A dose of realism for healthy urban policy: lessons from area-based initiatives in the UK

Investigating health and social outcomes of the Big Local community empowerment initiative in England: a mixed method evaluation

Background

Most research on community empowerment provides evidence on engaging communities for health promotion purposes rather than attempts to create empowering conditions. This study addresses this gap.

Intervention

Big Local started in 2010 with £271M from the National Lottery. Ending in 2026, it gives 150 relatively disadvantaged communities in England control over £1M to improve their neighbourhoods.

Objective

To investigate health and social outcomes, at the population level and among engaged residents, of the community engagement approach adopted in a place-based empowerment initiative.

Study design, data sources and outcome variables

This study reports on the third wave of a longitudinal mixed-methods evaluation. Work package 1 used a difference-in-differences design to investigate the impact of Big Local on population outcomes in all 150 Big Local areas compared to matched comparator areas using secondary data. The primary outcome was anxiety; secondary outcomes included a population mental health measure and crime in the neighbourhood. Work package 2 assessed active engagement in Big Local using cross-sectional data and nested cohort data from a biannual survey of Big Local partnership members. The primary outcome was mental well-being and the secondary outcome was self-rated health. Work package 3 conducted qualitative research in 14 Big Local neighbourhoods and nationally to understand pathways to impact. Work package 4 undertook a cost-benefit analysis using the life satisfaction approach to value the benefits of Big Local, which used the work package 1 estimate of Big Local impact on life satisfaction.

Results

At a population level, the impacts on 'reporting high anxiety' (-0.8 percentage points, 95% confidence interval -2.4 to 0.7) and secondary outcomes were not statistically significant, except burglary (-0.054 change in z-score, 95% confidence interval -0.100 to -0.009). There was some effect on reduced anxiety after 2017. Areas progressing fastest had a statistically significant reduction in population mental health measure (-0.053 change in z-score, 95% confidence interval -0.103 to -0.002). Mixed results were found among engaged residents, including a significant increase in mental well-being in Big Local residents in the nested cohort in 2018, but not by 2020; this is likely to be COVID-19. More highly educated residents, and males, were more likely to report a significant improvement in mental well-being. Qualitative accounts of positive impacts on mental well-being are often related to improved social connectivity and physical/material environments. Qualitative data revealed increasing capabilities for residents' collective control. Some negative impacts were reported, with local factors sometimes undermining residents' ability to exercise collective control. Finally, on the most conservative estimate, the cost-benefit calculations generate a net benefit estimate of £64M.

Main limitations

COVID-19 impacted fieldwork and interpretation of survey data. There was a short 4-year follow-up (2016/20), no comparators in work package 2 and a lack of power to look at variations across areas.

Conclusions

Our findings suggest the need for investment to support community organisations to emerge from and work with communities. Residents should lead the prioritisation of issues and design of solutions but not necessarily lead action; rather, agencies should work as equal partners with communities to deliver change.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research Programme (16/09/13) and will be published in full in Public Health Research; Vol. 11, No. 9. See the NIHR Journals Library website for further project information.

The impact of community engagement as a public health intervention to support the mental well-being of single mothers and children living under housing insecure conditions - a rapid literature review

BACKGROUND

In the UK, the population of homelessness and housing insecurity is increasing among families headed by mothers. The unique stressors of housing insecurity and living in accommodations ill-suited to long-term dwellings increase mental distress for mothers and children. Community engagement interventions present a public health opportunity to alleviate adverse outcomes for vulnerable families.

AIM

To synthesise and evaluate evidence of the impact of community engagement interventions in supporting the mental well-being of mothers and children living under housing insecure conditions. To synthesise the components of community engagement interventions as a public health intervention in alleviating mental well-being and non-health outcomes of mothers and children living under housing insecurity.

METHODS

A systematic search of five online bibliographic databases (MEDLINE, EMBASE, PsychINFO, Global Health and Child Development & Adolescent Studies) and grey literature (Carrot2) was conducted in May 2022. Primary studies with community engagement components and housing-insecure single-mother families were included. Intervention data was extracted using the TIDieR checklist and a community engagement keywording tool. The studies' quality was critically appraised using the MetaQAT framework.

RESULTS

Ten studies meeting inclusion criteria were identified, across two countries (USA & UK). Data from the studies reported positive significant effects for health and personal maternal outcomes in addition to higher positive effects for child health outcomes (e.g., decrease in depression symptoms). Interventions targeting social support and self-efficacy demonstrated potential to improve maternal and child outcomes via the maternal-child relationship. Community engagement at the design, delivery and evaluation intervention stages increased the level of community engagement, however there were tentative links to directly improving mental well-being outcomes.

CONCLUSION

There is evidence to suggest that community engagement may be applied as an effective intervention in supporting the mental well-being of mothers and children living under housing insecurity. Proposed intervention effectiveness may be achieved via psychosocial pathways such as improved maternal self-efficacy and social support. However, more embedded long-term process evaluations of these interventions are needed to establish maintenance of these observed benefits and to understand to what extent the findings apply to the UK context.

Do inhabitants profit from integrating a public health focus in urban renewal programmes? A Dutch case study

Background

Urban renewal traditionally involves policy sectors such as housing, transport, and employment, which potentially can enhance the health of residents living in deprived areas. Additional involvement of the public health sector might increase the health impact of these urban renewal activities. This study evaluates the health impact of an additional focus on health, under the heading of Healthy District Experiments (HDE), within districts where an urban renewal programme was carried out.

Methods

We evaluated changes in health outcomes before the start of the HDE and after implementation, and compared these changes with health changes in control areas, e.g. districts from the urban renewal programme where no additional HDE was implemented. Additionally, we gathered information on the content of the experiments to determine what types of activities have been implemented.

Results

The additional activities from the HDE were mostly aimed at strengthening the health care in the districts and at promoting physical activity. When we compared the prevalence in general health, mental health, overweight, obesity, smoking, and physical activity during the study period between the HDE districts and control districts, we found no significant differences in the rate of change. The study is limited by a small sample size and the cross-sectional nature of the data. These and other limitations are discussed.

Conclusion

We found no evidence for a beneficial health impact of the activities that were initiated with a specific focus on health, within a Dutch urban renewal programme. Specific attention for network management and the integration of such activities in the wider programme, as well as an allocated budget might be needed in order to sort a health impact.

Place-based approaches to improve health and development outcomes in young children: A scoping review

This scoping review examines the strength of evidence for the effectiveness of public policy-led place-based initiatives designed to improve outcomes for disadvantaged children, their families and the communities in which they live. Study designs and methods for evaluating such place-based initiatives were assessed, along with the contexts in which initiatives were implemented and evaluated. Thirty-two reports relating to 12 initiatives were included. Eleven initiatives used a quasi-experimental evaluation to assess impact, although there were considerable design variations within this. The remaining initiative used a pre- and post- evaluation design. Place-based initiatives by definition aim to improve multiple and interrelated outcomes. We examined initiatives to determine what outcomes were measured and coded them within the five domains of pregnancy and birth, child, parent, family and community. Across the 83 outcomes reported in the 11 studies with a comparison group, 30 (36.4%) demonstrated a positive outcome, and all but one initiative demonstrated a positive outcome in at least one outcome measure. Of the six studies that examined outcomes more than once post baseline, 10 from 38 outcomes (26.3%) demonstrated positive sustained results. Many initiatives were affected by external factors such as policy and funding changes, with unknown impact on their effectiveness. Despite the growth of place-based initiatives to improve outcomes for disadvantaged children, the evidence for their effectiveness remains inconclusive.

The Effectiveness of Integral Urban Strategies: Policy Theory and Target Scale. The European URBAN I Initiative and Employment

Integrated urban development strategies are shaping a new policy frame to cope with the complexity of urban problems. This implies multi-level policy mixes involving multiple goals, the collaboration between different actors, and policy theories based on complementarity between different policy tools (and their causal processes). As in other policies, the third aspect has been less analysed. This article studied the theory behind policy mixes developed in the European Union URBAN I Initiative framework and the effects on its employment inclusion goal. The policy theory suggests complementary effects between policy actions oriented toward economic activities and those oriented at increasing employment skills to, in turn, increase residents’ inclusion in the labour market. The quasi-experimental approach applied at the neighbourhood level in Spain showed a moderate influence on employment among the youngest age cohorts and a more evident impact on business density. Nevertheless, evidence concerning the complementarity between actions oriented at improving labour market demand and labour market supply in targeted neighbourhoods suggested in the program theory is less convincing. This exercise showed the methodological challenges in assessing the effectiveness of integral urban initiatives and offered some suggestions regarding the policy theory behind them through a European Union case.

A 'strategy of resistance'? How can a place-based empowerment programme influence local media portrayals of neighbourhoods and what are the implications for tackling health inequalities?

Place-based stigma is linked with health and social harms, but few studies have assessed what actions may reduce these. Area-based programmes are one potential strategy but may exacerbate stigma by targeting disadvantaged neighbourhoods. We reviewed newspaper coverage in two stigmatised neighbourhoods to identify whether a programme funded in these localities influenced reporting. While both areas were dominated by negative coverage, the progamme provided an impetus for some positive stories over time and enabled community activists to articulate alternative narratives about where they lived, countering negative external portrayals. The involvement of residents should be central to strategies to tackle place-based stigma.

Effect of the Financial Crisis on Socioeconomic Inequalities in Mortality in Small Areas in Seven Spanish Cities

Background: The aim of this study was to analyze the trend in socioeconomic inequalities in mortality in small areas due to several specific causes before (2001–2004, 2005–2008) and during (2009–2012) the economic crisis in seven Spanish cities. Methods: This ecological study of trends, with census tracts as the areas of analysis, was based on three periods. Several causes of death were studied. A socioeconomic deprivation index was calculated for each census tract. For each small area, we estimated standardized mortality ratios, and controlled for their variability using Bayesian models (sSMR). We also estimated the relative risk of mortality according to deprivation in the different cities, periods, and sexes. Results: In general, a similar geographical pattern was found for the socioeconomic deprivation index and sSMR. For men, there was an association in all cities between the deprivation index and all-cause mortality that remained stable over the three periods. For women, there was an association in Barcelona, Granada, and Sevilla between the deprivation index and all-cause mortality in the third period. Patterns by causes of death were more heterogeneous. Conclusions: After the start of the financial crisis, socioeconomic inequalities in total mortality in small areas of Spanish cities remained stable in most cities, although several causes of death showed a different pattern.

Does selective migration bias the health impact assessment of urban regeneration programmes in cross-sectional studies? Findings from a Dutch case study

We examined if the assessment of the health impact of a national Dutch regeneration programme depends on using either a repeated cross-sectional or longitudinal study design. This is important as only the latter design can incorporate migration patterns. For both designs, we compared trends in medication use between target and control districts. We found differences in medication use trends to be modest under the longitudinal design, and not demonstrable under the repeated cross-sectional design. The observed differences were hardly influenced by migration patterns. We conclude that in the Netherlands migration patterns had little effect on the health impact assessment of this national urban regeneration programme, so either the cross-sectional or longitudinal evaluation study design will do.

The effects of the London 2012 Olympics and related urban regeneration on physical and mental health: the ORiEL mixed-methods evaluation of a natural experiment

Background

There is limited evidence for public health policy-makers on the health impacts of urban regeneration programmes.

Objectives

To assess whether or not the London 2012 Olympic and Paralympic Games, and related urban regeneration, were associated with an increase in physical activity and mental health and well-being; to assess whether or not any benefits were sustained over time; and to capture the experiences of residents of the Olympic host boroughs.

Design

Quasi-experimental prospective cohort study of adolescents and their parents/carers, with a nested qualitative longitudinal study of families.

Setting

London boroughs of Newham, Barking and Dagenham, Tower Hamlets and Hackney.

Participants

A cohort of 2254 adolescents in 25 schools; a repeat cross-sectional study of parents/carers and a sample of 20 families for the qualitative study.

Intervention

The London 2012 Olympic and Paralympic Games, and urban regeneration primarily associated with the redevelopment of the Olympic Park for legacy use.

Primary outcome measures

Change in the proportion of respondents meeting physical activity recommendations (using self-reported physical activity); change in the proportion of respondents reporting depression and anxiety and change in well-being score.

Main results

At 6 months, adolescents who became inactive were less likely to come from the intervention borough (Newham) than from comparison boroughs [risk ratio (RR) = 0.69, 95% confidence interval (CI) 0.51 to 0.93]. At 18 months, there were no statistically significant differences between intervention and comparison boroughs for all adolescent physical activity and screen-time transitions. Those who visited the Olympic Park more than once a month were the least likely to remain inactive (RR 0.11, 95% CI 0.02 to 0.48) and the least likely to become inactive (RR 0.38, 95% CI 0.24 to 0.60) compared with those who were active at baseline and at the 18-month follow-up. No impacts on parental/carer physical activity were observed. Adolescents who were ‘no longer depressed’ (RR 1.53, 95% CI 1.07 to 2.20) or ‘remained depressed’ (RR 1.78, 95% CI 1.12 to 2.83) at 6 months were more likely to be from the intervention borough. For well-being, there was no association between boroughs and change in well-being between baseline and the 6-month follow-up. At 18 months’ follow-up, adolescents who ‘remained depressed’ (RR 1.93, 95% CI 1.01 to 3.70) were more likely to be from the intervention borough than from comparison boroughs. No associations were observed for well-being at 18 months. There was limited evidence of change for parental mental health and well-being. The qualitative study found that residents generally welcomed the unexpected chance to live in a cleaner, safer and more unified environment. The findings suggested that the Games temporarily alleviated certain stressors in the social and physical environment. Overall, the Games lessened participants’ sense of social exclusion and appeared to generate a sense of inclusion and respite, even if this was only temporary. Study limitations include the potential for adolescents to not be assigned the correct level of exposure to urban regeneration and the effect of reductions in central and local public budgets owing to the UK Government’s deficit reduction programme.

Conclusions

This study provided the highest quality data to date on the short- and medium-term social and health impacts of sporting mega-events. We found limited evidence that the London 2012 Olympic and Paralympic Games had a positive effect on adolescent or parental physical activity, mental health or well-being.

Funding

The National Institute for Health Research Public Health Research programme.

The effects of changes to the built environment on the mental health and well-being of adults: Systematic review

There is increasing interest in the influence of place on health, and the need to distinguish between environmental and individual level factors. For environmental-level factors, current evidence tends to show associations through cross-sectional and uncontrolled longitudinal analyses rather than through more robust study designs that can provide stronger causal evidence. We restricted this systematic review to randomised (or cluster) randomised controlled trials and controlled before-and-after studies of changes to the built environment. Date of search was December 2016. We identified 14 studies. No evidence was found of an effect on mental health from 'urban regeneration' and 'improving green infrastructure' studies. Beneficial effects on quality-of-life outcomes from 'improving green infrastructure' were found in two studies. One 'improving green infrastructure' study reported an improvement in social isolation. Risk-of-bias assessment indicated robust data from only four studies. Overall, evidence for the impact of built environment interventions on mental health and quality-of-life is weak. Future research requires more robust study designs and interdisciplinary research involving public health, planning and urban design experts.

Effects of living near an urban motorway on the wellbeing of local residents in deprived areas: Natural experimental study

BACKGROUND

Health and wellbeing are partly shaped by the neighbourhood environment. In 2011, an eight kilometre (five mile) extension to the M74 motorway was opened in Glasgow, Scotland, constructed through a predominantly urban, deprived area. We evaluated the effects of the new motorway on wellbeing in local residents.

METHODS

This natural experimental study involved a longitudinal cohort (n = 365) and two cross-sectional samples (baseline n = 980; follow-up n = 978) recruited in 2005 and 2013. Adults from one of three study areas-surrounding the new motorway, another existing motorway, or no motorway-completed a postal survey. Within areas, individual measures of motorway proximity were calculated. Wellbeing was assessed with the mental (MCS-8) and physical (PCS-8) components of the SF-8 scale at both time points, and the short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS) at follow-up only.

RESULTS

In multivariable linear regression analyses, cohort participants living nearer to the new M74 motorway experienced significantly reduced mental wellbeing over time (MCS-8: -3.6, 95% CI -6.6 to -0.7) compared to those living further away. In cross-sectional and repeat cross-sectional analyses, an interaction was found whereby participants with a chronic condition living nearer to the established M8 motorway experienced reduced (MCS-8: -3.7, 95% CI -8.3 to 0.9) or poorer (SWEMWBS: -1.1, 95% CI -2.0 to -0.3) mental wellbeing compared to those living further away.

CONCLUSIONS

We found some evidence that living near to a new motorway worsened local residents' wellbeing. In an area with an existing motorway, negative impacts appeared to be concentrated in those with chronic conditions, which may exacerbate existing health inequalities and contribute to poorer health outcomes. Health impacts of this type of urban regeneration intervention should be more fully taken into account in future policy and planning.

Health impacts of the M74 urban motorway extension: a mixed-method natural experimental study

Background

Making travel easier can improve people’s access to opportunities, but motor transport also incurs substantial undesirable health and social impacts.

Aims

To assess how a new urban motorway affected travel and activity patterns, road accidents and well-being in local communities, and how these impacts were experienced and brought about.

Design

The Traffic and Health in Glasgow study, a mixed-method controlled before-and-after study.

Setting

Glasgow, UK.

Participants

Repeat cross-sectional survey samples of 1345 and 1343 adults, recruited in 2005 and 2013, respectively. Of these, 365 formed a longitudinal cohort, 196 took part in a quantitative substudy using accelerometers and global positioning system receivers and 30, living within 400 m of the new motorway, took part in a qualitative substudy along with 12 other informants. Complementary analyses used police STATS19 road traffic accident data (1997–2014) and Scottish Household Survey travel diaries (2009–13).

Intervention

A new 5-mile, six-lane section of the M74 motorway, opened in 2011 and running through predominantly deprived neighbourhoods in south-east Glasgow, with associated changes to the urban landscape.

Main outcome measures

Differences in self-reported travel behaviour (1-day travel record), physical activity (short International Physical Activity Questionnaire) and well-being [Short Form 8 Health Survey (SF-8) and a short version of the Warwick–Edinburgh Mental Well-being Scale], and in the incidence of road traffic accidents.

Methods

A combination of multivariable cohort, cross-sectional, repeat cross-sectional and interrupted time series regression analyses comparing residents of the ‘M74 corridor’ intervention area and two matched control areas, complemented by novel qualitative spatial methods. Graded measures of the proximity of the motorway to each participant’s home served as a further basis for controlled comparisons.

Results

Both benefits and harms were identified. Cohort participants living closer to the new motorway experienced significantly reduced mental well-being (mental component summary of the SF-8 scale) over time compared with those living further away [linear regression coefficient –3.6, 95% confidence interval (CI) –6.6 to –0.7]. In the area surrounding an existing motorway, this association was concentrated among those with chronic conditions. In repeat cross-sectional analyses, participants living closer to a new motorway junction were more likely to report using a car at follow-up than those living further away (odds ratio 3.4, 95% CI 1.1 to 10.7). We found weaker quantitative evidence of a decline in physical activity participation and no quantitative evidence of an overall change in either active travel or accidents associated with motorway exposure. Qualitative evidence suggested that, although the new motorway improved connectivity for those with dispersed social networks and access to motor vehicles, the impacts were more complex for others, some of whom found the motorway to be a cause of severance. Changes in community composition and cohesion, and perceptions of personal safety, were widely perceived as more important to local people.

Limitations

A key limitation of natural experimental studies is that the risk of residual confounding cannot be eliminated.

Conclusions

Overall, these findings highlight the potential for urban infrastructural projects of this kind to add further burdens to already disadvantaged communities, exacerbating inequalities and contributing to poorer health outcomes. The health and social impacts of such initiatives should be more fully taken into account in planning and research.

Funding

The National Institute for Health Research Public Health Research programme.

Urban regeneration as population health intervention: a health impact assessment in the Bay of Pasaia (Spain)

Background

An important health issue in urban areas is how changes arising from the regeneration of city-areas affect social determinants of health and equity. This paper examines the impacts attributable to a new fish market and to delays in the regeneration of a port area in a deteriorated region of the Bay of Pasaia (Spain). Potential differential impacts on local residents and socially vulnerable groups were evaluated to determine health inequalities.

Methods

An in-depth, prospective and concurrent Health-Impact-Assessment (HIA) focused on equity was conducted by the regional Public Health Department, following the Merseyside guidelines. Data from different sources was triangulated and impacts were identified using qualitative and quantitative methods.

Results

The intervention area is characterised by poor social, environmental, and health indicators. The distinctness of the two projects generates contrasting health and inequality impacts: generally positive for the new fish market and negative for the port area. The former creates recreational spaces and improves urban quality and social cohesion. By contrast, inaction and stagnation of the project in the port area perpetuates deterioration, a lack of safety, and poor health, as well as increased social frustration.

Conclusions

In addition to assessing the health impacts of both projects this HIA promoted intersectoral partnerships, boosted a holistic and positive view of health and incorporated health and equity into the political discourse. Community-level participatory action enabled public health institutions to respond to new urban planning challenges and responsibilities in a more democratic manner.

Is it better to invest in place or people to maximize population health? Evaluation of the general health impact of urban regeneration in Dutch deprived neighbourhoods

AIM

To study the general health impact of urban regeneration programmes in deprived Dutch districts. We compared initiatives that focused on the improvement of place with initiatives that mainly invested in people.

METHOD

A quasi-experimental design compared the trend in good perceived general health in the target districts with comparison districts. Generalized general mixed models assessed the rate of change in prevalence of good health per half year during a prolonged period before and after the start of the interventions.

RESULTS

Neither the target districts that invested mainly in place nor the ones with interventions focused on people showed trends in general health different than comparison districts (p>0.05). However, only districts with interventions focused on place showed no deterioration in general health during the intervention period. The trend change in these districts differed significantly from the change in the districts that invested mainly in people (p<0.05).

CONCLUSION

Urban regeneration programmes that focus on place may be effective in promoting general health.

Trends in socioeconomic inequalities in mortality in small areas of 33 Spanish cities

BACKGROUND

In Spain, several ecological studies have analyzed trends in socioeconomic inequalities in mortality from all causes in urban areas over time. However, the results of these studies are quite heterogeneous finding, in general, that inequalities decreased, or remained stable. Therefore, the objectives of this study are: (1) to identify trends in geographical inequalities in all-cause mortality in the census tracts of 33 Spanish cities between the two periods 1996-1998 and 2005-2007; (2) to analyse trends in the relationship between these geographical inequalities and socioeconomic deprivation; and (3) to obtain an overall measure which summarises the relationship found in each one of the cities and to analyse its variation over time.

METHODS

Ecological study of trends with 2 cross-sectional cuts, corresponding to two periods of analysis: 1996-1998 and 2005-2007. Units of analysis were census tracts of the 33 Spanish cities. A deprivation index calculated for each census tracts in all cities was included as a covariate. A Bayesian hierarchical model was used to estimate smoothed Standardized Mortality Ratios (sSMR) by each census tract and period. The geographical distribution of these sSMR was represented using maps of septiles. In addition, two different Bayesian hierarchical models were used to measure the association between all-cause mortality and the deprivation index in each city and period, and by sex: (1) including the association as a fixed effect for each city; (2) including the association as random effects. In both models the data spatial structure can be controlled within each city. The association in each city was measured using relative risks (RR) and their 95 % credible intervals (95 % CI).

RESULTS

For most cities and in both sexes, mortality rates decline over time. For women, the mortality and deprivation patterns are similar in the first period, while in the second they are different for most cities. For men, RRs remain stable over time in 29 cities, in 3 diminish and in 1 increase. For women, in 30 cities, a non-significant change over time in RR is observed. However, in 4 cities RR diminishes. In overall terms, inequalities decrease (with a probability of 0.9) in both men (RR = 1.13, 95 % CI = 1.12-1.15 in the 1st period; RR = 1.11, 95 % CI = 1.09-1.13 in the 2nd period) and women (RR = 1.07, 95 % CI = 1.05-1.08 in the 1st period; RR = 1.04, 95 % CI = 1.02-1.06 in the 2nd period).

CONCLUSIONS

In the future, it is important to conduct further trend studies, allowing to monitoring trends in socioeconomic inequalities in mortality and to identify (among other things) temporal factors that may influence these inequalities.

Estimating the Impact of Health-related Behaviors on Geographic Variation in Cardiovascular Mortality: A New Approach Based on the Synthesis of Ecological and Individual-level Data

BACKGROUND

Incidence of and mortality from cardiovascular disease (CVD) exhibit a strong geographical pattern, with inhabitants of more affluent neighborhoods showing a substantially lower risk of CVD mortality than inhabitants of deprived neighborhoods. Thus far, there is insufficient evidence as to what extent these differences can be attributed to differences in health-related behaviors.

METHODS

Using a Hierarchical Related Regression approach, we combined individual and aggregate (ecological) data to investigate the extent to which small-area variation in CVD mortality in Dutch neighborhoods can be explained by several behavioral risk factors (i.e., smoking, drinking, overweight, and physical inactivity). The proposed approach combines the benefits of both an ecological analysis (in terms of data availability and statistical power) and an individual-level analysis (in terms of identification of the parameters and interpretation of the results).

RESULTS

After correcting for differences in age and sex, accounting for differences in the behavioral risk factors reduces income-related inequalities in CVD mortality by approximately 30%.

CONCLUSIONS

Direct targeting of the excess prevalence of unhealthy behaviors in deprived neighborhoods is identified as a relevant strategy to reduce inequalities in CVD mortality. Our results also show that the proposed Hierarchical Related Regression approach provides a powerful method for the investigation of small-area variation in health outcomes.

Challenges in the management of nutritional disorders and communicable diseases in child day care centers: a quantitative and qualitative approach

In Brazil, although many children from low income families attend day care centers with appropriate hygiene practices and food programs, they have nutritional disorders and communicable diseases. This quantitative and qualitative cross-sectional study identified staff challenges in child day care centers and suggested alternative activity management to prevent nutritional disorders and communicable diseases. The study included 71 nursery teachers and 270 children from public and philanthropic day care centers (teacher to child ratios of 1:2.57 and 1:6.40, respectively). Interviews and focus groups were conducted with teachers and parents, and anthropometry and blood samples were drawn from the children by digital puncture. Children in philanthropic child day care centers were more likely to be hospitalized due to communicable diseases. Teachers from philanthropic child day care centers had lower age, income and education and higher work responsibilities based on the number of children and working time. The focus groups characterized institutions with organized routines, standard food practices, difficulties with caretaking, and lack of training to provide healthcare to children. Strategies to improve children's health in day care settings should focus on training of teachers about healthcare and nutrition.

Changing the environment to improve population health: a framework for considering exposure in natural experimental studies

There is renewed optimism regarding the use of natural experimental studies to generate evidence as to the effectiveness of population health interventions. Natural experimental studies capitalise on environmental and policy events that alter exposure to certain social, economic or environmental factors that influence health. Natural experimental studies can be useful for examining the impact of changes to ‘upstream’ determinants, which may not be amenable to controlled experiments. However, while natural experiments provide opportunities to generate evidence, they often present certain conceptual and methodological obstacles. Population health interventions that alter the physical or social environment are usually administered broadly across populations and communities. The breadth of these interventions means that variation in exposure, uptake and impact may be complex. Yet many evaluations of natural experiments focus narrowly on identifying suitable ‘exposed’ and ‘unexposed’ populations for comparison. In this paper, we discuss conceptual and analytical issues relating to defining and measuring exposure to interventions in this context, including how recent advances in technology may enable researchers to better understand the nature of population exposure to changes in the built environment. We argue that when it is unclear whether populations are exposed to an intervention, it may be advantageous to supplement traditional impact assessments with observational approaches that investigate differing levels of exposure. We suggest that an improved understanding of changes in exposure will assist the investigation of the impact of complex natural experiments in population health.

Understanding the impact of area-based interventions on area safety in deprived areas: realist evaluation of a neighbour nuisance intervention in Arnhem, the Netherlands

BACKGROUND

Area-based health inequalities may partly be explained by higher levels of area disorder in deprived areas. Area disorder may cause safety concerns and hence impair health. This study assessed how, for whom and in what conditions the intervention Meeting for Care and Nuisance (MCN) had an impact on neighbour nuisance and area safety in four deprived districts in Arnhem, the Netherlands.

METHODS

Realist evaluation methodology was applied to uncover how, for whom, and under what conditions MCN was expected to and actually produced change. Expected change was based on action plans and scientific theories. Actual change was based on progress reports, media articles, interviews with district managers, and quantitative surveys.

RESULTS

Three levels of impact were distinguished. At the organisational level, partly as expected, MCN's coordinated partnership strategy enabled role alignment, communication, and leadership. This resulted in a more efficient approach of nuisance households. At the level of nuisance households, as expected, MCN's joint assistance and enforcement strategy removed many of the underlying reasons for nuisance. This resulted in less neighbour nuisance. At the district level, perceptions of social control and area safety improved only in one district. Key conditions for change included a wider safety approach, dense population, and central location of the district within the city.

CONCLUSIONS

This realist evaluation provided insight into the mechanisms by which a complex area-based intervention was able to reduce neighbour nuisance in deprived areas. Depending on wider conditions, such a reduction in neighbour nuisance may or may not lead to improved perceptions of area safety at the district level.

From built environment to health inequalities: An explanatory framework based on evidence

OBJECTIVE

The Health in All Policies strategy aims to engage every policy domain in health promotion. The more socially disadvantaged groups are usually more affected by potential negative impacts of policies if they are not health oriented. The built environment represents an important policy domain and, apart from its housing component, its impact on health inequalities is seldom assessed.

METHODS

A scoping review of evidence on the built environment and its health equity impact was carried out, searching both urban and medical literature since 2000 analysing socio-economic inequalities in relation to different components of the built environment.

RESULTS

The proposed explanatory framework assumes that key features of built environment (identified as density, functional mix and public spaces and services), may influence individual health through their impact on both natural environment and social context, as well as behaviours, and that these effects may be unequally distributed according to the social position of individuals.

CONCLUSION

In general, the expected links proposed by the framework are well documented in the literature; however, evidence of their impact on health inequalities remains uncertain due to confounding factors, heterogeneity in study design, and difficulty to generalize evidence that is still very embedded to local contexts.

Exploring complex causal pathways between urban renewal, health and health inequality using a theory-driven realist approach

INTRODUCTION

Urban populations are growing and to accommodate these numbers, cities are becoming more involved in urban renewal programs to improve the physical, social and economic conditions in different areas. This paper explores some of the complexities surrounding the link between urban renewal, health and health inequalities using a theory-driven approach.

METHODS

We focus on an urban renewal initiative implemented in Barcelona, the Neighbourhoods Law, targeting Barcelona's (Spain) most deprived neighbourhoods. We present evidence from two studies on the health evaluation of the Neighbourhoods Law, while drawing from recent urban renewal literature, to follow a four-step process to develop a program theory. We then use two specific urban renewal interventions, the construction of a large central plaza and the repair of streets and sidewalks, to further examine this link.

DISCUSSION

In order for urban renewal programs to affect health and health inequality, neighbours must use and adapt to the changes produced by the intervention. However, there exist barriers that can result in negative outcomes including factors such as accessibility, safety and security.

CONCLUSION

This paper provides a different perspective to the field that is largely dominated by traditional quantitative studies that are not always able to address the complexities such interventions provide. Furthermore, the framework and discussions serve as a guide for future research, policy development and evaluation.

Social change or business as usual at city hall? Examining an urban municipal government's response to neighbourhood-level health inequities

There is a renewed interest in the potential of municipal governments working collaboratively with local communities to address health inequities. A growing body of literature has also highlighted the benefits and limitations of participatory approaches in neighbourhood interventions initiated by municipal governments. However, few studies have investigated how neighbourhood interventions tackling health inequities work in real-time and in context, from the perspectives of Community Developers (CDs) who promote community participation. This study uses a process evaluation approach and semi-structured interviews with CDs to explore the challenges they face in implementing a community development, participatory process in the City of Hamilton's strategy to reduce health inequities - Neighbourhood Action. Findings demonstrate that municipal government can facilitate and suppress community participation in complex ways. CDs serve as significant but conflicted intermediaries as they negotiate and navigate power differentials between city and community actors, while also facing structural challenges. We conclude that community participation is important to bottom-up, resident-led social change, and that CDs are central to this work.

Evaluating the health inequalities impact of area-based initiatives across the socioeconomic spectrum: a controlled intervention study of the New Deal for Communities, 2002-2008

BACKGROUND

Previous evaluations of area-based initiatives have not compared intervention areas with the full range of areas from top to bottom of the social spectrum to evaluate their health inequalities impact.

SETTING

Deprived areas subject to the New Deal for Communities (NDC) intervention, local deprivation-matched comparator areas, and areas drawn from across the socioeconomic spectrum (representing high, medium and low deprivation) in England between 2002 and 2008.

DATA

Secondary analysis of biannual repeat cross-sectional surveys collected for the NDC National Evaluation Team and the Health Survey for England (HSE).

METHODS

Following data harmonisation, baseline and time trends in six health and social determinants of health outcomes were compared. Individual-level data were modelled using regression to adjust for age, sex, ethnic and socioeconomic differences among respondents.

RESULTS

Compared with respondents in HSE low deprivation areas, those in NDC intervention areas experienced a significantly steeper improvement in education, a trend towards a steeper improvement in self-rated health, and a significantly less steep reduction in smoking between 2002 and 2008. In HSE high deprivation areas, significantly less steep improvements in five out of six outcomes were seen compared with HSE low deprivation areas.

CONCLUSIONS

Although unable to consider prior trends and previous initiatives, our findings provide cautious optimism that well-resourced and constructed area-based initiatives can reduce, or at least prevent the widening of, social inequalities for selected outcomes between the most and least deprived groups of areas.

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.

Area-based interventions to ameliorate deprived Dutch neighborhoods in practice: does the Dutch District Approach address the social determinants of health to such an extent that future health impacts may be expected?

OBJECTIVE

We studied the local manifestation of a national procedural program that addressed problems regarding employment, education, housing and the physical neighborhood environment, social cohesion, and safety in the most deprived neighborhoods in the Netherlands. We aimed to assess if such a program, without the explicit aim to improve health, results in area-based interventions that address the social determinants of health to such an extent that future health impacts may be expected.

METHODS

We used standardized questionnaires and face-to-face interviews with 39 local district managers. We analyzed the content of the area-based interventions to assess if the activities addressed the social determinants of health. We assessed the duration and scale of the activities in order to estimate their potential to change social determinants of health.

RESULTS

Most districts addressed all six categories of social determinants of health central to the procedural program. Investments in broad-based primary schools, housing stock, green space, and social safety seemed to have the potential to result in district-level changes in social determinants. The scale of activities aimed at employment, income, educational attainment, and the social environment seemed too small to expect an impact at the district level.

CONCLUSION

We conclude that the area-based interventions addressed the neighborhood environment to such an extent that future health impacts of the Dutch District Approach may be expected. The health effects in the long term might be more substantial when area-based interventions were devoted more to the improvement of the socioeconomic circumstances of residents.

The untold story: examining Ontario's community health centres' initiatives to address upstream determinants of health

BACKGROUND

Unlike traditional primary care centres, part of the Community Health Centre (CHC) mandate is to address upstream health determinants. In Ontario, CHCs refer to these activities as Community Initiatives (CIs); yet, little is known about how CIs operate. The objective of this study was to examine the scope, resource requirements, partnerships, successes and challenges among selected Ontario CIs.

METHODS

We conducted qualitative interviews with 10 CHC staff members representing 11 CIs across Ontario. CIs were identified through an online inventory, recruited by e-mail and interviewed between March and June 2011.

RESULTS

Most CIs aim to increase community participation, while addressing social isolation and poverty. They draw minimal financial resources from their CHC, and employ highly skilled staff to support implementation. Most enlist support from various partners, and use numerous methods for community engagement. Successes include improved community relations, increased opportunities for education and employment and rewarding partnerships, while insufficient funding was a commonly identified challenge.

CONCLUSIONS

Despite minimal attention from researchers and funders, our findings suggest that CIs play key capacity-building roles in vulnerable communities across Ontario, and warrant further investigation.

Inequalities in noncommunicable disease mortality in the ten largest Japanese cities

The burden of noncommunicable diseases and social inequalities in health among urban populations is becoming a common problem around the world. This phenomenon is further compounded by population aging. Japan faces the task of maintaining its high level of population health while dealing with these challenges. This study focused on the ten largest cities in Japan and, using publicly available administrative data, analyzed standardized mortality ratios to examine inequalities in relative mortality levels due to major noncommunicable disease at both city and subcity levels. On average, the ten major cities had excess mortality due to cancer and lower mortality due to heart disease and cerebrovascular disease compared to the country as a whole. Substantial inequalities in relative mortality were observed both between and within cities, especially for heart disease and cerebrovascular disease among men. Inequalities in relative mortality levels within cities appear to be increasing over time even while relative mortality levels are decreasing overall. The widely observed health inequalities signal the need for actions to ensure health equity while addressing the burden of noncommunicable diseases. Increasingly, more countries will have to deal with these challenges of inequity, urbanization, aging, and noncommunicable diseases. Local health governance informed by locally specific data on health determinants and outcomes is essential for developing contextualized interventions to improve health and health equity in major urban areas.

GoWell: the challenges of evaluating regeneration as a population health intervention

OBJECTIVE

Urban regeneration can be considered a population health intervention (PHI). It is expected to impact on population health but the evidence is limited or weak, in part due to the difficulties of evaluating PHIs. We explore these challenges using GoWell as a case study.

METHOD

A 10-year evaluation of housing improvement and urban regeneration in 15 deprived areas in Glasgow, Scotland (2005-2015).

RESULTS

Challenges faced include: definition and changing nature of the intervention; identifying the recipients of the intervention; and constraints of study design affecting capacity to attribute effects. We have met these challenges by: adapting the evaluation to take account of changing intervention plans and delivery; making pragmatic choices about which populations to focus on for different parts of the study; and taking advantage of delayed delivery of some components to identify controls.

CONCLUSION

Commitment to a long-term evaluation by the Scottish Government and other partners has enabled us to develop a package of studies to investigate health and other outcomes, and the processes of a PHI. GoWell will contribute to the evidence base for interventions focused on tackling the wider determinants of health and help policymakers to be more explicit and realistic about what regeneration might achieve.

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.

Environmental interventions in low-SES neighbourhoods to promote healthy behaviour: enhancing and impeding factors

BACKGROUND

Social and physical environments are important drivers of socioeconomic inequalities in health behaviour. Although many interventions aiming to improve such environments are being implemented in underprivileged neighbourhoods, implementation processes are rarely studied. Acquiring insight into successful implementation may improve future interventions. The present study aimed to investigate factors influencing the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of social and physical environmental interventions aimed at promoting healthy behaviour in underprivileged neighbourhoods in The Netherlands.

METHODS

A large set of theory-based factors of successful implementation was assessed for 18 implemented interventions in three underprivileged neighbourhoods. Expert and target group panels scored the RE-AIM dimensions for each intervention. We analyzed the statistical significance of associations between theory-based factors and the actual RE-AIM in a statistical model, to identify factors associated with increased RE-AIM.

RESULTS

Six factors were identified: effectiveness and implementation success were higher when the target group was involved in the planning process, whereas maintenance increased in the absence of competition with other projects. If the current situation was inventoried during intervention development, the effectiveness, adoption and implementation were higher. These dimensions were also higher when the target group was informed before implementation. Involvement of the target group during implementation resulted in higher reach, effectiveness and adoption. Finally, lack of intervention staff worsened the reach.

DISCUSSION

This study contributes to the evidence base for effective implementation of environmental measures aimed at promoting healthy behaviours. In particular, interventions in which the target group was involved in the implementation process were associated with higher RE-AIM outcomes.

Health effects of neighborhood demolition and housing improvement: a prospective controlled study of 2 natural experiments in urban renewal

OBJECTIVES

We took advantage of a 2-intervention natural experiment to investigate the impacts of neighborhood demolition and housing improvement on adult residents' mental and physical health.

METHODS

We identified a longitudinal cohort (n = 1041, including intervention and control participants) by matching participants in 2 randomly sampled cross-sectional surveys conducted in 2006 and 2008 in 14 disadvantaged neighborhoods of Glasgow, United Kingdom. We measured residents' self-reported health with Medical Outcomes Study Short Form Health Survey version 2 mean scores.

RESULTS

After adjustment for potential confounders and baseline health, mean mental and physical health scores for residents living in partly demolished neighborhoods were similar to the control group (mental health, b = 2.49; 95% confidence interval [CI] = -1.25, 6.23; P = .185; physical health, b = -0.24; 95% CI = -2.96, 2.48; P = .859). Mean mental health scores for residents experiencing housing improvement were higher than in the control group (b = 2.41; 95% CI = 0.03, 4.80; P = .047); physical health scores were similar between groups (b = -0.66; 95% CI = -2.57, 1.25; P = .486).

CONCLUSIONS

Our findings suggest that housing improvement may lead to small, short-term mental health benefits. Physical deterioration and demolition of neighborhoods do not appear to adversely affect residents' health.

An evaluation of an urban renewal program and its effects on neighborhood resident's overall wellbeing using concept mapping

Urban renewal programs aim to improve physical and socioeconomic position of neighborhoods. However, due to the intervention's complexity, there is often little evidence of their impact on health and health inequalities. This study aimed to identify the perception of a group of neighborhood residents towards a large-scale urban renewal program in Barcelona and to explore its effects and importance on their wellbeing using concept mapping methodology. Our results indicate that the majority of urban renewal projects within the initiative, including improved walkability, construction of new public spaces and more community programs, have positive and important effects on the overall wellbeing of participants. This study presents an innovative method that diverts from traditional outcome-based evaluations studies often used within this field.

The role of community centre-based arts, leisure and social activities in promoting adult well-being and healthy lifestyles

Developed countries are experiencing high levels of mental and physical illness associated with long term health conditions, unhealthy lifestyles and an ageing population. Given the limited capacity of the formal health care sector to address these public health issues, attention is turning to the role of agencies active in civil society. This paper sought to evaluate the associations between participation in community centre activities, the psycho-social wellbeing and health related behaviours. This was based on an evaluation of the South West Well-being programme involving ten organisations delivering leisure, exercise, cooking, befriending, arts and crafts activities. The evaluation consisted of a before-and-after study with 687 adults. The results showed positive changes in self-reported general health, mental health, personal and social well-being. Positive changes were associated with diet and physical activity. Some activities were different in their outcomes-especially in cases where group activities were combined with one-to-one support. The results suggest that community centre activities of this nature offer benefits that are generically supportive of health behaviour changes. Such initiatives can perform an important role in supporting the health improvement objectives of formal health care services. For commissioners and partner agencies, accessibility and participation are attractive features that are particularly pertinent to the current public health context.

The Olympic Regeneration in East London (ORiEL) study: protocol for a prospective controlled quasi-experiment to evaluate the impact of urban regeneration on young people and their families

INTRODUCTION

Recent systematic reviews suggest that there is a dearth of evidence on the effectiveness of large-scale urban regeneration programmes in improving health and well-being and alleviating health inequalities. The development of the Olympic Park in Stratford for the London 2012 Olympic and Paralympic Games provides the opportunity to take advantage of a natural experiment to examine the impact of large-scale urban regeneration on the health and well-being of young people and their families.

DESIGN AND METHODS

A prospective school-based survey of adolescents (11-12 years) with parent data collected through face-to-face interviews at home. Adolescents will be recruited from six randomly selected schools in an area receiving large-scale urban regeneration (London Borough of Newham) and compared with adolescents in 18 schools in three comparison areas with no equivalent regeneration (London Boroughs of Tower Hamlets, Hackney and Barking & Dagenham). Baseline data will be completed prior to the start of the London Olympics (July 2012) with follow-up at 6 and 18 months postintervention. Primary outcomes are: pre-post change in adolescent and parent mental health and well-being, physical activity and parental employment status. Secondary outcomes include: pre-post change in social cohesion, smoking, alcohol use, diet and body mass index. The study will account for individual and environmental contextual effects in evaluating changes to identified outcomes. A nested longitudinal qualitative study will explore families' experiences of regeneration in order to unpack the process by which regeneration impacts on health and well-being.

ETHICS AND DISSEMINATION

The study has approval from Queen Mary University of London Ethics Committee (QMREC2011/40), the Association of Directors of Children's Services (RGE110927) and the London Boroughs Research Governance Framework (CERGF113). Fieldworkers have had advanced Criminal Records Bureau clearance. Findings will be disseminated through peer-reviewed publications, national and international conferences, through participating schools and the study website (http://www.orielproject.co.uk).

The impact of training for day-care educators on childhood anaemia in nurseries: an institutional randomised clinical trial

OBJECTIVE

To test the impact of training for educators on the health of children enrolled in public and philanthropic day-care nurseries.

DESIGN

A randomised, institutional, non-blind clinical trial was conducted. An educational intervention was performed in four day-care centres and the control group consisted of four other day-care centres. Interviews with the mothers, collection of blood from the children by digital puncture and anthropometry were performed. The chosen indicator for the improvement of health was anaemia (Hb <11 g/dl). An unconditional logistic regression model was set for the risk factors for anaemia, considering associations with P ≤ 0·05 as statistically significant.

SETTING

Eight day-care centres in the city of Sao Paulo, Brazil.

SUBJECTS

Two hundred and fifty-two children from day-care nurseries.

RESULTS

The children from the day-care centres that were not subject to intervention presented a 2·11 times greater risk (95% CI 1·04, 4·30; P = 0·40) of having anaemia at the end of the study independent of the control variables (sex, age, time in the day-care centre, anaemia at the beginning of the study, maternal age, use of oral iron supplements, number of siblings, per capita family income, use of antibiotics and the necessity of avoidable hospitalisations) used in the construction of the final logistical model.

CONCLUSIONS

The assessed educational intervention promoted significant changes in the health status of the children, reinforcing the importance of training for professionals who care for young children in day-care centres in developing countries in order to promote child health.

Housing and health inequalities: a synthesis of systematic reviews of interventions aimed at different pathways linking housing and health

Housing and neighbourhood conditions are widely acknowledged to be important social determinants of health, through three main pathways: (1) internal housing conditions, (2) area characteristics and (3) housing tenure. We conducted a systematic overview of systematic reviews of intervention studies to provide an overview of the evidence on the impact of housing and neighbourhood interventions on health and health inequalities. There is relatively strong evidence for interventions aimed at improving area characteristics and compelling evidence for warmth and energy efficiency interventions targeted at vulnerable individuals. However, the health impacts of area-level internal housing improvement interventions are as yet unclear. We found no reviews of interventions aimed at altering housing tenure. This remains an important area for further research and potentially new evidence syntheses.

Protocol for a mixed methods study investigating the impact of investment in housing, regeneration and neighbourhood renewal on the health and wellbeing of residents: the GoWell programme

BACKGROUND

There is little robust evidence to test the policy assumption that housing-led area regeneration strategies will contribute to health improvement and reduce social inequalities in health. The GoWell Programme has been designed to measure effects on health and wellbeing of multi-faceted regeneration interventions on residents of disadvantaged neighbourhoods in the city of Glasgow, Scotland.

METHODS/DESIGN

This mixed methods study focused (initially) on 14 disadvantaged neighbourhoods experiencing regeneration. These were grouped by intervention into 5 categories for comparison. GoWell includes a pre-intervention householder survey (n = 6008) and three follow-up repeat-cross sectional surveys held at two or three year intervals (the main focus of this protocol) conducted alongside a nested longitudinal study of residents from 6 of those areas. Self-reported responses from face-to-face questionnaires are analysed along with various routinely produced ecological data and documentary sources to build a picture of the changes taking place, their cost and impacts on residents and communities. Qualitative methods include interviews and focus groups of residents, housing managers and other stakeholders exploring issues such as the neighbourhood context, potential pathways from regeneration to health, community engagement and empowerment.

DISCUSSION

Urban regeneration programmes are 'natural experiments.' They are complex interventions that may impact upon social determinants of population health and wellbeing. Measuring the effects of such interventions is notoriously challenging. GoWell compares the health and wellbeing effects of different approaches to regeneration, generates theory on pathways from regeneration to health and explores the attitudes and responses of residents and other stakeholders to neighbourhood change.