PUBH6008 Strategies Of Improving Mental Health Of Middle Aged Women Assessment 2 Answer

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Question :

Subject Code and TitlePUBH6008: Capstone A: Applied Research Project in Public Health
AssessmentAssessment 2: Literature review
Length4,000 words
Learning OutcomesThis assessment addresses the following learning outcomes:

  1. Integrate and apply their knowledge and skills in public health
  2. Develop research skills and apply these to a public health issue
  3. Conduct a small literature review which critically analyses key issues on a public health research topic
  4. Define and justify a research question, based on the literature/public health issue, and outline its significance


By the end of module 3, student must provide to their learning facilitator a brief review of the literature on their chosen topic. The literature review must contain key references/theorists/researchers for the public health topic chosen. The literature review assignment must be designed to address the following questions:

  • Who are the key theorists/researchers in your public health topic?
  • What are the key issues?
  • What are the gaps in the existing body of knowledge?

The literature review should provide a basis for justifying a clear research question or hypothesis to be explored further.

You must also indicate the search strategy used for your literature review. For example, what were the key words you searched for, and which key databases or other sources did you use to conduct your literature review? (e.g. CINAHL, Proquest Public Health, Informit, Medline, Google Scholar).

Assessment Criteria:

  • Critical and comprehensive review of the literature (70%)
  • Clarity of research question/hypothesis (10%)
  • General assessment criteria (20%):
    • Provides a lucid introduction
    • Shows a sophisticated understanding of the key issues
    • Shows ability to interpret relevant information and literature in relation to chosen topic
    • Demonstrates a capacity to explain and apply relevant concepts
    • Shows evidence of reading beyond the required readings
    • Justifies any conclusions reached with well-formed arguments and not merely assertions
    • Provides a conclusion or summary
    • Correctly uses academic writing, presentation and grammar:
      • Complies with academic standards of legibility, referencing and bibliographical details (including reference list)
      • Writes clearly, with accurate spelling and grammar as well as proper sentence and paragraph construction
      • Uses appropriate APA style for citing and referencing research
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Answer :

Subject Code and Title PUBH6008: Capstone A: Applied Research Project in Public Health

Assessment 2: Literature review

Topic: Qualitative studies on strategies of improving the mental health of women in middle age and what are the various determinants of women’s mental health. 

Introduction to Literature Review

Mental health can be defined as a person’s condition in relation to their emotional and psychological wellbeing (Kohrt, Mendenhall, & Brown, 2015). Middle age is the phase after early adulthood and prior to old age accounting for an age group between 45 and 65 (Shinan-Altman, & Werner, 2019).The rising burden of mental health issues on society has long been a focus of study for the researcher. The underlying causes of mental health in any person can range from a variety of reasons. While mental disorders affect men and women equally, some mental health conditions are more prevalent among women over men. On the issue of gender disparities in relation to mental health, the World Health Organisation has stated some important facts. According to WHO (2019), mental illness is directly associated with disability and indisposition and lifespan prevalence rates of any type of mental condition is much higher than previously accounted for. The rate at which these are increasing is likely to affect half the world’s current population. However, diagnosis of mental disorder still lacks sometimes due to lack of patient's interest to seek professional help and sometimes due to lack of proper diagnostic methods at disposal. In such conditions, gender has emerged as a critical element of mental health disorders as gender controls the disparityin power and control that men and women possess in relation to the socioeconomic factors of mental health. In the case of most common mental disorders (CMDs) such as stress, depression, somatic complaints, andanxiety gender differences are observed as these conditions are more predominant in women compared to men. At the same time, several studies show that middle-aged women are more prone to be susceptible to a mental health condition or during the Middle Ages the underlying mental health issue becomes most glaring (Who, 2019). This literature review reviews the research work of various researchers to gain a background perspective on mental health issues and conditions in women in their middle ages. 

Prevalence of Mental health Disorders in Women

Existing trends

Barr, Kinderman, & Whitehead (2015) conducted a study to determine the trends in mental health inequalities in England that had occurred during the period of recession, austerity and welfare reform between the years 2004-2013. In order to investigate the trends, the researchers had used data from the Quarterly Labour Force Survey and determined the self-reported mental health problems by different socioeconomic groups. The study identified that between the period of 2009 to 2013, people reporting for mental health problems increased significantly, and this increase was most glaring among people with low education levels. The researchers had determined the welfare policies implemented since 2010 as the underlying causes of these trends. However, the study found no obvious trends that relate gender disparity with the rise in mental health issue reporting. No obvious relationship was established between unemployment, low education and rising mental health reporting, particularly in women.  

Boyd et al. (2015) evaluated gender differences associated to mental disorders as well as suicide rates in European countries and identified that pervasiveness of any lifetime disorder in women ranges from 10.8- 44.5% compared to 5.9- 26.5% in men. On the other hand, suicide attempt throughout the lifespan was found to be 0.8–5.4% in women compared to 0.3–2.4% in men. 

McManus et al. (2016) conducted a survey in England in relation to mental health and wellbeing on behalf of National Health Services and published several trends. The fourth series of the survey conducted on the citizens ofEngland determined various trends associated with mental illness. The study suggested that one in six adults living in England has one or other common mental disorder (CMD). In the case of women, stats suggest that one in five adult women has some type of CMD while for men, it is one in eight. The study also reported that reports associated with self-harm had increased among women compared to men across different age group since 2007, while young females are the high-risk group. The rates of CMD and self-harm are high, in those women and theyalso tested positive for posttraumatic stress disorder (PTSD) as well as bipolar disorder. The study showed that in 2014, one in five women between the age group 16 to 24 has reported had self-harmed themselves at one point of life. CMD symptoms are most glaring in all age groups in women compared to men. The study also revealed 12.6% of womenhad PTSD compared with 3.6% of men of the same age. 

CMD symptoms

Figure Source: (McManus et al. 2016)

self harm ever

Figure Source: (McManus et al. 2016)

Trends regarding treatment and support service use as detailed in this study suggested that white British middle-aged (35-54) females are more likely to receive treatments compared to black ethnic group females of the same age category. 

Finlay et al. (2015) suggested that over 50% of veterans in the criminal justice system have some sort of issue in relation to mental health or substance abuse information regarding female veterans are lacking. In order to document the prevalence of mental health and substance use problem diagnosis and treatment among female veterans compared to men, they conducted a study among 1535 females and 30,478 male veterans. Results of the study revealed that among female veterans the rate of mental health disorder was 88% compared to 76% in men and for substance abuse, this rate in the female is 58% compared to the 72% in males. The study thus concluded that female veterans are more indisposed to mental health disorders compared to men. Higgins et al. (2018) while investigating barriers that nurses and midwives encounter while addressing mental health issues among women. They also suggested clear associations between perinatal mental health issues and poor health outcomes for babies. For such reasons, perinatal mental health has become a focus of study and a reason for significant public health concern. The study also referred to the case of Ireland in 2016 that recorded 63,897 births, among which 15% of women encountered some type of mental illness in the perinatal period.

These studies have been extremely informative regarding the existing trends in mental disorders among women of different age groups, social classes and profession. The studies were focused more on drawing a statistical comparison between trends in women and men. However, none of these studies focused particularly on middle-aged women to identify trends and patterns of mental disorders.

Most prevalent mental health conditions

Ulfvebrand et al. (2015) investigated eating disorders and Psychiatric comorbidity in women and men associated to it and found that women with binge eating disorder have highest levels of comorbidity while for men the comorbidity was highest for Bulimia Nervosa. This suggested that eating disorders associated with stress are highly prevalent in women compared to men. Bandelow&Michaelis (2015) while investigating the epidemiology of anxiety disorders in the different population, identified that prevalence rates of these disorders in women are twice as high as men. Most common anxiety disorders to which women and more prone compared to men include panic disorders, GAD, Agoraphobia, SAD and specific phobia. For all types of anxiety disorders, the female to male ratio of susceptibility is 2:1. Grande et al. (2016) in their review investigated bipolar disorder in detail among different population and found that among the various classification of bipolar disorders, bipolar I affects both male and females equally and usually begins in young adulthood however women are more susceptible to prolapse and manic episodes during that time for bio-physiological changes and hormonal changes. They present more with a challenge for treatment options that need to administer drugs. Iliadou et al. (2019) developed a policy paper based on a literature review addressing mental ill health issues migrant and refugee women. The study stated that migrant and refugee women are highly vulnerable to some sort of mental illness and the rates are higher in this population compared to the host population. While about 10% of women around the world experience mental health issues anxiety and bipolar disorders are more prominent among perinatal women around the world. 12.7% of women in the world have been diagnosed with having major depressive disorders, while 37% show depressive symptoms. Moreover, migrant women experiencing single parenthood are more susceptible to stress and anxiety disorders. Kuehner (2017) when tried answering the question “why women are more prone to mental disorders than men?” through their research suggested that depression is more predominant in women compared to men suggesting it as one of the most common mental disorders observed in women. 

Underlying causes of mental health disorders in Women

Sharifi et al. (2014) while investigating the barriers associated mental health of middle-aged women stated that middle-age is an interesting point in a women’s life women in that age are at higher risk of developing psychotic conditions due to factors like biological and psychological alterations, mental and social stress and past history of abuse. Here 4 major underlying causes of mental disorders and psychiatric conditions in women are considered. 


Among various other causal factors, Giurgescu et al. (2015) investigated the impact of stress in relation to depressionwith a study subject group of African-American women. They projected a model of perceived stress and social support mediating the results of neighbourhood quality impacting on depressive symptoms throughout physiological state.As per the results of the study, the authors over that perceived stress partly mediate the neighbour quality's impact on depressive symptoms. The results indicated the necessity for establishing public health support interventions furthermore as health-related interventions for addressing stress-related depressive symptoms among ladies. Li & Graham (2017) investigated “why ladies area unit extremely at risk of anxiety, trauma- and stress-related disorders with special concentrate on the potential impact of sex hormones.” The analysis explicit that higher prevalence rates of stress-related disorders with exaggerated severity of symptoms of psychological state, co-morbidity and burden of psychological state among ladies compared to men. The analysis advised that ladies area unit subjected to secretion fluctuations a lot of throughout the biological cycle than men leading to them being a lot of susceptible to higher stress levels. The increased stress levels are directly associated with a variety of mental conditions such as depression and anxiety. With the key focus on investigating the relationship between stress and mental health disorders, Persson&Rossin-Slater (2018), identified that increased levels of stress result in mental conditions such as depression, anxiety and ADHD. Moreover, results of the study found women during pregnancy and gestation if subjected to increased levels of stress often tend to have gestation diabetes which impacts foetus outcomes also results in increasing the risks of having autism spectrum disorders. Karasz et al. (2019) also investigated the relationship between stress and mental health; however. The focused study group was South Asians. The research suggested that among South Asian community stigma associated with acceptance of mental illness is very high. The study suggested that understanding the association between stress and mental illness among South Asian women requires understanding culture-specific relations as well as developing solutions that involve community support aspects. 

Abuse and trauma

Savic et al. (2016) in their research involving Sudanese refugees, identified the impact of trauma on the mental health condition. While the study identified that trauma is not universally considered as a causal factor, it has a significant relationship with mental health disorders in refugees, especially in women. Machisa, Christofides, &Jewkes (2017) identified that most common mental health conditions that are predominant in women include Depression, post-traumatic stress disorder (PTSD), and binge drinking and these are mainly caused as a result of childhood experiences of abuse or abuse received from intimate partners. The results of the survey conducted by the researchers showed that 50% of the responding population of women had experienced intimate partner violence (IPV) while 18% of which has experienced abuse in the past 12 months of the survey undertaken by them. Among those who had experienced IPV, 11.6% had PTSD, and 14% have issues of binge drinking. The most astounding facts presented in the study was that 86% of the responding population had experienced child abuse. Cimino et al. (2019) investigated the effect of traumatic brain injury and IPV on mental health outcomes in black women. This research suggested that, severe IPV involving strangulation or traumatic head injury resulting in loss of consciousness results in traumatic brain injury resulting in altered brain pathology. Such situations result in altered brain functions as well as cognitive impairment, depression, and PTSD. The retrospective cohort study detailed that among 95% of black women have a history of child abuse IPV, history of forced sex and one-third of them have suffered some sort of traumatic brain injury making them at higher risk of mental disorders and cognitive impairment. Compared to white female and Latina women, these statistics are much higher in black women. Consequently, Wood (2019), conducted a systemic literature review to identify the impact of trauma on psychological issues in female prisoners. According to the study, the author suggested that large body of literature has already presented evidence of higher rates on mental illness among prisoners compared to non-imprisoned population accounting for 90% of the imprisoned population having some sort of mental health issue. Furthermore, the study revealed that relationship between traumatic experiences and mental illness is far higher in female prisoners than male prisoners and that for females, interpersonal sex-related trauma in childhood, adolescence and adulthood is a common underlying cause of mental illness. 

Menopause and Mental health

 A research conducted by Rossler et al. (2016) in Zurich has shown a significant relationship between menopause and mental health in women. The researcher followed up 168 women ages from 21 to 50 from a Swiss community to find out the irritability in them which increased only in menopausal women. Their research also showed that he neuroticism score were increased in women at the age of 30 who had preceding mental health problems which converted to psychological distress occurring in them between the ages 41 to 50. However, they concluded that mental health problems are not directly linked with the menopausal transition in women between ages 41 to 50. They postulated that these problems could be related to the preceding mental problems and other positives of dichotomisation or undisclosed overliftings as evident even before their menopausal transitions. Another study by Choi et al. (2018) was conducted based on the data of 9555 post menopausal women from the Korean survey. The study has also found no relation between the level of depression and the menopausal women.   

Bio-physiological factors

Bio-physiology can also be considered as an underlying cause for developing mental health conditions among both men and women. However, with respect to women being more susceptible to a common mental health disorder, physiology plays a major role. Bakalar et al. (2015) while investigating the risk factors associated with eating disorders, identified that women are more prevalent to Anorexia nervosa (AN) which a type of eating disorder accounting for 1.2-2.2%. The prevalence rates for Bulimia nervosa (BN) as well as Binge eating disorder (BED) are also high in women accounting for y 0.9–2.9 % and 1.9–3.6 % among women. All statics suggest that women are more indisposed to EDs than men. To answer the question of why such disparity is observed among men and women associated with EDs, the authors detailed Genetic Risk Factors, Physiological and Pubertal risk factors and Neurobiological risk factors. The study further suggested that adolescent girls with a history of adverse life events which carried the s-allele of the serotonin-transporter-linked polymorphic region were more likely to develop eminent BN symptoms. Further, physiological risk factors for EDs in women accounted for perinatal, hormonal, and weight-related predisposition factors while a clear association between AN and decreased levels of grey matter. The neurobiology of women is quite different than men accounting for women having 10% lesser grey matter compared to men, while women have higher levels of white matter.  

Kilpela et al. (2015) suggested that body-image causal factorassociated withdepression in women compared to men. The body image shifts are more prominent among older adults compared to adolescent and young women accounting for ageing-related physiological changes in shifting body image of adult women further. Body image shift in women are caused because of hormonal changes occurring in women’s body during adolescence and menopause and research have suggested a clear association between body dissatisfaction caused by body image shift and mental disorder in women. Such dissatisfaction often results in eating disorders, depressed mood ad suicidal thoughts in women. 

Existing ways of addressing mental health disorders in Women

There are several ways in which mental health disorders in women can be publicly addressed and based on the type of the disorder, necessary intervention methods and treatments can be recommended. As stated by Salt et al., (2017), for addressing such women’s mental health disorders, it is necessary to identify the key determinants of mental health in women. A brief description of some of the key determinants of mental health has been provided below.

Key determinants of mental health

Resettlement of refugees is a very timely activity which might take uncertain time to complete the process. As refugees face life-threatening circumstances before leaving their home countries, it is necessary to screen them for mental health issues before arranging for their resettlement. It is evident from this situation that life-threatening circumstances are one of the key determinants of mental health. As women are less resilient to violent events, such life-threatening incidents in their life can hamper their mental health and stability. Moreover, the effect of such violent events might linger in women well after they have overcome the situation and can even severely affect their personal life in the future. Hence, it is absolutely necessary to determine intervention methods that would help such women cope with their distressed and violent past. However, there are multiple internal and structural barriers that might affect the intervention process and delay the chance of recovery. Apart from this, armed conflicts, political violence and abuse of human rights also lead to people fleeing from their own country and seek asylum in other neighbouring countries. However, according to Shrestha-Ranjit et al., (2017), such drastic situations often lead to social, physical and even mental health problems that might affect their future lives. Women, who suffered from such traumatic experiences in their past, tend to hold on to these and often show instability in the form of mental health disorders. Past researches and studies on this subject clearly indicate that the consequences of traumatic experiences can be severe, and inability to cope with them is also a key determinant of mental health disorders in women. Such mental health issues can range from bipolar disorder, anxiety disorder, chronic depression, panic attacks, etc. It is necessary to screen such women as soon as possible to identify these key determinants and develop treatment and intervention methods to help them lead a normal life. If these key determinants of mental health disorders are not identified within a specific time span, chances of recovering from it grow thin, regardless of the intervention and methods later on. As stated earlier, women being less resilient to violence, conflicts or abuse, chances of these experiences lingering in their mind is also high. This is basically dependant on the female anatomy, psychology, and how the female brain is wired. Due to their high sensitivity to emotions, even the smallest amount of conflict or abuse can have a long-lasting negative effect which is reflected later on in their lives through various mental disorder symptoms. Some of the most well know, and existing intervention methods and treatments for women suffering from mental health disorder have been discussed in the following section.

Intervention/ treatment

Arranging for mental health screening procedures is quite effective to detect any mental disorders in women who have been in a refugee crisis. Processes like Refugee Health Screener – 15 (RHS-15) helps to assess such mental health issues in women. Subsequently, as stated by Place et al., (2016), intervention methods like Pathways to Wellness can be used to identify the structural and internal barriers that might affect the resettlement of refugee women. Apart from these, community collaborations to provide economic opportunities, social support and resources are equally helpful for women with traumatic and violent past. These are considered as a holistic approach to improving the quality of life of women suffering from mental health disorders. Apart from such holistic approaches, primary health care services are equally helpful to deal with women suffering from mental health disorders. Developing focus group discussions and interviews by health service providers can also be a viable treatment method of mentally ill women. It is through direct interaction with such women. A long-lasting solution could be determined to help them cope with their traumatic past and lead a healthy lifestyle.

Literature Gap

A gap in information can be clearly identified from the literature studied so far. While most of the studies were focused more on drawing a statistical comparison between trends in women and men, none of these studies focused particularly on middle-aged women to identify trends and patterns of mental disorders. With respect to most prevalent mental health conditions that were reviewed identified prevalent mental health conditions across a wide age group failing to specify conditions most prevalent among middle-aged women. Similarly, with respect to underlying causes of mental health disorders in Women, mental health conditions and causes appearing in adolescence and older adults were most focus apart from racial and ethnic differentiation taking almost no focus on identifying what causes mental health conditions among middle-aged women. Even the bio-physiological factors studied focus more on young girls and older adults compared to women in the middle ages. Identifying these gaps presents the rationale for undertaking further research for investigating strategies of improving the mental health of women in middle age because without a clear knowledge of key determinants and underlying causes strategies cannot be identified. 

Summary and Conclusion to Literature Review

Major themes associated with mental health conditions in women in their middle ages signifying an age group of 34-54 have been largely underrepresented in the research specific literature around the world. Knowledge associated with the key determinants of mental health in women in their middle ages is also highly restricted and limited. However, the increasing rates of mental disorder observed among women of this age group poses concerns for understanding the causal factors, the key determinants and the strategies associated with treatment, prevention and interventions. This could have a global impact in creating a psychologically healthier society where women encounter a lesser amount of mental distress and illness. Considering these aspects, the review concludes in favour of conducting a qualitative investigation for investigating appropriate strategies of improving the mental health of women in middle age.