Category Archives: Inequalities

New evidence linking availability of tobacco & smoking

The connection between the local availability of tobacco products and smoking behaviour has been underlined in new research from the CRESH team this week. Published in the journal Tobacco Control, we show how moving into an area of Scotland where tobacco products are more readily available can significantly increase the risk of smoking while pregnant. We estimate that a pregnant woman living in an area with the highest tobacco availability is 70% more likely to smoke than when she was living in an area with the lowest availability of tobacco products.

Why is this important? Firstly, smoking during pregnancy is a vital Public Health issue and is recognised as a key priority area for UK health policy. It is harmful for both the mother and the developing fetus and the effects for social and health outcomes can persist into childhood and adulthood. Since smoking is so strongly associated with poverty and deprivation, it also has an important role to play in the persistence of health inequalities across generations.

But there are other reasons why the research is important. Much of what we know, including previous research from CRESH, is based on information from a single point in time. While these studies are crucial in establishing the strength of associations, they are less useful for determining mechanisms. A key question that remains is whether high availability is the cause of smoking behaviour or whether retailers preferentially locate in areas of high demand. Both pathways are plausible but both carry very different conclusions and policy recommendations. Our latest research is able to address this question using information on smoking during pregnancy which is collected routinely as part of Scotland’s hospital maternity records. By looking at multiple pregnancies to the same individual, we were able to relate changes in smoking behaviour between pregnancies to changes in exposure to tobacco retailers from residential moves. This approach provides strong evidence that availability is causally linked to behaviour.

The policy implications are clear. As more and more countries move towards a “Tobacco Endgame” policy this, and other research, highlights how a focus on tackling the local availability of tobacco products will be crucial. In a week where the UK government has suggested that preventing poor health lies with “people choosing to look after themselves better, staying active and stopping smoking” our findings are a timely reminder of the importance of considering the wider set of structural factors that shape our health of which our residential environment is one important component.

Do people actually use the facilities in their home neighbourhood?

This blog explores a key question in neighbourhood and health research: if there is a facility or amenity close to someone’s home, is it OK to assume they use it? Surprisingly, this assumption is at the heart of a lot of health and environment research.

We often have data which tells us where facilities and amenities are, and we tend to make the assumption that proximity means use. So, for example, if we see that some neighbourhoods have more parks or more leisure facilities, we expect the people who live in that neighbourhood use them more. Understanding local amenity and facility use is important because we want to know whether / how these things affect health.

With technological advances in recent years, studies have started to collect precise data which tell us exactly where people go using global position system (GPS) devices. We no longer have to assume, for example, that if there’s a park close to a child’s home, they will visit it. The GPS tracks we collect will tell us if they did or not. That presents an opportunity to test our assumptions.

Do children use facilities they have access to in their home neighbourhood?

Our team is interested in children’s use of facilities in and around their homes and to test whether we need GPS to research this we conducted an analysis of facility availability and facility use for 30 10-year-old children living in Glasgow. We used data from GPS devices worn by the children for eight days. These children were part of our ‘Studying Physical Activity in Children’s Environments across Scotland’ Study (SPACES).

The diagram below shows what we did. Our key finding was that facility availability in the home neighbourhood is not a good indicator of facility use; the children used facilities from across a much wider area in the city, even if they had a facility close to their home.  For example, 18 of the 30 children (60%) had a leisure centre within their ‘neighbourhood’ (which we defined as 800m around their home). Only 3 of the 18 actually visited that facility (as identified by their GPS tracks). Of those 18 children, 8 actually visited a leisure centre outside of their ‘neighbourhood’. We saw the same kind of pattern when exploring availability and visits to playing fields, public parks and libraries

Blog graphic

Are our results similar to other research?

Yes, other studies that used GPS devices have found that children do spend time outside of their immediate home area for specific purposes. For example, a 2017 study by Chambers and colleagues in Wellington, New Zealand analysed leisure time GPS data (before and after school) in 114 children aged 11 to 13 years from 16 schools, and found that 38% of their leisure time was spent outside of the home neighbourhood (using a 750m buffer around the home). Time outside of the home neighbourhood was mostly spent visiting their school, other residential locations, and fast food outlets.

These results, and those from similar studies, show that it is important not to treat what’s in someone’s immediate home neighbourhood as a good measure of what they do, or in epidemiological language ‘what they are exposed to’. We must challenge the idea that residential neighbourhood is an adequate way to capture the socio-environmental factors which contribute to health. Many people, including children, can and do access environments well beyond their immediate home neighbourhood. We think that a much wider geographic area should be considered when we’re asking questions about how environment affects health and we call this the city-wide landscape.

What does this mean for future research?

It’s clear that the ‘traditional’ approach which uses someone’s neighbourhood (often defined by a distance around their home, or an administrative area in which their home sits) to assess their access to facilities or exposure to environments is seriously flawed.

  • Other methodological approaches are required to measure ‘exposure’ to environment;
  • We must move beyond traditional fixed neighbourhood-health relationships (although we can’t ignore them);
  • We should embrace and integrate innovative technology to explore mobility (e.g. GPS and accelerometer).

Of course, even when we’re able to see exactly where people go and what they do, we still need to understand the decisions people make about whether or not to visit or spend time at different places.

By Jon Olsen, Research Associate with the Neighbourhoods and Communities programme, MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.

Hard Times: Mental Health under Austerity event

How important for mental health are the changing social, economic and environmental conditions in the places where we live? Our research, funded by ESRC, addresses this question through a new and innovative study of mental health of people living in different parts of Scotland. We are focussing especially on the period since 2007 when economic recession and austerity have impacted to a varying extent across the country. This event will use interactive data visualisations to present our research findings, showing how audience polling techniques allow the participants to select topics of special interest for them, to help determine in ‘real time’ the focus of the results presented. This will be combined with an opportunity for group discussion and exchange of ideas among diverse participants, many of whom will be involved in mental health care and promotion of better mental health. We will be sharing new evidence and discussing the implications for policy and practice in different parts of Scotland. The event is also intended to help shape the future research agenda.

FREE to attend. Registration via Eventbrite. Refreshments provided.

LOCATION

The Melting Pot, 5 Rose Street, Edinburgh, EH2 2PR

Changing places and mental health: do changes in perceptions of neighbourhood influence anxiety and depression in adults?

Written by Dr Jon Olsen, Research Associate with the Neighbourhoods and Communities programme, MRC/CSO Social and Public Health Sciences Unit. This blog is mirrored on the SPHSU website.

Mental health problems are a global issue. In 2013 over 615 million individuals suffered from anxiety and/or depression across the world, a rise of 50% since 1990. How people experience their local environment can impact on mental health. Living in areas that are perceived to have higher levels of neighbourhood problems such as poor housing quality, limited amounts of greenspace, industrial activity, and high traffic volume, has been linked to poorer mental health by some research studies. But, few studies have explored how change in what people think about their neighbourhood is linked to change in their mental health. It would be useful to know this as improving the neighbourhood environment could strengthen mental health.

In our recently published study, we wanted to see how changes in what people thought about their neighbourhood impacted on residents’ mental health over time. We looked at two mental health outcomes: anxiety and depression. Adults who lived in West Central Scotland, an area including Glasgow and eight neighbouring local authorities, were asked to complete the same questionnaire in 1997 and 2010.

Glasgow, United Kingdom – October 20, 2013: People come to walk around and shop at the historic Barras Market Place flea market.

What did we find?

Overall, anxiety and depression in the people we spoke to reduced between 1997 and 2010. However, those who experienced worsening neighbourhood perceptions from 1997 to 2010 also had increased anxiety and depression scores.

Why this matters

Our study showed that worsening neighbourhood perceptions were linked with small increases in anxiety and depression scores. People living in areas where perceptions of the neighbourhood got worse, did not benefit from the general improvements in anxiety and depression scores enjoyed by the population as a whole; this could widen health inequalities.

Wheelie bins (blue for recycling, green for general refuse) lined up for collection in a Glasgow alley.

 

The take home message from this study

There is a clear need for national and local policy to target areas where neighbourhood conditions are substantially deteriorating to ensure people’s mental health does not suffer.

Further information about the study

We used data from the Transport, Housing and Well-being study; a postal survey of adults in eight local authority areas in the west of Scotland in 1997 and 2010. More information and a link to the full questionnaire can be found here: http://thaw.sphsu.mrc.ac.uk/.

Anxiety and depression was measured using the Hospital Anxiety and Depression Scale (HADS), a common measure of psychological distress that has been in use for over 30 years.

The full paper was published in the International Journal of Environmental Research and Public Health and is freely available here.

Disclaimer: The views expressed in this blog are those of the author.

The MRC/CSO Social and Public Health Sciences Unit is funded by the Medical Research Council and the Scottish Government Chief Scientist Office. The views expressed are not necessarily those of the Medical Research Council or the Scottish Government.

Jobs at the GCRF Centre for Sustainable, Healthy and Learning Cities and Neighbourhoods

Five Research Fellow posts are available at the GCRF Centre for Sustainable, Healthy and Learning Cities and Neighbourhoods (SHLC). SHLC is one of the 37 major projects funded for 4 years by the Global Challenges Research Fund (GCRF) Research Councils UK Collective Fund, which aims to build upon research knowledge in the UK, and strengthen research capacity overseas, to help address challenges in the developing countries.

SHLC will conduct comparative studies of urbanisation and the formation and differentiation of neighbourhoods in cities in order to address the challenges associated with large-scale rural-to-urban migration in Africa and Asia. The Centre, based at Glasgow, has eight international partners in South Africa, Tanzania, Rwanda, India, Bangladesh, China and the Philippines.

These jobs require expert knowledge in the areas of education, health, or urban studies in relation to developing countries from the perspective of development studies, geography, urban planning, urban studies, migration, public policy or other relevant social science disciplines.

Specifically, we expect each of the five posts to contribute specialist knowledge to the Centre in at least one of the following areas:

  • Cities, urbanisation and urban development in Africa, South Asia and/or East Asia
  • Education policy research and provision in developing countries
  • Health policy research and health facility provision in developing countries
  • Quantitative research and analytical skills including social survey, spatial analysis, GIS, Big Data.
  • Qualitative research and analytical skills and methods

    For further information and applying, please visit the following web site:
    https://www.gla.ac.uk/it/iframe/jobs/

    Search College of Social Sciences (Job Reference Number: 019448) Closing Date: 13th December 2017

Does place matter during recovery from alcohol dependence?

In a new paper, published in Health and Place, Niamh Shortt, Sarah Rhynas and Aisha Holloway ask ‘Can the environment play a role in recovery?’ Here they discuss the findings from the paper.

Place matters for health. We know that features of the natural, built, and social environment can be either health promoting or health damaging.  From previous research we know that the environment is likely to be significant in shaping health-related behaviours, including alcohol consumption (here and here) and smoking patterns (here and here). In a new paper we have explored individuals’ experience and perceptions of the role of place in recovery from alcohol dependence. We wanted to gain a better understanding of the influence of the environment on the everyday experiences of those in recovery.

In order to do this we worked alongside a group of individuals who attend a recovery café in Central Scotland.  We used photovoice, a participatory research method that enabled the participants to capture images of their recovery. Individuals at various stages of recovery, but all at least one year sober, were able to document features of the environment that enable and/or hinder their journey.  Nine participants captured a total of 468 photographs. During focus group discussions participants identified features of the environment that were therapeutic and risky.

Therapeutic environments

Almost all of the participants made references to natural, wide-open spaces, such as hills, the sea, green spaces, in which they found calm and healing.  Participants associated such spaces with escape, meditation, clearing a busy mind, calm and support (Figure 1).

Figure 1: ‘I’ve took a, a picture at the top of the Braids. Eh, one that looks onto Arthur’s seat. Really green Arthur’s seat. And to the right a bit looks as far doon, I think you can see Bass Rock. Eh, and all that beauty and scenery and it’s on our doorstep. And I use it for a bit of my meditation and clearing my mind and that’.

therapeutic

Aside from vast open spaces, participants also found support in more everyday spaces, including the recovery café itself or in their homes. The café provides a space where the participants could see that they are ‘not the only one’, other café users understand their behaviour and the café itself was seen as a place of refuge following difficult moments.

Risky environments

All of the participants highlighted places of risk within their everyday environments, for most the single biggest element of risk was the retail environment, including both the sale and marketing of alcohol. For one participant the constant presence of alcohol was summed up with a photograph of the view from his window that included the local shop (Figure 2).

Figure 2: ‘it’s just there right on my doorstep and the first sign is beers and ciders’.

risky

The same participant noted that, before recovery, he was able to navigate the city to buy alcohol 24 hours a day, the challenge for him now is to try to avoid it in an environment where it is so readily available.  Participants spoke of the difficulty of avoiding such triggers in the everyday.

Further themes discussed in this paper include the transitory nature of place (places moving from supportive to risky and vice versa) and shame and stigma. This paper demonstrates that the journey of recovery from alcohol dependence is embedded in place, with place both supporting and hindering recovery.  The findings confirm that people in recovery experience a particular set of challenges on a day-to-day basis. Of particular note here was the ubiquitous sale of alcohol and presence of alcohol marketing and promotions.  By viewing recovery as a journey we can begin to frame alcohol dependence as a process of change; change in both the individual and in the way in which the individual sees and interacts with the environment. According to Banonis ‘recovering from addiction is a daily choice’ (Banonis 1989, p.37), however such choices are not made in a vacuum. This paper extends previous work by the CRESH team that argues that such health-related choices can be made more or less difficult by the environment in which one lives.

 

Edinburgh Science Festival Event 2017: Why Places Matter for Mental Health and Wellbeing

The important influence of the places in which we live, work and play on our mental health and wellbeing was the topic of a recent lively discussion at the Edinburgh Science Festival 2017 organized through Centre for Research on Environment, Society and Health (CRESH).

The event was chaired by Professor Jamie Pearce, (from School of GeoSciences at the University of Edinburgh and CRESH) and, in his introduction, he emphasised the policy-relevance of the event as evidenced by  the Scottish Government’s newly released Mental Health Strategy 2017-2027. The Strategy details how institutions, services and organisations will work together to enhance mental health in Scotland. Especially relevant for this discussion was the acknowledgement on P8 of the report that ‘Working to improve mental health care is not just the preserve of the NHS or the health portfolio. We will be working not only across the Scottish Government, but also across the wider public services to harness the broadest range of opportunities to improve the population’s mental health…’.  It is therefore acknowledged that promoting good mental health and wellbeing is not only about medical care, but also involves action to improve the ‘wider determinants’ of mental health – especially how conditions in the places where we live, work, learn and play can affect mental health and wellbeing.

We were therefore interested to explore how academic research contributes to our understanding of how places affect wellbeing.  Our main aim was to exchange ideas with our audience of over 70 people, representing a range of views from those living in the communities in and around Edinburgh. Several participants also reported on knowledge and experience gained in their professional lives, including medical practitioners, public health specialists, leaders in independent organisations whose mission relates to mental health and wellbeing (such as Support in Mind, and the Cyrenians), urban planners and architects and social service providers.

The event started with a series of comments from a panel of academic researchers representing a variety of social science disciplines, who introduced ideas from academic research that may help to frame thinking on these issues.

Professor Sarah Curtis (Professor Emeritus at Durham University) used her own experience of volunteering in the Edible Garden project at the Botanic Gardens to illustrate ideas from Health Geography about Therapeutic Landscapes, originally put forward by Wil Gesler (e.g. in his book on Healing Places).  This conceptual framework suggests we can think of places in terms of: material and physical landscapes (agreeable and relaxing green spaces, water spaces and built environments), social landscapes (supportive social relationships and community processes) and symbolic landscapes (features of our environment that stand for beliefs, principles and memories that are important for us). All of these dimensions of places, experienced in the different settings where we spend our lives, can be important for creating and maintaining our sense of mental wellbeing.  These features of landscapes, the ways they change, and how different groups of people experience them over time, have been studied extensively by health geographers (e.g. reviewed by Sarah Curtis in her book Space, Place and Mental Health).

Professor Steve Platt (Professor Emeritus at University of Edinburgh) then presented ideas from research in Sociology and Health Policy about what we might consider the ‘reverse’ of therapeutic landscapes; focussing on factors that are associated with risk of suicide and why suicide matters for suicide prevention. He used the example of the iconic Golden Gate Bridge in San Francisco, which has been a ‘magnet’ for people intent on taking their own lives.  He described the public controversies surrounding action to alter the architectural form of the bridge in order to install protective structures to reduce the suicide risk. He also underlined the evidence for socio-economic deprivation as a risk factor for suicide, with the risk of suicide being 2-3 times higher in the local areas in Scotland ranked among the worst 10% for social deprivation, as compared with populations living in areas ranked in the least deprived areas. He went on to elaborate further on the idea of suicidogenic contexts combining various dimensions that may be cultural, socio-economic, political, historical, as well as including built infrastructures and other aspects of the physical environment.

The significance for wellbeing of green space, viewed from a Landscape Architecture perspective, was introduced by Professor Catharine Ward Thompson, Director of the OPENspace Centre at the University of Edinburgh’s College of Art. She underlined that, since stress is a major problem for society and is associated with physiological as well as mental illness, researchers at OPENspace, together with their colleagues from around the world, are exploring how attractive and accessible green spaces can have beneficial ‘restorative’ effects on our mental state and help us to cope better with stress.  Studies using biomarkers (that measure the functioning of psychoneuroendochrine systems in the human body) show that our mental and physical states are linked, which helps to explain why environments that help to restore mental wellbeing are also helpful for our physical health. Good access to green and natural spaces in the residential environment is associated with lower levels of stress as shown by these biomarkers, as well as from self-reports of stress among people out of work and living in urban poverty. Attractive green spaces are often also places where we enjoy supportive social relationships and healthy physical exercise.  Conversely, when there is a shortage of green space in the urban environment, this appears to be associated with feelings of loneliness and lack of social support. Professor Ward Thompson has published research exploring these relationships in the journal Landscape and Urban Planning and the International Journal of Environmental Research and Public Health. Findings such as these help to strengthen the case for providing and maintaining access to healthy green spaces, such as public parks and gardens, allotments, and public rights of way in the countryside.

Dr Niamh Shortt (School of GeoSciences at the University of Edinburgh) leads research at CRESH relating to how aspects of consumption and retail environments are significant for behaviours linked to mental health and wellbeing. She focused her talk especially on issues associated with alcohol consumption and unhealthy drinking, which can be closely linked to mental distress and mental health conditions. While lower income groups report consuming the same, or less, alcohol on average than higher income groups, they suffer more from alcohol related harm. This has been called the ‘Alcohol Harm Paradox’. Dr Shortt presented findings from research she is leading which show that risks of unhealthy alcohol use are not only associated with individual level characteristics, but can also be influenced by the social and commercial environment.   Access to and advertising of retail outlets selling alcohol is not currently controlled to the same extent as for tobacco sales, yet research is showing that there the ways people drink may be influenced by the organization and availability of alcohol retailing in their neighbourhood, and that this is especially important for those living in poorer areas who may be most reliant on their local retail facilities. This research demonstrates the importance for wellbeing of work of retail planning and licensing systems.

As the discussion widened to include the audience at this event, a number of other thoughtful and important points were made. We heard from a number of representatives of relevant non-academic organizations, explaining how actions to promote mental wellbeing and to prevent and treat mental illness may draw upon research, and also contributes to knowledge about ‘what works’ to promote wellbeing.

Dr Margaret Douglas, Consultant in Public Health Medicine for NHS Lothian, underlined concerns about the unequal impacts of places on both health for different groups in Scottish society. She highlighted links between physical and mental health. The geographical variations in mental health and wellbeing, and inequalities between rich and poor areas, are a major issue for public health in Scotland, as in other countries, so research is important to help to identify the places where health disadvantage is most concentrated and needs for mental health care are greatest. This said, not all of the people most at risk of poor mental wellbeing and mental illness live in the poorest areas, so that there is also a need for information on the social and geographical pattern of mental health problems across the whole of Scotland. Dr Douglas particularly noted the range of aspects of the environment that are important for health. Her comments drew attention to the range of partners who need to collaborate to address actions to improve the various environmental factors that are beneficial for wellbeing and can help to prevent mental health problems. The Scottish Health and Inequalities Impact Assessment Network has produced documents summarising evidence on several aspects of the environment including community venues, greenspace, transport and housing.

These comments were reinforced by Johnny Cadell, from Architecture and Design Scotland, who underlined the significance of Scottish Government architecture policy (Creating Places), Scottish Planning Policy and the Place Standard, which promote healthy environments across Scotland. The Place Standard is a joint initiative between Scottish Government, Health Scotland and Architecture & Design Scotland. The discussion highlighted the strong interest in how good urban design can benefit mental health. We noted that there is very good potential for the transfer of knowledge from research into policy and practice, and this is gaining momentum through collaboration between researchers and government agencies promoting various initiatives, such as work by the Design Council entitled ‘Active by Design’ and, in Scotland, initiatives such as ‘Good Places Better Health’, ‘Go Well in Glasgow’ and, most recently, the development of the ‘Place Standard Tool’ to guide local development. Increasingly, Health Impact Assessment is being applied to interventions outside the medical sector, to ensure that health impacts of new urban developments are considered at the planning stage. The Place Standard brings together commitments in architecture policy (Creating Places) to produce a tool linking spatial design with the health/wellbeing agenda and the commitment in Good Places Better Health to produce a ‘Neighbourhood Quality Standard’.  Those involved in Good Places Better Health and Go Well were closely involved in the design of the new tool.

Frances Simpson, from Support in Mind, helpfully drew attention to the fact that a good deal of research is currently focussed on more urban communities, but that it is also important to understand the experience of the rural communities in Scotland.  Among a range of activities promoted by Support in Mind is a project that is currently collecting valuable information on what it is like living with mental ill-health in rural Scotland.  Communities in rural areas may benefit from greater proximity to extensive green spaces than those living in cities, but there are other issues such as social isolation and exclusion, and problems of access to the right kinds of mental health services, which need to be considered in rural settings. These points resonate with an article recently published by Hester Parr and Chris Philo in The Geographer magazine reporting research involving participants in rural areas.

Hugo Whitaker, from the charitable organization Cyrenians, also pointed out that recovering from mental illness can be a long process and that access to supportive environments over time can be very helpful to restoring mental wellbeing. He provided examples (including 2 film clips) of how community gardens and healthy activities organised in grounds that are part of NHS estates can help to restore and maintain good health.

A number of useful film clips have also been published by the Green Exercise Partnership  to help spread the word about this kind of activity (see example film here), as well as recordings of individual accounts from the perspective of those involved in design and planning (here) and stories of patient users’ experiences: (here).

Also relevant to this debate is the Our Natural Health Service action programme. It shows how “high quality local greenspace, supportive nature-based projects, and better links between health and social care practitioners and the environment sector, can be part of the solution to many of Scotland’s health issues.” NHS Lothians’s report ‘Health Promoting Health Service: Action in Secondary Care Settings’ issued by the Chief Medical Officer in October 2015 includes targets on “current use and improved plans of the outdoor estate for physical activity (green exercise and active travel) for staff, patients and the local community” as well as targets for staff health and wellbeing.

The debate included further comments from a number of other members of the audience. Points made by the panel about long term effects were picked up on by a retired General Practitioner who practised in one of the most deprived areas in Scotland. He commented that deprivation was transmitted across generations and that the conditions causing mental health problems in one generation would resurface in the next generation who were also treated in his surgery. Research reporting on the environmental experiences of people at different life stages was considered. For example, experiences of adolescents were commented on and it was pointed out that mental health problems can become apparent relatively early in life, and that young people have relatively little control over the social and physical environment, so it is important for their voices to be heard in environmental planning processes. Aspects of the environment that are beneficial for wellbeing of young people vary from those which are important for adults, so their experience needs to be taken into consideration.

Individuals with different characteristics may react quite variably a given environment and research can help to improve understanding of how places interacting with personal characteristics relate to mental wellbeing. It was noted, for example, that people vary in terms of cognitive and physical abilities and that making public spaces well adapted and inclusive for people with a range of abilities can help to promote mental wellbeing for all ability groups.

Other comments underlined the importance of a sense of autonomy and freedom to exercise independence and choice in the way we interact with our environment. It was noted that it was not only the visual aspect of the environment that was important, and that it was important for architects and others designing the environment to be sensitive to aspects such as noise levels and ambient temperature which can also affect one’s sense of wellbeing in a particular setting.

Overall, this event clearly demonstrated the breadth of interest in the question of why places matter for mental health and wellbeing. The panel were very grateful to the audience for engaging in the discussion and making such thoughtful comments and to SciFest for organizing the event. We felt this was a good example of how academic researchers and others with relevant ideas and experiences can join together to ‘co-produce’ our understanding of the research agenda and how research can help to inform action. We hope to be able to keep in touch with participants, via the CRESH webpages and blog, in order to share future research findings and knowledge of what is important for our wellbeing in the places where we live.