Background
In this chapter, the effect of change in the built environment on the mental health (depression and anxiety) and well-being of the ENABLE London study cohort is examined, overall and by housing sector. This chapter also examines whether or not change in neighbourhood perceptions is associated with change in mental health and well-being.
Introduction
Depression and anxiety are recognised as global causes of disease.176 Depressive disorders are one of the leading causes of years lived with disability and a leading cause of disability-adjusted life-years.176 Globally, > 30 million people, 4.4% of the world population,176 are estimated to be affected by depression. This number is increasing, especially in low-income countries where common mental disorders (CMDs) such as depression and anxiety are more likely to occur as a result of population increases and people living longer.176,177 These figures highlight the importance of non-fatal health outcomes in the measurement of disease burden.178 In the UK, CMDs are the most prevalent health condition.179 Around one in six people in England report depression and/or anxiety at any one time.180 Subjective well-being (how people feel about their lives) is recognised to be a critical measure of the overall mental health status of the population and an important marker of quality of life,181 a key indicator of inequalities in health.182
There is a growing recognition of the importance of the local built environment to mental health. Increasing evidence from both cross-sectional and longitudinal studies suggests that both structural and social attributes of a neighbourhood can affect the mental health of residents.183–185 Negative perceptions of the neighbourhood (e.g. perceived level of accessibility to green space, more crime, feeling unsafe, less walkability) have been found to be associated with depression, anxiety,186–188 and both physiological and self-reported measures of stress.189 Positive perceptions are associated with higher rates of physical activity, which, in turn, may reduce depression and cardiovascular risk with potential benefits for both physical and mental health.190
The World Health Organization reports that through healthier environments premature death and disease can be prevented, and estimates that 23% of global mortality is caused by modifiable environmental factors.191 Environments that are healthy and sustainable (i.e. well-designed, accessible features such as walkability, transport and green space) provide residents with positive perceptions of where they live, which can lead to better mental health and enhanced well-being, and improve both physiological and self-reported measures of stress.189 Positive perceptions are associated with higher rates of physical activity, which, in turn, may reduce depression and cardiovascular risk and, therefore, have potential benefits for both physical and mental health.190 The influence of the built environment on mental health may be stronger among those who are more socioeconomically disadvantaged188 and who often reside in poor-quality environments192–194 characterised by lower perceived safety, access to fewer shops and leisure facilities, and higher levels of crime;195,196 however, the evidence is weak.
The ENABLE London study provided a unique opportunity to evaluate the effect of moving into accommodation based on active design principles on mental health and well-being outcomes.
Methods
Outcomes
Depression, anxiety and well-being
Depression and anxiety at baseline and follow-up were measured using the Hospital Anxiety and Depression Scale; seven items assessed depression and seven items assessed anxiety.57 Each item was scored between 0 and 3, which provided a maximum score of 21 for each subscale. Higher scores indicated the presence of depression and anxiety. One missing response on any of the subscales was imputed using the mean from the sum of scores in each subscale.197 Three questions examined well-being: ‘Overall, how satisfied are you with your life nowadays?’, ‘Overall, to what extent do you feel that the things you do in life are worthwhile?’ and ‘Overall, how happy did you feel yesterday?’. Each item was rated on a scale from 1 (not at all) to 10 (extremely), with higher scores indicating positive well-being.198
Neighbourhood perceptions
Two neighbourhood perception scales were developed at baseline, crime-free and quality, using exploratory factor analysis on 14 neighbourhood perception items included in the questionnaire64 (see Chapter 3 for further details). Scores for each participant were derived for each scale; higher scores indicated positive neighbourhood perceptions, that is that neighbourhoods were crime-free and were of better neighbourhood quality. The same items were used to derive scores at follow-up.
Statistical methods
Baseline
Univariate analyses examined baseline differences in the proportion of participants who reported depression, anxiety and low levels of well-being, and baseline differences in mean neighbourhood perception scores by housing sector and between East Village and control groups. Multilevel logistic regression models were used to examine the associations between the housing sector and the binary outcomes of depression, anxiety and well-being, which allowed for household clustering as a random effect (model A), with adjustment for covariates including age, sex and ethnicity (model B), marital status (model C), educational level (model D) and health status (i.e. ‘LLI’, model E). Analyses were restricted to 1213 (95%) participants with complete data on all outcomes and covariates at baseline.
Follow-up
A total of 92% (n = 808/877) of participants had complete data on all outcomes of interest at follow-up. Multilevel linear regression models examined change in the levels of depression, anxiety, well-being and neighbourhood perceptions, comparing those who moved to East Village with those who did not, for the cohort as a whole and in stratified analyses by housing sector. Analyses were adjusted for baseline household clustering, as well as age group, sex and ethnic group (model 1). Associations between change in mental health/well-being outcomes and change in neighbourhood perception scores were also examined.
Results
At baseline, 14% of the cohort were classified as depression cases, 31% reported anxiety and one-quarter reported lower levels of well-being (see Table 1). A gradient was observed in the depression levels across housing sectors, where a higher proportion of social housing participants reported depression (21%), than intermediate (10%) and market-rent groups (9%). Similar proportions of participants in social housing and market-rent groups reported anxiety (33%), with a lower proportion in the intermediate group (28%). A gradient was also observed in low levels of life satisfaction across the housing sectors: 33% of social housing participants reported low levels of life satisfaction, compared with 22% of intermediate and 19% of market-rent participants. Low levels of feeling that life is worthwhile and happiness were reported similarly across the housing sectors.
Baseline mental health and well-being
Logistic regression analyses showed appreciably higher levels of depression among participants seeking social housing than in participants from the intermediate group [odds ratio (OR) 2.5, 95% CI 1.6 to 3.9] (Table 19, model A). The ORs were similar after adjustment for age, sex, ethnicity (model B) and marital status (model C), but marginally attenuated after adjustment for educational level (model D) and health status (model E). Levels of depression were marginally lower in the market-rent group than in the intermediate group for model A but almost identical in models B to E (see Table 19). The social housing sector were more likely to be anxious than those seeking intermediate housing (OR 1.3, 95% CI 0.9 to 1.8; model A) and ORs were slightly stronger after adjustment for age, sex, ethnicity (model B) and other covariates (models C to E). Levels of anxiety were also higher in the market-rent group than in the intermediate group, with similar ORs (OR 1.3, 95% CI 0.9 to 2.0; model A), which remained after adjustment for covariates (models B to E). Those in the social housing sector were more likely to report lower levels of life satisfaction than those participants seeking intermediate housing (OR 1.7, 95% CI 1.2 to 2.3), although this was progressively weakened by adjustment (models B to E) and was no longer statistically significant. Similarly, there were no significant differences in low levels of satisfaction between market-rent and intermediate groups. Low feelings such as ‘things you do in life are worthwhile’ were marginally higher in social housing and market-rent groups than in those seeking intermediate housing, but differences were not statistically significant and not materially affected by adjustment (models A to E). Low levels of happiness were higher in the social group than in the intermediate housing sector (model A, OR 1.3, 95% CI 1.0 to 1.8), and in the market-rent group compared with the intermediate housing sector (model A, OR 1.5, 95% CI 1.0 to 2.2), which remained similar after adjustment for sociodemographic factors (models B to D) and health status (model E).
| Outcome by housing sector | Model, OR (95% CI); p-value | ||||
|---|---|---|---|---|---|
| A | B | C | D | E | |
| Depression case | |||||
| Intermediate | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Social housing | 2.50 (1.61 to 3.87); < 0.001 | 2.32 (1.37 to 3.94); 0.002 | 2.34 (1.37 to 3.99); 0.002 | 1.95 (1.07 to 3.54); 0.03 | 1.89 (1.02 to 3.48); 0.04 |
| Market-rent | 0.85 (0.47 to 1.54); 0.59 | 0.99 (0.53 to 1.83); 0.96 | 0.98 (0.53 to 1.82); 0.95 | 0.99 (0.53 to 1.85); 0.97 | 1.04 (0.55 to 1.97); 0.90 |
| Anxiety case | |||||
| Intermediate | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Social housing | 1.27 (0.92 to 1.75); 0.15 | 1.45 (0.99 to 2.13); 0.06 | 1.47 (1.00 to 2.16); 0.05 | 1.45 (0.94 to 2.25); 0.09 | 1.38 (0.89 to 2.13); 0.15 |
| Market-rent | 1.34 (0.90 to 2.00); 0.15 | 1.30 (0.88 to 1.94); 0.19 | 1.28 (0.86 to 1.90); 0.23 | 1.29 (0.87 to 1.92); 0.21 | 1.33 (0.89 to 1.98); 0.16 |
| Low levels of life satisfaction | |||||
| Intermediate | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Social housing | 1.66 (1.20 to 2.30); 0.002 | 1.44 (0.98 to 2.12); 0.06 | 1.41 (0.96 to 2.09); 0.08 | 1.32 (0.85 to 2.04); 0.22 | 1.25 (0.81 to 1.94); 0.31 |
| Market-rent | 0.80 (0.53 to 1.23); 0.32 | 0.82 (0.53 to 1.26); 0.36 | 0.78 (0.50 to 1.20); 0.26 | 0.78 (0.50 to 1.20); 0.26 | 0.80 (0.52 to 1.24); 0.31 |
| Low levels of feeling that life is worthwhile | |||||
| Intermediate | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Social housing | 1.33 (0.97 to 1.81); 0.08 | 1.35 (0.93 to 1.97); 0.11 | 1.36 (0.93 to 2.00); 0.12 | 1.20 (0.78 to 1.85); 0.41 | 1.15 (0.74 to 1.78); 0.54 |
| Market-rent | 1.15 (0.78 to 1.71); 0.48 | 1.13 (0.76 to 1.69); 0.54 | 1.09 (0.73 to 1.64); 0.67 | 1.09 (0.73 to 1.64); 0.66 | 1.12 (0.75 to 1.68); 0.58 |
| Low levels of happiness | |||||
| Intermediate | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Social housing | 1.33 (0.96 to 1.84); 0.09 | 1.41 (0.96 to 2.08); 0.08 | 1.38 (0.94 to 2.04); 0.10 | 1.33 (0.86 to 2.06); 0.20 | 1.29 (0.83 to 2.01); 0.25 |
| Market-rent | 1.48 (0.99 to 2.20); 0.05 | 1.51 (1.01 to 2.24); 0.04 | 1.46 (0.98 to 2.18); 0.06 | 1.48 (0.99 to 2.21); 0.05 | 1.50 (1.01 to 2.24); 0.05 |
Neighbourhood perceptions
There were consistent inverse associations between neighbourhood perceptions and all mental health and well-being outcomes, where better perceptions were associated with poorer mental health and well-being scores (see Report Supplementary Material 21). Hence, we examined the impact of further adjustment of baseline housing sector differences in depression, anxiety and well-being for neighbourhood perception scores (Table 20). Additional adjustment for neighbourhood perceptions of crime (see model 2, Table 20) and quality (see model 3, Table 20) weakened the higher levels of depression and other marginally higher adverse mental health/well-being outcomes among social housing participants compared with intermediate participants, suggesting that neighbourhood perceptions are a partial explanation for these housing sector differences. However, adjustment for neighbourhood perceptions had no effect on the mental health/well-being associations between market-rent and intermediate participants (see Table 20).
| Outcome by housing sector | Model, OR (95% CI); p-value | ||
|---|---|---|---|
| 1 | 2 | 3 | |
| Depression case | |||
| Intermediate | 1.00 | 1.00 | 1.00 |
| Social housing | 1.89 (1.02 to 3.48); 0.04 | 1.73 (0.93 to 3.21); 0.08 | 1.57 (0.85 to 2.91); 0.15 |
| Market-rent | 1.04 (0.55 to 1.97); 0.90 | 1.05 (0.55 to 1.98); 0.89 | 1.05 (0.55 to 1.98); 0.89 |
| Anxiety case | |||
| Intermediate | 1.00 | 1.00 | 1.00 |
| Social housing | 1.38 (0.89 to 2.13); 0.15 | 1.20 (0.78 to 1.87); 0.41 | 1.23 (0.79 to 1.90); 0.363 |
| Market-rent | 1.33 (0.89 to 1.98); 0.16 | 1.32 (0.89 to 1.96); 0.16 | 1.32 (0.89 to 1.96); 0.16 |
| Low levels of life satisfaction | |||
| Intermediate | 1.00 | 1.00 | 1.00 |
| Social housing | 1.25 (0.81 to 1.94); 0.311 | 1.13 (0.72 to 1.77); 0.60 | 1.02 (0.65 to 1.61); 0.92 |
| Market-rent | 0.80 (0.52 to 1.24); 0.31 | 0.80 (0.51 to 1.24); 0.31 | 0.79 (0.51 to 1.24); 0.30 |
| Low levels of worthwhile | |||
| Intermediate | 1.00 | 1.00 | 1.00 |
| Social housing | 1.15 (0.74 to 1.78); 0.54 | 1.06 (0.68 to 1.65); 0.80 | 0.97 (0.62 to 1.51); 0.88 |
| Market-rent | 1.12 (0.75 to 1.68); 0.58 | 1.12 (0.74 to 1.68); 0.59 | 1.11 (0.74 to 1.67); 0.61 |
| Low levels of happiness | |||
| Intermediate | 1.00 | 1.00 | 1.00 |
| Social housing | 1.29 (0.83 to 2.01); 0.25 | 1.17 (0.75 to 1.83); 0.50 | 1.07 (0.69 to 1.66); 0.77 |
| Market-rent | 1.50 (1.01 to 2.24); 0.045 | 1.51 (1.00 to 2.25); 0.047 | 1.50 (1.01 to 2.22); 0.047 |
A comparison of the baseline characteristics of those who subsequently moved to East Village with those of people who did not (Table 21) showed little difference in mental health and well-being outcomes, overall and by housing sector. The exception was that there were higher median anxiety scores in the control group than in the East Village group among social housing participants and conversely higher levels in the East Village group than in the control group among the intermediate group. There were also baseline differences in neighbourhood perceptions by subsequent control and intervention groups. The overall baseline crime-free and quality scores were markedly higher in the control group than in those who subsequently moved to East Village; for quality, these differences were also evident by housing sector.
| Outcomes/perceptions | All housing sectors, median (IQR) | Housing sector, median (IQR) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Social | Intermediate | Market-rent | ||||||||||
| Control (N = 402) | East Village (N = 406) | p-valuea | Control (N = 109) | East Village (N = 192) | p-valuea | Control (N = 189) | East Village (N = 171) | p-valuea | Control (N = 104) | East Village (N = 43) | p-valuea | |
| Mental health and well-being | ||||||||||||
| Depressionb | 3.5 (1.2–5.8) | 3.5 (1.2–5.8) | 0.71 | 4.7 (2.3–7.0) | 4.7 (2.3–7.0) | 0.74 | 3.5 (1.2–5.8) | 3.5 (1.2–4.7) | 0.34 | 2.3 (1.2–4.7) | 2.3 (1.2–3.5) | 0.46 |
| Anxietyb | 6.0 (4.0–8.0) | 5.9 (3.0–8.0) | 0.71 | 6.0 (4.0–9.0) | 5.0 (3.0–8.0) | 0.03 | 5.0 (3.0–7.0) | 6.0 (4.0–9.0) | 0.02 | 7.0 (4.0–9.0) | 5.0 (3.0–8.0) | 0.29 |
| Life satisfactionc | 7.0 (7.0–8.0) | 7.0 (6.0–8.0) | 0.94 | 7.0 (6.0–9.0) | 7.0 (6.0–9.0) | 0.64 | 7.0 (7.0–8.0) | 7.0 (6.0–8.0) | 0.40 | 7.0 (7.0–8.0) | 7.0 (7.0–8.0) | 0.72 |
| Worthwhilec | 8.0 (7.0–9.0) | 8.0 (7.0–9.0) | 0.50 | 8.0 (7.0–9.0) | 8.0 (7.0–10.0) | 0.21 | 8.0 (7.0–9.0) | 8.0 (7.0–9.0) | 0.37 | 8.0 (7.0–8.0) | 7.0 (7.0–8.0) | 0.60 |
| Happyc | 8.0 (6.0–9.0) | 8.0 (6.0–9.0) | 0.40 | 8.0 (6.0–9.0) | 8.0 (6.0–9.0) | 0.54 | 8.0 (7.0–9.0) | 8.0 (6.0–8.0) | 0.08 | 7.0 (6.0–8.0) | 7.0 (6.0–9.0) | 0.72 |
| Neighbourhood perceptions | ||||||||||||
| Crimed | 3.0 (0.0–5.0) | 2.0 (–2.0–5.0) | 0.001 | 1.0 (–2.0–4.0) | 0.0 (–3.0–3.0) | 0.08 | 3.0 (1.0–6.0) | 3.0 (0.0–6.0) | 0.45 | 4.0 (1.0–5.5) | 4.0 (2.0–7.0) | 0.38 |
| Qualitye | 5.0 (2.0–8.0) | 3.0 (–1.0–6.0) | < 0.001 | 4.0 (1.0–7.0) | 2.0 (–2.0–5.0) | <0.001 | 5.0 (2.0–8.0) | 4.0 (0.0–7.0) | 0.02 | 5.0 (3.0–9.0) | 4.0 (1.0–6.0) | 0.05 |
Follow-up
Moving to East Village was associated with small improvements in depression and anxiety scores (except for the social housing sector who showed a slight increase in anxiety), although none of these effects was statistically significant (Table 22). Although moving to East Village was also associated with modest improvements in well-being scores, none of the effects was statistically significant, except for life satisfaction among the intermediate sector (0.34, 95% CI 0.04 to 0.65). However, moving to East Village was strongly associated with improved neighbourhood perceptions of a crime-free and better quality neighbourhood, both overall and by housing sector. Notably, the largest effect size for improved perceptions of a crime-free neighbourhood associated with moving to East Village was observed among the social housing group (see Table 22).
| Outcome | All housing sectors (N=808), difference (95% CI); p-value | Housing sector, difference (95% CI); p-value | ||
|---|---|---|---|---|
| Social (N = 301) | Intermediate (N = 360) | Market-rent (N = 147) | ||
| Depression | ||||
| Model 1a | –0.26 (–0.65 to 0.14); 0.20 | –0.35 (–1.10 to 0.40); 0.36 | –0.26 (–0.80 to 0.29); 0.35 | 0.00 (–0.83 to 0.82); 0.99 |
| Model 2b | –0.18 (–0.59 to 0.22); 0.38 | –0.12 (–0.87 to 0.63); 0.76 | –0.16 (–0.74 to 0.42); 0.59 | 0.07 (–0.79 to 0.93); 0.87 |
| Anxiety | ||||
| Model 1a | –0.15 (–0.61 to 0.32); 0.54 | 0.45 (–0.44 to 1.34); 0.32 | –0.49 (–1.10 to 0.13); 0.12 | –0.45 (–1.49 to 0.59); 0.39 |
| Model 2b | –0.11 (–0.59 to 0.37); 0.65 | 0.46 (–0.47 to 1.39); 0.33 | –0.45 (–1.10 to 0.21); 0.18 | –0.44 (–1.45 to 0.57); 0.39 |
| Life satisfaction | ||||
| Model 1a | 0.19 (–0.04 to 0.41); 0.10 | 0.06 (–0.38 to 0.50); 0.78 | 0.31 (0.03 to 0.60); 0.03 | 0.11 (–0.36 to 0.58); 0.64 |
| Model 2b | 0.17 (–0.06 to 0.40); 0.15 | 0.10 (–0.36 to 0.56); 0.67 | 0.34 (0.04 to 0.65); 0.03 | 0.11 (–0.37 to 0.58); 0.66 |
| Feeling life is worthwhile | ||||
| Model 1a | 0.07 (–0.15 to 0.28); 0.54 | 0.15 (–0.28 to 0.58); 0.50 | 0.00 (–0.28 to 0.28); 0.99 | 0.12 (–0.33 to 0.57); 0.59 |
| Model 2b | 0.06 (–0.16 to 0.29); 0.57 | 0.18 (–0.27 to 0.63); 0.44 | 0.08 (–0.21 to 0.38); 0.58 | 0.14 (–0.31 to 0.60); 0.53 |
| Feeling happy yesterday | ||||
| Model 1a | 0.21 (–0.06 to 0.48); 0.12 | 0.16 (–0.34 to 0.66); 0.52 | 0.33 (–0.05 to 0.71); 0.09 | 0.12 (–0.47 to 0.71); 0.69 |
| Model 2b | 0.19 (–0.09 to 0.46); 0.19 | 0.19 (–0.35 to 0.72); 0.49 | 0.36 (–0.05 to 0.76); 0.08 | 0.14 (–0.47 to 0.75); 0.65 |
| Crime | ||||
| Model 1a | 3.37 (2.85 to 3.90); < 0.001 | 4.14 (3.21 to 5.07); < 0.001 | 3.29 (2.55 to 4.02); < 0.001 | 1.85 (0.62 to 3.08); 0.003 |
| Model 2b | 3.36 (2.83 to 3.90); < 0.001 | 3.95 (2.97 to 4.94); < 0.001 | 3.54 (2.76 to 4.32); < 0.001 | 1.88 (0.64 to 3.12); 0.003 |
| Quality | ||||
| Model 1a | 4.91 (4.41 to 5.40); < 0.001 | 4.52 (3.68 to 5.37); < 0.001 | 5.11 (4.43 to 5.80); < 0.001 | 5.08 (3.81 to 6.35); <0.001 |
| Model 2b | 4.98 (4.48 to 5.48); < 0.001 | 4.40 (3.51 to 5.29); < 0.001 | 5.30 (4.58 to 6.03); < 0.001 | 5.19 (3.92 to 6.47); <0.001 |
Relating 2-year change in neighbourhood perceptions to mental health and well-being scores (see Report Supplementary Material 22) showed that improved crime-free and quality scores were associated with decreased levels of depression and anxiety (all p-values ≤ 0.01). Although there was less of an effect of neighbourhood perceptions on well-being scores, there was some evidence that improved perceptions of quality were related to reduced reporting of low levels of life satisfaction (p = 0.05) and feeling worthwhile (p = 0.01).
Discussion
Baseline findings
At baseline, those seeking social housing were more likely to be depressed, anxious and less satisfied with life than those from intermediate and market-rent housing sectors. These housing sector differences in mental health and well-being outcomes appeared to be partially or wholly explained by demographic factors, including age, sex, ethnicity and partner/marital status, which are all well-recognised factors associated with psychological distress and well-being.199,200 However, increased levels of depression among the social group persisted after adjustment for these potential confounders. This finding is consistent with a body of literature showing that those in social housing are more socioeconomically disadvantaged and at greater risk of poorer mental health outcomes, which is associated with increased stress exposures related to their surroundings.22,201–203 Poorer well-being and neighbourhood characteristics, such as perceived levels of increased crime and decreased safety and access to green space, have all been shown to have adverse effects on depression, anxiety and well-being;46,188,194,204 it has been suggested that prolonged exposure to poor-quality neighbourhoods may have an amplifying effect.205 Our results show that positive perceptions of neighbourhoods being crime-free and quality appeared to reduce levels of depression (as well as moderating non-significant associations with anxiety and poorer well-being) among those in the social sector compared with those seeking intermediate housing, suggesting that the negative neighbourhood perceptions observed among those seeking social housing may partly contribute to the higher levels of depression within this group. It was noteworthy that the sociodemographic characteristics of those seeking market-rent and intermediate accommodation were similar, and there were little differences in mental health and well-being except in having a marginally lower prevalence of feeling happy the previous day among the market-rent group. Allowing for neighbourhood perceptions attenuated these modest differences in levels of happiness and, unsurprisingly, did not alter the similarities in other mental health and well-being-related outcomes.
The differences observed with the social sector demonstrate the potential importance of the built environment on mental health among the more disadvantaged, which is entirely consistent with a body of literature showing the effect of the built environment on depression, anxiety and well-being.153,187,204 Hence, it remains entirely plausible that the mental health outcomes of those affected by poorer surroundings might be improved by moving people into environments that encourage positive well-being,206 which longitudinal follow-up of the ENABLE London cohort was able to examine.
Follow-up findings
Despite observing sizeable improvements in objective measures of the built environment (see Chapter 3) and neighbourhood perceptions associated with moving to East Village, particularly in the social sector where there were marked improvements in perceptions of a crime-free neighbourhood, there was little evidence of improved mental health and well-being outcomes after 2 years (although there was a modest improvement in life satisfaction among those living in intermediate East Village accommodation).
Unfortunately, there is very limited literature to put these study findings in context, as few longitudinal studies have examined the long-term effects of urban regeneration schemes on health, and even fewer have examined effects specifically on mental health and well-being-related outcomes.207 One notable exception is a large-scale experimental study carried out in five US cities, the Moving to Opportunity (MTO) study, which examined the long-term effect of being randomised to receive or not receive housing vouchers to encourage moving from high- to low-poverty neighbourhoods on the physical and mental health of 4606 minority low-income families.208–210 Although improvements in living conditions among the intervention group were demonstrated over a 10- to 15-year period, there was little difference in adult mental health-related outcomes and economic self-sufficiency between groups, although a small improvement in subjective well-being associated with moving to less deprived neighbourhoods was observed.206,208 However, there were mixed effects among the participants’ offspring. There was evidence of increased rates of depression, stress and conduct disorders at follow-up among teenage boys who moved to less deprived areas but, conversely, reduced rates of conduct disorders among girls.210 Other more direct evaluations of urban regeneration schemes in Spain211 and the Netherlands212 have shown little effect on mental health outcomes from after 3211 to 5 years.212 From a UK perspective, a large long-term housing improvement programme in Glasgow, Scotland, showed a small positive effect on mental health scores after 2 years213 and found that mental health scores in the most deprived areas that received higher levels of investment improved more after 5 years than lower investment areas.214 However, effects were small and less favourable findings showed that the scheme may have actually increased fear of crime, as relocation may have disturbed established social networks.215 Other UK studies that have examined the effect of urban regeneration programmes, including change in the built environment, have also shown little effect on mental health and well being outcomes, although change in the built environment has not always been well defined.216 The closest study to ours geographically also used a natural experiment to examine the effect of London Olympic regeneration among 2254 children attending secondary schools across the London Borough of Newham, compared with pupils attending schools in other east London boroughs. They found no effect of urban regeneration on self-reported physical activity, mental health and well-being outcomes after 18 months, and repeated cross-sectional surveys among 995 parents suggested that levels of anxiety and depressive symptoms might have increased as opposed to decreased in Newham, compared with control areas.217
In summary, the effects of urban regeneration on mental health-related outcomes appears modest at best and mixed, not applying equally across population groups. Our finding that moving to East Village did not have any sizeable effect on mental health/well-being-related outcomes is entirely consistent with these studies, suggesting that more needs to be done to demonstrate the effect of change in the local environment on mental health and well-being, and to understand why greater differences are not observed.96
The ENABLE London study was carried out to provide robust evidence of the effect of the built environment on health (particularly in a UK context). However, a key limitation is that the mental health and well-being outcomes were secondary to the main hypothesis of the study (where the primary outcome was physical activity) and lacked statistical power. Moreover, the staged recruitment, whereby those in social housing were moved in before those in other housing types, before the East Village development was fully complete, may have dampened exposure effects and not allowed sufficient time for social networks to become established. Although no appreciable changes in physical activity and adiposity outcomes were observed (see Chapter 3), which could have plausibly affected mental health and well-being, it remains possible that longer-term follow-up may demonstrate significant effects. However, this seems unlikely given the modest effects on mental health and well-being outcomes observed after 2 years and that continued development of the area, including high-rise accommodation blocks and reductions in green space,218 could potentially lead to adverse effects (see Chapter 9).
Despite the growing need for more housing, particularly in major cities, opportunities to examine the potential health impact of such developments are limited. It is widely accepted that area regeneration programmes should be designed to have positive impacts on its residents, as well as reducing health inequalities.219,220 However, it is challenging to create high-density urban environments with appropriate local facilities to promote positive health behaviours while also protecting residents from the potentially adverse effects of high-density housing.221 There is little understanding of what is considered to be the optimum density to encourage social contact while moderating other exposures, especially among the more disadvantaged.153 Further research is needed to establish how people from different socioeconomic backgrounds living in the same neighbourhood interact with each other and their local built environment to identify specific aspects that may be contributing to poorer health. Such studies will inform the planning and design of housing developments for improved mental health and well-being.