642 T. Pienkowski et al.


evidence overwhelmingly focused on the non-material con- tributions of nature tomental health. Yet the directmaterial contributions of nature, such as food, fuel, materials and other products, play crucial roles in people’s lives worldwide (IPBES, 2019), particularly in low-income settings. These material aspects of people’s lives could be important predic- tors of mental health (Lund et al., 2010). For example, forests can support food security, a social determinant of mental health (Ickowitz et al., 2014; Jones, 2017). Furthermore, many studies exploring the psychological


benefits of nature exposure come from the Global North, often from urban contexts (Fisher et al., 2021). For example, a systematic map of 276 studies linking nature exposure and mental health found that 83% were conducted in predomi- nantly high-income Europe, North America, Australia and New Zealand, and only 15% in Asia (Collins et al., 2020). Similar patterns can be observed in other reviews linking na- ture and mental health (Twohig-Bennett & Jones, 2018; Wendelboe-Nelson et al., 2019). But nearly 4 billion people live in lower-middle- and low-income countries, of which nearly 60% live in rural areas (World Bank, 2021). The geographically biased understanding of how inter-


acting with ecosystems affects mental health is of concern, as many in the rural Global South depend on nature for their basic needs (Fedele et al., 2021), can be highly exposed to its loss (Powers & Jetz, 2019) and have limited access to mental healthcare services (Vigo et al., 2019). Amore repre- sentative understanding could be useful in several ways. A Global Action Plan for Biodiversity and Health has been proposed to help mainstream biodiversity–health linkages into cross-sectoral and sector-specific planning (CBD SBSTTA, 2021). A better understanding of these links could help decision-makers account for (and thus take ad- equate action to avert) the full health costs of the global bio- diversity crisis. Furthermore, this understanding could identify opportunities to support both conservation and human health. For example, livelihood-focused conserva- tion interventions could simultaneously protect nature whilst directly and indirectly enhancing people’s quality of life in ways that could support their mental health (Wright et al., 2016; Pienkowski et al., 2022). Finally, accounting for the role of ecosystems could help explain variation in mental health between groups, such as the observed but unex- plained differences between communities in Uganda (Kinyanda et al., 2011, 2013, 2017). One commonly used marker of mental health is the pres-


ence and severity of psychological distress, a state of emo- tional disturbance that impairs day-to-day activities and social functioning (Drapeau et al., 2012). Although not itself a disorder, severe psychological distress is ‘indicative of im- paired mental health and might reflect commonmental dis- orders, like depressive and anxiety disorders’ (Viertiö et al., 2021,p. 2). Our exploratory case study was conducted amongst nine rural communities in Nyabyeya Parish,


western Uganda. This Parish borders Budongo Forest Reserve, a valuable site for nature conservation, but one that has experienced extensive recent land-use change. Therefore, the relationship between ecosystems and people’s experiences of psychological distress could be particularly acute. Within the case study, we ask: (1)How do Nyabyeya’s residents describe their experiences of distress? (2) What are the perceived stressors causing this distress? (3) How do interactions with ecosystems influence these stressors?


Conceptual framework


We developed a generic conceptual framework describing how interactions between social systems and ecosystems could influence social determinants of psychological dis- tress. This framework was intentionally broad, providing a general structure but allowing themes to emerge from the data. This framework has been described in detail previously (Pienkowski et al., 2022), and so is only briefly presented here (but see Supplementary Material 1). The first compo- nent of the framework describes how excessive exposure to stressors could increase the risk of psychological distress (Fig. 1).Weexplored experiences of distress using locally ap- propriate idioms of distress (Nichter, 2010). The second component of the framework describes broad categories of stressors faced by populations experiencing poverty, draw- ing on the Voices of the Poor initiative (Narayan et al., 2000). This initiative identified five categories of stressors: material lack and want; physical ill-being; bad social rela- tions; insecurity and vulnerability; and powerlessness, frus- tration and anger. These stressors could represent potential social determinants of mental health (Lund et al., 2018). The final component describes how the interaction of social and ecological systems defines the context of people’s lives, in- cluding the stressors they face. Ostrom provides a multi- level framework for organizing and structuring the many features found in socio-ecological systems, including agro-ecological systems (Ostrom, 2007). This socio- ecological systems framework is often used to examine a specific phenomenon of interest, termed the action situation.


Study site: Nyabyeya Parish and the surrounding areas


The scope of the case study includes Nyabyeya Parish, the nine communities within it and the surrounding area (Fig. 2; Supplementary Material 2). The area has experi- enced substantial changes in land cover since 1994, with widespread loss of forest outside forest reserves and a shift from subsistence to contract farming (Babweteera et al., 2018). These socio-ecological changes would be expected to affect the livelihoods of residents, many of whom are


Oryx, 2024, 58(5), 641–649 © The Author(s), 2024. Published by Cambridge University Press on behalf of Fauna & Flora International doi:10.1017/S0030605323001710


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