Neighbourhood problems lead to depression, but effects vary across countries

Neighbourhood characteristics are linked to mental health in older age, but the magnitude of effects might differ across countries. Using data from 16 different countries, our paper in the American Journal of Epidemiology indicated that country-level social, political, economic and environmental characteristics may explain differences in how neighbourhood affects mental health.

Depression, local area and macro-level context

Depression is a common mental disorder with substantial disability and economic burden worldwide. More than 10% of adults aged 50 years and older present depressive symptoms with an even greater proportion of the population suffering in older age groups. Older adults spend more time in their neighbourhood, so that social and physical features of the residential area become increasingly important for them.

Signs of neighbourhood disorder, such as crime, vandalism and exposure to rubbish, are thought to indicate problems in the residential environment, by elevating the level of stress and fear among residents. On the other hand, positive aspects of neighbourhoods such as social cohesion – which is often characterised as a sense of community, help and support among neighbours – have the potential to buffer the effects of stress and contribute to healthy ageing. Both neighbourhood disorder and social cohesion has been linked to mental health problems.

Neighbourhoods are situated within macro-level environments capturing larger geographic areas such as local authorities, counties or even countries (Figure 1). Policies, as well as social, economic and environmental characteristics of macro environments can affect citizens’ life and health, and also shape the physical and social characteristics of local communities, where people live and age. It is important, as both local and macro-level environments are modifiable, presenting opportunities for improving population mental health and contributing to healthy ageing.

Figure 1: Local and macro-level determinants of depression

Neighbourhoods influence mental health among older adults

We investigated the associations between neighbourhood disorder, lack of social cohesion and depression among adults aged 50 and over. Longitudinal information on perceived neighbourhood characteristics and depressive symptoms across 16 high-income countries were utilised, including 32000 older adults. Results showed that living in an area with significant neighbourhood disorder increased the chance of developing depression (Figure 2), and so did lack of social cohesion (Figure 3). If people were already in retirement, effects became stronger.

Figure 2: Neighbourhood disorder impacting depression across 16 high-income countries. Odds Ratios <1.0 indicate decreased odds of depression by exposure to neighbourhood disorder; Odds Ratios >1.0 express increased odds. Small black diamonds are country-specific estimates, larger empty diamonds are pooled effects across group of countries. Abbreviations: ELSA, English Longitudinal Study of Ageing; HRS, Health and Retirement Study; SHARE, Survey of Health, Ageing and Retirement in Europe.

Neighbourhood effects differ across countries

As the magnitude of the associations varied across the 16 included countries, we further explored country-level differences.

Figure 3: Lack of social cohesion impacting depression across 16 high-income countries. Odds Ratios <1.0 indicate decreased odds of depression by lack of social cohesion; Odds Ratios >1.0 express increased odds. Small black diamonds are country-specific estimates, larger empty diamonds are pooled effects across group of countries. Abbreviations: ELSA, English Longitudinal Study of Ageing; HRS, Health and Retirement Study; SHARE, Survey of Health, Ageing and Retirement in Europe.

Amongst other, we found that in countries with higher population density, lack of social cohesion was more detrimental for mental health. Particularly in the oldest age groups, where limited mobility is more likely present, neighbours can be an important source of social and emotional support. In countries where people live closer to each other, not having proper social ties to neighbours can lead to social isolation and higher risk of developing mental health problems.

Also, in countries with higher pension spending, the adverse effect of neighbourhood disorder on depression was buffered for individuals already in retirement. It is plausible that by providing material resources, more generous welfare states equip older people to deal with stressors arising from less safe and deteriorated residential neighbourhoods.

Macro-level context and policy recommendations

Understanding how larger context can influence mental health inequalities across neighbourhoods has the potential to inform policy, and provide more tailored recommendations. For example, tackling crime and vandalism in countries with lower pension spending would be particularly beneficial for mental health, as older people has less material resources to protect themselves from the negative effects of neighbourhood disorder. Supporting social ties and improving social capital in densely populated areas may stronger contribute to healthy ageing and lead to better mental health among older adult.

By Gergő Baranyi, School of Geosciences, University of Edinburgh

Two Postdoctoral Researchers (Health & Environment)

We are currently seeking to recruit two Postdoctoral Researchers (Health & Environment) to join the CRESH team at the University of Edinburgh and contribute to two studies on the geography of unhealthy commodities.

The first position is part of the UK Prevention Research Partnership (UKPRP) Consortium – SPECTRUM (Shaping Public hEalth poliCies To Reduce ineqUalities and harm). SPECTRUM has an ambitious programme of research, knowledge exchange and public engagement focusing on the commercial determinants of health relating to tobacco, alcohol and food.

The second role will contribute to an ESRC funded project ‘Change in alcohol and tobacco availability, population health and the lived experience’ which will measure change in the availability of alcohol and tobacco in Scottish neighbourhoods over time and explore how this change relates to health outcomes and how residents experience the availability of alcohol and tobacco in their neighbourhoods.

Closing date for both positions is 16th October 2019.

Please get in touch with Professor Jamie Pearce or Professor Niamh Shortt to discuss either role: Jamie.Pearce@ed.ac.uk Niamh.Shortt@ed.ac.uk

https://www.jobs.ac.uk/job/BVI122/postdoctoral-researcher-health-and-environment-tobacco-and-alcohol

https://www.jobs.ac.uk/job/BVI153/postdoctoral-researcher-health-and-environment

New ESRC funded study on Tobacco and Alcohol

We are delighted to announce that we have been awarded funding from the ESRC for a project exploring tobacco and alcohol environments in Scotland. The project ‘Change in alcohol and tobacco availability, population health and the lived experience’ will be funded for 3 years, beginning December 2019 for a total of £761, 470. The project will be led by Professor Niamh Shortt with co-investigators from the University of Edinburgh (Professor Jamie Pearceand Dr Tom Clemens), Glasgow Caledonian University (Professor Carol Emslie) and the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow (Professor Richard Mitchell).

This research will measure change in the availability of alcohol and tobacco in Scottish neighbourhoods over time and explore how this change relates to health outcomes and how residents experience the availability of alcohol and tobacco in their neighbourhoods. The findings will be important because smoking and alcohol consumption are leading causes of illness and death. In Scotland smoking causes one in every 5 deaths and one in 20 deaths is related to alcohol. This harm is not equally shared; those on the lowest incomes suffer the greatest harm. These illnesses and deaths are preventable. The World Health Organisation recommends that nations prioritise interventions that reduce the supply of alcohol and tobacco.

Why might neighbourhood supply of alcohol and tobacco matter? Research suggests that when there are a lot of outlets in a neighbourhood this impacts upon consumption in three ways. 1. The outlets may be more competitive and drive prices down to attract customers. 2. Oversupply may normalise the products when they are sold alongside everyday commodities, such as bread and milk. 3. Tobacco and alcohol may simply be easier to buy in areas where there are more outlets.

In order to explore the relationship between supply, behaviour and harm we need data on the location of every outlet in Scotland selling tobacco and/or alcohol. Ideally, to be able to say something about whether the relationship may be causal, we need this data over time. We have already collected data on the specific location of every outlet selling tobacco and licensed to sell alcohol over multiple time periods (2012 and 2016 (nationwide alcohol and tobacco – see paper here) and 2008 (alcohol in four cities – see paper here)). As part of this project we will collect updated data for 2019/20. This will allow us to measure this change over time. Using an approach called trajectory modelling we will group neighbourhoods that have had a similar degree of change; some neighbourhoods may have lost, or gained, local shops or pubs, whereas some may not have changed at all. We will then identify features of these neighbourhoods that may be driving this change, for example the age profile of the population or poverty levels. This will help policy makers understand the drivers of change in our neighbourhoods.

To measure the relationship between changing supply and harm we will link these trajectories, and our measures of availability at each time point, to alcohol and tobacco health outcomes (behaviour, illness and death). We will use statistical models to see whether areas experiencing an increase or decrease in outlets have seen a corresponding increase or decrease in these outcomes. This will allow us to get a better understanding of whether an over supply of alcohol and tobacco is related to smoking and alcohol consumption and harm. These findings will provide important evidence related to the provision of such commodities in our neighbourhoods.

Although these statistics are important to report we also need to understand why an oversupply of alcohol and tobacco may influence behaviour and harm. Whilst the literature suggests the pathways listed above, we know little about the experiences of individuals living in neighbourhoods with contrasting availability. We don’t understand the individual experience of any of these pathways. Professor Carol Emslie will lead a qualitative work package and researchrs will meet with groups of individuals, in neighbourhoods of contrasting trajectories, to talk to them about the supply of alcohol and tobacco. We will explore their experiences of neighbourhood and assess how their perceived notions of their neighbourhood availability contrast with our statistical measures. Finally, we will meet with residents, retailers and policy stake-holders to explore potential interventions related to supply. Policies at this level require public, retailer and political support. We will discuss the priorities held by various groups, present our quantitative results and gauge attitudes towards potential interventions.

Throughout the project will be committed to knowledge exchange, public events and speaking with non academic partners. If you wish to know more about this research, or would like one of the researchers to come to your organisation to provide you initial findings (once the project is under way) then contact the Principal Investigator here: niamh.shortt@ed.ac.uk

An atlas of change in Scotland’s built environment 2016-17

By Laura Macdonald from the MRC/CSO  Social and Public Health Sciences Unit, University of Glasgow @theSPHSU

Our neighbourhood environments change and evolve often; some changes are minor, while others involve major transformation. Change can take various forms; green space created or removed, existing housing or amenities demolished, new housing estates built, new motorways created, or existing transport infrastructure modified or extended. Change may affect neighbourhood residents’ physical or mental health, or health-related behaviours, to their benefit or to their detriment. To study how change in our neighbourhoods might affect our health we need robust information but data showing how our neighbourhoods are changing, at a fine geographic scale, for the whole of Scotland, did not exist – until now! This is why we created an atlas showing what’s changed, and an interactive mapping application which allows you to explore the data yourself. Continue reading An atlas of change in Scotland’s built environment 2016-17

Children in deprived areas encounter shops selling tobacco six times more frequently than those in well-off areas

By Dr Fiona Caryl.

Our new study  looking at exposure of children to tobacco retailing, recently published in the journal Tobacco Control, shows that an average 10-to-11-year-old child in Scotland comes within 10m of a shop selling tobacco 43 times a week. This rises to 149 times a week for children living in the poorest areas—six times more than the 23 encounters a week experienced by children living in affluent areas. This demonstrates an unexpectedly large inequality in the amount of times children are exposed to tobacco sales. Unexpected because in the same study we showed that tobacco outlets are 2.6 times more common around the homes of children living in the most deprived areas than the least. Yet we found a six-fold difference in exposure because we used GPS trackers (fully consented and ethics-approved, of course) to follow exactly where children moved through their environments. We found that most exposure came from convenience stores (41%) and newsagents (15%) on school days, with peaks before and after school hours. At weekends, we found most exposure came from supermarkets (14%), with a peak around midday.

Why does this matter? This may not sound like a lot of exposure, and we might ask if a child is really exposed to tobacco just by being in or near a shop selling tobacco, especially after the ban on point-of-sale (POS) tobacco displays. But then we don’t actually know how many micro-exposures it takes to make a child think that smoking is a normal, acceptable and widespread behaviour rather than a major cause of premature death. Research into advertising suggests that the mere-exposure to indirect and incidental stimuli can influence attitudesnon-consciously when they’re repeatedly presented. The ban on POS tobacco displays has reduced children’s susceptibility to smoking, but children still notice tobacco on sale. In fact, recent research shows that the conspicuousness and prominence of tobacco in shops varies considerably between areas of high and low deprivation. And the difference in prominence has been increasing since the POS ban.

The difference in the number of times children in poor areas are in or near to places selling tobacco is most concerning when you consider the pathways leading people to start smoking. Most adult smokers start when they are teenagers, and the availability of tobacco products is a key factor in in why people start to smoke and why they find it hard to give-up. Our findings raise important questions about when and where tobacco products are sold and the messaging this is sending to children.

Liveable urban environments: an opportunity or threat to reducing health inequities?

Creating ‘liveable’ urban environments is seen as an important way of improving the health and wellbeing of the residents in our towns and cities. Yet it is not clear whether the focus amongst planners and other policymakers on fashioning liveability is an opportunity – or threat – to reducing health inequities. On the one hand improving the resources and infrastructure in local communities might benefit everyone but particularly those who are most dependent on what is close by. On the other hand, it is possible that if liveability interventions are poorly or unevenly implemented, or inappropriate to the particular needs of the local population, then health inequities may widen. This issue was the focus of our new research recently published in Social Science & Medicine where we found evidence that some aspects of liveability have reduced inequities, whereas other aspects have not led to a reduction, or in some cases even increased, health inequities.

The notion of liveability has been around for a long while and is underpinned by the United Nation’s New Urban Agenda. The aim is to ensure equitable delivery of sustainable urban development – including local infrastructure and services, and housing amongst many other urban features – and to improve the living social and physical conditions for urban dwellers, including their health. Given these important and laudable goals it is perhaps surprising that so few studies have looked at what effects liveability has on health inequities. Health inequities continue to increase across many countries, including the UK and Australia; identifying what works in the long-term to reduce health inequities remains a policy priority for many national governments and international agencies.

In our new work we examined the international evidence to see when and where urban liveability might pose an opportunity or threat to reducing health inequities. We looked across a series of urban liveability features (education; employment; food, alcohol, and tobacco; green space; housing; transport; and walkability) and asked whether intervening on these aspects of place can serve to widen or narrow inequities.

Our findings show that the urban liveability agenda offers opportunities to help address health inequities but the effects differ from place to place. It was also clear that we need to keep in mind that urban liveability is just one part of a much broader urban system; whilst improving aspects of urban liveability can improve the health for some populations in a local area, it may not be the case for others. In some cases, the health benefits of urban liveability are restricted to specific (and sometimes more prosperous) communities. In fact, in more extreme cases urban liveability interventions can result in local people being pushed out of their community (e.g. through associated hikes in rental prices), with negative implications for their health and wellbeing.

We believe that the findings from this research include some important messages for policymakers and urban planners tasked with identifying ways to improve people’s health and reduce health inequities. Designing our neighbourhoods to become more liveable offers some significant opportunities to enhance health. However, it is also apparent liveability interventions need to be implemented in ways that meet the needs of all population groups living in the area, including the most vulnerable. As researchers, it is important that we continue to monitor the impact of liveability interventions on inequities and seek a better understanding of how these issue relate to the wider urban and social systems affecting our health.

Hannah Badland & Jamie Pearce

Mental health problems are common among prisoners in low-income and middle-income countries

In a major international review, we found very high rates of psychiatric and substance use disorders among prisoners in low-income and middle-income countries. The results from the systematic review and meta-analysis published in Lancet Global Health showed that the prevalence of psychosis, depression, and drug and alcohol use disorders is much higher in this marginalised population in comparison to the community, pointing to unmet needs and calling for action in research and policy.

Mental health and substance use problems are common among individuals involved in the criminal justice system. Incarcerated men and women often come from disadvantaged socioeconomic and family background, and frequently have a life history of victimisation and substance use, making them more vulnerable to mental health problems. While in prison, they often remain undiagnosed and untreated. Prisoners with unmet mental health needs have higher mortality, especially by suicide, and greater risk of recidivism and reoffending after release in the community, leading to multiple imprisonments.

Although 70% of the worldwide prison population are residing in low-income and middle-income countries (LMIC), almost all scientific evidence is coming from studies conducted in high-income countries. It is an important limitation as recommendations from a mostly Western context might not be applicable or generalizable to poorly resourced settings. Prison conditions in LMICs are usually very harsh, characterised by overcrowding, poor nutrition, and sanitation, and limited or complete lack of access to basic health care. To provide evidence for future research and policy making, we conducted a systematic review and meta-analysis on prison prevalence studies in LMICs.

After screening 6000 titles and abstracts from 17 electronic global databases, we identified 23 relevant publications based on 14,527 prisoners from 13 different LMICs. Considering a one year time interval, approximately 6.2% of the prisoners had psychosis, 16.0% major depression, 3.8% alcohol use disorders, and 5.1% drug use disorders. To illustrate the immense burden of mental health problems, we quantified the difference between the prevalence among prisoners in each sample and in the sex-matched general populations of the respective countries. Prevalence rates among prisoners were 16 times higher for psychosis, 6 times higher for major depression and illicit drug use disorder prevalence, and twice as high for alcohol use disorders, indicating a significant public health concern and large unmet health care needs in this marginalised group. Moreover, rates in prison populations of LMICs might be even higher than in high-income countries.

Based on our findings, we presented several implications and recommendations for research and policy.

  1. While a review from 2012 on prison mental health in high-income countries identified over 100 samples, we were able to find only 23 studies from a much larger and diverse group of countries. There is a need further evidence from LMICs to adequately plan interventions for prisoners with mental disorders, especially from regions underrepresented in research such as Central and East Asia, and Central America.
  2. Because correctional facilities in LMICs often lack basic health care, the implementation of cost-effective interventions and scalable treatments for individuals with mental health problems is crucial.
  3. Imprisonment could present an opportunity to treat people with mental health and substance use problems who otherwise would be difficult to reach for health services. National governments in LMICs should move the responsibility for prison health care from prison administrations to the national health services.
  4. Since human right violations, and physical and psychological abuse are more common in resource-poor correctional settings, increasing mental health literacy among staff and protecting the rights and health of people with mental illnesses should be a priority for penal justice policies.

The invited comment on our paper gives a valuable and very practical recommendation on how to improve mental health services in correctional facilities. Training prison health workers by mental health professionals using the WHO’s Intervention Guide for mental disorders (mhGAP-IG), could be a cost-effective and valuable programme for addressing the treatment gap among prisoners in LMICs and coming closer to the Sustainable Development Goals declared by the United Nations.

By Gergo Baranyi, PhD Student in Human Geography and Marie Sklodowska-Curie Early Stage Researcher, The University of Edinburgh