‘Boots’ theory: why mental health initiatives need to address economic inequalities

Mental health promotion initiatives can be costly – but so too are the consequences of poor mental health. For this editorial I want to unpack the ‘boots’ theory of socioeconomic unfairness, and explore its implications for mental health funding. Boots theory has been around for some time, but I only came across it recently. For those who are equally unaware, boots theory explains how the wealthy can afford to live cheaply while the poor cannot. The theory is called ‘boots’, because of how Terry Pratchett, in his 1993 book Men at Arms, initially described it:

A really good pair of leather boots cost fifty dollars. But an affordable pair of boots, which were sort of OK for a season or two and then leaked like hell when the cardboard gave out, cost about ten dollars. Those were the kind of boots Vimes always bought, and wore until the soles were so thin that he could tell where he was in Ankh-Morpork on a foggy night by the feel of the cobbles. But the thing was that good boots lasted for years and years. A man who could afford fifty dollars had a pair of boots that'd still be keeping his feet dry in ten years’ time, while the poor man who could only afford cheap boots would have spent a hundred dollars on boots in the same time and would still have wet feet.

Paradoxically, ‘boots’ theory shows that the less money someone has, the more things cost in the long run. An example of this is a friend of mine, a single mother with two children. As she was renting, she needed to keep the yard tidy. She was not able to buy a lawn mower because she did not have the cash and so instead had to pay for someone to mow her lawn. Over time, the money she spent on someone to do this would well and truly have bought her a lawn mower but she just did not have the cash up front. Boots theory can also be seen for those who rent and so cannot afford to buy a house and those who are in low paid employment and cannot afford to take time off to get an education and so acquire better paid employment. The cycle of poverty is thus perpetuated and often occurs across generations.

Even though poverty can be either the cause or the result of mental health problems, research has repeatedly demonstrated that economic hardship produces an environment that is harmful to the mental health of individuals, families and communities (Knifton & Inglis, 2020). Those living in poverty often face high levels of stress while struggling to make ends meet, usually living in unsafe or crowded housing and eating a poor diet (McDaid et al., 2019). Poverty can also negatively impact children’s brain development. In the United States, Weissman et al. (2023) found that amongst 9–11-year-olds, lower family income was associated with smaller hippocampal volume and more symptoms of mental health challenges such as anxiety, depression, aggression, impulsivity and inattention. Tellingly, the availability of monetary assistance programs reduced this disparity by 34%; likewise, in those US states with Medicaid expansion, the disparity was reduced by 43% (Weissman et al., 2023). Moreover, the income-associated disparity in mental health symptoms was 48% lower in states with larger cash benefits than in states with lower cash benefits (Weissman et al., 2023). Weissman et al. (2023) findings remained significant after controlling population density, education equity and incarceration rates. Taking these results further, we know that child poverty leads to poor educational, employment and health outcomes and on a national level to welfare dependency and lost revenue (Brooks-Gunn et al., 1995; Reupert, 2020).

Although anyone can be impacted by mental health challenges, some groups are more are risk than others. Children who have parents with mental health and/or substance misuse issues and those living in out of home care are more at risk of developing mental health problems than their same age counterparts (Reupert & Maybery, 2016; Townsend et al., 2020). Adults with a history of trauma and violence, those who have experienced homelessness or incarceration and particular groups such as refugees, indigenous people and isolated older people are more susceptible to acquiring mental health problems (McKay et al., 2021; Reupert et al., 2015). And all of the aforementioned child and adult groups are at higher risk of living with financial hardship (McDaid et al., 2019) which can further amplify mental health problems.

If we are serious about preventing mental health problems, national wide initiatives are required that address poverty and inequalities around the cost of living. The findings from Weissman et al. (2023) demonstrate that risk can be substantially reduced through economic actions taken during childhood. Other economic initiatives are also needed across the life course, including key life transition points, such as leaving school, becoming a parent, losing a job or retiring from the labour force. ‘Boots’ theory clearly shows that the playing field is not even and individual efforts alone are insufficient. Instead, political, systemic efforts are needed to address these inequalities.

This issue demonstrates the inequalities of certain demographic groups around the world. The first paper highlights the association between certain demographic groups and mood changes during the pandemic as reported by Polish university students (Guszkowska et al., 2022). Ansari et al. (2022) found that the prevalence of depression and anxiety of the Bhil indigenous population in India, was high, especially when combined with older age and low levels of social support.

Another paper, from Walsh et al. (2023) offers a national approach to developing a mental health promotion plan in Ireland. Further showcasing the richness of the field, Bolognino et al. (2023) evaluated the differential effects of mindful breathing meditation and loving-kindness meditation and Lau et al. (2023) documented the experiences of managers when using a workforce leadership initiative, called the Therapy Capacity Framework. The final paper in this issue comes from Canada, which examined the effects of context on the perception of the language of suicide (Howell et al., 2023). As can be seen by the current issue, the journal continues to fulfil its remit to provide a bridge between research and practice, disseminate evidence-based approaches and advocate for necessary changes in policy and practice.