Rethinking time as a social determinant of mental health
Last year the ABC’s Catalyst ran a program to help four pre-diabetic Australians regain their health. Two men and two women participated. Three completed the program and reported benefits, but one women dropped out. It was, in her words, “too much”; she had too much going on with her family and job to add the time needed for her health on top of everything else. How might a psychologist help her with this? Is it a problem of her motivation, her self-care, her coping skills, a symptom of anxious or overwhelmed thinking, or a reflection of other stresses and pressures? The answer is yes, to at least some of these, but it is also about a whole lot more.
This woman is not alone. Last year the National Australia Bank (NAB) released results from its national survey of wellbeing measuring Australians’ life satisfaction and meaning, happiness and anxiety. They found that the most commonly reported detractor of wellbeing, ahead of substance abuse, harassment and bullying, or worries about retirement funding, was not having enough time. In fact, they found that an average Australian would pay $68 for an extra hour of time in the day. Australian Bureau of Statistics data further indicate that one in four women and one in three men feel they are always, or often, rushed or pressed for time. When Australians have care responsibilities it rises to one in two (ABS, 2018).
It is hard to imagine that a problem on this scale is simply all in the head, although it is clearly affecting people’s wellbeing, emotions and relationships. What we hope to do in this brief article is explain why time has become problematic for so many people and what this means for their health and wellbeing.
The use of time
On a superficial level, time can be thought of as the minutes and hours per day, for which everyone has the same allocation. Time is something people need for almost all activities, and it is finite: it cannot be stretched, borrowed or banked. This means that every new demand on people – to commute across congested cities, to combine work while caring for others, to deal with complexity (of information, procedures and administrative requirements), learn new technologies or wait to access under resourced services – all have a time cost, but this is rarely reckoned with, counted or acknowledged.
Time can also be thought of as a resource people need for their wellbeing, in many ways similar to income. In fact, the equation of time with money is well accepted in our market economy. Efficiency, speed and rapid turnaround are expected and common in our technologically enabled 24-hour economy, as is work on weekends and nights. It was not always so; 100 years ago the ability to travel, communicate or process information was an order of magnitude slower than it is today (Rosa, 2003). Fifty years ago the workforce was also predominantly male. In families, one person gave about 45 hours to paid employment, their time freed up by a partner who did the rest, a division of time enshrined in the Harvester decision (Chapman, 2007). Nowadays we have a much more gender-balanced workforce (47% female, 53% male) and this has dramatically changed time within households. With two people working in most couple families, employment hours add up to around 75 per week, and this places pressure on finding time for caregiving and other household tasks (Jacobs & Gerson, 1998).
Working time patterns are also changing, a high incidence of short hours among women workers and very long weekly hours among men. The very top-end of our work-hour distribution is growing (AIHW, 2017). At least a quarter of all employed Australians work past the National Employment Standard of 38 weekly work-hour recommendation. One in eight employed Australians work longer than 50 hours per week (ABS, 2010).
Health impacts of doing too much
These gradual changes in the demands on our time have meant that for many, time has become a precious resource, and has changed how people behave. It is now common to try to save time by speeding up behaviours or activities, so that rushing has become a widespread contemporary experience (Southerton, 2003). Another strategy people are using to alleviate “doing too much” is cutting back on less ‘urgent’ demands, and our research shows that health is one of these trade-offs, which brings me back to the women from the Catalyst program (Venn & Strazdins, 2017).
In fact, lack of time is the most common reason people give for not eating healthy food or exercising enough – ahead of lack of knowledge or income (Djupegot et al., 2017; Spinney & Millward, 2010; Strazdins, Welsh, Broom, & Paolucci, 2016; Venn & Strazdins, 2017). Lack of time, therefore, is one of the drivers of the chronic diseases now evident – it is one of the way lifestyle choices are socially contoured.
Our own research shows how doing too much at work and at home impacts mental health. We find that there are work-hour tipping points beyond which work hours impair mental health, locking in gender inequality in career advancement (because women cannot work the same paid hours as men due to their extra time spent providing care) as well as higher rates of psychological distress in women (Dinh, Strazdins, & Welsh, 2017).
Students are another population vulnerable to the impacts of time on their mental health. More than half of all tertiary students combine paid work with full-time study, and nearly one in three (30%) work more than 20 hours a week (note the average full-time study load is 40 hours a week) (Universities Australia, 2017). Preliminary research we conducted with university undergraduates found that students are experiencing time scarcity from the competing demands of study and paid work (Grimmond, Yazidjoglou, & Strazdins, 2019). As participation in paid work is becoming necessary for many young Australians due to rising university fees and costs of living, the research shows young people are trading-off time for sleep, rest, socialising, healthy eating and exercise, and all of these are affecting their mental health. The majority of tertiary students we interviewed attributed their distress and anxiety to time pressure.
Time scarcity not only affects adult’s wellbeing but it is changing children’s wellbeing as well. Gunnarsdottri and colleagues (2015) found that when parents experienced time pressure, 18.6 per cent of their children had mental health problems compared to 10.1 per cent whose parents experienced no or only slight time pressure. Similarly, an Australian study explored father’s work and family time from the perspectives of their children. Aspects of time use such as work on weekends, an inability to control start and stop times, long hours and fathers’ time pressure all negatively affected children’s views on time spent together (Strazdins, Baxter, & Li, 2017). Although mental health was not directly measured, research on work and family conflict (which is largely centred on time conflicts and time constraints) shows clear pathways from parent mental health (both mothers and fathers) to children’s across a range of ages (Dinh et al., 2017).
These findings open discussion into the adverse effects of fathers’ as well as mothers’ time constraints and the potential effects on their relationships with their children and their children’s mental health. Together the evidence suggests that time’s impact on mental health extends beyond any immediate and direct effects on individuals to also shape the wellbeing of others – broadening the implications of time poverty for mental health across the population.
Time as a social determinant of health
Time (and time scarcity) is another emerging and important determinant of mental health and wellbeing, similar to social determinants such as income, housing, education and employment. Who has control over their time, the types of time demands they face, and whose time is valued (or not) reflects their power and resources, and shapes their life choices and options. While psychologists cannot address these social and economic contexts easily in their practice, there is a time dimension to the contexts within which people live, work and grow up, and it is influencing their mental health as well as their options to cope. And there are some people (parents, single mothers, tertiary students, carers of the elderly or disabled) for whom the time pressures are extreme. Being aware of the time costs and difficulties of accessing services and treatment, as well as the time costs of interventions, are important for psychological treatment efficacy and also for social equity.
There are some precedents out there to guide a time-sensitive approach to mental health practice and interventions. Research on preventative parenting education programs, for example, has found that lack of time and scheduling conflicts are the top barriers to at risk parent participation and retention. The Raising Successful Children Program, an eight-session preventative parent program designed for high-risk parents, scheduled sessions at times convenient to parents, provided transport to families to and from the session, supplied meals for all family members, and provided child care. The participation rate for this program was 70 per cent, much higher than in comparable projects. Designing the program to address time barriers was more effective for retention than monetary incentives (Dumka, Garza, Roosa & Stoerzinger, 1997).
An excellent discussion of the influence of social determinants on mental health was published in InPsych in February 2019. The articles A social determinants approach and Moving beyond diagnosis drew attention to this gap in psychological practice and case conceptualisation (Johnson & Sampson, 2019; Mayers & Agnew, 2019). In effect, a social determinants of health approach requires taking a different perspective – of the population, not just the individual. This approach is quite compatible with the way psychologists view mental health.
The population perspective starts from the premise that the drivers of disease and distribution reflect the characteristics and circumstances of society. The central principles of the population perspective are that:
- health manifests along a continuum in the population
- causes of the distribution of disease can be different to causes of individual cases
- ubiquitous causes can exert a powerful impact of health but are not always detectable when looking within a population
- large numbers of people exposed to small risks can generate many more ‘cases of disease’ than small numbers of people exposed to a high risk (Rose, 2008).
A population mental health perspective means that intervention strategies are not only confined to treating an individual’s mental health problems, but seek to reduce risk by addressing some of the contextual causes. The authors of the two aforementioned nicely articulated the necessity of acknowledging that psychological processes interplay with social settings if the profession is to deliver sensitive and equitable practice and care. Along with other important social resources – income, education, housing and care settings for example – time needs to be added to the list. It has become an influential but largely unacknowledged social context for mental health and psychological practice.
The first author can be contacted at [email protected]