Neighbourhood renewal and health: evidence from a local case study

Does Willingness to Pay Differ for Mental and Physical Health?

OBJECTIVES

The urban environment can have a significant impact on mental and physical health. Health impact appraisal of new developments should address these issues. However, transferable economic valuation evidence for urban planners in the United Kingdom is thin, especially around mental health, making it harder to estimate the cost-efficiency of public health interventions to address these conditions. A further complication is that mental health may be perceived differently from physical health. This study examines willingness to pay (WTP) to avoid depression and lower back pain.

METHODS

WTP estimates were obtained by applying contingent valuation tasks in an online survey with a representative sample in the United Kingdom (N = 1553). Interval regression models were used to estimate the effects of disease severity, payment frequency, and respondent characteristics on WTP.

RESULTS

Respondents' WTP to avoid both conditions was relatively high (around 5%-6% of stated income to return to current health state). Depression was rated as being twice as burdensome on quality of life than pain, and bids to avoid depression were 20% to 30% more than pain. Analysis of motivation responses suggests mental health treatment is perceived as less easy to access and less effective than the equivalent for pain, and respondents expect a larger burden on their family and relationships as they try to manage their condition themselves.

CONCLUSIONS

Results suggest that depression bids may be affected by uncertainty around access to effective treatment in the healthcare system. This has implications for how mental illness may be prioritized in resource allocation toward public health interventions.

The Uncontrollable Mortality Risk Hypothesis: Theoretical foundations and implications for public health

The 'Uncontrollable Mortality Risk Hypothesis' employs a behavioural ecological model of human health behaviours to explain the presence of social gradients in health. It states that those who are more likely to die due to factors beyond their control should be less motivated to invest in preventative health behaviours. We outline the theoretical assumptions of the hypothesis and stress the importance of incorporating evolutionary perspectives into public health. We explain how measuring perceived uncontrollable mortality risk can contribute towards understanding socioeconomic disparities in preventative health behaviours. We emphasize the importance of addressing structural inequalities in risk exposure, and argue that public health interventions should consider the relationship between overall levels of mortality risk and health behaviours across domains. We suggest that measuring perceptions of uncontrollable mortality risk can capture the unanticipated health benefits of structural risk interventions, as well as help to assess the appropriateness of different intervention approaches.

A Systematic Review of Studies Describing the Effectiveness, Acceptability, and Potential Harms of Place-Based Interventions to Address Loneliness and Mental Health Problems

Given the links between the built environment and loneliness, there is interest in using place-based approaches (addressing built environment characteristics and related socio-spatial factors) in local communities to tackle loneliness and mental health problems. However, few studies have described the effectiveness, acceptability, or potential harms of such interventions. This review aimed to synthesize the literature describing local community-based interventions that target place-based factors to address loneliness and mental health problems, informing the development of future public health approaches. We searched PsycINFO, Medline, and Embase using a structured search strategy to identify English-language studies evaluating the effectiveness, acceptability, and potential harms of place-based community interventions in addressing loneliness and mental health problems, both in general and clinical populations. Seven studies met the inclusion criteria, classified as evaluating provision of community facilities (such as clubhouses), active engagement in local green spaces, and housing regeneration. None were randomised trials. Quantitative and qualitative findings suggested promising effects and/or acceptability of six interventions, with minimal potential harms. There is a clear need for randomised trials or quasi-experimental studies of place-based interventions to describe their effectiveness in addressing loneliness and mental health problems, as well as complementary qualitative work investigating acceptability. This will inform future policy development.

Experiences of place attachment and mental wellbeing in the context of urban regeneration

Urban regeneration is an important policy focus across the European Union, with initiatives seeking to address inequalities in public health. Although theoretically such initiatives should produce benefits for mental wellbeing, this lacks strong supporting evidence. The current research addressed a prior overreliance on quantitative methods and underappreciation of the psychological significance of place, through the adoption of qualitative interviews with residents, as part of an independent review of a £650m regeneration project. Interpretative phenomenological analysis was utilised to explore the processes involved in residents' mental wellbeing and place attachment. Analysis developed three super-ordinate themes: 'feelings of control', 'social and community relations', and 'understandings and definitions of place'. These highlight issues relating to physical health, social isolation, community cohesion, as well as the potential for regeneration activities to undermine various elements of the people-place relationship.

Effects of an urban regeneration program on related social determinants of health in Chile: A pre-post intervention study

Urban regeneration programs, such as "Programa Quiero mi Barrio" (PQMB) that is carried out in neighborhoods with greater deprivation across Chile, can improve health and quality of life in socio-economically deprived neighborhoods. The aim of this study was to analyze the effects of this program on the physical, social, and safety environments of neighborhoods intervened between 2011 and 2018, according to gender and socioeconomic position. Four indices and six sub-indices were constructed to measure physical, social, and safety environments of the neighborhoods. We conducted a pre- and post-intervention analysis with 2095 people using linear models adjusted for repeated measurements. After the intervention, participants had an improved perception of physical, social, and safety environments, as well as the use of spaces, particularly among women and people with higher levels of education. Therefore, the PQMB program is a form of public policy that can improve the quality of life and health of people living in underprivileged areas.

In the Subtropical Monsoon Climate High-Density City, What Features of the Neighborhood Environment Matter Most for Public Health?

Urbanization and climate change have been rapidly occurring globally. Evidence-based healthy city development is required to improve living quality and mitigate the adverse impact of the outdoor neighborhood environment on public health. Taking Guangzhou as an example to explore the association of neighborhood environment and public health and preferably to offer some implications for better future city development, we measured ten environmental factors (temperature (T), wind-chill index (WCI), thermal stress index (HSI), relative humidity (RH), average wind speed (AWS), negative oxygen ions (NOI), PM2.5, luminous flux (LF), and illuminance (I)) in four seasons in four typical neighborhoods, and the SF-36 health scale was employed to assess the physical and mental health of neighborhood residents in nine subscales (health transition(HT), physiological functions (PF), general health status (GH), physical pain (BP), physiological functions (RP), energy vitality (VT), mental health (MH), social function (SF), and emotional functions (RE)). The linear mixed model was used in an analysis of variance. We ranked the different environmental factors in relation to aspects of health and weighted them accordingly. Generally, the thermal environment had the greatest impact on both physical and mental health and the atmospheric environment and wind environment had the least impact on physical health and mental health, respectively. In addition, the physical health of the resident was more greatly affected by the environment than mental health. According to the results, we make a number of strategic suggestions for the renewal of the outdoor neighborhood environment in subtropical monsoon climate high-density cities and provide a theoretical basis for improving public health through landscape architecture at the neighborhood scale.

The relationship between buildings and health: a systematic review

Background

The built environment exerts one of the strongest directly measurable effects on physical and mental health, yet the evidence base underpinning the design of healthy urban planning is not fully developed.

Method

This study provides a systematic review of quantitative studies assessing the impact of buildings on health. In total, 7127 studies were identified from a structured search of eight databases combined with manual searching for grey literature. Only quantitative studies conducted between January 2000 and November 2016 were eligible for inclusion. Studies were assessed using the quality assessment tool for quantitative studies.

Results

In total, 39 studies were included in this review. Findings showed consistently that housing refurbishment and modifications, provision of adequate heating, improvements to ventilation and water supply were associated with improved respiratory outcomes, quality of life and mental health. Prioritization of housing for vulnerable groups led to improved wellbeing. However, the quality of the underpinning evidence and lack of methodological rigour in most of the studies makes it difficult to draw causal links.

Conclusion

This review identified evidence to demonstrate the strong association between certain features of housing and wellbeing such as adequate heating and ventilation. Our findings highlight the need for strengthening of the evidence base in order for meaningful conclusions to be drawn.

Strengths, altered investment, risk management, and other elaborations on the behavioural constellation of deprivation

We are grateful to have received so many insightful commentaries from interested colleagues regarding our proposed behavioural constellation of deprivation (BCD) and our thoughts on its causes and consequences. In this response article, we offer some clarifications regarding our perspective and tackle some common misperceptions, including, for example, assumptions that the BCD is adaptive and that it should include all behaviours that vary with socioeconomic status. We then welcome some excellent proposals for extensions and modifications of our ideas, such as the conceptualisation of the BCD as a risk-management strategy and the calls for a greater focus on strengths and differential investment rather than deficits and disinvestment. Finally, we highlight some insightful explorations of the implications of our ideas for ethics, policy, and practice.

Making the Case for "Whole System" Approaches: Integrating Public Health and Housing

Housing conditions have been an enduring focus for public health activity throughout the modern public health era. However, the nature of the housing and health challenge has changed in response to an evolution in the understanding of the diverse factors influencing public health. Today, the traditional public health emphasis on the type and quality of housing merges with other wider determinants of health. These include the neighbourhood, community, and "place" where a house is located, but also the policies which make access to a healthy house possible and affordable for everyone. Encouragingly, these approaches to policy and action on housing have the potential to contribute to the "triple win" of health and well-being, equity, and environmental sustainability. However, more effective housing policies (and in public health in general) that adopt more systemic approaches to addressing the complex interactions between health, housing, and wider environment are needed. This paper illustrates some of the key components of the housing and health challenge in developed countries, and presents a conceptual model to co-ordinate activities that can deliver the "triple win." This is achieved by offering a perspective on how to navigate more effectively, inclusively and across sectors when identifying sustainable housing interventions.

City scale climate change policies: Do they matter for wellbeing?

Climate change mitigation policies aim to reduce climate change through reducing greenhouse gas (GHG) emissions whereas adaption policies seek to enable humans to live in a world with increasingly variable and more extreme climatic conditions. It is increasingly realised that enacting such policies will have unintended implications for public health, but there has been less focus on their implications for wellbeing. Wellbeing can be defined as a positive mental state which is influenced by living conditions. As part of URGENCHE, an EU funded project to identify health and wellbeing outcomes of city greenhouse gas emission reduction policies, a survey designed to measure these living conditions and levels of wellbeing in Kuopio, Finland was collected in December 2013. Kuopio was the northmost among seven cities in Europe and China studied. Generalised estimating equation modelling was used to determine which living conditions were associated with subjective wellbeing (measured through the WHO-5 Scale). Local greenspace and spending time in nature were associated with higher levels of wellbeing whereas cold housing and poor quality indoor air were associated with lower levels of wellbeing. Thus adaption policies to increase greenspace might, in addition to reducing heat island effects, have the co-benefit of increasing wellbeing and improving housing insulation.

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Climate change policies may change wellbeing-associated living conditions in a city.

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Local greenspace and nature immersion associated with higher levels of wellbeing.

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Climate change adaption policy to increase greenspace may increase wellbeing.

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Housing which is cold or has low quality indoor air associated with lower wellbeing.

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A housing insulation policy may increase wellbeing if ventilation is adequate.

Can housing improvements cure or prevent the onset of health conditions over time in deprived areas?

BACKGROUND

There is a need for more evidence linking particular housing improvements to changes in specific health conditions. Research often looks at generic works over short periods.

METHODS

We use a longitudinal sample (n = 1933) with a survey interval of 2-5 years. Multivariate logistic regression is used to calculate the odds ratios of developing or recovering from six health conditions according to receipt of four types of housing improvements.

RESULTS

Receipt of fabric works was associated with higher likelihood of recovery from mental health problems and circulatory conditions. Receipt of central heating was also associated with higher likelihood of recovery form circulatory conditions. No evidence was found for the preventative effects of housing improvements.

CONCLUSIONS

Health gain from housing improvements appears most likely when targeted at those in greatest health need. The health impacts of area-wide, non-targeted housing improvements are less clear in our study.

[Child health environment in the context of relocating of camp site families to social housing]

INTRODUCTION

Housing interventions aimed at overcoming poverty can lead to changes in the health status of children by modifying risk factors in their physical and social environment

OBJECTIVE

the aim was to identify children's environmental health factors to change with the relocation of families from slums to public housing.

SUBJECTS AND METHOD

A cross-sectional study was conducted in children ages 2-8 years old of families relocated to public housing (n=115) who were compared to children residing in slums (n=88) in Santiago, Chile. Family socioeconomic characteristics, indoor environment and neighborhoods were collected. It was included respiratory symptoms, accidents and maternal-child care of children. χ2, Fisher and Mann-Whitney test were used to compare groups.

RESULTS

There were differences in households related to pets keeping, presence of humidity/molds in homes, types of fuels, and perceived safety problems in neighborhoods (p<0.05). The families from slums reported higher tenancy of pets (73.8% v/s 32.2%%), humidity/molds in homes (43.,2% v/s 18.3%), use of wood for heating (39.8% v/s 0.0%), compared with families of public housing. Residents of public housing perceived more safety problems in neighborhood, and children have more asthma related symptoms and have lower diversity of accidents in home.

CONCLUSION

Among the factors studied, indoor air quality and safety in neighborhoods could be linked to changes from the relocation of families. This reinforces the need to deepen the positive and negative influences of residential mobility of these groups focused on child welfare perspective.

The longitudinal effects of neighbourhood social and material deprivation change on psychological distress in urban, community-dwelling Canadian adults

OBJECTIVE

The purpose of this study was to assess how longitudinal changes in neighbourhood material and social deprivation affect distress outcomes in adult Canadians.

STUDY DESIGN

This study used a prospective cohort approach.

METHODS

We paired data from 2745 urban participants of Canada's National Population Health Survey-who completed the Kessler 6-Item psychological distress screening tool at baseline and follow-up-with neighbourhood social and material deprivation data from the census-based Pampalon Deprivation Index. Data were paired using participants' postal code. We conducted multiple linear regression models, which were stratified by baseline deprivation level and controlled for key confounders.

RESULTS

Most participants lived in neighbourhoods that did not change drastically in social or material deprivation level during the six years between baseline and follow-up. We found that a worsening of material settings was significantly associated with worsening distress scores at follow-up. This finding is discussed in the context of existing literature, and made relevant for urban health research and policy.

Wellbeing impacts of city policies for reducing greenhouse gas emissions

To mitigate climate change, city authorities are developing policies in areas such as transportation, housing and energy use, to reduce greenhouse gas emissions. In addition to their effects on greenhouse gas emissions, these policies are likely to have consequences for the wellbeing of their populations for example through changes in opportunities to take physical exercise. In order to explore the potential consequences for wellbeing, we first explore what ‘wellbeing’ is and how it can be operationalized for urban planners. In this paper, we illustrate how wellbeing can be divided into objective and subjective aspects which can be measured quantitatively; our review of measures informs the development of a theoretical model linking wellbeing to policies which cities use to reduce greenhouse gas emissions. Finally, we discuss the extent to which the links proposed in the conceptual model are supported by the literature and how cities can assess wellbeing implications of policies.

Social safety, self-rated general health and physical activity: changes in area crime, area safety feelings and the role of social cohesion

The aim of this study was to examine whether changes over time in reported area crime and perceived area safety were related to self-rated general health and physical activity (PA), in order to provide support for a causal relationship between social safety and health. Additionally, we investigated whether social cohesion protects the residents against the negative impact of unsafe areas on health and PA. Multilevel logistic regression analyses were performed on Dutch survey data, including 47,926 respondents living in 2974 areas. An increase in area level unsafety feelings between 2009 and 2011 was associated with more people reporting poor general health in 2012 in that area, but was not related to PA. Changes in reported area crime were not related to either poor general health or PA. The social cohesion in the area did not modify the effect of changes in social safety on health and PA. The results suggest that tackling feelings of unsafety in an area might contribute to the better general health of the residents. Because changes in area social safety were not associated with PA, we found no leads that such health benefits were achieved through an increase in physical activity.

Inequalities in the social determinants of health of Aboriginal and Torres Strait Islander People: a cross-sectional population-based study in the Australian state of Victoria

INTRODUCTION

Aboriginal Australians are a culturally, linguistically and experientially diverse population, for whom national statistics may mask important geographic differences in their health and the determinants of their health. We sought to identify the determinants of health of Aboriginal adults who lived in the state of Victoria, compared with their non-Aboriginal counterparts.

METHODS

We obtained data from the 2008 Victorian Population Health Survey: a cross-sectional computer-assisted telephone interview survey of 34,168 randomly selected adults. The data included measures of the social determinants of health (socioeconomic status (SES), psychosocial risk factors, and social capital), lifestyle risk factors, health care service use, and health outcomes. We calculated prevalence ratios (PR) using a generalised linear model with a log link function and binomial distribution; adjusted for age and sex.

RESULTS

Aboriginal Victorians had a higher prevalence of self-rated fair or poor health, cancer, depression and anxiety, and asthma; most notably depression and anxiety (PR = 1.7, 95% CI; 1.4-2.2). Determinants that were statistically significantly different between Aboriginal and non-Aboriginal Victorians included: a higher prevalence of psychosocial risk factors (psychological distress, food insecurity and financial stress); lower SES (not being employed and low income); lower social capital (neighbourhood tenure of less than one year, inability to get help from family, didn't feel valued by society, didn't agree most people could be trusted, not a member of a community group); and a higher prevalence of lifestyle risk factors (smoking, obesity and inadequate fruit intake). A higher proportion of Aboriginal Victorians sought help for a mental health related problem and had had a blood pressure check in the previous two years.

CONCLUSIONS

We identified inequalities in health between Aboriginal and non-Aboriginal Victorians, most notably in the prevalence of depression and anxiety, and the social determinants of health (psychosocial risk factors, SES, and social capital). This has implications for evidence-based policy development and may inform the development of public health interventions.

The association between neighborhood residential rehabilitation and injection drug use in Baltimore, Maryland, 2000-2011

This study utilized multilevel cross-classified models to longitudinally assess the association between neighborhood residential rehabilitation and injection drug use. We also assessed whether relocating between neighborhoods of varying levels of residential rehabilitation was associated with injection drug use. Residential rehabilitation was categorized into three groups (e.g. low, moderate, high), and lagged one visit to ensure temporality. After adjusting for neighborhood and individual-level factors, residence in a neighborhood with moderate residential rehabilitation was associated with a 23% reduction in injection drug use [AOR=0.77; 95% CI (0.67,0.87)]; residence in a neighborhood with high residential rehabilitation was associated with a 26% reduction in injection drug use [AOR=0.74; 95% CI (0.61,0.91)]. Continuous residence within neighborhoods with moderate/high rehabilitation, and relocating to neighborhoods with moderate/high rehabilitation, were associated with a lower likelihood of injection drug use. Additional studies are needed to understand the mechanisms behind these relationships.

The effects of an urban renewal project on health and health inequalities: a quasi-experimental study in Barcelona

BACKGROUND

In the last decade, the Neighbourhoods Law in Catalonia (Spain) funded municipalities that presented urban renewal projects within disadvantaged neighbourhoods focusing on physical, social and economic improvements. The objective of the study was to evaluate the effects of this law on the health and health inequalities of residents in the intervened neighbourhoods in the city of Barcelona.

METHODS

A quasi-experimental predesign and postdesign was used to compare adult residents in five intervened neighbourhoods with eight non-intervened comparison neighbourhoods with similar socioeconomic characteristics. The Barcelona Health Survey was used for studying self-rated and mental health in pre (2001, 2006) and post (2011) years. Poisson regression models stratified by sex were used to compute prevalence ratios comparing 2011 with 2006, and later stratified by social class, to study health inequalities.

RESULTS

The intervened neighbourhoods had a significant decrease in poor self-rated health in both sexes while no significant changes occurred in the comparison group. When stratified by social class, a significant improvement was observed in poor self-rated health in the manual group of the intervened neighbourhoods in both sexes, resulting in a decrease in self-rated health inequalities. Similar results were observed in poor mental health of women, while in men, poor mental health worsens in both neighbourhood groups but mostly in the comparison group.

CONCLUSIONS

The Neighbourhoods Law had a positive effect on self-rated health and seems to prevent poor mental health increases in both sexes and especially among manual social classes.

Reducing social inequities in health through settings-related interventions -- a conceptual framework

INTRODUCTION

The creation of supportive environments for health is a basic action principle of health promotion, and equity is a core value. A settings approach offers an opportunity to bridge these two, with its focus on the interplay between individual, environmental and social determinants of health.

METHODS

We conducted a scoping review of the literature on theoretical bases and practical applications of the settings approach. Interventions targeting social inequities in health through action on various settings were analyzed to establish what is done in health equity research and action as it relates to settings.

RESULTS

Four elements emerged as central to an equity-focused settings approach: a focus on social determinants of health, addressing the needs of marginalized groups, effecting change in a setting's structure, and involving stakeholders. Each came with related challenges. To offer potential solutions to these challenges we developed a conceptual framework that integrates theoretical and methodological approaches, along with six core guiding principles, into a 'settings praxis'.

CONCLUSIONS

Reducing social inequities in health through the creation of supportive environments requires the application of the settings approach in an innovative way. The proposed conceptual framework can serve as a guide to do so, and help develop, implement and evaluate equity-focused settings-related interventions.

Economic analysis of the health impacts of housing improvement studies: a systematic review

BACKGROUND

Economic evaluation of public policies has been advocated but rarely performed. Studies from a systematic review of the health impacts of housing improvement included data on costs and some economic analysis. Examination of these data provides an opportunity to explore the difficulties and the potential for economic evaluation of housing.

METHODS

Data were extracted from all studies included in the systematic review of housing improvement which had reported costs and economic analysis (n=29/45). The reported data were assessed for their suitability to economic evaluation. Where an economic analysis was reported the analysis was described according to pre-set definitions of various types of economic analysis used in the field of health economics.

RESULTS

25 studies reported cost data on the intervention and/or benefits to the recipients. Of these, 11 studies reported data which was considered amenable to economic evaluation. A further four studies reported conducting an economic evaluation. Three of these studies presented a hybrid 'balance sheet' approach and indicated a net economic benefit associated with the intervention. One cost-effectiveness evaluation was identified but the data were unclearly reported; the cost-effectiveness plane suggested that the intervention was more costly and less effective than the status quo.

CONCLUSIONS

Future studies planning an economic evaluation need to (i) make best use of available data and (ii) ensure that all relevant data are collected. To facilitate this, economic evaluations should be planned alongside the intervention with input from health economists from the outset of the study. When undertaken appropriately, economic evaluation provides the potential to make significant contributions to housing policy.

Towards sustainable structures for neighbourhood development? Healthy city research in four Swedish municipalities 2003-2009

PURPOSE

A vehicle to reduce health inequalities and improve public health has been provided by programmes at a neighbourhood level. The purpose of this paper is to analyse the development processes in four municipalities for achieving sustainable structures in area-based development programmes during and after a formal partnership period.

DESIGN/METHODOLOGY/APPROACH

A case-study database was compiled based on the strategic and local work of four municipalities and four municipal housing companies who cooperated in the Partnership for Sustainable Welfare Development 2003-2009. The case-study database includes nine in-depth studies with interviews (n = 68), participant observations (n = 125), a survey (n = 1,160), and documents. The data are analysed using three theoretical concepts: political support, alliances, and citizen participation.

FINDINGS

Political support, alliances, and citizen participation are important building blocks in neighbourhood development work. However, when the partnership ended there was little left that could function as a sustainable structure. Political support seems to be a means to reach the target, including ensuring a consistent approach and allocation of resources. However, the support must continue also after the intervention period, when the formal partnership collaboration ends, otherwise the established structure will soon decompose. Citizen participation is another precondition for a sustainable structure able to continue despite reduced municipal support. Alliances have the best chance of forming sustainable structures when they involve both the strategic and the operational level.

ORIGINALITY/VALUE

Even though many evaluations have been conducted to capture the process of interventions, little attention has been given to the challenges facing the outcomes of the intervention when it comes to making permanent the activities for reducing health inequalities. This paper is an attempt to deal with these challenges.

Environmental interventions to reduce fear of crime: systematic review of effectiveness

BACKGROUND

Fear of crime is associated with negative health and wellbeing outcomes, and may mediate some impacts of the built environment on public health. A range of environmental interventions have been hypothesized to reduce the fear of crime.

METHODS

This review aimed to synthesize the literature on the effectiveness of interventions in the built environment to reduce the fear of crime. Systematic review methodology, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance, was used. Studies of environmental interventions which reported a fear of crime outcome and used any prospective evaluation design (randomized controlled trial (RCT), trial or uncontrolled before-and-after study) were included. Eighteen databases were searched. The Hamilton tool was used to assess quality. A narrative synthesis of findings was undertaken.

RESULTS

A total of 47 studies were included, 22 controlled and 25 uncontrolled, with total sample sizes ranging from n = 52 to approximately n = 23,000. Thirty-six studies were conducted in the UK, ten studies in the USA and one study in the Netherlands. The quality of the evidence overall is low. There are some indications that home security improvements and non-crime-related environmental improvements may be effective for some fear of crime outcomes. There is little evidence that the following reduce fear of crime: street lighting improvements, closed-circuit television (CCTV), multi-component environmental crime prevention programs or regeneration programs.

CONCLUSIONS

There is some evidence for the effectiveness of specific environmental interventions in reducing some indicators of fear of crime, but more attention to the context and possible confounders is needed in future evaluations of complex social interventions such as these.

Housing improvements for health and associated socio-economic outcomes

BACKGROUND

The well established links between poor housing and poor health indicate that housing improvement may be an important mechanism through which public investment can lead to health improvement. Intervention studies which have assessed the health impacts of housing improvements are an important data resource to test assumptions about the potential for health improvement. Evaluations may not detect long term health impacts due to limited follow-up periods. Impacts on socio-economic determinants of health may be a valuable proxy indication of the potential for longer term health impacts.

OBJECTIVES

To assess the health and social impacts on residents following improvements to the physical fabric of housing.

SEARCH METHODS

Twenty seven academic and grey literature bibliographic databases were searched for housing intervention studies from 1887 to July 2012 (ASSIA; Avery Index; CAB Abstracts; The Campbell Library; CINAHL; The Cochrane Library; COPAC; DH-DATA: Health Admin; EMBASE; Geobase; Global Health; IBSS; ICONDA; MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; NTIS; PAIS; PLANEX; PsycINFO; RIBA; SCIE; Sociological Abstracts; Social Science Citations Index; Science Citations Index expanded; SIGLE; SPECTR). Twelve Scandinavian grey literature and policy databases (Libris; SveMed+; Libris uppsök; DIVA; Artikelsök; NORART; DEFF; AKF; DSI; SBI; Statens Institut for Folkesundhed; Social.dk) and 23 relevant websites were searched. In addition, a request to topic experts was issued for details of relevant studies. Searches were not restricted by language or publication status.

SELECTION CRITERIA

Studies which assessed change in any health outcome following housing improvement were included. This included experimental studies and uncontrolled studies. Cross-sectional studies were excluded as correlations are not able to shed light on changes in outcomes. Studies reporting only socio-economic outcomes or indirect measures of health, such as health service use, were excluded. All housing improvements which involved a physical improvement to the fabric of the house were included. Excluded interventions were improvements to mobile homes; modifications for mobility or medical reasons; air quality; lead removal; radon exposure reduction; allergen reduction or removal; and furniture or equipment. Where an improvement included one of these in addition to an included intervention the study was included in the review. Studies were not excluded on the basis of date, location, or language.

DATA COLLECTION AND ANALYSIS

Studies were independently screened and critically appraised by two review authors. Study quality was assessed using the risk of bias tool and the Hamilton tool to accommodate non-experimental and uncontrolled studies. Health and socio-economic impact data were extracted by one review author and checked by a second review author. Studies were grouped according to broad intervention categories, date, and context before synthesis. Where possible, standardized effect estimates were calculated and statistically pooled. Where meta-analysis was not appropriate the data were tabulated and synthesized narratively following a cross-study examination of reported impacts and study characteristics. Qualitative data were summarized using a logic model to map reported impacts and links to health impacts; quantitative data were incorporated into the model.

MAIN RESULTS

Thirty-nine studies which reported quantitative or qualitative data, or both, were included in the review. Thirty-three quantitative studies were identified. This included five randomised controlled trials (RCTs) and 10 non-experimental studies of warmth improvements, 12 non-experimental studies of rehousing or retrofitting, three non-experimental studies of provision of basic improvements in low or mIddle Income countries (LMIC), and three non-experimental historical studies of rehousing from slums. Fourteen quantitative studies (42.4%) were assessed to be poor quality and were not included in the synthesis. Twelve studies reporting qualitative data were identified. These were studies of warmth improvements (n = 7) and rehousing (n = 5). Three qualitative studies were excluded from the synthesis due to lack of clarity of methods. Six of the included qualitative studies also reported quantitative data which was included in the review.Very little quantitative synthesis was possible as the data were not amenable to meta-analysis. This was largely due to extreme heterogeneity both methodologically as well as because of variations in the intervention, samples, context, and outcome; these variations remained even following grouping of interventions and outcomes. In addition, few studies reported data that were amenable to calculation of standardized effect sizes. The data were synthesised narratively.Data from studies of warmth and energy efficiency interventions suggested that improvements in general health, respiratory health, and mental health are possible. Studies which targeted those with inadequate warmth and existing chronic respiratory disease were most likely to report health improvement. Impacts following housing-led neighbourhood renewal were less clear; these interventions targeted areas rather than individual households in most need. Two poorer quality LMIC studies reported unclear or small health improvements. One better quality study of rehousing from slums (pre-1960) reported some improvement in mental health. There were few reports of adverse health impacts following housing improvement. A small number of studies gathered data on social and socio-economic impacts associated with housing improvement. Warmth improvements were associated with increased usable space, increased privacy, and improved social relationships; absences from work or school due to illness were also reduced.Very few studies reported differential impacts relevant to equity issues, and what data were reported were not amenable to synthesis.

AUTHORS' CONCLUSIONS

Housing investment which improves thermal comfort in the home can lead to health improvements, especially where the improvements are targeted at those with inadequate warmth and those with chronic respiratory disease. The health impacts of programmes which deliver improvements across areas and do not target according to levels of individual need were less clear, but reported impacts at an area level may conceal health improvements for those with the greatest potential to benefit. Best available evidence indicates that housing which is an appropriate size for the householders and is affordable to heat is linked to improved health and may promote improved social relationships within and beyond the household. In addition, there is some suggestion that provision of adequate, affordable warmth may reduce absences from school or work.While many of the interventions were targeted at low income groups, a near absence of reporting differential impacts prevented analysis of the potential for housing improvement to impact on social and economic inequalities.

Smoking and intention to quit in deprived areas of Glasgow: is it related to housing improvements and neighbourhood regeneration because of improved mental health?

Background

People living in areas of multiple deprivation are more likely to smoke and less likely to quit smoking. This study examines the effect on smoking and intention to quit smoking for those who have experienced housing improvements (HI) in deprived areas of Glasgow, UK, and investigates whether such effects can be explained by improved mental health.

Methods

Quasi-experimental, 2-year longitudinal study, comparing residents’ smoking and intention to quit smoking for HI group (n=545) with non-HI group (n=517), adjusting for baseline (2006) sociodemographic factors and smoking status. SF-12 mental health scores were used to assess mental health, along with self-reported experience of, and General Practitioner (GP) consultations for, anxiety and depression in the last 12 months.

Results

There was no relationship between smoking and HI, adjusting for baseline rates (OR=0.97, 95% CI 0.57 to 1.67, p=0.918). We found an association between intention to quit and HI, which remained significant after adjusting for sociodemographics and previous intention to quit (OR 2.16, 95% CI 1.12 to 4.16, p=0.022). We found no consistent evidence that this association was attenuated by improvement in our three mental health measures.

Conclusions

Providing residents in disadvantaged areas with better housing may prompt them to consider quitting smoking. However, few people actually quit, indicating that residential improvements or changes to the physical environment may not be sufficient drivers of personal behavioural change. It would make sense to link health services to housing regeneration projects to support changes in health behaviours at a time when environmental change appears to make behavioural change more likely.

A pre-and-post study of an urban renewal program in a socially disadvantaged neighbourhood in Sydney, Australia

BACKGROUND

Urban renewal programs aim to target both the physical and social environments to improve the social capital, social connectedness, sense of community and economic conditions of residents of the neighbourhoods. We evaluated the impact of an urban renewal program on the health and well-being of residents of a socially disadvantaged community in south-western Sydney, Australia.

METHODS

Pre- and post-urban renewal program surveys were conducted with householders by trained interviewers. The urban renewal program was conducted over 16 months and consisted of internal upgrades (including internal painting; replacement of kitchens, bathrooms and carpets; general maintenance), external upgrades (including property painting; new fencing, carports, letterboxes, concrete driveways, drainage and landscaping), general external maintenance, and social interventions such as community engagement activities, employment initiatives, and building a community meeting place. The questionnaire asked about demographic characteristics, self-reported physical activity, psychological distress, self-rated health, and perceptions of aesthetics, safety and walkability in the neighbourhood. We used the paired chi-square test (McNemars test) to compare paired proportions. A Bonferroni corrected p-value of <0.0013 denoted statistical significance.

RESULTS

Following the urban renewal program we did not find statistically significant changes in perceptions of aesthetics, safety and walkability in the neighbourhood. However, post-urban renewal, more householders reported there were attractive buildings and homes in their neighbourhood (18% vs 64%), felt that they belonged to the neighbourhood (48% vs 70%), that their area had a reputation for being a safe place (8% vs 27%), that they felt safe walking down their street after dark (52% vs 85%), and that people who came to live in the neighbourhood would be more likely to stay rather than move elsewhere (13% vs 54%). Changes in psychological distress and self-rated health were not statistically significant.

CONCLUSIONS

We found an increase, in the short-term, in the proportion of householders reporting improvements in some aspects of their immediate neighbourhood following the urban renewal program. It will be important to repeat the survey in the future to determine whether these positive changes are sustained.

The influence of neighbourhood disadvantage on smoking cessation and its contribution to inequalities in smoking status

INTRODUCTION AND AIMS

Individual smokers from disadvantaged backgrounds are less likely to quit, which contributes to widening inequalities in smoking. Residents of disadvantaged neighbourhoods are more likely to smoke, and neighbourhood inequalities in smoking may also be widening because of neighbourhood differences in rates of cessation. This study examined the association between neighbourhood disadvantage and smoking cessation and its relationship with neighbourhood inequalities in smoking.

DESIGN AND METHODS

A multilevel longitudinal study of mid-aged (40-67 years) residents (n = 6915) of Brisbane, Australia, who lived in the same neighbourhoods (n = 200) in 2007 and 2009. Neighbourhood inequalities in cessation and smoking were analysed using multilevel logistic regression and Markov chain Monte Carlo simulation.

RESULTS

After adjustment for individual-level socioeconomic factors, the probability of quitting smoking between 2007 and 2009 was lower for residents of disadvantaged neighbourhoods (9.0-12.8%) than their counterparts in more advantaged neighbourhoods (20.7-22.5%). These inequalities in cessation manifested in widening inequalities in smoking: in 2007 the between-neighbourhood variance in rates of smoking was 0.242 (P ≤ 0.001) and in 2009 it was 0.260 (P ≤ 0.001). In 2007, residents of the most disadvantaged neighbourhoods were 88% (OR 1.88, 95% credible intervals (CrI) 1.41-2.49) more likely to smoke than residents in the least disadvantaged neighbourhoods: the corresponding difference in 2009 was 98% (OR 1.98, 95% CrI 1.48-2.66).

CONCLUSION

Fundamentally, social and economic inequalities at the neighbourhood and individual levels cause smoking and cessation inequalities. Reducing these inequalities will require comprehensive, well-funded and targeted tobacco control efforts and equity-based policies that address the social and economic determinants of smoking.

A rating scale for housing-based health hazards

OBJECTIVES

This study investigated the validity and responsiveness of a rating scale designed to assess the housing-based hazards and their relationships to burden of disease symptoms in the building occupants.

STUDY DESIGN

A population-based cross-sectional survey.

METHODS

Random-digit dialing with computer-assisted phone interviews was conducted to obtain information from 642 households in the City of Saginaw, Michigan about 71 housing-based hazards, symptoms of 43 diseases often associated with environmental exposures and demographic characteristics. The housing-based hazard index (HHI) was calculated from scores of hazards across the following eight dimensions: structural scale (18 items); moisture/mold scale (8 items), electrical scale (7 items), ventilation and combustion appliances scale (6 items); pest scale (6 items); pets scale (4 items), fire scale (6 items) and lifestyle-associated factors scale (12 items). Each item was assigned a relative score based on the likelihood that the housing occupants would be exposed to the hazard, the potential for serious health impacts, and the reported strength of its association with childhood lead poisoning and respiratory diseases. The psychometric properties of HHI and individual domains (scales) were assessed along with the associations between these indicators and the inventory of disease symptoms.

RESULTS

The reliability of HHI was demonstrated by assessments of its dimensionality and internal consistency. Analysis of the predictive validity and responsiveness indicates that HHI and scores for most of the individual scales can discriminate between households in relation to the burden of reported disease symptoms.

CONCLUSIONS

The HHI represents a valid, reasonably reliable, and parsimonious measure of hazards that are congruent with the burden of symptoms generally associated with housing-related diseases.

Neighbourhood development and public health initiatives: who participates?

Citizen participation in neighbourhood development is one way to promote public health and contribute to the well-being of individuals. However, some people participate while others do not. This study examines the individual characteristics of people who during the past 2 years have participated in a neighbourhood development process compared with potential and non-participants. Socio-demographic factors, perceptions and behaviour were analysed in a cross-sectional study. A questionnaire was answered by 1160 randomly chosen citizens over the age of 18 who lived in three Swedish cities. The most important single factor related to participation in neighbourhood development was prior experience of participation, such as attempting to influence city policies by contacting politicians, submitting a citizen proposal, etc. Furthermore, having frequent political discussions with neighbours was another behavioural factor that was found associated to people's participation in neighbourhood development. Among socio-demographic factors, only ethnicity was found significant after controlling for other factors; i.e. people born outside the Nordic countries were less likely to participate.

Neighbourhood planning improvement: physical attributes, cognitive and affective evaluation and activities in two neighbourhoods in Rome

This study proposes a psychological analysis of the relationships between people and their residential environment in two neighbourhoods in Rome, within the theoretical framework of place theory. The analysis was aimed at getting indications for neighbourhood improvement, which can lead to residential satisfaction and neighbourhood attachment. We considered both constructs as the result of the relationships between the physical attributes of the environment, the cognitive perceptions and the affective appraisals of residents, and the activities they carry out. The role of socio-demographic and residential variables was also considered. Theoretical implications of results and indications for neighbourhood improvement are discussed. Residential satisfaction and neighbourhood attachment have a different pattern of predictors, emerging from all the dimensions of analysis we considered. Using hierarchical linear models, cognitive, affective and behavioural variables emerged as significant first-level predictors of both criteria, and physical attributes were found to be significant second-level predictors. In addition, the joint analysis of objective neighbourhood features and residents' experience within a place-specific framework showed to be an effective approach to identify relevant domains for neighbourhood improvement. Commercial and leisure facilities can contribute to make the neighbourhood more lively; building density and green areas have inverse effects on the prevalence of social activities.

The SHARP study: a quantitative and qualitative evaluation of the short-term outcomes of housing and neighbourhood renewal

Background

The SHARP study was set up to evaluate the short (1 year) and longer-term (2 year) effects on health and wellbeing of providing new social housing to tenants. This paper presents the study background, the design and methods, and the findings at one year.

Methods

Data were collected from social tenants who were rehoused into a new, general-purpose socially-rented home developed and let by a Scottish Registered Social Landlord (the "Intervention" group). These data were collected at three points in time: before moving (Wave 1), one year after moving (Wave 2) and two years after moving (Wave 3). Data were collected from a Comparison group using the same methods at Baseline (Wave 1) and after two years of follow-up (Wave 3). Qualitative data were also collected by means of individual interviews. This paper presents the quantitative and qualitative findings at 1 year (after Wave 2).

Results

339 Intervention group interviews and 392 Comparison group interviews were completed. One year after moving to a new home there was a significant reduction in the proportion of Intervention group respondents reporting problems with the home, such as damp and noise. There was also a significant increase in neighbourhood satisfaction compared with Baseline (χ² = 35.51, p < 0.0001). Many aspects of the neighbourhood improved significantly, including antisocial behaviour. In terms of environmental aspects and services the greatest improvements were in the general appearance of the area, the reputation of the area, litter and rubbish, and speeding traffic. However, lack of facilities for children/young people and lack of safe children's play areas remained a concern for tenants.

Conclusion

This study found that self-reported health changed little in the first year after moving. Nonetheless, the quantitative and qualitative data point to improvements in the quality of housing and of the local environment, as well as in tenant satisfaction and other related outcomes. Further analyses will explore whether these effects are sustained, and whether differences in health outcomes emerge at 2 years compared with the Comparison group.

'Lost': listening to the voices and mental health needs of forced migrants in London

Research into the mental health needs of asylum seekers and refugees has revealed that they are likely to experience poorer mental health as well as higher levels of exclusion and vulnerability than native populations. This paper reports on data drawn from semi-structured interviews of 21 refugees and asylum seekers that describe the complexity experienced by those living in exile, and the necessity for a more integrated and holistic approach in the planning and delivery of services to support mental health. Incorporating a perspective from service users will encourage providers to take account of the multitude of practical, social, cultural, economic and legal difficulties that can influence the long-term mental health of this population. The implications highlight a need to shift from a simple biomedical model of the causes and effects of ill-health to a social model, which will require reorganisation not only in healthcare but in welfare, housing, employment and immigration policy.

Peer and neighbourhood influences on teenage pregnancy and fertility: Qualitative findings from research in English communities

Geographic variation in teenage pregnancy is attributable to social and cultural, as well as demographic, factors. In some communities and social networks early childbearing may be acceptable, or even normative. It is these places that are the focus of policy initiatives. This paper reports the findings of a qualitative study of neighbourhood and peer influences on the transition from pregnancy to fertility among 15 young mothers in three English locations. Data were also collected from nine local health workers. The findings show that, from the mothers' perspective, there was no evidence that peers influenced behaviour. However, the data did suggest that early childbearing might be normative in some communities.

Public housing, health and health behaviors: is there a connection?

This paper explores the relationship between public housing, health outcomes, and health behaviors among low-income housing residents. While public housing can be a dangerous and unhealthy environment in which to live, the subsidized rent may free up resources for nutritious food and health care. In addition, public housing may be of higher quality than the available alternatives, it may provide easier access to health clinics willing to serve the poor, and it may link residents to social support networks, which can improve mental health and the ability to access higher-quality grocery stores. To test whether there is a "back-door" health benefit to the public housing program, we analyze data from the Fragile Families and Child Wellbeing Study. We minimize the effects of selection into public housing with controls and instrumental variables estimation and find that the results are somewhat sensitive to the instrumental variable used, and thus, we conclude that we are unable to detect a robust health benefit from public housing for our measures of health. However, we do find some evidence that public housing residency has mixed effects on domestic violence, increases obesity, and worsens mothers' overall health status.

Impediments to policy implementation: The offer of free installation of central heating to an elderly community has limited uptake

OBJECTIVES

Increasing the warmth of homes in the UK to combat excess winter mortality has become an important part of public policy. This study examined the success of a local initiative to provide free installation of central heating for a group of elderly people.

STUDY DESIGN

Cohort study.

METHODS

The uptake of the offer of central heating was monitored through its different stages. Where possible, comments were invited from the elderly tenants to whom the offer was made; a sub-sample was interviewed about their views.

RESULTS

Of 1181 tenants approached, only around one-quarter finally received central heating within the year. Reasons for the low uptake included inaccuracies in estimating those eligible as well as tenants' worries over upheaval and mess, health concerns and fear of increased heating costs.

CONCLUSION

Successful policy implementation requires not only command of appropriate financial resources and the backing of local 'implementers', but also the local resources with which the policy will engage, especially local knowledge, and the 'targets' of the policy initiative, in this case the elderly tenants.

"The walls were so damp and cold" fuel poverty and ill health in Northern Ireland: results from a housing intervention

This article reports the findings from an evaluation of a fuel poverty programme in the Armagh and Dungannon Health Action Zone in Northern Ireland. Focusing on a rural community, it adds to the debate surrounding the hidden nature of rural fuel poverty. As part of the programme, energy efficiency measures, including some central heating systems, were installed in 54 homes. Surveys were conducted both pre and post intervention and analysed to assess any changes. The programme demonstrated that energy efficiency intervention can lead to improvements in health and well being, increased comfort levels in the home and a reduction in the use of health services, therefore having potential cost savings for the NHS. Some households, however, remain in fuel poverty after having full central heating installed, reflecting the significant contribution of low income on the production of fuel poverty. The article concludes by suggesting that interventions in this area require commitment from multiple sectors of society, including health professionals and local communities.

Neglected diseases of neglected populations: thinking to reshape the determinants of health in Latin America and the Caribbean

BACKGROUND

People living in poverty throughout the developing world are heavily burdened with neglected communicable diseases and often marginalized by the health sector. These diseases are currently referred to as Neglected Diseases of Neglected Populations. The neglected diseases create social and financial burdens to the individual, the family, the community, and the nation.

DISCUSSION

Numerous studies of successful individual interventions to manage communicable disease determinants in various types of communities have been published, but few have applied multiple interventions in an integrated, coordinated manner. We have identified a series of successful interventions and developed three hypothetical scenarios where such interventions could be applied in an integrated, multi-disease, inter-programmatic, and/or inter-sectoral approach for prevention and control of neglected diseases in three different populations: a slum, an indigenous community, and a city with a mix of populations.

SUMMARY

The objective of this paper is to identify new opportunities to address neglected diseases, improve community health and promote sustainable development in neglected populations by highlighting examples of key risk and protective factors for neglected diseases which can be managed and implemented through multi-disease-based, integrated, inter-programmatic, and/or inter-sectoral approaches. Based on a literature review, analysis and development of scenarios we visualize how multiple interventions could manage multiple disease problems and propose these as possible strategies to be tested. We seek to stimulate intra- and inter-sectoral dialogue which will help in the construction of new strategies for neglected diseases (particularly for the parasitic diseases) which could benefit the poor and marginalized based on the principle of sustainability and understanding of key determinants of health, and lead to the establishment of pilot projects and activities which can contribute to the achievement of the Millennium Development Goals.

Housing and public health

This review considers the broad area of housing and public health, one of the traditional and core areas of public health research and intervention. The review takes into account the range of factors, acting at different levels, directly and indirectly, through which housing affects health. In public health terms, housing affects health in a myriad of relatively minor ways, in total forming one of the key social determinants of health. The paper closes by considering how the improvement of housing and neighborhoods has been a core activity of public health and a central component in tackling poverty. Investment in housing can be more than an investment in bricks and mortar: It can also form a foundation for the future health and well-being of the population. Addressing poor-quality housing and detrimental neighborhoods, in the broadest sense, is thus a task that should be grasped with vigor and determination by all those involved in public health.

Health impact assessment of housing improvements: incorporating research evidence

BACKGROUND

Health impact assessment (HIA) has been widely recommended for future social policies and investment, such as housing improvement. However, concerns have been raised about the utility and predictive value of an HIA. Use of existing research data would add more weight to forecasts by an HIA. METHODS, RESULTS, and

CONCLUSIONS

A recent systematic review of housing intervention studies found a lack of research. The authors recommended that a broader evidence base would be needed to support HIA. In response to consultation with policymakers and HIA practitioners this paper presents a way in which research can be used to inform HIA. Based on the systematic review, the authors have developed a table of synthesised findings indicating the expected health effects of specific housing improvements. The authors also reviewed observational data of housing associated health risks to highlight the key impacts to consider when doing a housing HIA. The findings are presented and the authors discuss how they should be used to inform evidence based housing HIA. In addition to considering the existing research, HIA must consider the local relevance of research. Consultation with local stakeholders also needs to be incorporated to the final assessment. The lack of data and the difficulties in gathering and reviewing data mean that not all HIAs will be able to be informed by research evidence. Well conducted prospective validation of HIAs would contribute to the development of healthy housing investment by informing future housing HIA.

Health effects of housing improvement: systematic review of intervention studies

OBJECTIVE

To review the evidence on the effects of interventions to improve housing on health.

DESIGN

Systematic review of experimental and non-experimental housing intervention studies that measured quantitative health outcomes.

DATA SOURCES

Studies dating from 1887, in any language or format, identified from clinical, social science, and grey literature databases, personal collections, expert consultation, and reference lists.

MAIN OUTCOME MEASURES

Socioeconomic change and health, illness, and social measures.

RESULTS

18 completed primary intervention studies were identified. 11 studies were prospective, of which six had control groups. Three of the seven retrospective studies used a control group. The interventions included rehousing, refurbishment, and energy efficiency measures. Many studies showed health gains after the intervention, but the small study populations and lack of controlling for confounders limit the generalisability of these findings.

CONCLUSIONS

The lack of evidence linking housing and health may be attributable to pragmatic difficulties with housing studies as well as the political climate in the United Kingdom. A holistic approach is needed that recognises the multifactorial and complex nature of poor housing and deprivation. Large scale studies that investigate the wider social context of housing interventions are required.