Social Determinants of Depression

Introduction

Mental health gained momentum only several decades ago when people identified the link between individuals’ mental wellbeing and their functioning in the community, as well as the overall performance of the society as a whole (Richter et al., 2019; Silva et al., 2016). It has been acknowledged that the provision of mental health services to underprivileged people is seen as an important ground for addressing social disparities, especially those related to the life in rural areas (Fernández-Niño et al., 2019). People’s perspectives regarding their mental health and their access to the corresponding services have undergone considerable changes, as people of color acknowledge the existing disparity and some of the potential outcomes of such a situation (Holley et al., 2016; Villatoro et al., 2018; Wilson et al., 2018). The most recent research on the factors causing inequity in access to mental health care and its outcomes is mainly associated with social aspects (Creedon & Cook, 2016; Derr , 2016; Stepanikova & Oates, 2017).

The primary elements of people’s social life that have the strongest impact on their access to health care are seen as income and education (Assari, 2017; Barr, 2019). Income is regarded as the central factor restricting people’s access to mental health services although this type of care has been included in diverse insurance packages available to the underprivileged population (Creedon & Cook, 2016). Low-income families still have limited knowledge regarding the services available to them, as well as access to training regarding the relevance of their mental health (Memon et al., 2016). Education is closely related to the financial aspect as people with a low level of education tend to have a low income and insufficient understanding of the ways mental health affects their lives (Hall, 2018). Considerably less attention has been paid to such social factors as ethnicity and age. Researchers tend to consider these components in conjunction with the factors mentioned above, income or education, as well as a combination of these two factors. Moreover, age-related research is often confined to the child and adolescent development (Cuijpers et al., 2019; Hodgkinson et al., 2017; Platell et al., 2017).

Since the focus has been mainly on social aspects contributing to the existing disparities, the corresponding theoretical frameworks have been used (Detels et al., 2017; Barr, 2019). The social class theory has been utilized to explore the nature and consequences of the existing inequity in Americans’ access to mental health care (Detels et al., 2017; Barr, 2019). This approach is natural and has enabled researchers to identify the exact relationship between people’s income and education and access to healthcare services (Barr, 2019). Nevertheless, other factors may be influential as well since people’s age or ethnicity are important aspects to consider when analyzing individuals’ behavior (Assari, 2017; Hodgkinson et al., 2017; Platell et al., 2017). These four aspects can be seen as major social factors influencing people’s choices and perspectives, including their perceived barriers to mental healthcare services (Hodgkinson et al., 2017; Platell et al., 2017). Age is a factor that can expand the scope of social class research due to the developmental peculiarities of people at different stages of their lives, which is associated with different worldviews, access to resources, and health conditions. The social class theory may be further developed to encompass these relevant elements.

By examining the relation between socioeconomic status and access to mental health services, the researcher may be able to understand how, in certain communities, the need to access mental health care can be promoted, which can help reduce the number of severe mental illnesses or adverse effects associated with mental illnesses that remain untreated for extensive periods. Hence, empirically, the exploration of this topic for a Ph.D. study can help determine the actual relationship between ethnicity, age, and decision to obtain mental health care. From a practical perspective, this study will help develop programs that target increasing the awareness about mental health problems. Theoretically, this study will extend the boundaries of the existing social class framework to include ethnicity and age as important factors.

Statement of the Problem

While the need to address mental health issues has been recognized as a public health concern, there remain significant gaps between the need for and treatment of mental disorders. Given the number of individuals who need mental health services but do not receive them, it is vital to identify the factors that contribute to mental health services’ underutilization. The study seeks to address the underutilization of mental services by low-income individuals focusing on age, ethnicity, income, and education as contributing factors. These low socioeconomic status (SES) groups include diverse racial and ethnic minorities, unemployed persons, and new immigrants (Villatoro et al., 2018). Globally, 50% of people with mental disorders receive no treatment. In developed countries, the percentage varies from 35 to 50% and 76 to 85% in low or middle-income countries. This trend is a clear indication that mental-related disorders are on the rise, and it is time that the concerned authorities spring into action to tame these numbers. According to Maura et al. (2017), factors indicated as the major contributors to the underutilization of mental services have become part of many people’s lives. The unemployment rate is high, people are afraid to speak about their mental conditions, and discrimination based on ethnicity and race has become widespread in the society and little is being done to address it.

There is little or no data on how SES has significantly affected people’s use of mental health services. The available statistics indicate the same, and if left unchecked, it may lead to mental health and socioeconomic deterioration of vulnerable groups. As such, the study will seek to explore how SES contributes to the underutilization of mental health services.

Purpose of the Study

The study purposes to logically and expliciltly identify how SES contributes to the underutilization of mental health services. It will incorporate a survey to determine the participants’ SES and their perceived access to psychological care. The data obtained will then be processed and analyzed to obtain the relationship between the variables.

The key independent variables to the study are income and education. Additional independent variables that may not be crucial to the study but will also be considered are race, ethnicity, and age. They will be discussed in relation to the dependent variables, which will be the perceived need for mental health assistance and access to such, using statistical software. A prospective study will be conducted among individuals of age 18 and over with mental disorders will be monitored for over 1.5 years. The study will be conducted in six towns scattered across the country. Participants will be recruited through sampling shortly after the report to MindCare has been approved. They will be asked to complete a fully structured questionnaire certified by the World Health Organization and the World Mental Health Survey Initiative.

Theoretical or Conceptual Framework

One of the key ways to understand the barriers that people face in accessing mental health services and why many opt to leave the treatment is to use Karl Marx’s social-class theory. The theory originates from a series of individual personal interests that relate to human struggle and social alienation. The study will apply the theory to analyze the relationship between SES and access to mental health services. Individual SES characteristics play a significant part in determining individual access to mental health services (Detels et al., 2017). Those with substantial income will receive the services regularly since they can afford it. Those with low income, on the other hand, may choose not to access quality care. These individuals will disregard the illness at its early stages due to a lack of funds and ignorance due to a lack of education. They recognize the seriousness of the illness when it has become dangerous. The disparity is further exacerbated by the need to earn money to treat the disorder that might be getting worse. As such, the primary factors that determine one’s SES status are their income and education, which govern one’s ability to recognize their problems and access care when necessary.

However, other factors can also contribute to one’s ability to address their issues via the healthcare system. One’s ethnicity can affect the effectiveness of their care upon accessing ethnic and racial communities being served to different extents through the medical system. The ethnicity of an individual may also affect an individual’s ability to access quality mental health services. Lack of support from governments by providing infrastructure and resources to the marginalized and minority communities serves to increase underutilization. These people may become ignorant of such services, and in some communities, they may even regard the mentally ill people as cursed or an outcast. Age also serves as a contributor to the rising number of underutilization of mental health services. The problem’s prevalence increases with age, and as such, this impedes an individual’s ability to earn income through work. As such, these four causes can affect one’s health through the differences in ways healthcare facilities treat them or their willingness to seek care. However, their effects are likely to be less significant than those based on cultural factors. Race can also be a factor in care access, with various SES because of efforts undertaken to serve these particular population segments.

This belief is reflected in the conceptual framework, which considers the relationship between SES, care access, and health outcomes. It is similar to the one proposed by Barr (2019), where one’s socioeconomic conditions directly influence their health outcomes, with access contributing to this relationship as a mediating variable through being affected by the former and being correlated with the latter. With that said, the study will also consider health a determinant of perceived access to reflect the effects of an increased need to access care and the associated costs lowering access. As the study focuses on the relationship between SES and access, it will not consider the indirect effects of access on health, as such a consideration would be out of the research scope.

The author believes the three additional independent variables to act as moderators, influencing the relationship between SES and access to care. People with the same socioeconomic conditions, but differences in these variables may exhibit different access levels. However, the author expects a majority of the differences to be relegated to the primary variables, which leads to the belief that people with low SES may be underserved in terms of access. The possibility warrants investigation, and, therefore, the author has decided to make it central to this study and obtain information that confirms or denies the idea. Quantitative research would help gain a preliminary picture of the situation, which can then be explored with a supplementary qualitative study if necessary. The research questions and hypotheses were formulated to clarify the matter and investigate different aspects of the relationship.

The social class theory provides understanding of the problem which is assessing how SES contributes to the underutilization of mental health services. The social class theory is appropriate for addressing the problem based on the fact that it incorporates all the factors that have been pointed to one deciding not to receive the mental health services. Low income, age, lack of eduction, and ethnic and racial discrimination define an individual’s SES and this is echoed by the social class theory. The theory extends to the study’s statement problem whereby it acknowledges that the problem is there, and thus, there is the need for the concerned authorities to strategize on ways that they can solve the problem. Thus, by doing so, the theory will help the study achieve its purposes of making sure that every individual with mental disorder has access to mental health services. The social class theory provides a lens by which to answer the research questions which ask what effects do SES have on perceived access to psychological care? The social class theory will support a response to the research questions by providing concrete pieces of evidence that will be helpful in the study.

Nature of the Study

Studies usually incorporate different forms of study methods to accomplish various objectives. Among these methods, there are the cross-sectional design, an observational study design method (Refiee et al., 2018). In this study design, the outcome and exposures in the study participants at measured by the investigator concurrently. The criteria of exclusion and inclusion are used in selecting participants in the study, after which assessing the outcomes and exposure is carried out. The study is largely used for population-based surveys and in assessing disease prevalence in clinic-based samples. The study is inexpensive and is usually conducted relatively faster since it can be done before planning a cohort study or a baseline in a cohort study. Quantitative study design, on the other hand, aims to establish the relationship between the dependent and independent variables in a population (Bloomfield & Fisher, 2019). The designs are either descriptive or experimental. Using a sample of hundreds or even thousands usually guarantees an accurate estimate of the relationship between variables in a descriptive study, and it is less likely to be biased.

The qualitative method offers the researcher an avenue to conduct a study based on quantities. It focuses on understanding human behavior from an informant’s perspective, whereby it does assume a dynamic and negotiated reality. It allows the researcher to collect data through participant observation easily and interviews, and the data is analyzed based on the themes from descriptions by informants. The quantitative method, on the other hand, offers the researchers facts about social phenomena. The method assumes a fixed and measurable reality on the concept being investigated since the data collection is done through measuring things. The statistical and numerical analysis of data offers the researcher an accurate outcome. Based on this study, a quantitative study design will be the best-suited design due to its accuracy, and it uses deductive reasoning that allows an individual to form a hypothesis, collect data, and use the collected data after the analysis is made and the conclusion shared.

There are four main types of quantitative research; quasi-experimental, correlational, experimental, and descriptive research. Correlational research attempts to establish the existing relationship between two or more variables using statistical data (Cox, 2019). The distributions of variables and data relationships are studied only and cannot be manipulated. Quasi-experimental research focuses on establishing cause-effect relationships among variables. In this research, an independent variable can be identified but cannot be manipulated by the experimenter. The effects of the independent variable on the dependent variable are usually measured. Descriptive research establishes an association between variables while experimental establishes causality, and it is usually regarded as true experimentation since it uses scientific methods to establish the cause-effect of a relationship among group variables(Cox, 2019). Of the four types of qualitative research, correlational research will be the best fit for my study since it allows one to determine between two or more variables using statistical data.

The present study seeks to gain insights from the selected demographic cohort at a specific point in time; hence, it is cross-sectional. Besides, it is fair to consider it observational as the author intends to measure the effect of a risk factor (socioeconomic status) without administering any intervention. There is no control or deliberation regarding who is and who is not exposed to the selected risk factor. The study’s scope is limited to communities residing in California (potentially, to only one town) and varying their socioeconomic status. The scope’s narrowness is explained by ensuring that participants discuss the same psychological facilities in their replies for further comparison.

Preferably, the sample will display sufficient diversity and include individuals from different socioeconomic classes and communities. The chosen inquiry method is a survey that determines participants’ socioeconomic status (SES) and their perceived access to mental health care. Administering this procedure will provide the author with quantitative data. That will help to understand the nature of the relationship between three variables – income and education (independent) and access to mental health care (dependent).

The type of statistical methodology used in the present study hinges upon key assumptions and limitations of the data. Indeed, its quality largely determines the validity and reliability of results. Tentatively, the research objectives may be achieved by using multiple linear regression due to the presence of two independent variables. However, the proposed statistical model might prove to be inapplicable. It may happen if the author will detect multicollinearity between independent variables, which is possible since income and education do correlate (Hall, 2018). Lastly, biases in data such as missing data points should not be overlooked. If the missingness appears systematic, particular care will need to be taken to improve the robustness of the analysis.

Research Questions

The below questions explore the relationship between SES and access to care, as well as health outcomes. They are the most important topics of inquiry for this study, though they are not necessarily the only ones.

• RQ1. What effect does one’s socioeconomic status have on their perceived access to psychological care?
• RQ2. What effect do one’s race, ethnicity, and age on the relationship between one’s SES and their mental health?

Hypotheses

The hypotheses establish the types of relationships that the author expects to find between the variables in the study. They are consistent with the theoretical and conceptual frameworks and outline the potential disparities, or lacks thereof, that may be found as a result of the data collection and analysis.

• H1₀. There is no relationship between a person’s income and their perceived access to mental healthcare.
• H1_a. People with a lower income will have worse perceived access to mental healthcare than those with a higher income.
• H2₀. There is no relationship between a person’s education level and their perceived access to mental healthcare.
• H2_a. People with a lower education level will have worse perceived access to mental healthcare than those with a higher level.
• H3₀. There is no relationship between a person’s income and long-term mental health outcomes.
• H3_a. People with a lowr income will have worse long-term mental health outcomes than those with higher income.
• H4₀. There is no relationship between a person’s education level and their long-term mental health outcomes.
• H4_a. People wih a lowr education level will have worse long-term mental health outcomes than those with a higher level.
• H5₀. People with current mental health concerns do not perceive their access to mental healthcare differently from people in similar circumstances who do not have any.
• H5_a. People with current mental health concerns possess a more negative perception of their access to mental healthcare than people in similar circumstances who do not have any.
• H6₀. People of different races in comparable socioeconomic circumstances have a similar perception of their access to mental healthcare.
• H6_a. People of different ethnicities in comparable socioeconomic circumstances have a different perception of their access to mental healthcare.
• H7₀. People of different ages in comparable socioeconomic circumstances have a similar perception of their access to mental healthcare.
• H7_a. People of older ages see their access to mental healthcare as worse than that of younger people in similar socioeconomic circumstances.

Significance of the Study

The selected research problem deserves the attention of practitioners and scholars alike due to several reasons. Firstly, the issue of unequal access to mental health care requires serious consideration at different levels, including local, state, and governmental. Without addressing the question properly, healthcare practitioners will not be able to help all those in need, which will inevitably lead to the deterioration of the problem. Research findings indicate that the mental health of individuals is gradually declining, which necessitates finding effective solutions (Richter et al., 2019). However, without providing all population groups with equal opportunities, society will not be able to cope with the emerging adverse trends in the mental health sphere. Meanwhile, according to Assari (2017), there exists a disproportional division of high-quality mental health care, depending on people’s socioeconomic and ethnic features. Since the present study aims at finding answers to the question of which socioeconomic factors have the greatest effect on people’s access to care, it is of high relevance and advances the guiding framework significantly.

Research on socioeconomic status and access to therapy will contribute to the field of research because the emphasis of this study is on social aspects within the scope of the factors resulting in disproportions in the framework of mental health care, on which the most recent related investigations are primarily focused (Creedon & Cook, 2016; Derr, 2016; Stepanikova & Oates, 2017). Another reason why the research will be of great use is that it will contribute to existing literature and provide ample material for further studies. Specifically, the ways older adults with low socioeconomic factors identify their mental health care needs will be singled out in the study. Having this information available, further research can focus on the methods of mitigating barriers to care access. Perhaps, scholars will be able to find links between socioeconomic factors (SES) and people’s likelihood to address specialists for help or remain silent about their issues. Furthermore, researchers will be able to compare health indicators of older adults with low high SES, older adults with other age groups, and, finally, people from different ethnic communities. Each of these studies will contribute to the enhancement of the nation’s mental health since by locating differences between population groups, it will be possible to search for solutions to the problems each of them might be having. Also, since the study will single out perceived barriers of ethnic minority groups to the use of psychotherapy, doctors and nurses will be able to predict and overcome them.

It is expected that dissertation findings will not only find solutions to existing social drawbacks in access to care but also offer ways of preventing the most typical problems, thereby minimizing the risks of developing mental issues in older adults from minority groups.

Definitions of Key Terms

Education. Education is defined as the process of learning as a result of which a student receives knowledge; educational centers, schools, colleges, and universities are traditionally considered the central tools for education (“Education,” 2020).

Family Well-Being. Family Well-Being refers to the overall sense of satisfaction of family members, defined by collective and individual behavior, in which the needs of both the individual and the family as a whole are realized (IHC, 2016).

Financial Security. The concept of Financial Security belongs to the category of a person’s subjective perception of their economic well-being, sufficient to finance their private life and achieve their goals (Cautero, 2019).

Holistic Care. Health care refers to the psychological care of patients that emphasizes the principles of humanism: taking into account their physical, behavioral, emotional, and spiritual aspects (Jasemi et al., 2017).

Income. Income is money, or some equivalent value, that a person receives in exchange for any services or goods, whatever the form of activity is (Kagan, 2020).

Inequality In Healthcare. Inequality In Healthcare includes injustices in the provision of medical care among different cohorts of the population. Meanwhile, it is essential to clarify that such inequities can be addressed through humanist social policies (“Definitions for health inequalities,” n.d.) The environment in which an individual is brought up, taught, and worked limits their opportunities because of potential inequality in healthcare.

Mental Disorders. Mental Disorders that are defined as chronic or occasional states that directly affect the thinking, emotions, feelings, mood, and behavior of the individual; panic attacks, OCD, phobias, depression, PTSD, schizophrenia are examples (“Mental disorders,” 2020).

People’s Perception Of Access. People’s Perception Of Access can be defined as understanding and seeing phenomena and items from a certain angle (Fernández-Niño et al., 2019); in the context of access, perception is justified by the correlation between an individual’s expectations and their socio-economic situation, which corresponds to an individual’s ability to accept assistance.

Physical Activity. Physical Activity is defined by the World Health Organization (2020) as body movements, that consume energy resources.

Physical Health. Physical Health implies not only the absence of diseases but also maintaining a healthy lifestyle (Felman, 2020).

Psychological Care. Psychological Care, or psychotherapy, is defined as the intentional use of clinical methods based on scientifically proven principles of psychology to maintain or improve the patient’s psychological awareness, including emotional, cognitive, or behavioral ones, in necessary directions (Cuijpers et al., 2019).

Psychological Health. The World Health Organization (2018) defines Psychological Health as a state of mental well-being in which an individual is fully aware of his or her abilities, can work and contribute to his or her life and society.

Psychosocial Care. Psychological Care is a broad concept that includes the psychological and emotional well-being individuals or their families, using such categories as self-esteem, adaptation, communication, social functioning, and relationships (“Theories of psychological care,” 2020).

Socioeconomic Class. The fact that some people may not be able to access certain services or goods is explained by the Socioeconomic Class, which is defined as a group of people with similar social and economic status, level of education, professional skills, ethnic origin, and heritage (Tarver, 2020).

Socioeconomic Status. Socioeconomic Status, SES, is a multidimensional term and is defined as the quality of life realized through the opportunities, rights, and benefits provided by an individual in society (American Psychological Association, n.d.).

Vulnerable Social Groups. Vulnerable Social Groups include the people living in poverty, as well as citizens who are isolated from society due to physical or age restrictions, ethnic minorities, individuals with drug or alternative addictions, and homeless people (“Vulnerable social groups,” 2016)..

Summary

Psychological health is an integral part of health: in other words, a person cannot be considered to be fully healthy unless they are mentally sound. In recent years, the medical community has refined the methods of treating mental disorders. For all their advantages, the medicalization of mental health ignores the context in which these issues occur and develop. Holistic care that sees a patient beyond their condition needs to take into consideration their socioeconomic status (SES) before suggesting changes and treatment plans.

The present study hypothesizes that SES, and namely, its two key elements – income and education, determine a person’s chances of accessing the necessary psychological services. Recent literature and data suggest that, indeed, in the United States, the mental healthcare system caters to the needs of various communities in disproportionately different ways. Some communities enjoy improved availability of services while others struggle to receive help, which only aggravates and escalates their situation. What also plays a significant role in promoting mental health is people’s perception of access. The purpose of this study is to research the factors that shape said perception.

This study employs quantitative, cross-sectional design and focuses on communities with various education and income residing in California. It is expected to recruit around 300 participants with diverse needs and backgrounds. The primary hypotheses for this study are that there is a relationship between education and income and access to psychological care. Namely, the author expects to discover that individuals with lower income and poorer education do not enjoy the same level of availability to mental health services as their peers. If successful, the findings of the study will contribute to the body of research on the subject matter and serve as an impetus to further studies. They could also inform decisions regarding healthcare strategies at higher levels.

References

American Psychological Association. (n.d.). Children, youth, families and socioeconomic status. Web.

Assari, S. (2017). Social determinants of depression: The intersections of race, gender, and socioeconomic status. Brain Sciences, 7(12), 156. Web.

Cautero, R. (2019). What is financial security, and how do you get it? Yahoo Finance. Web.

Creedon, T. B., & Cook, B. L. (2016). Access to mental health care increased but not for substance use, while disparities remain. Health Affairs, 35(6), 1017-1021.

Cuijpers, P., Quero, S., Dowrick, C., & Arroll, B. (2019). Psychological treatment of depression in primary care: recent developments. Current Psychiatry Reports, 21(12), 129-139. Web.

Definitions for health inequalities. (n.d.). NHS. Web.

Derr, A. S. (2016). Mental health service use among immigrants in the United States: A systematic review. Psychiatric Services, 67(3), 265-274.

Delgadillo, J., Asaria, M., Ali, S., & Gilbody, S. (2016). On poverty, politics and psychology: The socioeconomic gradient of mental healthcare utilisation and outcomes. The British Journal of Psychiatry, 209(5), 429-430.

Education. (2020). Cambridge Dictionary. Web.

Felman, A. (2020). What is good health? Medical News Today. Web.

Fernández-Niño, J. A., Chavarro, L. M., Vásquez-Rodríguez, A. B., Rojas-Botero, M. L., Hernández-Neuta, G. E., Peñuela-Poveda, A. M., & Rodríguez, D. A. (2019). Perception of effective access to health services in Territorial Spaces for Training and Reincorporation, one year after the peace accords in Colombia: A cross-sectional study. F1000Research, 8(2140), 1-44.

Finegan, M., Firth, N., Wojnarowski, C., & Delgadillo, J. (2018). Associations between socioeconomic status and psychological therapy outcomes: A systematic review and meta‐analysis. Depression and Anxiety, 35(6), 560-573.

Gonzalez, M. G., Swanson, D. P., Lynch, M., & Williams, G. C. (2016). Testing satisfaction of basic psychological needs as a mediator of the relationship between socioeconomic status and physical and mental health. Journal of Health Psychology, 21(6), 972-982.

Hall, J. D. (2018). The effects of the quality and quantity of education on income inequality. Economics Bulletin, 38(4), 2476-2489.

Hodgkinson, S., Godoy, L., Beers, L. S., & Lewin, A. (2017). Improving mental health access for low-income children and families in the primary care setting. Pediatrics, 139(1), 1-9.

Holley, L. C., Tavassoli, K. Y., & Stromwall, L. K. (2016). Mental illness discrimination in mental health treatment programs: Intersections of race, ethnicity, and sexual orientation. Community Mental Health Journal, 52(3), 311-322.

IHC. (2016). What’s important for family wellbeing [PDF document]. Web.

Jasemi, M., Valizadeh, L., Zamanzadeh, V., & Keogh, B. (2017). A concept analysis of holistic care by hybrid model. Indian Journal Of Palliative Care, 23(1), 71-80. Web.

Kagan, J. (2020). Income. Investopedia. Web.

Maura, J., & de Mamani, A. W. (2017). Mental health disparities, treatment engagement, and attrition among racial/ethnic minorities with severe mental illness: A review. Journal of Clinical Psychology in Medical Settings, 24(3-4), 187-210.

Memon, A., Taylor, K., Mohebati, L. M., Sundin, J., Cooper, M., Scanlon, T., & de Visser, R. (2016). Perceived barriers to accessing mental health services among black and minority ethnic (BME) communities: A qualitative study in Southeast England. BMJ Open, 6(11), 1-9.

Mental disorders. (2020). MedlinePlus. Web.

Packness, A., Halling, A., Simonsen, E., Waldorff, F. B., & Hastrup, L. H. (2019). Are perceived barriers to accessing mental healthcare associated with socioeconomic position among individuals with symptoms of depression? Questionnaire-results from the Lolland-Falster Health Study, a rural Danish population study. BMJ Open, 9(3), 1-10.

Platell, M., Cook, A., & Martin, K. (2017). Barriers to mental health care for disadvantaged adolescents: Perspectives of service providers. Advances in Mental Health, 15(2), 198-210.

Richter, D., Wall, A., Bruen, A., & Whittington, R. (2019). Is the global prevalence rate of adult mental illness increasing? Systematic review and meta‐analysis. Acta Psychiatrica Scandinavica, 140(5), 393-407. Web.

Silva, M., Loureiro, A., & Cardoso, G. (2016). Social determinants of mental health: A review of the evidence. The European Journal of Psychiatry, 30(4), 259-292.

Stepanikova, I., & Oates, G. R. (2017). Perceived discrimination and privilege in health care: The role of socioeconomic status and race. American Journal of Preventive Medicine, 52(1), S86-S94.

Tarver, E. (2020). Social economics. Investopedia. Web.

Theories of psychological care in nursing. (2020). Nursing Answers. Web.

Villatoro, A. P., Mays, V. M., Ponce, N. A., & Aneshensel, C. S. (2018). Perceived need for mental health care: The intersection of race, ethnicity, gender, and socioeconomic status. Society and Mental Health, 8(1), 1-24.

Vulnerable social groups: Before and after the crisis. (2016, July 11). European Parliament. Web.

Wilson, S. L., Gaunt, C. J., Jones, K. N., & Solomon, C. (2018). Correlation between perception and the underutilization of mental health services in the treatment of depression amongst African Americans. EC Psychology and Psychiatry, 7, 263-269.

World Health Organization. (2018). Mental health: Strengthening our response. Web.

World Health Organization. (2020). Physical activity. WHO. Web.