Do Urban Regeneration Programmes Improve Public Health and Reduce Health Inequalities? A Synthesis of the Evidence From UK Policy and Practice (1980–2004)

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  Do Urban Regeneration Programmes Improve Public Health and Reduce Health Inequalities? A Synthesis of the Evidence From UK Policy and Practice (1980–2004)
  See discussions, stats, and author profiles for this publication at: Do urban regeneration programmes improvepublic health and reduce health inequalities? Asynthesis of the evidence...  Article   in  Journal of Epidemiology & Community Health · March 2006 DOI: 10.1136/jech.2005.038885 · Source: PubMed CITATIONS 93 READS 32 4 authors , including: Some of the authors of this publication are also working on these related projects: SOPIE: Supporting Older People into Employment   View projectHilary ThomsonUniversity of Glasgow 84   PUBLICATIONS   1,630   CITATIONS   SEE PROFILE Rowland Graham AtkinsonThe University of Sheffield 94   PUBLICATIONS   3,029   CITATIONS   SEE PROFILE All content following this page was uploaded by Rowland Graham Atkinson on 29 April 2015. The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the srcinal documentand are linked to publications on ResearchGate, letting you access and read them immediately.  RESEARCH REPORT Do urban regeneration programmes improve public healthand reduce health inequalities ?  A synthesis of the evidencefrom UK policy and practice (1980–2004) Hilary Thomson, Rowland Atkinson, Mark Petticrew, Ade Kearns ............................................................................................................................... See end of article for authors’ affiliations.......................Correspondence to:Hilary Thomson, MRCSocial and Public HealthSciences Unit, 4 Lilybank Gardens, Glasgow G128RZ, UK;  Accepted for publication17 October 2005.......................  J Epidemiol Community Health  2006; 60 :108–115. doi: 10.1136/jech.2005.038885 Objectives:  To synthesise data on the impact on health and key socioeconomic determinants of health andhealth inequalities reported in evaluations of national UK regeneration programmes. Data Sources:  Eight electronic databases were searched from 1980 to 2004 (IBSS, COPAC, HMIC, IDOX,INSIDE, Medline, Urbadisc/Accompline, Web of Knowledge). Bibliographies of located documents andrelevant web sites were searched. Experts and government departmental libraries were also contacted. Review methods:  Evaluations that reported achievements drawing on data from at least two target areasof a national urban regeneration programme in the UK were included. Process evaluations andevaluations reporting only business outcomes were excluded. All methods of evaluation were included.Impact data on direct health outcomes and direct measures of socioeconomic determinants of health werenarratively synthesised. Results:  19 evaluations reported impacts on health or socioeconomic determinants of health; data from 10evaluations were synthesised. Three evaluations reported health impacts; in one evaluation three of four measures of self reported health deteriorated, typically by around 4%. Two other evaluations reportedoverall reductions in mortality rates. Most socioeconomic outcomes assessed showed an overallimprovement after regeneration investment; however, the effect size was often similar to national trends.In addition, some evaluations reported adverse impacts. Conclusion:  There is little evidence of the impact of national urban regeneration investment onsocioeconomic or health outcomes. Where impacts have been assessed, these are often small and positivebut adverse impacts have also occurred. Impact data from future evaluations are required to informhealthy public policy; in the meantime work to exploit and synthesise ‘‘best available’’ data is required. P olicies and interventions that tackle the root causes of poor health have recently been promoted by the UK andother EU governments as an important component of national strategies to improve health and reduce healthinequalities. 1–6 The need to ground these strategies onevidence has also been highlighted. 2 7 8 Most recently theWanless report stated that ‘‘every opportunity to generateevidence from current policy and practice needs to berealised’’, and pointed to the value of systematic reviewmethods in this regard. 2 National programmes of urbanregeneration, or area based initiatives (ABIs), are oneexample of large scale investment tackling urban deprivationand the socioeconomic determinants of health, for example,employment, education, income, and housing; in the UK £11billion has been spent on these initiatives over the past 20 years. The potential for this significant investment to lead tohealth improvement may seem obvious and indeed iscurrently used as a justification of such large scale invest-ment (box 1). 1 9–11 However a systematic review of theimpacts of ABI programmes on health or the socioeconomicdeterminants of health has not yet been done.The dearth of data validating links between regeneration 12 or housing investment within regeneration programmes 13 and subsequent health improvement has already beenestablished in both systematic 13 and non-systematicreviews. 12 But these reviews have relied largely on the resultsof formal research studies. Other relevant data and valuablelessons from previous policy interventions may remainhidden within government reports of policy evaluations.For example, large scale evaluations of ABIs are commis-sioned by government departments but their findings arerarely published in academic journals and the public health value of the evaluations’ findings seems to have beenoverlooked. In addition, evaluations of ABI programmesmay be more likely to prioritise assessments of socioeconomicoutcomes, over health outcomes. Impacts on socioeconomicoutcomes have been recommended as a pragmatic and moreimmediate alternative to assessments of health impacts where health impact data are absent or difficult to obtain. 4  A systematic examination of both the health and thesocioeconomic impacts reported in national ABI evaluationsmay therefore allow exactly the type of synthesis called for byWanless. 2  WHAT IS THE EVIDENCE THAT NATIONALPROGRAMMES OF URBAN REGENERATION (ABIs)IMPROVE HEALTH ? We carried out a synthesis of evaluations of national ABIprogrammes in the UK over 24 years (1980–2004) to examinethe evidence that such major investments can have an impacton population health, the socioeconomic determinants of health, and health inequalities. We used existing systematicreview methods for this synthesis. 14 METHODS Search strategy  We searched for the srcinal reports of national evaluationsof all the UK government’s nine national ABI programmessince 1980. (A brief description of each ABI programme’sactivities, focus, years of implementation, and level of funding in the UK since 1980 is provided in table 1.) Eight 108  electronic databases were searched (Bath Information andData Services International Bibliography of the SocialSciences (BIDS IBSS, 1980–2004), COPAC (1980–2004),Health Management Information Consortium (HMIC,1988–2004), IDOX Information Service (1980–2004),INSIDE (1980–2004), Ovid Medline (1980–2004), Urbadisc/  Accompline (1980–2004), Web of Knowledge (1980–2004)).Because of the specific nature of the review topic, thedatabases were searched for any text containing theprogramme names or their commonly used abbreviations(for example, SRB for single regeneration budget). Relevantgovernment departmental libraries were contacted for detailsof archived reports. Bibliographies of located documents andidentified relevant web sites were also searched (http://, urgsrb.html). Authors of national ABI evaluations and anauthor’s (AK) own experience in this specialist field weredrawn on to identify experts; identified experts werecontacted to ask about further documentation available thatmay not have been identified by our search strategy. Inclusion and exclusion criteria Evaluations that reported achievements or impacts drawingon data from at least two target areas of a national ABIprogramme in the UK were included. Evaluations of singletarget areas or of projects within programme areas wereexcluded as the review aimed to assess the general impacts of a national programme; we assumed that single area evalua-tions may be less able than multi-area evaluations to accountfor local peculiarities that may influence outcomes. Annualreports and routine audits of programme activity wereexcluded unless they were presented as an evaluation orassessment of the programme’s achievements. Where it wasclear that the document reported on a process or strategy fordelivering urban regeneration rather than on the outcomes of  ABI investment these documents were excluded (for exam-ple, the use of inter-agency partnership working in thedelivery of ABI programmes). All methods of evaluation wereincluded (for example, qualitative, quantitative case study,retrospective or prospective studies). Evaluations reportingonly business and enterprise outcomes were not included. Screening and selection Titles of identified documents were screened by one reviewerto exclude obviously irrelevant or duplicate documents, after which titles and abstracts were screened independently bytwo reviewers. Where there was disagreement or uncertainty Table 1  Main activities and funding of national ABI programmes in the UK since 1969  ABI programme (ordered by date) + estimated expenditure Main focus of programme Urban Programme 1969–1980s about £274m/year Grant based programme to deal with areas of special social need through supplementation of existing programmes covering economic, environmental, employment and social projects.Urban Development Corporations (UDC) 1981–1998£2120mProperty and economic regeneration to attract inward investment.Estate Action 1985–1995 £1975m Housing led regeneration, addressing both improvements to physical aspects of housing as well ashousing management. 47  New Life for Urban Scotland (New Life) 1988–1998£485mComprehensive multi-agency regeneration programme to improve housing, environment, serviceprovision, training and employment for local people in four areas. 48 Small Urban Renewal Initiatives (SURI) 1990–2003£160m + Housing led regeneration to widen housing choice, improve quality of housing quality and the localenvironment, improve economic prospects and lever public and private funding. 27  City Challenge 1992–1998 £1162.5m Comprehensive multi-agency regeneration to improve quality of life of residents in run downareas. 35 Single Regeneration Budget (SRB) 1995–2001 £5703m  + £20301m from private sector Comprehensive multi-agency regeneration through initiatives on employment, training, economicgrowth, housing, crime, environment, ethnic minorities and quality of life (including health, sport,and cultural opportunities). 32 Regeneration Partnerships (now known as Social InclusionPartnerships (SIPs)) 1996 £52mCoordinated approach to tackle and prevent social exclusion and demonstrate innovative practices.Main activities focus on education and training, and initiatives to reduce poverty, crime, andpromote employment, enterprise, empowerment, and health. 34 New Deal for Communities (NDC) £2000m 1998–2008 Neighbourhood based programme delivered through multi-agency partnerships. Aims: to reduceinequalities in crime, worklessness, education, housing, and health between the 39 target areas andthe rest of England. Key characteristics of this programme are: long term commitment to deliver realchange, communities in partnership with key agencies, community involvement and ownership,joined up thinking and solutions, and action based on evidence about ‘‘what works’’ and what doesn’t. 49 Box 1 The potential for health improvement iscurrently an important justification for largescale public investment in ABIs N  ‘‘Local neighbourhood renewal and other regenerationinitiatives are in a particularly good position to addresshealth inequalities because they have responsibility for dealing with the wider determinants that have impact on people’s physical and mental health.’’ 1 N  ‘‘The benefits of including health in the strategy of regeneration strategy are twofold. First there are thedirect benefits of improving peoples’ physical andmental health and wellbeing. Second are the indirect benefits for employment, quality of life, levels of stressand the cost of hospital admissions or medicines.’’ 9 N  ‘‘Area regeneration has a key contribution to make toimproving health. It tackles the social, economic, andenvironmental problems of multiple deprivation. And it embodies the concerted approach the government seeks to foster.’’ 10 N  Aims of current national ABI (New Deal for Communities). ‘‘Lower worklessness and crime, andbetter health, skills, housing and physical environ-ment.’’ N  To narrow the gap on these measures between themost deprived neighbourhoods and the rest of thecountry.’’ 11 N  A tally of available funding for programmes includedin our review produced an estimate that over £11bn(16bn euros) of public money has been spent on ABIsin England alone between 1980 and 2002. Urban regeneration programmes, public health, reduce health inequalities 109  the full document was obtained and screened independentlyby two reviewers. Data extraction was carried out by RA and HT. Data extraction Impact data, defined as a measure of change in a givenoutcome over time, were extracted for health and selectedsocioeconomic outcomes. Health outcomes were any directmeasure of health (quality of life, wellbeing, health,morbidity, mortality) or intermediate measure of health(for example, registration/use/satisfaction with local healthservices). Socioeconomic outcomes relevant to the determi-nants of health were defined as outcomes pertaining tohousing, education, training, income, or employment. Theseincluded both direct measures (for example, householdincome, housing quality) and intermediate measures (receiptof welfare, satisfaction, with housing). Impacts on crime andneighbourhood outcomes (for example, satisfaction withlocal shops) were also extracted. Gross output data (reportsof monies spent and investment activity, for example,number of dwellings built or improved, use of new sportscentre) were not extracted. Data synthesis Impact data on direct health outcomes and direct measuresof socioeconomic determinants of health were synthesised.Stakeholders’ and evaluators’ overall assessment of impactson direct outcomes were not included in the synthesis.Intermediate outcomes were not included in the datasynthesis. RESULTS  A total of 896 references were identified of which 86 initiallyappeared relevant; 35 were included in the final review(fig 1). Sixteen evaluations used gross outputs exclusively toreport programme achievement. Nineteen evaluationsassessed health and social impacts and were included in Evaluations included in synthesis Evaluations reporting impacts on healthand/or impacts on socioeconomicdeterminants of health. Reported impactsbased on routine population data orresident survey data (qualitative orquantitative) (n = 10)(See table 2)Evaluations reporting health orsocioeconomic impacts withsupporting data (n = 16)Evaluations reporting health orsocioeconomic impacts basedon stakeholders' retrospectiveestimation of programme impactsand/or unclear estimates of routine data (n = 6) Evaluations reporting impacts (change in outcomes over time) (n = 19)(See table wi)Evaluations with noassessment of direct health orsocioeconomic impacts (n = 1)Evaluations reporting grossoutputs and monies spent, butno assessment of impacts (n = 16)Process evaluations excluded(n = 51)Total citations resulting frominitial database search (n = 896)Evaluations reporting on ABIachievements (n = 35)Evaluation documentsretrieved (n = 86)Evaluations reporting impacts on health or socioeconomic outcomes(employment, housing, income,education) (n = 18)Evaluations reporting healthor socioeconomic impactsbut with no supporting datapresented (n = 2)Citations clearly not relevantfrom and excluded after initialscreening of titles, for example,non-UK, editorial (n = 810) Figure 1  Flow diagram of identifyingincluded evaluations.110 Thomson, Atkinson, Petticrew, et al  the first stage of the review (see table w1 on line http:// 15–34 Impact evaluations: methods, data quality and choiceof outcome measures Nine evaluations were carried out prospectively. 23 24 26–28 30 31 34  All but two 20 26 of the impact evaluations used a case studyapproach, where the evaluators selected a few sites torepresent the national programme. Detailed reporting of evaluation methods, data sources, and sample sizes was poor;in two evaluations some impacts were reported without anysupporting data. 23 24 Furthermore, evaluators frequentlyreported that data on included outcomes were unavailable,resulting in non-reporting 17 23 24 29 or presentation of incom-plete data in the final document. 16 19 28 34 Evaluations assessing impacts relied heavily on routinestatistics collected by the UK government as well asstakeholders’ perceptions or the evaluators’ overall estimatesof impacts. Six evaluations included a prospective survey of residents, 23 24 26 28 32 34 one of which was a panel survey of thesame residents at both time points. 32 Ten of the 19 impactevaluations reported impacts on direct health or socio-economic outcomes (table 2). 18 22 25–28 30–32 34 Data synthesis of direct impacts on health andsocioeconomic status Impacts on direct health and socioeconomic outcomesreported in the evaluations were self reported health status,mortality rates, employment (long term unemployment,employment, unemployment), household income, educa-tional attainment, housing quality, and housing costs (rent)(table 2). A narrative synthesis of these impacts is presentedbelow. Impacts on self reported health and mortality rates Impacts on self reported health or mortality rates werereported in three evaluations. 26 31 32 In one evaluation thatsurveyed the same residents before and after the programme,three of four measures of self reported health deteriorated,typically by ¡ 3.8%. 32 Two other evaluations reported overallimprovements in mortality rates (standardised mortality rate131  v  114 26 and 122  v  118, 31 crude mortality rate  2 0.6% 31 )although standardised mortality rates increased in some casestudy areas in one of these evaluations. 26 Impacts on employment and unemployment  Employment measures were the most frequently includedoutcome measure and data were reported in nine evalua-tions. 18 25–28 30 31 32 34 Improvements were reported in all butone evaluation. 18 However, this simple tally of positiveimpacts conceals the specifics of type of outcome assessed,negative effects, and missing data.Three evaluations reported improvements in employment(% working age in employment  + 6% 26 + 4% 32 and number of households with at least one person economically active + 9% 27 ), but in one of these evaluations employment rate fellin two of the four case study areas 26 and in anotherevaluation there was no additional improvement whencompared with the national trend in employment rates. 32 Eight evaluations reported impacts on unemploymentoutcomes; in six of these positive impacts were reported (%unemployed 2 1.3%, 31 unemployment rate 2 3.8%, 34 2 10.8% 30 numbers of unemployment claimants 2 32%, 34 2 29.5%, 25 and% working age economically inactive  2 5.3%, 26 2 4%, 32 ). Intwo evaluations overall impact on employment outcomes were negative (unemployment rate  + 0.3%, 28 % unemployed- + 3.35% 18 ). While improvements in unemployment measures were regularly reported, in two evaluations a mix of negativeand positive impacts on unemployment measures werereported across case study areas 26 28 and in a further threeevaluations the improvements reported were similar tonational or regional trends over the same time period. 25 31 34 Impact on long term unemployment was reported in threeevaluations (% of unemployed who have been unemployed . 12 months, 28 30 and % of (unemployed  +  employed popula-tion) who have been unemployed  . 12 months 31 ). In twoevaluations of the SRB long term unemployment fell( 2 1.6% 31 and 2 17% 30 ), although in one of these evaluationsrates of long term unemployment increased relative tostandardised English rates. 31 In one evaluation of CityChallenge an overall increase in long term unemployment was reported, although both increases and decreases werereported within individual case study areas (range 2 4.1% to + 5.8%). 28 Impacts on educational attainment  Five evaluations (1988–1999) reported impacts on schoolachievement. Improvements in proportions of ‘‘pupils obtain-ing  . 4 GCSEs’’ or ‘‘ . 2 standard grades’’ (Scotland) wereconsistently reported in the four evaluations that includedthis outcome (mean impact  + 6.25%). 26 28 30 31 However,similar improvements in the proportion of ‘‘pupils obtaining . 4 GCSEs’’ were also reported across England over this timeand two evaluations reported little or no improvement whenthe findings were compared with national data. 30 31 Despiteoverall improvements, both negative and positive impacts onthe proportion of respondents reporting ‘‘any member of household with CSE/GCSE/O level’’ 32 or ‘‘school leavers withno GCSEs’’ 28  were reported across case study areas in twoevaluations. Impacts on household income The number of households with incomes below £100 per week was assessed in two evaluations 26 32 and an overallimprovement was reported. However, in one of theseevaluations a range of negative and positive impacts on thisoutcome were reported across the four case study areas( 2 34% to  + 3%). 26 Impacts on housing quality and rent  The proportion of original residents living in improvedhousing after ABI investment was only reported in oneevaluation (42.5%). 22  Another evaluation assessed changes inhousing costs; average social housing rent doubled over theperiod of investment, seven to eight years. 25 DISCUSSION This review is a direct response to Wanless’s call to tap ‘‘everyopportunity to generate evidence from current policy andpractice’’. 2 The use of conventional systematic reviewmethods to synthesise impact data for both socioeconomicoutcomes as well as health outcomes is a novel attempt topresent evidence tailored to inform healthy public policy. Thedata synthesis suggests that previous ABIs may have smallpositive impacts (median size of positive impact reported ¡ 5.5%, range 1.0% to 32.0%, for example, unemploymentrate  2 3.8%, 34 households with income of less than £100 2 4% 32 ) across a range of key socioeconomic determinants of health, although these impacts may mirror national trends.Small positive health impacts are also reported, but adversehealth impacts remain a real possibility.However, reports of impacts in the evaluations of ABIs arerare. In the UK, evaluation of ABI achievement has reliedheavily on reports of gross outputs and monies spent (forexample, number of new houses built), rather than reports of the actual impacts effected by the investment (for example,change in the proportion of residents living in poor qualityhousing). Even when an impact evaluation has been Urban regeneration programmes, public health, reduce health inequalities 111
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