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Social integration in global mental health: what is it and how can it be measured?

Published online by Cambridge University Press:  25 May 2012

J. N. Baumgartner
Global Mental Health Program, Mailman School of Public Health, Columbia University, New York, NY, USA FHI 360, Washington, DC, USA
E. Susser
Global Mental Health Program, Mailman School of Public Health, Columbia University, New York, NY, USA New York State Psychiatric Institute, New York, NY, USA



Global mental health movements increasingly highlight social integration as a key outcome for mental health services. This creates a pressing need to better articulate and measure this outcome. Much of the work in social integration thus far has been in high-income countries (HIC), and is not directly applicable across diverse socio-cultural environments. We discuss promising concepts and measures of social integration with potential for global cross-cultural application. Then, we present some of the challenges of developing measures for global and cross-cultural use, and suggest ways to confront these challenges. Although we focus primarily on adults with severe mental disorders in low- and middle-income countries (LMIC), the questions we raise are also relevant to children, other mental disorders and HIC.


We identify and describe four distinct conceptual frameworks for social integration that have emerged over the past decade. Then, we discuss the challenge of developing corresponding measures, and the further challenge of developing global cross-cultural measures. We suggest that a key concept shared across much previous and emerging work is active participation in community and civic life. As a platform for future development of global cross-cultural measures of this and other concepts, we propose guidelines and present examples of feasible, previously used strategies.


Emerging concepts of social integration hold great promise, but as yet, there are no corresponding measures suitable for global cross-cultural use. We propose that it is feasible to develop such measures, and that their development will facilitate the advance of community mental health services and the science of global mental health.

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Copyright © Cambridge University Press 2012

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Abdallah, C, Cohen, CI, Sanchez-Almira, M, Reyes, P, Ramirez, P (2009). Community integration and associated factors among older adults with schizophrenia. Psychiatric Services 60, 16421648.CrossRefGoogle ScholarPubMed
Anthony, WA (1993). Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal 16, 1123.CrossRefGoogle Scholar
Bass, JK, Ryder, RW, Lammers, M-C, Mukaba, TN, Bolton, PA (2008). Post-partum depression in Kinshasa, Democratic Republic of Congo: Validation of a concept using a mixed-methods cross-cultural approach. Tropical Medicine and International Health 13, 19.CrossRefGoogle ScholarPubMed
Baumgartner, JN (2004). Measuring disability and social integration among adults with psychotic disorders in Dar es Salaam, Tanzania. Ph.D. dissertation, University of North Carolina at Chapel Hill: Chapel Hill, NC.Google Scholar
Bellack, AS (2006). Scientific and consumer models of recovery in schizophrenia: Concordance, contrasts, and implications. Schizophrenia Bulletin 32, 432442.CrossRefGoogle ScholarPubMed
Berkman, LF, Glass, T, Brissette, I, Seeman, TE (2000). From social integration to health: Durkheim in the new Millennium. Social Science and Medicine 51, 843857.CrossRefGoogle ScholarPubMed
Berry, HL, Rodgers, B, Dear, KBG (2007). Preliminary development and validation of an Australian community participation questionnaire: Types of participation and associations with distress in a coastal community. Social Science and Medicine 64, 17191737.CrossRefGoogle Scholar
Betancourt, T, Bass, J, Borisova, I, Neugebauer, R, Speelman, L, Onyango, G, Bolton, P (2009). Assessing local instrument reliability and validity: a field-based example from northern Uganda. Social Psychiatry and Psychiatric Epidemiology 44, 685692.CrossRefGoogle ScholarPubMed
Bolton, P (2001 a). Cross-cultural validity and reliability testing of a standard psychiatric assessment instrument without a gold standard. Journal of Nervous and Mental Disease 189, 238242.CrossRefGoogle ScholarPubMed
Bolton, P (2001 b). Local perceptions of the mental health effects of the Rwandan genocide. Journal of Nervous and Mental Disease 189, 243248.CrossRefGoogle ScholarPubMed
Bolton, P, Tang, AM (2002). An alternative approach to cross-cultural function assessment. Social Psychiatry and Psychiatric Epidemiology 37, 537543.CrossRefGoogle ScholarPubMed
Burns, T, Patrick, D (2007). Social functioning as an outcome measure in schizophrenia studies. Acta Psychiatrica Scandinavica 116, 403418.CrossRefGoogle ScholarPubMed
Caqueo-Urízar, A, Gutiérrez-Maldonado, J, Ferrer-García, M, Morales, AU, Fernández-Dávila, P (2011). Typology of schizophrenic symptoms and quality of life in patients and their main caregivers in northern Chile. International Journal of Social Psychiatry [Epub ahead of print].Google ScholarPubMed
Chatterjee, S, Patel, V, Chatterjee, A, Weiss, HA (2003). Evaluation of a community based rehabilitation model for chronic schizophrenia in rural India. British Journal of Psychiatry 182, 5762.CrossRefGoogle ScholarPubMed
Cobigo, V, Stuart, H (2010). Social inclusion and mental health. Current Opinion in Psychiatry 23, 453457.CrossRefGoogle ScholarPubMed
Collins, P, Patel, V, Joestl, S, March, D, Insel, TR, Daar, AS, Anderson, W, Dhansay, MA, Phillips, A, Shurin, S, Walport, M, Ewart, W, Savill, SJ, Bordin, IA, Costello, EJ, Durkin, M, Fairburn, C, Glass, RI, Hall, W, Huang, Y, Hyman, SE, Jamison, K, Kaaya, S, Kapur, S, Kleinman, A, Ogunniyi, A, Otero-Ojeda, A, Poo, MM, Ravindranath, V, Sahakian, BJ, Saxena, S, Singer, PA, Stein, DJ, Scientific Advisory Board and the Executive Committee of the Grand Challenges on Global Mental Health (2011). Grand challenges in global mental health. Nature 475, 2730.CrossRefGoogle Scholar
Deegan, P (1988). Recovery: the lived experience of rehabilitation. Psychosocial Rehabilitation Journal 11, 1119.CrossRefGoogle Scholar
Department of Health and Human Services (DHHS) (2003). President's New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America. Final Report. DHHS Publication No. SMA-03-3832. DHHS: Rockville, MD.Google Scholar
Fisher, DV (1994). Health care reform based on an empowerment model of recovery by people with psychiatric disabilities. Hospital and Community Psychiatry 45, 913915.Google ScholarPubMed
Gulcur, L, Tsemberis, S, Stefancic, A, Greenwood, RM (2007). Community integration of adults with psychiatric disabilities and histories of homelessness. Community Mental Health Journal 43, 211228.CrossRefGoogle Scholar
Hopper, K (2007). Rethinking social recovery in schizophrenia: What a capabilities approach might offer. Social Science and Medicine 65, 868879.CrossRefGoogle Scholar
Jablensky, A, Sartorius, N, Ernberg, G, Anker, M, Korten, A, Cooper, JE, Day, R, Bertelsen, A (1992) Schizophrenia: manifestations, incidence and course in different cultures: a World Health Organization ten-country study. Psychological Medicine, 22(4), 197.Google Scholar
Leff, JP, Warner, R (2006). Social Inclusion of People with Mental Illness. Cambridge University Press: Cambridge, UK.CrossRefGoogle Scholar
Lehman, LF (1998). A quality of life interview for the chronically mentally ill. Evaluation and Program Planning 11, 5162.CrossRefGoogle Scholar
Link, BG, Cullen, FT, Frank, J, Wozniak, JF (1987). The social rejection of former mental patients: Understanding why labels matter. American Journal of Sociology 92, 1461–500.CrossRefGoogle Scholar
Link, BG, Yang, LH, Phelan, JC, Collins, PY (2004). Measuring mental illness stigma. Schizophrenia Bulletin 30(3), 511541.CrossRefGoogle ScholarPubMed
Maj, M (2011). The rights of people with mental disorders: WPA perspective. Lancet 378, 15341535.CrossRefGoogle Scholar
Mandiberg, JM (2010). Another way: Enclave communities for people with mental Illness. American Journal of Orthopsychiatry 80, 167173.CrossRefGoogle ScholarPubMed
Mandiberg, JM (in press). The failure of social inclusion: an alternative approach through community development. Psychiatric Services.Google ScholarPubMed
McColl, MA, Davies, D, Carlson, P, Johnston, J, Minnes, P (2001). The community integration measure: development and preliminary validation. Archives of Physical Medicine and Rehabilitation 82(4), 429–34.CrossRefGoogle ScholarPubMed
Ministério da Saúde (2004). Legislação em Saúde Mental: 1990–2004, 5a edn.Editora MS: Brasília.Google Scholar
Morgan, C, Burns, T, Fitzpatrick, R, Pinfold, V, Priebe, S (2007). Social exclusion and mental health: Conceptual and methodological review. British Journal of Psychiatry 191, 477483.CrossRefGoogle ScholarPubMed
Movement for Global Mental Health (2011). Retrieved 6 April 2012 from Scholar
ODPM/SEU (Office of the Deputy Prime Minister/Social Exclusion Unit) (2004). Mental Health and Social Inclusion. Cabinet Office: London.Google ScholarPubMed
PAHO/WHO (1990). Declaration of Caracas. WHO: Geneva.Google ScholarPubMed
Pan African Network of People with Psychosocial Disabilities (PANUSP) (2011). Cape Town Declaration of October of 2011. Retrieved 6 April 2012 from Scholar
Patel, V, Araya, R, Chatterjee, S, Chisholm, D, Cohen, A, De Silva, M, Hosman, C, McGuire, H, Rojas, G, van Ommeren, M (2007). Treatment and prevention of mental disorders in low and middle income countries. Lancet 270(9591), 9911005.CrossRefGoogle Scholar
Perkins, DD, Florin, P, Rich, RC, Wandersman, A, Chavis, DM (1990). Participation and the social and physical environment of residential blocks: Crime and community context. American Journal of Community Psychology 18, 83115.CrossRefGoogle Scholar
Prince, M (2008). Measurement validity in cross-cultural comparative research. Epidemiology and Psychiatric Science 17, 211220.CrossRefGoogle ScholarPubMed
Rose, D (2001). Users' Voices: The perspective of Mental Health Service Users on Community and Hospital Care. Sainsbury Centre for Mental Health: London.Google Scholar
Sen, AK (1992). Inequality Re-examined. Harvard University Press: Cambridge, MA.Google Scholar
Sen, AK (1999). Development as Freedom. Knopf: New York.Google Scholar
Susser, E, Baumgartner, JN, Stein, Z (2010). Commentary: Sir Arthur Mitchell – pioneer of psychiatric epidemiology and of community care. International Journal of Epidemiology 39, 14171425.CrossRefGoogle Scholar
Susser, M (1968). Community Psychiatry: Epidemiologic and Social Themes. Random House: New York, NY.Google Scholar
Thornicroft, G, Brohan, E, Rose, D, Sartorius, N, Leese, M, INDIGO Study Group (2009). Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. Lancet 373, 408415.CrossRefGoogle ScholarPubMed
Üstün, TB, Chatterji, S, Kostanjsek, N, Rehm, J, Kennedy, C, Epping-Jordan, J, Saxena, S, von Korffe, M, Pullf, C and in collaboration with WHO/NIH Joint Project (2010). Developing the World Health Organization Disability Assessment Schedule 2.0. Bulletin of the World Health Organization 88, 815823.CrossRefGoogle ScholarPubMed
van Brakel, WH, Anderson, AM, Mutatkar, RK, Bakirtzief, Z, Nicholls, PG, Raju, MS, Das-Pattanayak, RK (2006). The Participation Scale: measuring a key concept in public health. Disability and Rehabilitation 28, 193203.CrossRefGoogle ScholarPubMed
Ware, NC, Hopper, K, Tugenberg, T, Dickey, B, Fisher, D (2007). Connectedness and citizenship: redefining social integration. Psychiatric Services 58, 469474.CrossRefGoogle ScholarPubMed
Ware, NC, Hopper, K, Tugenberg, T, Dickey, B, Fisher, D (2008). A theory of social integration as quality of life. Psychiatric Services 59, 2733.CrossRefGoogle ScholarPubMed
Wong, YL, Solomon, PL (2002). Community integration of persons with psychiatric disabilities in supportive independent housing: a conceptual model and methodological considerations. Mental Health Services Research 4, 1328.CrossRefGoogle Scholar
WHOQOL Group (1998 a). The World Health Organization Quality of Life Assessment: development and general psychometric properties. Social Science and Medicine 46, 15691585.CrossRefGoogle ScholarPubMed
WHOQOL Group (1998 b). Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychological Medicine 28, 551558.CrossRefGoogle ScholarPubMed
World Health Organization (2001). International Classification of Functioning, Disability and Health (ICF). WHO: Geneva.Google ScholarPubMed
World Health Organization (2004). Promoting Mental Health: Concepts, Emerging Evidence, Practice: Summary Report. A Report from WHO in Collaboration with the Victorian Health Promotion Foundation (VICHEALTH) and the University of Melbourne. WHO: Geneva.Google Scholar
World Health Organization (2005). Mental health policy, plans and programmes (updated version 2). [From the Mental Health Policies and Service Guidance Package.] WHO: Geneva.Google Scholar
World Health Organization (2007 a). Monitoring and Evaluation of Mental Health Policies and Plans. [From the Mental Health Policies and Service Guidance Package.]. WHO: Geneva.Google Scholar
World Health Organization (2007 b). UN Convention on the Rights of Persons with Disabilities: A Major Step Forward in Promoting and Protecting Rights. WHO: Geneva.Google Scholar
World Health Organization (2010). mhGAP Intervention Guide for Mental, Neurological, and Substance Use Disorders in Non-Specialized Health Settings. WHO: Geneva.Google ScholarPubMed
World Health Organization (2011). WHO Qualityrights: Act, unite and empower for better mental health. Retrieved 6 April 2012 from Scholar
World Health Organization (2012). Process of translation and adaptation of instruments. Retrieved 6 April 2012 from Scholar
Yang, LH, Kleinman, A, Link, BG, Phelan, JC, Lee, S, Good, B (2007). Culture and stigma: Adding moral experience to stigma theory. Social Science and Medicine 64, 15241535.CrossRefGoogle Scholar
Yang, LH, Link, BG, Valencia, E, Alvarado, R, Huynh, N, Nguyen, K, Morita, K, Saavedra, M, Wong, C, Susser, E (in press). Operationalizing culture via 'What Matters Most' and the culture-specific assessment of stigma. Cadernos de Saude Coletiva of the Federal University of Rio de Janeiro.Google Scholar
Yanos, P, Felton, B, Tsemberis, S (2007). Exploring the role of housing type, neighborhood characteristics, and lifestyle factors in the community integration of formerly homeless persons diagnosed with mental illness. Journal of Mental Health 16, 703717.CrossRefGoogle Scholar
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