisations impact on global health problems, both positive and negative. 

Communicable and non-communicable diseases account for a significant portion of global mortality. Heart disease, cancer, obesity, and respiratory problems account for roughly seven out of ten deaths worldwide. Eighty-two percent of premature deaths occur in low- and middle-income countries (LMICs) (WHO, 2019). These statistics have risen due to four main risk factors: tobacco use, excessive alcohol use, sedentary lifestyles, and unhealthy diets (WHO, 2019). 

Three significant inventions led to tobacco’s popularity during the nineteenth century. A method has been discovered for manufacturing cigarettes that are lighter and more pleasurable to smoke. The invention of safety matches greatly improved the ease of smoking. The first cigarette processing machine was invented, resulting in a major reduction in cigarette production (Bach, 2007). Around a billion tobacco users live in developing countries, out of a total global population of 1.22 billion (Yach and Bettcher, 2000). The US’s global hegemony has influenced marketing campaigns in low- and middle-income countries (LMICs), where the highest proportion of people die from cardiovascular and lung diseases. (2008) (World Health Organization). The marketing campaign targets women by capitalizing on the non-Western world’s view of Western society’s democratic, glamorous, and sophisticated picture. Weight loss and beauty are portrayed in a misleading manner in order to appeal to women’s interests and desires. This portrayal of Western culture has an impact on those living in LMICs. This then has an impact on the global increase of non-communicable diseases, resulting in a mode of Globalisation in which the tobacco industry’s Globalisation coexists with the smoking populations of their respective countries (Yach and Bettcher, 2000). 

Obesity is a condition that can be prevented in large part by changing one’s diet and adopting healthy lifestyle habits. Obesity, however, is a risk factor for many NCDs and is related to increased morbidity and mortality (Nishida, Borghi, Branca & De Onis, no date). Prevalence rates have continued to rise across the world, affecting every country regardless of socioeconomic status, culture, or race (Antipatis & Gill, 2001). The rate has tripled since the late 1990s (Wolfenden et al., 2019). According to statistics, obesity-related diseases result in 3 million deaths and merely under 36 million disability-adjusted life years per year. The WHO’s recently appointed Director-General has often mentioned obesity as a significant new global epidemic. Even though she expressly stated industry caused the outbreak, only a few attempts to fix the problem have been made so far. Obesity was once considered a fringe interest in most major medical societies. It was only in the last two decades it became a commonly accepted medical issue in clinical practice. Governments’ interests in public health are restricted unless driven by decades of solid lobbying and overwhelming medical evidence, including the dangers of smoking or potentially dangerous diseases like SARS or Ebola. Nevertheless, it has been proposed that no healthcare system in the world will cope with the full impact of the immense cost of care incurred due to obesity and its complications (James, 2018). 

The obesity epidemic has been linked to mechanisms of globalization that encourage obesity by overwhelming low-income country economies with affordable, obesity – promoting products and distributing Western-style fast food chains (dependency/world system’s theory). Domestic factors such as the increasing consumption of processed foods in reaction to economic production and greater opportunities for women as economies develop (the “modernization” theory) are possible explanations (Fox, Feng, and Asal, 2019). Globalization, or the unrestricted flow of information, technology, culture, and capital between countries, has been both a beneficial and detrimental force, especially in the realm of health. Globalization has aided in the emancipation of thousands of people from severe poverty, reduced hunger and infectious disease, and improved people’s overall quality of life. The problem is that the same economic and social changes that improved peoples and countries wealth have actually expanded their waistlines too, leading to developing countries’ global obesity epidemic. 

Numerous LMICs grapple with the so-called “dual burden” of obesity and malnutrition; however, while malnutrition continues in many countries, obesity has surpassed underweight in prevalence. Currently, there are more people are obese on a global scale, owing largely to globalization. It has developed McDonald’s franchises in cities such as Mumbai. As a result, the “nutrition revolution,” a term that refers to the obesity-causing transition away from conventional diets toward Western ones brought on by modernization and wealth, has been accelerated (Boston and Ma, 2012). 

The transition, which has been exacerbated by the global obesity epidemic and nutrition relation illnesses, is ingrained in globalization processes. It alters the fundamental characteristics of agricultural and food structures, by varying the accessibility, price, and attractiveness of foods on the market (Hawkes, 2006). 

Conclusion 

Globalisation, therefore, has progressed in synch with the fruition of social cultures. Nonetheless, the existing globalization process is unprecedented in terms of its pace and depth of change. To label globalization as “beneficial” or “disadvantageous” for health would be oversimplistic and inaccurate. For example, global migration is increasing as a result of spatial change (Lee, 2004). The debate about globalization and health in high-income countries is often presented around the risk of transmitting severe and infectious diseases like SARS and more recently, Covid 19. Additionally, developed countries fear the financial burden associated with the influx of obese people from developing countries. The threats that high-income economies can distribute to other parts of the globe through goods like cigarettes and processed food, as well as macroeconomic policies that influence foreign direct investment and debt levels, are less well-known. Furthermore, there is a tendency to overlook the benefits of migration flows for high-income countries. For example, the distribution of health workers from poorer nations helps under-resourced healthcare systems in high-income countries, sometimes at the expense of developing-world capacity. To put it another way, increased movement of people and goods leads to a complex calculation of benefits and costs for each group. 

Equally, temporal variation influences disease/illness transmission. Owing to the rapidity with which modern transportation networks run, pathogens have the ability to spread worldwide in a matter of hours (as illustrated by the SARS outbreak). By contrast, advanced technology allows the health system to respond to such emergencies more efficiently (Lee, 2004; Hunt, 2019). For instance, an international system of institutions organized by the WHO and connected through international infrastructures is capable of rapidly detecting and reacting to influenza virus changes. 

Finally, Western publicity and advancements have assisted in the expansion of knowledge of so-called “lifestyle” diseases (e.g., obesity) within specific populations within LMICs. Since it comprises of the global transfer of policies regulating the provision and financing of health services, the expansion of health sector restructuring can also be considered a process of cognitive globalisation. Thus, national health systems are tasked with the responsibility of sorting through and adapting these policies to local conditions. Additionally, global recognition results in an increase in the sharing of health care principles, ethical values, and standards (Lee and Collin, 2016; Lee, 2004). 

Along with individual change, global health laws must be changed. In the year after the introduction of the smoking ban, the UK saw nearly a 3% drop in hospital stays for people with cardiac ailments. It also saw a 93 percent decrease in air pollution levels in public buildings in the twelve months following the smoking ban in 2007. The smoking ban showed that policy changes can improve society’s health, and similar results are needed for LMICs to improve theirs. To assist in this endeavour, the NCD Alliance was founded by over 2,000 non-governmental organizations and charities to raise cardiovascular diseases to a public health priority (Yach and Bettcher, 2000; BauLd, 2011). 

Castell’s network society concept exemplifies how IGOs and NGOs will work cooperatively to reduce NCDs in epidemic-prone countries. The UN’s efforts to combat poverty through the Millennium Development Goals reflect how globalisation has brought nations together to ensure that everybody has access to knowledge about global events. This encourages non-governmental organizations to campaign on behalf of the health and rights of the entire world’s population. To be deemed a globalisation success, the earth must be treated as a single entity, with all governments, global North or South, cooperating holistically to improve the lives of the world’s most oppressed people. 

References

Antipatis, V. J. and Gill, T. P. (no date) ‘Obesity as a Global Problem’, INTERNATIONAL TEXTBOOK OF OBESITY, p. 21. 

BauLd, P. L. (2011) ‘Impact of smokefree legislation in England: Evidence review’, p. 23. 

Beck, U. (1992) ‘From Industrial Society to the Risk Society: Questions of Survival, Social Structure and Ecological Enlightenment’, Theory, Culture & Society, 9(1), pp. 97–123. doi: 10.1177/026327692009001006. 

Benatar, S. (2009) Global Health: Where to Now? – Global Health Governance, moam.info. Available at: https://moam.info/global-health-where-to-now-global-health-governance_59c38a2a1723ddd5d97c7758.html (Accessed: 2 May 2021). 

Boston, 677 Huntington Avenue and Ma 02115 +14951000 (2012) Globalization, Obesity Prevention Source. Available at: https://www.hsph.harvard.edu/obesity-prevention-source/obesity-causes/globalization-and-obesity/ (Accessed: 17 March 2021). 

Costa-Font, J. and Mas, N. (2016) ‘“Globesity”? The effects of globalization on obesity and caloric intake’, Food Policy, 64, pp. 121–132. doi: 10.1016/j.foodpol.2016.10.001. 

Economics Online (2020) ‘Globalisation – what are the key characteristics of globalisation? | Economics Online | Economics Online’, 27 January. Available at: https://www.economicsonline.co.uk/Global_economics/Globalisation_introduction.html (Accessed: 23 February 2021). 

Hamner, S. et al. (2006) ‘The role of water use patterns and sewage pollution in incidence of water-borne/enteric diseases along the Ganges river in Varanasi, India’, International Journal of Environmental Health Research, 16(2), pp. 113–132. doi: 10.1080/09603120500538226. 

Hawkes, C. (2006) ‘Uneven dietary development: linking the policies and processes of globalization with the nutrition transition, obesity and diet-related chronic diseases’, Globalization and Health, 2, p. 4. doi: 10.1186/1744-8603-2-4. 

Hunt, C. (2019) ‘Globalisation is Both the Cause and the Cure of Global Health Problems. Critically Evaluate this Claim’, Social Sciences Blog, 12 July. Available at: https://sunderlandsocialsciences.wordpress.com/2019/07/12/globalisation-is-both-the-cause-and-the-cure-of-global-health-problems-critically-evaluate-this-claim/ (Accessed: 2 May 2021). 

IInfed (2017) ‘Globalization: theory and experience – infed.org’: Available at: https://infed.org/mobi/globalization-theory-and-experience/ (Accessed: 23 February 2021). 

James, W. P. T. (2018) ‘Obesity: A Global Public Health Challenge’, Clinical Chemistry, 64(1), pp. 24–29. doi: 10.1373/clinchem.2017.273052. 

Lee, K. (2004) ‘Globalisation: what is it and how does it affect health?’, The Medical Journal of Australia, 180(4), pp. 156–158. doi: 10.5694/j.1326-5377.2004.tb05855.x. 

Mir, U. R., Majeed Qadri, and Syeda Mahnaz Hassan (2014) ‘Understanding Globalization and its Future: An Analysis’, p. 20. 

Racoma, B. (2019) How McDonald’s Adapts Around the World, Day Translations Blog. Available at: https://www.daytranslations.com/blog/how-mcdonalds-adapts-around-the-world/ (Accessed: 18 April 2021). 

Raine, K. D. (2012) ‘Obesity epidemics: inevitable outcome of globalization or preventable public health challenge?’, International Journal of Public Health, 57(1), pp. 35–36. doi: 10.1007/s00038-011-0322-0. 

Shanmugam, R. (2020) ‘What is Global Health and why it was important to us?’, Global Journal of Research and Review, 7(2). Available at: https://www.imedpub.com/abstract/what-is-global-health-and-why-it-was-important-to-us-33973.html (Accessed: 18 April 2021). 

Thompson, A. K. (2015) The Hyper-Globalist/ Optimist View of Globalization, ReviseSociology. Available at: https://revisesociology.com/2015/09/19/optimist-globalization-hyper-globalism-neoliberalism/ (Accessed: 9 March 2021). 

Thompson, A. K. (2015) The Pessimist View of Globalization, ReviseSociology. Available at: https://revisesociology.com/2015/09/21/pessimist-view-globalization/ (Accessed: 9 March 2021). 

Thompson, A. K. (2015) The Transformationalist View of Globalization, ReviseSociology. Available at: https://revisesociology.com/2015/09/24/transformationalist-globalization/ (Accessed: 9 March 2021). 

Upali, P. (2017) ‘An Introduction to the Theoretical Perspectives of Globalisation’, p. 18. 

WHO (2021) Non communicable diseases. Available at: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases (Accessed: 2 May 2021). 

Yach, D. and Bettcher, D. (2000) ‘Globalisation of tobacco industry influence and new global responses’, Tobacco Control, 9(2), pp. 206–216. doi: 10.1136/tc.9.2.206. 

Mental Health – Male Suicide in Ireland

​Issue: Male suicide in Ireland

Suicide is a substantial cause of mortality in Ireland and Mental health disorders are the highest risk factor for suicide in Ireland (Department of Public Health, 2001). In Ireland 80% of suicides are committed by men (Ryan, 2018) and  are less likely to attend mental health services (Department of Public Health, 2001). Can the stigma of men accessing mental health support as a cultural behaviour issue (O’Donnell & Richardson, 2018) and economic crisis causing male unemployment (McGuill, 2016), be the causes for this phenomenon or does current policy lack gender sensitive and wider social determinants of health (O’Donnell & Richardson, 2018)? ​

Background

Several Acts relating to Mental Health Legislation were implemented in Ireland in the nineteen centuries however it was not until 1945 that an important change in the delivery and development of psychiatric services was introduced in Ireland with The Mental Treatment Act of 1945 (Kelly, 2008). In 1971 the Health Care Board took over responsibility from the Local Health Authorities and developed a Community Care programme and mental health services began to implement changes in line with the policy document “Planning for the Future” (Community Health Organizations, 2014). Recognition of mentally ill patients was established in 1991 by the United Nations and The Human Rights Act (Kelly, 2008).  In the mid to late 1990’s an important change surged with the formation of the National Task Force on Suicide which resulted in an interdisciplinary communication system between General Practitioners and Primary Care Teams with Volunteer Organizations (Mugtaba, Parnell, & Haley, 2016). A new piece of Legislation was established in Ireland in 2001, the Mental Health Act 2001, although this Act was only fully implemented in 2006 (Zahid & Mansoor, 2012). ​

Since 2001 Ireland has witnessed the male suicide rate being in average four times higher than female suicide (National Suicide Research Foundation, 2020) and on examination of data provided it was determined that rural areas with common levels of religious celebration have higher levels of suicide (Cleary, 2005). Social and cultural expectations of masculinity through times have played a negative role on the well-being of Irish Men as well as expected male behaviour patterns like alcohol and drug abuse, coping mechanisms and risky behaviour (Garcia, 2016). Alcohol abuse has been a significant risk factor for suicide in Ireland (Department of Health, 2001).  Additionally, men disclosing difficulties and struggles to others were perceived as weak and associated with feminine or homosexual type behaviour (Cleary, 2005).​

The History of Suicide in Ireland is long charged with the taboo stigma of religious beliefs in conjunction with Criminal Law (Hanna, 1997). Suicide was decriminalized in Ireland in June of 1993 with the Introduction of the Criminal Law (Suicide) Act, 1993 (Mugtaba, Parnell & Haley, 2016) however, the role on taboo around suicide continue to be played by the Church (McGarry, 2016). Unemployment amongst men has been identified as another risk factor of suicide and during the Celtic Tiger, a period of economic boom (1996-2006) although suicide rates were stable, suicide amongst unemployed men raised (Corcoran & Arensman, 2010). Irish Society has always viewed men as bread winners or carers to their partners or children and these expectations continue to be cultural issues to the well-being of men (Garcia, 2016). In 2001, a published study on Suicide in Ireland concluded that Mental Health disorders remained the highest factor for suicide in Ireland and even though suicide in men is five times higher than in women, men are less likely than women to have attended mental health services (Department of Public Health, 2001). ​

Current Status

Irish Government current policy ‘Sharing the Vision – a Mental Health Policy for Everyone’ is an upgrade to ‘A Vision for change’ policy and aims to prioritize mental health in Ireland and to focus on primary intervention and positive mental health for everyone (Department of Health, 2020). In response to the promotion of mental health, the Government created in recent years, “Connecting for Life – Ireland National Strategy to Reduce Suicide 2015-2020” which is now prolonged until 2024 (Department of Health, 2020) and identifies men as being amongst the highest at-risk cohorts with evidence of vulnerability and at increased risk of suicidal behaviour (HSE, 2018). Last year the HSE also devised a review and proposal “Integrating Suicide Prevention into policy- making” (HSE,2020). Another welcome addition to this strategy is the development of a national free training plan on suicide awareness and prevention for local authorities and frontline staff (ASIST – Applied Suicide Intervention Skills Training), and SAFE TALK which is a basic free suicide prevention training programme available to everyone (HSE, 2021). ​

Despite the upgrades of Irish policies regarding suicide, currently there is still limited progress on implementation of previous set goals (Mental Health Reform, 2020). Staffing goals from previous policy ‘A Vision for Change’ only reached 78% of recommended mental health staffing and  today there are fewer staff working in mental health  than in 2008 (MHR, 2020). It has also been identified that early intervention is essential to prevent suicide despite this, 33% of people are waiting over a year for a primary care psychological appointment (MHR, 2020). Access to these services can only be granted through a referral by the patient’s GP and are not available in all centres neither some of the counties have an emergency care psychological service available (HSE, 2020). ​

Current policy has limitations on current data systems on suicide in Ireland and fails to provide broader characteristics on people who died by suicide despite World Health Organization (WHO) recommendations that Governments should provide real time data, which is essential to national suicide prevention strategies to accurately identify cohorts and risk factors to suicide and self-harm (HSE, 2019). Ireland’s National strategy to reduce suicide also presents limited progress on many of its goals since it was first implemented in 2015 (HSE, 2019) and lacks gender sensitivity and wider social determinants of health (O’Donnell & Richardson, 2018). Irish mental health policy does not categorically deal with gender (Bergin, Wells & Owen, 2013) although WHO recommendations alert for a gender sensitivity within policy development and health services and it considers gender a paramount determinant of mental health and mental illness (WHO, 2004).​

Currently, there are also several  volunteer services available such as a 24hour helpline provided by the Samaritans (Mental Health Ireland.ie, 2021), and counselling services provided by Pieta House who are Volunteer Organizations and rely on public donations.

Key Considerations

Irish Government current policy ‘Sharing the Vision – a Mental Health Policy for Everyone’ has allocated a budget of €38 M for the implementation of new mental health services (gov.ie, 2020), however it was recommended that to develop the new mental health services it would be necessary at least €50 M (Mental Health Reform, 2020). The budget is strongly criticised by the Psychiatric Nurses Association (PNA) and deemed inadequate to meet growing service demand (PNA.ie, 2020). The budget has a direct impact on mental health services availability and provision. Current policy is strongly criticized by the Irish Hospital Consultants Association (IHCA) who argue that this policy fails to address critical staffing shortages in mental health. IHCA also argue that the funding allocated to Mental Health is insufficient and therefore it will not be possible to reduce long waiting lists for access to mental health services or to provide quality care to mental health patients (IHCA, 2020). Statistics show that of all males that have committed suicide only 20% received out-patient psychiatric treatment and less than 15% received in-patient psychiatric treatment (National Suicide Research Foundation, 2020).​

Social Justice Ireland (2019) argues that to provide good mental health services it necessary to consider the connection between ill health and issues regarding social determinants of health such as housing, employment, education, etc., however this is not being met. Rates of unemployment are associated with mental health decline and rise of suicide rates in men (O’Donnell & Richardson, 2018). There is  evidence that employment is positive for mental health, however, in current Irish policies, very little has been fulfilled relating to unemployment among people with mental health issues  and, there is also a lack of early intervention in assisting people who develop mental health problems with their vocational and employment needs (Mental Health Reform, 2012).​

To tackle the suicide issue in Ireland it is essential to understand suicidal behaviour and focus on priority groups such as men who currently present much higher rates of suicide. Despite this, limited progress has been made in relation to the collection on baseline data on suicidal behaviour. Although it would be more difficult and costly to carry surveys focused on priority groups, it would be a major contribution on understanding suicidal behaviour, as suggested by Professor Steve Plat and could provide an important impact in shaping focused policies and adequate and relevant resources. In addition, available accurate and timely data on suicide would allow the provision of national and local responses to the changing epidemiology and characteristics of suicidal behaviour in Ireland (HSE, 2019). ​

Conclusion/Recommendations

• Alongside outdated Mental health policy (Mental Health Reform, 2021), staffing deficits within psychiatric services, lengthy waiting lists for mental health services and the percentage of funding allocated to mental services dropping, the Mental Health System in Ireland is at crisis (Press association, 2021). ​
• To successfully tackle the male suicide issue in Ireland it is foremost necessary to understand its causes and to address them to successfully implement a relevant and efficient policy and adequate preventative and response services. This can only be achieved with a significant increase of budget allocated for mental health services, focused research and implementation of educational programmes as well as addressing the issues surrounding the various social determinants of health.​

References

• Bergin, M., Wells, J.S. G. & Owen, S. (2013) ‘Towards a gendered perspective for Irish mental health policy and service provision’, Journal of Mental Health, Vol. 22, Issue 4, p350-360. Available from: 10.3109/09638237.2012.714513 Accessed on [21/03/2021]​
• Cleary, A. (2005) ‘Death rather than disclosure: struggling to be a man’, Irish Journal of Sociology, vol. 14 Issue 2, p155-176. Available from:10.1177/079160350501400209 Accessed on [17/04/2012]​
• Community Health Organizations (CHO) Report (2014), HSE.ie [online] Available from: https://www.hse.ie/eng/services/publications/corporate/cho-chapter-3.pdf Accessed on [08/03/2021]​
• Corcoran, P. & Arensman, E. (2010) ‘Suicide and employment status during Ireland’s Celtic Tiger economy’, European Journal of Public Health, Volume 21, Issue 2, April 2011, Pages 209–214 Available from: https://doi.org/10.1093/eurpub/ckp236 Accessed on [11/04/2021]​
• Department of Health (2020) Sharing the Vision: A mental health policy for everyone (2020) [0nline] Available from: https://www.gov.ie/en/press-release/3a39c-minister-for-health-and-minister-for-mental-health-extend-national-suicide-reduction-strategy-to-2024/ Accessed on [21/03/2021]​
• Department of Health (2020) Sharing the Vision: A mental health policy for everyone (2020) [0nline] Available from: https://www.gov.ie/en/press-release/3a39c-minister-for-health-and-minister-for-mental-health-extend-national-suicide-reduction-strategy-to-2024/ Accessed on [14/03/2021]​
• Departments of Public Health on Behalf of the Chief Executive Officers of the Health Board (2001) ‘Suicide in Ireland, A National Study’ [online] Available from: https://www.drugsandalcohol.ie/5723/1/Suicide_in_Ireland.pdf Accessed on [14/03/2021]​
• Garcia, F. (2016) ‘Coping and suicide amongst the lads: expectations of masculinity in post-traditional Ireland. Basingstoke, Hampshire: Palgrave Macmillan. Available from: https://ebookcentral.proquest.com/lib/sunderland/detail.action?docID=4716435  Accessed on [13/04/2021]​
• Hanna, J. (1997) “Long Shadow of Suicide”, The Irish Times[online]. Available from: https://www.irishtimes.com/culture/long-shadow-of-suicide-1.45898 Accessed on [13/03/2021]​
• HSE (2019) Report of the Research Advisory Group for the National Framework for Suicide Prevention Strategy (2019) [online],  Available from:  https://www.hse.ie/eng/services/list/4/mental-health-services/connecting-for-life/publications/cfl-interim-strategy-review.pdf Accessed on [14/03/2021]​
• HSE (2020) Integrating suicide prevention into policy-making [online] Available from: https://www.hse.ie/eng/services/list/4/mental-health-services/connecting-for-life/publications/suicide-prevention-and-policy-making.pdf Accessed on [08/03/2021]​
• HSE (2021) ASIST, Applied Suicide Prevention Skills Training [online] Available from: https://www.hse.ie/eng/services/list/4/mental-health-services/connecting-for-life/training/types-of-training/asist.pdf Accessed on [21/03/2021]​
• Irish Hospital Consultants Association (2020) ‘New mental health policy fails to address critical staffing deficits, says IHCA’ [online], Available from :https://www.ihca.ie/news-and-publications/new-mental-health-policy-fails-to-address-critical-staffing-deficits-says-ihca#:~:text=The%20IHCA%20has%20warned%20that,in%20the%20acute%20psychiatric%20services Accessed on [21/03/2021]​
• Kelly, B. D. (2008)’ The Mental Treatment Act 1945 in Ireland: an historical enquiry’, History of Psychiatry Vol.19(73 Pt 1):47-7.  Available from:10.1177/0957154X06075949 Accessed on [21/03/2021]​
• MacGuill, D. (2016) ‘Fact Check; You asked, we answered – suicide, austerity, and the Troubles [online] The Journal.ie. Available from: https://www.thejournal.ie/suicide-austerity-troubles-ireland-tim-pat-coogan-3124487-Dec2016/ Accessed on [14/03/2021]​
• McGarry, P. (2016) ‘Church ‘contributed greatly’ to taboos on suicide – Martin’, The Irish Times [online]. Available from: https://www.irishtimes.com/news/social-affairs/religion-and-beliefs/church-contributed-greatly-to-taboos-on-suicide-martin-1.2501031 Accessed on [11/04/2021]​
• Mental Health Ireland (2021) Support [online], Available from: https://www.mentalhealthireland.ie/get-support/ Accessed on [17/04/2021]​
• Mental Health Reform (2012) Employment and Mental Health: A briefing paper [online] Available from:https://www.mentalhealthreform.ie/wp-content/uploads/2012/12/Employment-and-Mental-Health-Briefing-Paper.pdf Accessed on [14/03/2021]​
• Mental Health Reform (2020) Mental Health Budget Summary [online] Available from: https://www.mentalhealthreform.ie/wp-content/uploads/2020/09/Mental-Health-Budget-2020-Summary.pdf Accessed on [21/03/2021]​
• Mental Health Reform (2020) Mental Health Reform Pre-Budget Submission (2020) [online] Available from:https://www.mentalhealthreform.ie/wp-content/uploads/2020/08/Mental-Health-Reform-Pre-Budget-Submission-2021-Final.pdf Accessed on [21/03/2021]​
• Mugtaba, O., Parnell, A.C. & Haley, C. (2016) “Suicide shall cease to be a crime”: suicide and undetermined death trends 1970-200 before and after the decriminalization of suicide in Ireland 1993, Irish Journal Medical Science, vol 186, Issue 1, pages 201-205, Available from:10.1007/s11845-016-1468-9  Accessed on [08/03/2021]​
• National Suicide Research Foundation (2020) ‘Suicide’ [online]. Available from:https://www.nsrf.ie/statistics/suicide/  Accessed on [21/03/2021]​
• O’Donnel, S. & Richardson, N. (2018) Middle-Aged men and suicide in Ireland [online] Men’s Health Forum in Ireland. Available from: https://www.hse.ie/eng/services/publications/mentalhealth/middle-aged-men-and-suicide-in-ireland-executive-summary.pdf Accessed on [08/03/2021]​
• Press Association (2021) “More than 8,500 young people on waiting list for primary care psychological services, Dáil hears” [online] The Journal.ie. Available from: https://www.thejournal.ie/dail-mental-health-5345171-Feb2021/ Accessed on [08/03/2021]​
• Psychiatric Nurses Association of Ireland (PNA.ie) (2020) ‘Budget allocations for mental health totally inadequate to fund mental health strategy and meet growing demands for services’  [online], Available from:https://www.pna.ie/index.php/news/press-and-media-information/1172-budget-allocation-for-mental-health-totally-inadequate-to-fund-mental-health-strategy-and-meet-growing-demand-for-services Accessed on [17/04/2021]​
• Ryan, O. (2018) “Men account for eight in 10 suicides in Ireland” [online] The Journal.ie. Available from: https://www.thejournal.ie/suicide-rates-ireland-4267893-Oct2018/ Accessed on [08/03/2021]​
• Social Justice Ireland (2019) Providing good mental health services is a necessary investment in the future [online], Available from: https://www.socialjustice.ie/content/policy-issues/providing-good-mental-health-services-necessary-investment-future Accessed on [13/03/2021]​
• World Health Organization (2004) The world health report 2004 – changing history [online], Available from: https://www.who.int/whr/2004/en/ Accessed on [21/03/2021]​
• Zahid, l. & Mansoor, A. M. (2012) Mental Health Legislation in Ireland: A Lot done, More to do, Journal of the American Academy of Psychiatry and the Law Online, Vol.40 Issue 2, p266-269 Available from: http://jaapl.org/content/40/2/266 Accessed on [21/03/2021]​