“Being Alone and Expectations Lost”: A Realist Theory of Neighborhood Context,Stress,Depression,and the Developmental Origins of Health and Disease

Abstract

We have previously reported on the findings of a critical realist concurrent triangulated mixed method multilevel study that sought to identify and explain complex perinatal contextual social and psychosocial mechanisms that may influence the developmental origins of health and disease. That study used both emergent and construction phases of a realist explanatory theory building method. The purpose of this article is to present the thesis, theoretical framework, propositions, and models explaining neighborhood context, stress, depression, and the developmental origins of health and disease. The analysis draws on an extensive extant literature; intensive (qualitative), extensive (quantitative), and multilevel studies used for phenomena detection, description, and emergent phase theory development; and the abductive and retroductive analysis undertaken for the theory construction phase. Global, economic, social, and cultural mechanisms were identified that explain maternal stress and depression within family and neighborhood contexts. There is a complex intertwining of historical, spatial, cultural, material, and relational elements that contribute to the experiences of loss and nurturing. Emerging is the centrality of social isolation and “expectation lost” as possible triggers of stress and depression not only for mothers but possibly also for others who have their dreams shattered during life’s transitions. The thesis: In the neighborhood spatial context, in keeping with critical realist ontology, global-economic, social, and cultural-level generative powers trigger and condition maternal, psychological, and biological-level stress mechanisms, resulting in the phenomenon of maternal depression and alteration of the infants’ developmental trajectory.

Keywords

realism theory stress depression developmental origins of health and disease

Introduction

We present here the theoretical framework, propositions, and thesis stemming from a theory building study of neighborhood context, stress, depression, and the developmental origins of health and disease. Our early studies of maternal stress and depression proposed that group-level socioeconomic deprivation, neighborhood environments, social networks, and ethnic diversity had causal effects on postnatal depressive symptomatology and other perinatal outcomes (Eastwood, Phung, & Barnett, 2011). Several recent social epidemiologist commentators have argued for the use of realist philosophy to generate health and social theory (Muntaner, 1999, 2013; O’Campo & Dunn, 2012). Subsequently, we undertook a “critical realist concurrent triangulated mixed method multilevel study that sought to identify and explain complex perinatal contextual social and psychosocial mechanisms that may influence the developmental origins of health and disease” (Eastwood, Jalaludin, & Kemp, 2014). That study used both emergent and construction phases of a realist explanatory theory building method (Figure 1).

Figure 1.

Phases of explanatory theory building.

Intensive (qualitative), extensive (quantitative), and multilevel studies were used for phenomena detection and description, and emergent phase theory development (Eastwood, Jalaludin, Kemp, & Phung, 2013, 2014a, 2014b; Eastwood, Jalaludin, Kemp, Phung, & Adusumilli, 2013; Eastwood, Jalaludin, Kemp, Phung, & Barnett, 2012, 2013; Eastwood, Jalaludin, Kemp, Phung, Barnett, & Tobin, 2012; Eastwood, Kemp, & Jalaludin, 2014, 2015; Eastwood, Kemp, & Jalaludin, 2016a).

Drawing on those studies and in keeping with our previously reported protocol (Eastwood et al., 2014), the construction phase undertook abductive and retroductive triangulation of the reported empirical findings and emergent theory development. The methods included “1) defining stratified levels; 2) analytic resolution; 3) abductive reasoning; 4) comparative analysis (triangulation); 5) retroduction; 6) postulate and proposition development; 7) comparison and assessment of theories; and 8) conceptual frameworks and model development” (Eastwood, Kemp, & Jalaludin, 2016b, p. 2; Box 1).

Box 1.

Construction Phase Methods (Eastwood, Kemp, & Jalaludin, 2016b).

Stratified Levels
A hallmark of critical realist analysis is the ontological assumption that reality consists of hierarchically ordered levels where a lower level creates the conditions for a higher level. The higher level is not, however, determined by the lower level, and has its own “generative mechanisms.” The above approach is useful as an analytical framework, but “in reality levels are entwined and [the] mechanisms could be supporting each other or counteracting each other, and the outcome in a specific context is the result of a very complex interplay between levels and mechanisms” (B. Danermark & Gellerstedt, 2004, p. 350). In this study, we focused the analysis on mechanisms operating at the psychosocial and social levels, while maintaining awareness of the existence and importance of the other levels.
Analytic Resolution
Analytic resolution was undertaken in both the emergent qualitative and quantitative studies as part of procedures such as coding of categories, situational analysis, and factor analysis. Further analytic resolution was also undertaken during the theory construction phase. The process contributes to the identification of the best theoretical explanation. A risk of this process is the loss of details regarding the complexity of the processes under study. To partially address this, the analytic process involved checking back to the empirical findings in both the qualitative and quantitative studies.
Abductive Reasoning
Abductive reasoning is the hallmark of realist reasoning. It is the reinterpretation and recontextualization of phenomena within a conceptual framework or a set of ideas. Modell (2009) observes that “abduction does not move directly from empirical observations to theoretical inferences, as is the case in purely inductive research, but relies heavily on theories as mediators for deriving explanations” (p. 213). We approached the abductive process in three stages: The first step was to recontextualize or redescribe the phenomena identified within one of the most abstract concepts emerging from the emergent phase, such as social capital or “big business.” This abductive inference was imbedded within the theory generation processes of the emergent phase. The second stage recontextualized the observed phenomena through the lens of theories arising from the literature, key informants, and the earlier theory generation (such as social capital or acculturation theory). Finally, abduction was undertaken as part of the inference to best explanation.
Comparative Analysis (triangulation)
As discussed above, we used an integration of methods, data collection, and analysis as proposed by Yin (2006) and Woolley (2009). Comparative analysis was used during the emergent phase, and in this way the two arms of the study remained integrated. In the theory construction phase, findings from the intensive (qualitative) and extensive (quantitative) study arms were compared. The intensive qualitative studies provided causal explanations of possible mechanisms, whereas the extensive quantitative studies assist with distinguishing regularities, patterns, and features of the population groups. During this phase of the comparative analysis, the relevant literature was reviewed in more depth and treated as a third source of information for the comparative analysis. Divergence of findings was given particular attention as it is here that “new” knowledge or understanding can be elicited through the abductive and retroductive reasoning.
Retroduction
Retroduction is a process where we move from a description and analysis of concrete phenomena to reconstruct the basic conditions for those phenomena to be what they are. In this way, thought operations and counterfactual thinking are used to argue toward counterfactual and transfactual conditions. In critical realist analysis of causal inference, structures or entities are viewed as having causal powers, or mechanisms, that have a tendency to produce events or outcomes. Contextual conditions thus play an important role in the realist understanding of causality because causal powers may only result in an event occurring under certain conditions (Pawson, 2006).
Postulates and Propositions Development
From a hypothetico-deductive perspective, Dubin (1969, p. 205) states that propositions are often expressed as “if a then b” deductive statements. The hypothetico-deductive approach to theory building requires a “closed” system, and that the theory be tested within the empirical world with “things observable” (p. 205). By contrast, critical realism views reality as an “open system” where causative processes are always contextually determined. Critical realism also seeks to discover the hidden mechanisms that explain the empirical phenomena. Thus, realist theoretical propositions are about how “mechanisms (M) are fired in contexts (C) to produce outcomes (O)” (Pawson & Tiley, 1997, p. 85). Causal relationships only occur when the generative mechanism comes into operation. Sometimes, different mechanisms produce the same outcome. The contextual conditions determine whether the generative mechanism(s) will come into play and the nature of the outcome. The contextual conditions include other mechanisms that may either trigger or counteract the causal mechanism. A graphical representation critical realist propositions will be used here (Figure 2) to summarize the findings of the comparative analysis (triangulation), and abductive and retroductive reasoning.
Comparison and Assessment of Theories
Critical realist methodologists Danermark and colleagues (2002), and Haig (2005) both identify a stage in explanatory research and theory construction where comparison and assessment of the identified theories and abstractions are undertaken. Haig (2005) argued for Thagard’s (1992) formulation of Inference to the Best Explanation, which included the seven principles of symmetry, explanation, analogy, data priority, contradiction, competition, and acceptability, and three criteria: consilience, simplicity, and analogy (Thagard, 1988). Ward (2009) argued that the commonly used Bradford Hill “criteria” are an Inference to Best Explanation within a realist epistemology. We used, therefore, both the Thagard and Hill principles of best explanation as part of the abductive process and assessment of theories.
Conceptual Frameworks and Models
Finally, we used the typology of conceptual frameworks, theory, and models proposed by Carpiano and Daley (2006) where the different levels of abstraction move from the broadest level of conceptualization (framework) to the more focused (model). A model may draw on several theories, and when presented as a diagram a conceptual model may provide a visualization of proposed causal linkages.

Building on the analysis and propositions of the construction phase, we present here the theoretical framework, propositions, and thesis of neighborhood context, stress, depression, and the developmental origins of health and disease.

Theoretical Propositions

Based on the theoretical framework (below) and our published work, we embed a series of realist theoretical propositions. Those propositions will be used for theoretical modeling that will subsequently be utilized in future confirmatory empirical and programmatic studies. The approach taken here will be in keeping with the postpositivist assumption of “impossibility of scientific proof” and the criteria of falsification (Carpiano & Daley, 2006).

From a hypothetico-deductive perspective, Dubin (1969) states that “propositions are often expressed as ‘if a then b’ deductive statements. The hypothetico-deductive approach to theory building requires a ‘closed’ system and that theory be tested within the empirical world with ‘things observable’” (p. 205).

By contrast, as we have previously observed (Eastwood et al., 2016b),

“Critical realism views reality as an ‘open system’ where causative processes are always contextually determined. Critical realism seeks to discover the hidden mechanisms that explain the empirical phenomena.” Thus realist theoretical propositions are about how “mechanisms (M) are fired in contexts (C) to produce outcomes (O).” (Context mechanism outcome [CMO] propositions; Pawson & Tiley, 1997, p. 85)

In addition,

Causal relationships only occur when the generative mechanism comes into operation. Sometimes different mechanisms produce the same outcome. The contextual conditions determine whether the generative mechanism(s) will come into play and the nature of the outcome. The contextual conditions include other mechanisms that may either trigger or counteract the causal mechanism. A graphical representation of the critical realist CMO propositions will be used (Figure 2). (Eastwood et al., 2014)

Figure 2.

Graphical representation of critical realist CMO propositions.

Thus, the focus will be on testable realist propositions where “x causes y (in circumstances c).” The explanation may also include comment on the structure that underlies the generative mechanism (structure of X).

Our underlying postulate (untested assumption) is as follows:

Maternal psychological stress is a necessary, but not sufficient, cause of depressive symptoms.

Theoretical Framework

The theoretical framework takes a critical realist perspective of perinatal social context, stress, depression, and the developmental origins of health and disease (Bhaskar, 1975; B Danermark, Ekstrom, Jakobsen, & Karlsson, 2002; Layder, 1993; Pawson, 2006; Sayer, 2000), and builds on the emerging literature on stress process (Aneshensel, 2009; Avison, Aneshensel, Schieman, & Wheaton, 2010; Hogue, Hoffman, & Hatch, 2001; Pearlin, Menaghan, Lieberman, & Mullan, 1981), social isolation (Cacioppo & Hawkley, 2003; Hortulanus & Machielse, 2006), social exclusion (Bonner, 2006; Hutchison, Abrams, & Christian, 2007), social capital (Bourdieu, 1986; Carpiano, 2006; Kawachi, Subramanian, & Kim, 2008; Putnam, 1993), segregation (Acevedo-Garcia & Lochner, 2003; Kramer & Hogue, 2009), acculturation (Berry, 1997; Nauck, 2008), globalization (Florey, Galea, & Wilson, 2007), neighborhood effects on health (Ellen, Mijanovich, & Dillman, 2001; Kawachi & Berkman, 2003; Macintyre, Ellaway, & Cummins, 2002), perinatal adversity (Culhane & Elo, 2005; Matthews & Meaney, 2005; Misra, Guyer, & Allston, 2003), and the developmental origins of health and disease (Barker, 1992; Ben-Shlomo & Kuh, 2002; Gluckman & Hanson, 2006).

We have responded to the call for a realist approach to social epidemiological theory building (C Muntaner, 1999; Raphael, 2006) and draw on the philosopher Bhaskar’s (1975) articulation of critical realism with its ontological stratification of reality. Such a stratified ontological perspective adds theoretical depth to the layered ecological models advanced by earlier social epidemiologists (Kaplan, 2004; Krieger, 2001; Lynch, 2000; Susser & Susser, 1996). The first stratified ontological domain consists of the empirical experienced reality, the actual or possible events if activated, and the real which comprises structures, mechanisms, powers, and agency of participants. The second domain of reality consists of hierarchically ordered levels. Each level has its own specific generative mechanisms that constitute or define a level (B Danermark, 2002). Mechanisms, objects, and events exist at each different strata which I have defined here as biological, psychological, social, cultural, and global economic. The critical realist interpretation also makes a distinction between the real and actual with “generative” or causal powers that may, or may not, be activated depending upon other conditions or context, such as those existing in the “open system” of the social world.

Developmental Origins of Health and Disease

As previously reported (Eastwood, Kemp, & Jalaludin, 2014),

We take as our starting point the proposition that antenatal and postnatal maternal stress and depression adversely impact on the developmental origins of health and disease. We cannot yet be certain of the biological level mechanisms that alter the genotypic and phenotypic response to perinatal adversity but the triggering of genetic, neuroendocrine and physiological mechanisms, and psychological and nutritional stress are regarded as strong contenders. (Gluckman & Hanson, 2006; Matthews & Meaney, 2005; Meaney, 2010)

Maternal stress at the psychological level thus may trigger biological-level mechanisms that alter her unborn infants’ developmental trajectory (Gluckman, Hanson, & Beedle, 2007; Meaney, 2010). The role here of antenatal maternal depression is less clear. It is either an indicator and an outcome of maternal psychological-level stress, or alternatively, an independent trigger of biological-level events as suggested by its impact on infant temperament (Davis et al., 2007).

We have also previously noted (Eastwood, Kemp, & Jalaludin, 2014, p. 1) that “postnatal depression and anxiety have consistently been demonstrated to adversely impact on maternal-infant interaction and attachment (Beck, 1995; Martins & Gaffan, 2000; Murray, Stanley, Hooper, King, & Fiori-Cowley, 1996) and subsequent child cognitive, language, behavioural and psychological problems” (Cogill, Caplan, Alexandra, Robson, & Kumar, 1986; Cummings & Davies, 1994; Downey & Coyne, 1990; Gelford & Teti, 1990; Murray, Hipwell, Hooper, Stein, & Cooper, 1996; Sohr-Preston & Scaramella, 2006). Postnatal depression may also be associated with subsequent maternal and childhood obesity (Herring et al., 2008; Surkan, Kawachi, & Peterson, 2008), not breast fed (Dennis & McQueen, 2009; Henderson, Evans, Straton, Priest, & Hagan, 2003), and maternal health harming behaviors such as tobacco and drug addiction (Cinciripini et al., 2010; Lancaster et al., 2010; Rubio, Kraemer, Farrell, & Day, 2008).

Drawing on the above theoretical position and the findings of our published studies (Eastwood, Jalaludin, Kemp, Phung, & Barnett, 2012; Eastwood, Jalaludin, Kemp, Phung, Barnett, & Tobin, 2012; Eastwood et al., 2015), we have made the following three critical realist (CMO) propositions (Figure 3).

Figure 3.

CMO model of maternal depression and outcomes.

Stress and Depression

That depression is caused by psychological stress is increasingly certain (Kinderman, 2005; Stone, Lin, & Quartermain, 2008). Less clear, in critical realist terms, is whether stress is a necessary condition and must be present for there to be depression. The phenomenon of perinatal depression has repeatedly been found to be associated with stressful life events (Beck, 1996, 2001; National Health and Medical Research Council [NHMRC], 2000; O’Hara & Swain, 1996; Wilson et al., 1996). We agree with Beck (1992, 1993, 2002) that depressed mothers experience an “incongruity between expectations and the reality of motherhood,” a sense of pervasive loss, and loneliness. We propose here that this psychologically felt stress, be it internally or externally triggered, is a necessary condition for perinatal depression.

“But stress in itself is not a sufficient mechanism and the tendency of stress to cause depression is conditional on other personal characteristics and social and cultural context” (Eastwood et al., 2013). Following Pearlin et al. (1981), it is argued here “that the generative power of stress is conditioned, or moderated, by personal resources such as coping and by social resources such as social support” (Eastwood et al., 2013). Those personal resources such as mastery, agency, self-esteem, optimism, mattering, emotional reliance, and personal predisposition may themselves be conditioned by social context.

The notion of agency and mastery, from a critical realist perspective of agency (Archer, 1995, p 175), means that mothers themselves have “generative powers,” and may, or may not, be able to influence and control the environmental and experiential forces acting upon them. But the actual outcome will be the result of the interplay between what Archer (1995, p. 175) calls structural, cultural, and agential emergent properties of society, each with its own “generative mechanisms” and relative autonomy. Thus, a mothers individual agency, and ability to “cope,” may be enabled or blocked by her social (structural) and cultural context.

The Triggering Events

Drawing on the stress process model, we further argue that the triggers of perinatal depression are event stressors

such as poor health, childbirth experience, loss of status, loss of financial income, loss of control, unmet expectations, irritable infant and partner behaviour. Chronic stressors may also contribute and include: status strains (i.e. race, sole parent, poverty, and religion), role strains (i.e. wife, motherhood, and daughter), ambient strains (i.e. neighbourhood crime, services, physical decay of environs), and quotidian strains (i.e. loneliness, daily hassle of sole parenthood). (Eastwood et al., 2016, p. 6)

In keeping with a critical realist meta-theory, these triggering mechanisms arise from structural, cultural, and agential generative mechanisms, including income inequality, class structure, social exclusion, social isolation, and access to social services, neighborhood physical environments, and gender roles, cultural expectations of motherhood, ethnic segregation and acculturation.

Building on the above theoretical position and the findings of our previous individual-level published studies, we have made the following three critical realist (CMO) propositions in relation to psychological-level stress and depression (Figure 4).

Figure 4.

CMO model of psychological stress and depression.

Contextual “Stressor” Mechanisms

Aneshensel (2009) argues that the stress process model provides a means of explaining mental health disparities that arise from people’s disadvantaged placement within a social hierarchy. The emphasis here is on a generative mechanism called social stress that is generated by disadvantaged social status. Social stress is defined as a state of arousal that results from social demands that tax the ordinary adaptive capacity of the individual, or from blocking of the means to attain personal goals. Drawing on social isolation (Hortulanus & Machielse, 2006), materialist (Bartley, 2004), and social exclusion (Millar, 2007) theories, social stress arising from hierarchical placement is joined by theoretical explanations, arguing that mechanisms arising from social and economic structures marginalize individuals and groups from social and material resources, and block attainment of their aspirations. Pregnant women and mothers may be unable to access neighbors, friends, family, services, transport, phone, and their partners’ support. In this social context of exclusion, the expectations and dreams of mothers may be shattered as they lose control and are overwhelmed with pervasive loss.

The social structures generating social exclusion and social stress include occupational class structures, racism, and residential, ethnic, and educational segregation resulting in “depressed communities” with few amenities, decayed environments, and perceived unsafe streets. Business, service, and political structures contribute to the marginalization of “depressed communities” through the centralization of amenities, services, and sporting opportunities. The impact on the lives of mothers is to be “stuck in the middle of nowhere . . . being couped up in a house with a kid 24/7” (Eastwood, Kemp, & Jalaludin, 2014).

Contextual Buffering Mechanisms

The buffering role that support plays, in relation to both the stress process and perinatal depression, is strong and consistently shown (Aneshensel, 2009; Beck, 1996, 2001; NHMRC, 2000; O’Hara & Swain, 1996; Pearlin et al., 1981; Wilson et al., 1996). Studies have consistently shown a negative correlation between postpartum depression, and emotional and instrumental support during pregnancy (Beck, 1996; Menaghann, 1990; O’Hara & Swain, 1996; Richman, Raskin, & Gaines, 1991; Ritter, Hobfoll, Lavin, Cameron, & Hulsizer, 2000; Seguin, Potvin, St-Denis, & Loiselle, 1999). Drawing on our earlier critical realist theory generation, we argue that

the support mechanisms received by mothers are determined by her social and cultural context. Drawing on both Social Network (Crow, 2004) and Social Capital (Kawachi et al., 2008) Theory it is evident that social structures can generate strong social bonds with a clear demarcation between “insiders” and “outsiders.” This “bonding” and “bridging” social capital is generated from complex social structures and has been associated with protection from mental health disorders (Fone, Lloyd, & Dunstan, 2007; Stafford, De Silva, Stansfeld, & Marmot, 2008). However, strong bonding ties within disadvantaged communities also may be a detriment to the health of residents (Kawachi et al., 2008). For migrant ethnic mothers access to support is critical. In this social context they must rely on both ethnic bonding capital and the bridging capital provided by supportive social structures. (Eastwood et al., 2013)

Carpiano (2006) describes neighborhood social capital as a resource inherent within the networks of neighborhood residents, with social cohesion generating the necessary conditions for group members to access those resources. The structural antecedents of both social cohesion and social capital are the local, and surrounding, socioeconomic conditions, residential stability, and ethnic, family, gender, age, and social class composition. Together with policy-level mechanisms such as social and economic interventions, conditions may be created that have a tendency to buffer social and cultural stressor mechanisms.

Drawing on the above theoretical position and the findings of our ecological and multilevel published studies we have made the following two critical realist (CMO) propositions in relation to social stress, psychological stress, and buffers (Figures 5 and 6).

Figure 5.

CMO model of social stress, psychological stress, and buffers.

Figure 6.

CMO model of social stress and buffers.

Based on the above eight realist propositions, a model of social isolation, stress, and depression is proposed (Figure 7).

Figure 7.

Model of social isolation, stress, and depression.

Cultural Mechanisms

Critical realists define culture as a distinct ontological level (Archer, 1995; B. Danermark & Gellerstedt, 2004). This is consistent with current multilevel cultural and cross-cultural psychological theory (Adamopoulos, 2008). Under this thesis, separate and different mechanisms operate at the cultural level from those at the social or psychological levels. Drawing on Beck’s (2002) concept analysis of postnatal depression, culturally defined expectations of motherhood may be shattered by the reality of a new mother’s lived experience. In keeping with cultivation theory and social expectation theory (McQuail, 1994), global media will play an important role in the “cultivating and acculturation” process, shaping all mothers’ beliefs and expectations of pregnancy, childbirth, and parenting to a selective view of reality.

The cultural differentialism paradigm of cultural theory (Ritzer, 2008) would hold that mothers’ deep cultural practices and expectations will remain largely unaffected by globalization and media. In juxtaposition, cultural hybridization will be occurring within local South West Sydney neighborhood settings producing new and distinctive cultural realities. Within these cultural fluxes, migrant mothers’ family and personal cultural expectations will generate stress. As observed by Beck (2002), these conflicting expectations and experiences of motherhood lead mothers “down the path to becoming overwhelmed, perceiving themselves as failures as mothers, and bearing a suffocating burden of guilt” (p. 470).

We have made the following three critical realist (CMO) propositions (Figures 8 -10) based on the above theoretical position and the findings of our migrant multilevel study (Eastwood, Jalaludin, Kemp, Phung, & Barnett, 2013), and the three intensive studies of mothers’ experiences (Eastwood et al., 2016; Eastwood, Kemp, & Jalaludin, 2014; Eastwood et al., 2015).

Figure 8.

CMO of migrant mechanisms.

Figure 9.

CMO cultural mechanisms—Expectations of mothers.

Figure 10.

CMO cultural mechanisms—Mothers’ expectations.

Global-Economic Mechanisms

As observed by Clark (2005), “Everything in the situation both constitutes and affects most everything else in the situation in some way . . . Here the macro/meso/micro distinctions dissolve in the presence/absence” (p. 72). Globalization theory (Ritzer, 2008), and conceptual frameworks of globalization and health (Galea, 2007; Labonte & Torgerson, 2005) describe the global and economic generative powers that will affect neighborhood context and the lived experiences of mothers and their families. In tension are two economic systems of globalization—transnational capitalism and socialist globalization—each with mechanisms capable of influencing migration, media, corporate business, social services, politics, and policy. Drawing on Labonte and Torgerson (2005), the global context will condition, at the policy level, macroeconomic, labor, food security, environmental protection, political power, public provision, and migration and refugee policies. Together, and separately from, the generative powers of corporate business, these policy-level mechanisms will shape urbanization, disparities, community capacity, and service access with resulting impacts on triggers, and conditioners, of maternal stress and depression.

Historical and Spatial Context

The spatiotemporal situation of people and resources affects the nature of social phenomena (Sayer, 2000). With global, policy, social, psychological, and biological processes occurring over time, the historical and life-course context will influence or condition the tendencies of causal mechanisms. Thus, individual histories will unfold inside the larger historical sweep of social (and cultural) evolution (Layder, 1993). Although time has a single dimension and is irreversible, space has three dimensions and movement is reversible. Drawing on Bourdieu (1977; cited by Sayer, 2000), structures, objects, mechanisms, and individuals can reversibly interact within space. Thus, individuals who compose a neighborhood influence that neighborhood and adjacent neighborhood context, which in turn has a reciprocal temporal and spatial impact on those and other individuals who reside or move through the neighborhood. Sayer (2000) argues that in some respects, space or geography is vital, but in others, as illustrated by the ability of things and people to remain the same in different settings, it makes only small differences. The implication of Sayer’s thesis is that spatial conditioning of maternal depression and stress will be in turn conditioned by generative properties of social, cultural, and historical context.

Based on the above realist propositions, a model of social isolation and “expectations lost” is proposed (Figure 11).

Figure 11.

Model of social isolation and “expectations lost.”

Thesis

Drawing together the above analysis, we propose the following:

Thesis of Neighborhood Context, Stress, Depression, and Developmental Origins of Health and Disease

In the neighborhood spatial context, in keeping with critical realist ontology, global-economic, social, and cultural-level generative powers trigger and condition maternal, psychological, and biological-level stress mechanisms, resulting in the phenomenon of maternal depression and alteration of the infants’ developmental trajectory.

Conclusion

The purpose of this article was to present the thesis, theoretical framework, propositions, and models explaining neighborhood context, stress, depression, and the developmental origins of health and disease. The article utilized the empirical findings and theory generation of our previous publications.

Global, economic, social, and cultural mechanisms were identified that explain maternal stress and depression within family and neighborhood contexts. There is a complex intertwining of historical, spatial, cultural, material, and relational elements that contribute to the experiences of loss and nurturing. Emerging is the centrality of social isolation and “expectation lost” as possible triggers of stress and depression not only for mothers but possibly also for others who have their dreams shattered during life’s transitions (Figure 11). In these situations, social and cultural context can either nurture and support, or marginalize and isolate.

We will use the theories developed here for future confirmatory studies and realist program theory development.

Footnotes

Acknowledgements

The authors thank Anne Eastwood for her assistance with the qualitative research, and Hai Phung and the Child and Family Health nurses of the previous South Western Sydney Area Health Service (SWSAHS) for their efforts in the collection and maintenance of the IBIS database.

Authors’ Note

The research discussed in this article was originally presented at the 17th International Conference on Integrated Care, Dublin, May 8-10, 2017, an abstract of which was published in the International Journal of Integrated Care.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

John Eastwood

Author Biographies

John Eastwood ED is currently executive clinical director Clinical Services Integration and director of Community Paediatrics, Sydney Local Health District; Visiting Academic Sydney Children’s Hospital Network; Conjoint Associate Professor School of Women’s and Children’s Health, UNSW; and Adjunct Associate Professor Menzies Centre for Health Policy, University of Sydney. John Eastwood has an extensive international career in population child health and well-being, as an international development consultant, paediatrician, public health physician, and national child health policy advisor and public health policy director for the New Zealand Government. His current research interests are in social inequalities of health and injury, the developmental origins of health and disease, children’s development, injury prevention and global health policy for children.

Lynn Kemp is professor and director, Translational Research and Social Innovation (TReSI), member of the Ingham Institute of Applied Research, School of Nursing and Midwifery, University of Western Sydney. Originally trained as a nurse, Lynn is a primary health care researcher who leads a collaborative team of cross-disciplinary academic and industry researchers from multiple universities and agencies, conducting Australian-first research programs in the areas of comprehensive and integrated primary health care provision in early childhood and home visiting, health impact assessment and working with disadvantaged communities and populations. Lynn is recognised as one of the leading primary health care early childhood researchers in Australia and is a member of several key NSW and Australian government committees on early childhood.

Bin Jalaludin holds a medical degree, a masters in public health and a doctorate, all from the University of Sydney. He is currently director, Epidemiology, Healthy People and Places Unit, South Western Sydney Local Health District. He has a conjoint professorial appointment at the University of New South Wales, is an honorary senior research fellow at the Woolcock Institute of Medical Research, leader of the Population and Health Services Research Stream at the Ingham Institute for Applied Medical Research, and on the editorial board of Environmental Health. His research interests are in the areas of environmental epidemiology, built environment, social epidemiology and health services.

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