Academic journal article South African Journal of Psychiatry

Social Capital, Pathway to Care and Duration of Untreated Psychosis: Findings from a Low- and Middle-Income Country Context

Academic journal article South African Journal of Psychiatry

Social Capital, Pathway to Care and Duration of Untreated Psychosis: Findings from a Low- and Middle-Income Country Context

Article excerpt

Socio-environmental factors, measured at both the individual (e.g. unemployment and low socioeconomic status (1-3)) and neighbourhood level (e.g. urbanicity, ethnic density, deprivation and income inequality (4-8)), are associated with an increased incidence of psychosis. Such factors may also affect pathways to care and the duration of untreated psychosis (DUP) in first-episode psychosis (FEP) within middle-income countries such as South Africa. Longer DUP is known to be predictive of poorer short- and long-term outcome in high- as well as low- and middle-income country (LAMIC) contexts. (9-11) DUP, the period between onset of psychotic symptoms and commencement of treatment, often has a markedly skewed distribution, with most individuals presenting soon after the onset of psychosis (within 10 weeks (12)), and a few presenting many years later. Since this delay has negative implications for course and outcome, it is important to identify factors that may contribute to long DUP, (13) as well as those which might be protective against longer DUP.

One feature of the social environment that may be protective against serious mental disorders is social capital. Referring to the ability of individuals to draw on collective group-level resources, social capital is a concept that emerged from the social, economic and political sciences, (14) but in recent years has also entered the health domain as a possible explanatory factor for variations in health, and as a potential target for interventions. (15) Social capital describes aspects of social networks, relations, trust and power, and incorporates the following aspects of social life: (14) the extent and intensity of engagement and participation in social activities, community structures and civic life; the extent and intensity of social networks, relationships and support; local civic identity and sense of belonging, solidarity and equality with other members; reciprocity and norms of co-operation and a sense of obligation or responsibility to help others; shared values with the community; and trust in the community. It can be studied as a property of individuals or as a property of groups (ecological). The latter is most commonly measured by aggregating individual social capital at a particular spatial level, such as a city neighbourhood. (15)

There is a growing literature on the relationships between social capital and mental health. (15-19) It has been hypothesised that social capital reduces negative life events and long-term difficulties and protects against mental ill-health. (20) Mental healthcare service use and hospitalisation have been measured in relation to neighbourhood levels of social capital. Strong neighbourhood trust and social cohesion were found to reduce mental healthcare service use in children from socioeconomically deprived neighbourhoods in Maastricht in The Netherlands, (19) while low levels of linking social capital was associated with increased hospitalisation due to psychosis in the Swedish adult population, even after adjustment for neighbourhood deprivation. (21)

Whether aspects of the social environment, including social capital, are associated with DUP and pathways to care remains unclear, particularly within LAMIC settings, but this potentially has important implications for health service provision. Compton and colleagues (22) examined socioeconomic predictors of DUP in a sample of African-American FEP patients and found that those without health insurance, with financial problems or barriers to seeking help, had a significantly longer DUP. In a review of published studies of DUP from LAMICs, Large and colleagues (23) found an inverse relationship between gross domestic product and DUP. Therefore, at an ecological level, lower income correlates with a longer DUP. Finally, in the only study to have investigated the possible association between neighbourhood social factors and DUP, Kirkbride and colleagues (24) reported no relationship between neighbourhood-level factors and DUP. …

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