Journal of Psychosocial Nursing and Mental Health Services

Guest Editorial Free

Addressing Social Determinants of Mental Health Through Coalitions

Patricia J. Kelly, PhD, MPH, APRN

The author has disclosed no potential conflicts of interest, financial or otherwise.

Nurses working in the field of mental health appreciate the complexity of the issues that challenge almost all of their patients. Many of these issues are syndemics, a term coined by Singer (2009) that indicates the clustering and complex interaction of multiple health and social issues. An understanding of syndemics provides a comprehensive view of health problems, such as HIV, severe mental illness, and substance abuse. Farmer (2001) documented how high rates of HIV infection, substance abuse, and tuberculosis in many communities cannot be effectively addressed unless the contributions of poverty, poor schools, and joblessness are tackled as well.

González-Guarda, Florom-Smith, and Thomas (2011) explored the clustering health conditions of substance abuse, intimate partner violence, HIV infection, and mental health among Hispanic individuals; Kelly, Cheng, Spencer-Carver, and Ramaswamy (2014) showed the interrelated issues of childhood sexual and physical abuse, domestic violence, and mental illness among women incarcerated in community jails. For many, the successful treatment of mental illness depends on having resources for substance abuse treatment, employment, and housing.

It can be paralyzing to understand that the problems of patients do not exist in a social or medical vacuum because it makes solving them seem overwhelming, if not almost impossible. Working in a domestic violence shelter that is able to only provide basic food and housing services, or in a community mental health facility that is unable to address housing issues, is frustrating. Such frontline work often leaves nurses neither time nor energy to take action on the upstream policy decisions, such as the availability of low-income housing, the creation of entry-level jobs, or the establishment of community-level treatment for posttraumatic stress disorder. All of these community programs could actually make a difference and greatly improve the quality of life of the men, women, and children whom nurses see on a daily basis. For example, nurses working in a domestic violence shelter would optimally screen clients for acute and chronic conditions, identify health services that are accessible for their care (including mental health and substance abuse treatment if necessary), and support them in identifying employment opportunities and affordable housing alternatives. When such services do not exist, it is easy for discouragement to set in.

Engaging with community coalitions is an excellent way to address the syndemic nature of mental health problems. As interdisciplinary activities, coalitions bring together the expertise of various agencies and projects to complement nurses’ skills; these collaborations allow effective management of many aspects of community problems that have an impact on health, including education, literacy, jobs, housing, transportation, and adequate food supply. Nurses can make important contributions to coalitions that work to address the critical impact of these social determinants on the physical and mental health of those whom they serve (Marmot & Bell, 2012).

For example, the Kansas City Reentry Coalition has gathered together representatives from local police, housing, literacy, health care, and job creation agencies for monthly meetings to share program information and opportunities to address the barriers faced by individuals returning to the community after incarceration. Originally organized 4 years ago out of the Metropolitan Crime Commission, all community agencies providing any type of support services to ex-offenders were invited. Information about the Coalition spread through word-of-mouth, and currently, more than 100 agencies participate. A recent initiative involved the elimination of a major impediment to employment: “the box” on employment forms that asked if the applicant had ever been arrested or had a criminal justice background. This is important for nurses working in mental health because 33.1% of men and 63.3% of women in the criminal justice system reported mental health problems (Rogers et al., 2012). The initiative addressed the reality that 70 million Americans (i.e., one in four adults) have a criminal record—at the same time that background checks have increased as an employment screen (U.S. Bureau of Justice Statistics, 2012). The ability to have a job and earn a living is a critical prerequisite to successful reintegration into society after incarceration.

Coalition members in Kansas City followed the example of 62 local jurisdictions across the United States and worked to get support from community organizations, educate city council members about the importance of employment for ex-offenders, and provide resources to the human resources staff of major employers (National Employment Law Project, 2014). Although the initiative is limited to city hiring and its recent implementation hinders assessment of its impact in terms of numbers, it provides a model for fair hiring practices that private employers might adapt.

As the only nurse (and the only representative of health care services) at most of these meetings, it has been exciting and broadening to hear firsthand the many initiatives available in the community to address the syndemic of community corrections. Examples such as the Re-entry Coalition exist in communities around the country and are an excellent way to break out of the silos in which many of us are still forced to work and provide services. I urge you to look outside of your clinics and programs to learn about and contribute to them. Our patients and our communities will be the richer for your contributions.

Patricia J. Kelly, PhD, MPH, APRN


School of Nursing and Health Studies

University of Missouri-Kansas City

Kansas City, Missouri


  • Farmer, P. (2001). Infections and inequalities: The modern plagues. Berkeley, CA: University of California.
  • González-Guarda, R.M., Florom-Smith, A.L. & Thomas, T. (2011). A syndemic model of substance abuse, intimate partner violence, HIV infection, and mental health among Hispanics. Public Health Nursing, 28, 366–378. doi:10.1111/j.1525-1446.2010.00928.x [CrossRef]
  • Kelly, P.J., Cheng, A.L., Spencer-Carver, E. & Ramaswamy, M. (2014). A syndemic model of women incarcerated in community jails. Public Health Nursing, 31, 118–125. doi:10.1111/phn.12056 [CrossRef]
  • Marmot, M. & Bell, R. (2012). Fair society, healthy lives. Public Health, 126(Suppl. 1), S4–S10. doi:10.1016/j.puhe.2012.05.014 [CrossRef]
  • National Employment Law Project. (2014). Ban the box resource guide. Retrieved from
  • Rogers, J.D., Ramaswamy, M., Cheng, C.I., Richter, K. & Kelly, P.J. (2012). Perceptions of neighborhood social environment and drug dependence among incarcerated women and men: A cross-sectional analysis. Substance Abuse Treatment, Prevention and Policy, 7, 39–52. doi:10.1186/1747-597X-7-39 [CrossRef]
  • Singer, M. (2009). Introduction to syndemics: A critical systems approach to public and community health. San Francisco, CA: Jossey-Bass.
  • U.S. Bureau of Justice Statistics. (2012). Survey of state criminal history information systems. Retrieved from


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